A qualitative assessment of the referral system at district level in Zimbabwe: implications on efficiency and effective delivery of health services

This exploratory study describes the nature and magnitude of the problem of health referrals, health-seeking behavior, perceptions, and knowledge at the district level in Zimbabwe. Data were obtained from focus groups with 159 persons in Tsholotsho and 132 persons in Murewa; from discussions with health personnel from the 6 health centers in Murewa and the 2 rural hospitals in Tsholotsho; and from records among a systematic sample of 400 new outpatients during October 1993 and March 1994 in Murewa district. Findings indicate that 71.8% in outpatient departments at Murewa Hospital had no access to a health center. 24.3% by-passed the health center for treatment at the hospital. 3.8% were referred by health centers. The absolute number of referrals did not change during 1991-93. However, the number directly accessing services from outside the district rose. Focus group participants reported their intention to use the nearest clinic for an illness. In Tsholotsho, people initially used the village community worker/headman. If illness was perceived as serious, patients would go to a hospital. For minor illness, people used traditional herbal remedies. If illness did not change after remedies, the clinic was consulted. Some illnesses were perceived as outside the realm of medicine. Most distinguished between a health center and a hospital, but were unaware of the important, superior functions of the health center. Most did not understand the logic behind the referral system, but appreciated referrals and not the cost of hospital treatment or transportation. The community was unaware of Ward Health Teams. Many did not understand the new fee policy introduced in 1994.     

Fluorescence studies of the location and membrane accessibility of the palmitoylation sites of rhodopsin

Fluorescent fatty acid labels have been incorporated into the palmitoylation sites of rhodopsin and used to probe the membrane accessibility and location of these sites. The fluorescence properties of anthroyloxy and pyrenyl fatty acids bound to rhodopsin were investigated in a reconstituted vesicle system. Collisional quenching of fluorescence by stearic acid (DSA) labeled with doxyls in the 16, 12, and 5 positions was used to determine the membrane accessibility and disposition of the modifying fatty acids. To properly determine the membrane concentration of these quenchers, the dependence of the Stern-Volmer parameters on both quencher and vesicle concentration was determined. An analysis of these dependences provided a correction for partitioning of the quencher between the aqueous phase and the membrane. After this correction, the relative effectiveness of doxyl quenchers was 16-DSA > 12-DSA > 5-DSA. Parallel studies on free anthroyloxy and pyrenyl fatty acids incorporated into the reconstituted system showed the same dependence on quencher position. These results indicate that the labels at the palmitoylation sites of rhodopsin are situated in the membrane much as a free fatty acid. This anchoring of the palmitates in the membrane results in the formation of a fourth cytoplasmic loop.     

The adaptive capacities of patients with panic disorders (a psychophysiological study)

Contingent-negative deviation (CND) and orientational reaction (OR) were studied in 9 women suffering from typical (according to DSM-III-R) panic disorders (PD) and 12 healthy females. CND recording was made after giving neutral (70 dB, 1000 Hz) and stress (120 dB, 2000 Hz) pairs of sounds. Patients with PD were divided in two groups depending upon CND amplitudes. The first group (4 patients) was distinguished from healthy individuals by high CND amplitude (which significantly decreased after reaction on stress sound), by delay of extinction of cutaneogalvanic reaction (CGR) and by higher electromyogram amplitude. The second group (5 patients with more severe course of PD) was characterized by low amplitudes of CND and electromyogram, by absence of changes in CND after stress sound, by delay of extinction of CGR and nonspecific response. Above-mentioned data were evidence of psychophysiological heterogeneity of typical PD. The results were interpreted from a position of adaptive abilities of patients with PD, using ineffective and immature psychophysiological strategies of overcoming stress.     

Objectives, results and future prospects of burn treatment in 1997

When burn injuries to the skin are extensive, delays in wound closure contribute to multiple organ failure because the availability of donor sites does not allow early and permanent coverage of excised wounds. From 1991 to 1996, 30 patients with a mean burn size of 78% total body surface area (65% full-thickness) underwent skin grafting with autologous cultured epidermis (AEC) performed in the labs of Genzyme Tissue Repair Company. Twenty three were adults and seven children under 15 (mean age 29, range 2.5 to 70); 27 suffered inhalation injury; 3 presented with multiple trauma and 2 with blast injury. As soon as possible wound beds were excised and temporarily covered with allografts or with sandwich or meshed autografts; the mean surface covered with autografts was 28 +/- 12%. Keratinocytes grafts were applied to a mean of 37 +/- 16.5%, an average of 210 grafts of 25 to 30 cm2. Three patients died respectively at day 67, 81 and 90. At time of gaze backing removal, the mean percentage of culture engraftment was 69% (range 25 to 95); this engraftment was higher for children (74%) and very bad above 60 (25%). The mean length of hospitalisation was 114 +/- 30 days. The definitive coverage by AEC was evaluated through the percentage of secondary autografted area: 10 +/- 9.5% (range 0 to 46). The average cost by patient was 98,500$ or 16$ by cm2 of culture. The weakness of epithelialisation makes essential a dermal support to the keratinocytes cultures, allodermis is now currently used, perhaps the new skin substitutes will give the ideal missing piece.     

Dens invaginatus--a pathway to pulpal pathology: a literature review

Dens invaginatus is the most common dental anomaly in a group of dental anomalies, related by their embryologic development and by the fact that their defects provide a potential pathway for bacteria to cause pulpal pathology. It occurs when the inner enamel epithelium invaginates into the dental papilla prior to calcification. It exists in erupted teeth as an enamel-lined tract, which either ends in a blind sac inside the crown or root or exits into the periodontal ligament. The lining may be incomplete in areas and may not protect the pulp. Methods of providing preventive treatment for teeth with dens invaginatus are described. When pulpal pathosis occurs, the dens may displace the pulp and complicate access cavity preparation and subsequent endodontic treatment, adversely affecting the prognosis. The learning objective of this article is to present treatment planning considerations and suggestions.     

DNA-protein interactions in CpG islands and DNAse I sensitive chromatin]

DNA-protein interactions were studied in the chromatin preparations obtained according to different procedures by means of nucleoprotein-celite chromatography. Three discrete fractions dissociating in 1M, 2M and 3M NaCl were observed in all preparations. The 1M fraction prevails in DNaseI-sensitive chromatin and the 2M fraction--in the resistant. Chromatin solubilized by MspI restrictase (the active chromatin) contains the 1M and 3M fractions, one solubilized by AluI (inactive)--the 2M fraction. Distribution of the fractions is different in proliferating and quiescent cells.