Hormonal, global, and regional haemodynamic responses to a vascular antagonist of vasopressin in patients with congestive heart failure with and without hyponatraemia.

The pathophysiological role of an increase in circulating vasopressin in sustaining global and regional vasoconstriction in patients with congestive heart failure has not been established, particularly in patients with hyponatraemia. To assess this further, 20 patients with congestive heart failure refractory to digoxin and diuretics were studied before and 60 minutes after the intravenous injection (5 micrograms/kg) of the vascular antagonist of vasopressin [1(beta-mercapto-beta,beta-cyclopentamethylene-propionic acid), 2-(0-methyl) tyrosine] arginine vasopressin. Ten patients were hyponatraemic (plasma sodium less than 135 mmol/l) and 10 were normonatraemic. In both groups of patients the vascular vasopressin antagonist did not alter systemic or pulmonary artery pressures, right atrial pressure, pulmonary capillary wedge pressure, cardiac index, or vascular resistances. Furthermore, there was no change in skin and hepatic blood flow in either group after the injection of the vascular antagonist. Only one patient in the hyponatraemic group showed considerable haemodynamic improvement. He had severe congestive heart failure and a high concentration of plasma vasopressin (51 pmol/l). Plasma renin activity, vasopressin, or catecholamine concentrations were not significantly changed in response to the administration of the vasopressin antagonist in either the hyponatraemic or the normonatraemic groups. Patients with hyponatraemia, however, had higher baseline plasma catecholamine concentrations, heart rate, pulmonary pressure and resistance, and lower hepatic blood flow than patients without hyponatraemia. Plasma vasopressin and plasma renin activity were slightly, though not significantly, higher in the hyponatraemic group. Thus the role of vasopressin in sustaining regional or global vasoconstriction seems limited in patients with congestive heart failure whether or not concomitant hyponatraemia is present. Vasopressin significantly increases the vascular tone only in rare patients with severe congestive heart failure and considerably increased vasopressin concentrations. Patients with hyponatraemia do, however, have raised baseline catecholamine concentrations, heart rate, pulmonary arterial pressure and resistance, and decreased hepatic blood flow.

Identification of care needs of patients with and without the use of a classification instrument

Objective: To analyze the agreement and disagreement between the assessments by applying or not a patient classification instrument, and to investigate the association between the agreement and personal and professional characteristics of the evaluators. Method: This is a descriptive exploratory study. 105 patients were hospitalized in a teaching hospital in the state of Sao Paulo, using the kappa statistic (weighted) and the Bootstrap method. Results: The agreement between the assessments were​​: kw 0.87 (instrument x internal evaluator), kw 0.78 (instrument x external evaluator) and kw 0.76 (between evaluators) and the influence of some personal and professional characteristics. The assessments conducted through the use of an instrument contemplated a greater number of areas of care in relation to when the instrument was not applied. Conclusion: The use of this instrument is recommended in order to more effectively identify care needs of patients.




Oxidative-nitrosative stress and systemic vascular function in highlanders with and without exaggerated hypoxemia.

BACKGROUND: Acute exposure to high altitude stimulates free radical formation in lowlanders, yet whether this persists during chronic exposure in healthy, well-adapted and maladapted highlanders suffering from chronic mountain sickness (CMS) remains to be established. METHODS: Oxidative-nitrosative stress (as determined by the presence of the biomarkers ascorbate radical [A •- ], via electron paramagnetic resonance spectroscopy, and nitrite [NO 2 2 ], via ozone-based chemiluminescence) was assessed in venous blood of 25 male highlanders in Bolivia living at 3,600 m with CMS (n 5 13, CMS 1 ) and without CMS (n 5 12, CMS 2 ). Twelve age- and activity-matched, healthy, male lowlanders were examined at sea level and during acute hypoxia. We also measured fl ow-mediated dilatation (FMD), arterial stiffness defined by augmentation index normalized for a heart rate of 75 beats/min (AIx-75), and carotid intima-media thickness (IMT). RESULTS: Compared with normoxic lowlanders, oxidative-nitrosative stress was moderately increased in the CMS 2 group ( P , .05), as indicated by elevated A •- (3,191 457 arbitrary units [AU] vs 2,640 445 AU) and lower NO 2 2 (206 55 nM vs 420 128 nM), whereas vascular function remained preserved. This was comparable to that observed during acute hypoxia in lowlanders in whom vascular dysfunction is typically observed. In contrast, this response was markedly exaggerated in CMS 1 group (A •- , 3,765 429 AU; NO 2 2 , 148 50 nM) compared with both the CMS 2 group and lowlanders ( P , .05). This was associated with systemic vascular dysfunction as indicated by lower ( P , .05 vs CMS 2 ) FMD (4.2% 0.7% vs 7.6% 1.7%) and increased AIx-75 (23% 8% vs 12% 7%) and carotid IMT (714 127 m M vs 588 94 m M). CONCLUSIONS: Healthy highlanders display a moderate, sustained elevation in oxidative-nitrosative stress that, unlike the equivalent increase evoked by acute hypoxia in healthy lowlanders, failed to affect vascular function. Its more marked elevation in patients with CMS may contribute to systemic vascular dysfunction.

Neuropathological, clinical and molecular pathology in female fragile X premutation carriers with and without FXTAS.

Fragile X-associated tremor/ataxia syndrome (FXTAS) is an adult-onset neurodegenerative disorder associated with premutation alleles of the fragile X mental retardation 1 (FMR1) gene. Approximately 40% of older male premutation carriers, and a smaller proportion of females, are affected by FXTAS; due to the lower penetrance the characterization of the disorder in females is much less detailed. Core clinical features of FXTAS include intention tremor, cerebellar gait ataxia and frequently parkinsonism, autonomic dysfunction and cognitive deficits progressing to dementia in up to 50% of males. In this study, we report the clinical, molecular and neuropathological findings of eight female premutation carriers. Significantly, four of these women had dementia; of the four, three had FXTAS plus dementia. Post-mortem examination showed the presence of intranuclear inclusions in all eight cases, which included one asymptomatic premutation carrier who died from cancer. Among the four subjects with dementia, three had sufficient number of cortical amyloid plaques and neurofibrillary tangles to make Alzheimer's disease a highly likely cause of dementia and a fourth case had dementia with cortical Lewy bodies. Dementia appears to be more common than originally reported in females with FXTAS. Although further studies are required, our observation suggests that in a portion of FXTAS cases there is Alzheimer pathology and perhaps a synergistic effect on the progression of the disease may occur.

Life expectancy with and without disability

Average life expectancy reached 78.8 years in Europe in 2002 (WHO 2003); most Europeans can, therefore, now anticipate living well past 75 years of age. Projections in industrialized nations suggest a continuing mortality decline in the next decades 1 while birth rates will probably continue to decline, resulting in further ageing of these nations. As those aged 80 years and over are the fastest expanding segment of the older population, concerns are growing about a potential dramatic increase in the number of disabled persons. The ageing of the population and the related increase in chronic disease burden have already had major impacts on most Western health-care systems, and will probably further affect these systems in the future as the baby-boom generation becomes older. For instance, in Switzerland, it is estimated that costs due to long-term care could more than double by 2030, from 6.5 to 15.3 billion SFr.2 Similar trends are expected in most European countries. As a consequence, postponement of the onset of disability, with a compression of functional dependency into a shorter period towards the end of life, is becoming a major goal. To successfully achieve this goal and improve the control of growing health and social care expenditures, various strategies of health promotion and disease prevention are developed and tested. Although several of these experiences had some effects on functional decline and institutional placement, they have not been shown to be cost-effective. Additional strategies are, therefore, needed to prevent or delay the onset of disability in older persons, reduce functional impairment, and face the challenge of an increasing disabled elderly population.

A new method for constructing exact tests without making any assumptions

We present a new method for constructing exact distribution-free tests (and confidence intervals) for variables that can generate more than two possible outcomes.This method separates the search for an exact test from the goal to create a non-randomized test. Randomization is used to extend any exact test relating to meansof variables with finitely many outcomes to variables with outcomes belonging to agiven bounded set. Tests in terms of variance and covariance are reduced to testsrelating to means. Randomness is then eliminated in a separate step.This method is used to create confidence intervals for the difference between twomeans (or variances) and tests of stochastic inequality and correlation.

Doctors without borders: The returns to an occupational license for Soviet immigrant physicians in Israel

Re-licensing requirements for professionals that move across borders arewidespread. In this paper, we measure the returns to an occupationallicense using novel data on Soviet trained physicians that immigrated toIsrael. An immigrant re-training assignment rule used by the IsraelMinistry of Health provides an exogenous source of variation inre-licensing outcomes. Instrumental variables and quantile treatmenteffects estimates of the returns to an occupational license indicate excesswages due to occupational entry restrictions and negative selectioninto licensing status. We develop a model of optimal license acquisitionwhich suggests that the wages of high-skilled immigrant physicians in thenonphysician sector outweigh the lower direct costs that these immigrantsface in acquiring a medical license. Licensing thus leads to lower averagequality of service. However, the positive earnings effect of entry restrictionsfar outweighs the lower practitioner quality earnings effect that licensinginduces.

The contributions of rare objects in correspondence analysis

Correspondence analysis, when used to visualize relationships in a table of counts(for example, abundance data in ecology), has been frequently criticized as being too sensitiveto objects (for example, species) that occur with very low frequency or in very few samples. Inthis statistical report we show that this criticism is generally unfounded. We demonstrate this inseveral data sets by calculating the actual contributions of rare objects to the results ofcorrespondence analysis and canonical correspondence analysis, both to the determination ofthe principal axes and to the chi-square distance. It is a fact that rare objects are oftenpositioned as outliers in correspondence analysis maps, which gives the impression that theyare highly influential, but their low weight offsets their distant positions and reduces their effecton the results. An alternative scaling of the correspondence analysis solution, the contributionbiplot, is proposed as a way of mapping the results in order to avoid the problem of outlying andlow contributing rare objects.

The brain uses single-trial multisensory memories to discriminate without awareness.

Multisensory experiences enhance perceptions and facilitate memory retrieval processes, even when only unisensory information is available for accessing such memories. Using fMRI, we identified human brain regions involved in discriminating visual stimuli according to past multisensory vs. unisensory experiences. Subjects performed a completely orthogonal task, discriminating repeated from initial image presentations intermixed within a continuous recognition task. Half of initial presentations were multisensory, and all repetitions were exclusively visual. Despite only single-trial exposures to initial image presentations, accuracy in indicating image repetitions was significantly improved by past auditory-visual multisensory experiences over images only encountered visually. Similarly, regions within the lateral-occipital complex-areas typically associated with visual object recognition processes-were more active to visual stimuli with multisensory than unisensory pasts. Additional differential responses were observed in the anterior cingulate and frontal cortices. Multisensory experiences are registered by the brain even when of no immediate behavioral relevance and can be used to categorize memories. These data reveal the functional efficacy of multisensory processing.

Implementação do abc (activity-based costing) numa empresa prestação de serviços de saúde

O presente trabalho cujo título é Implementação do ABC numa empresa prestadora de serviços de Saúde, tem como finalidade a obtenção do grau de licenciatura em Contabilidade e Administração e tem como principal objectivo a implementação do método ABC numa pequena e média empresa de prestação de serviços de saúde, como um instrumento de apoio á gestão. Para a introdução da Contabilidade de Gestão na empresa, há que se escolher um método/sistema de apuramento de gastos que espelha a realidade da empresa, e de uma certa forma o ABC é o método ideal para apuramento de resultados sem distorções. O ABC (Activity-Based Cost) apura os resultados através da relação de causa-efeito, considerando que as actividades é que geram gastos e os objectos de custeio é que consomem as actividades. É aplicável tanto nas empresas industriais como nas empresas prestadoras de serviços, apesar de inicialmente ter sido concebido para as empresas industrias, isto é, para as grandes empresas devido aos avultados recursos financeiros e humanos como também pelo tempo necessário para a sua implementação. Mas o modelo matricial apresentado por Roztcki et al (1999) permite a aplicação deste método nas PME com poucos recursos financeiros e de tempo, utilizando uma folha de cálculo no Excel. Será este modelo a ser proposto e poderá ser implementado na clínica. O modelo apresentado foi testado num estudo de caso realizado numa clínica. Com a realização dos testes foi detectado algumas dificuldades e limitações, as maiores dificuldades encontradas foram a identificação das actividades e dos cost drivers, devido à complexidade do sector. A implementação foi concluída com sucesso, proporcionando informações detalhadas dos gastos dos produtos/serviços prestados em toda a clínica. This work was done as a requisite for obtaining a degree in Accounting and Administration, and is titled “The Implementation of ABC – Activity Based Cost in a company that provides health services”. Its main purpose is to analyze the implementation of ABC method in a small and medium-sized enterprise which provides health services to support decision making by the Managers. To adopt management accounting in a company, it’s necessary to choose a cost qualifying system that reflects the reality of the company and in a certain way ABC is the method which can determine the results without any distortion. ABC (Activity-Based Cost) determines the results through cause-and-effect relationship, whereas the activities generate spending while costing objects consume the activities. It’s applicable both in industrial companies as in services providers, although it was initially designed for industrial companies, that is, to large companies, due to the huge financial and human resources existent as well as by the time required for its implementation. But the matrix model presented by Roztckiet al (1999) allows application of this method in small and medium-sized enterprises with limited financial resources and time, using a spreadsheet in Excel. This model will be proposed and could be implemented in any clinic. The model was tested in a case study, undertaken in a private clinic. With the realization of the tests, some problems and limitations were detected, and the major difficulties encountered were the identification of activities and cost drivers, due to the complexity of the sector. The implementation was completed successfully, providing detailed information of the products services spending throughout the clinic.

Regional industrialisation without national growth: The Catalan industrialization and the growth of Spanish economy (1830-1861)

This paper has two main objectives. First, it provides a stylised descriptionof the Catalan industrial path of the period 1830-1861. Second, it reviewsthe evolution of the Catalan industry in the Spanish context and, thus, canserve to describe the relative importance of the Catalan industrialexperience. Consequently, it is mainly devoted to computing and analysing thegrowth rates of Catalan industries during the early phase of industrialisation.The results show that Catalonia experienced a true process ofindustrialisation during the period 1830 to 1861, but that its contributionin rapid increase in Spanish GDP was relatively small.

Exact tests for correlation and for the slope in simple linear regressions without making assumptions

We present an exact test for whether two random variables that have known bounds on their support are negatively correlated. The alternative hypothesis is that they are not negatively correlated. No assumptions are made on the underlying distributions. We show by example that the Spearman rank correlation test as the competing exact test of correlation in nonparametric settings rests on an additional assumption on the data generating process without which it is not valid as a test for correlation.We then show how to test for the significance of the slope in a linear regression analysis that invovles a single independent variable and where outcomes of the dependent variable belong to a known bounded set.