Determinants of quality of advanced cancer care in Latin America. A look at five countries: Argentina, Brazil, Cuba, Mexico and Peru

The World Health Organization reports that nearly half a million people died of cancer in Latin America in 2001. As a growing public health problem, cancer is now either the first or second leading cause of death among adults in most Latin American nations. Despite these trends, information on the quality of care people with advanced cancer in Latin America receive has been limited. This study assessed the quality of advanced cancer care in diverse Latin American countries and institutions by surveying cancer care providers from: Argentina; Brazil; Cuba; Mexico; and Peru. This study also identified the most salient factors that influence the quality of this care at the national and institutional levels and compared these factors across countries. This study was based on the secondary analyses of data collected by the University of Texas M. D. Anderson's WHO/PAHO Collaborating Center in Supportive Cancer Care from March 2000 to November 2002. The sample for this survey was a convenience sample of physicians and nurses who treat cancer patients in these regions. Strategies for the dissemination of this survey included: mass mailings; distribution at professional meetings/conferences; collaboration with regional institutions, professional organizations and PAHO; and the posting of online surveys. The strongest predictor of providers' assessments of the quality of advanced cancer care was their ratings of access to care. This major finding reflects a shared equitable notion of quality care among providers from diverse countries and medical institutions that is highly interrelated with providing accessible care to those with advanced cancer. Higher ratings of the affordability of care, an increased reported availability of end-of-life services and opioid analgesics, practicing in either a private hospital or specialized cancer center, and practicing in Cuba were also associated with higher provider ratings of the quality of advanced cancer care. The findings of this study contribute towards the much needed body of knowledge that may guide the formulation of policies and interventions aimed at improving the care for people with advanced cancer in Latin America. ^

Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

The Elegant Simplicity of Family Preservation Practice Legecies and Lessons

An earlier version of this manuscript was prepared for the Chapin Hall invitational seminar on family preservation, The Chapin Hall Center for Children at the University of Chicago, September 16 & 17, 1999. The author wishes to acknowledge the comments and helpful suggestions of seminar participants-Jacqueline McCroskey, Martha Shirk, Fran Jacobs, John Schuerman, Lee Schorr, Charlotte Booth, Kristi Nelson, Susan Kelly, Frank Farrow, and Susan Notkin. These comments, as indeed many of their prior contributions, have had a seminal effect on my thinking about family preservation services over the years. Clark Peters and other Chapin Hall staff deserve special thanks for creating the conditions necessary to produce a lively and productive discussion. As always, Harold Richman, Executive Director of Chapin Hall, and Hermon Dunlap, Smith Professor at the School of Social Service Administration of the University of Chicago, as seminar convenor combined perfectly the skills of gracious host and incisive critic. We in the child welfare field are in his debt for continually raising the level of discourse in our field. In the end, as it should be, the thoughts and opinions in the following paper are wholly my own.

The organizations transcomplejas from the perspective of the nursing

El propósito del artículo es el análisis de las organizaciones transcomplejas desde la perspectiva de la Enfermería, en el contexto del paradigma de la complejidad. Todos los cuestionamientos realizados a las ciencias de la modernidad fueron necesarios para dar al mundo desarrollos de enorme significación, como es el paradigma de la complejidad donde se rescata la idea de la totalidad universal y con ella el holismo dentro de las organizaciones, si se consideran estas como organismos vivo; y este aplicado al campo de la salud donde los profesionales del cuidado de la salud entre ellos la enfermería ha aceptado la perspectiva de salud holística como, más que la ausencia de enfermedad, como la realización individual. La humanidad vive una crisis de fragmentación que conduce a sentimientos y emociones destructivas de la armonía y del arte de vivir en equilibrio. La perspectiva holistica se preocupa de promover la salud mediante la prevención y se aplica a las personas que se recuperan de una enfermedad y desean aprender a prevenir su repetición y mejorar su estatus de salud futura. Así, la enfermería estudia la totalidad o la salud de los humanos, reconociendo que los humanos están en continua interacción con su medio ambiente

Analysis of advanced European nuclear fuel cycle scenarios including transmutation and economic estimates

Four European fuel cycle scenarios involving transmutation options (in coherence with PATEROS and CPESFR EU projects) have been addressed from a point of view of resources utilization and economic estimates. Scenarios include: (i) the current fleet using Light Water Reactor (LWR) technology and open fuel cycle, (ii) full replacement of the initial fleet with Fast Reactors (FR) burning U?Pu MOX fuel, (iii) closed fuel cycle with Minor Actinide (MA) transmutation in a fraction of the FR fleet, and (iv) closed fuel cycle with MA transmutation in dedicated Accelerator Driven Systems (ADS). All scenarios consider an intermediate period of GEN-III+ LWR deployment and they extend for 200 years, looking for long term equilibrium mass flow achievement. The simulations were made using the TR_EVOL code, capable to assess the management of the nuclear mass streams in the scenario as well as economics for the estimation of the levelized cost of electricity (LCOE) and other costs. Results reveal that all scenarios are feasible according to nuclear resources demand (natural and depleted U, and Pu). Additionally, we have found as expected that the FR scenario reduces considerably the Pu inventory in repositories compared to the reference scenario. The elimination of the LWR MA legacy requires a maximum of 55% fraction (i.e., a peak value of 44 FR units) of the FR fleet dedicated to transmutation (MA in MOX fuel, homogeneous transmutation) or an average of 28 units of ADS plants (i.e., a peak value of 51 ADS units). Regarding the economic analysis, the main usefulness of the provided economic results is for relative comparison of scenarios and breakdown of LCOE contributors rather than provision of absolute values, as technological readiness levels are low for most of the advanced fuel cycle stages. The obtained estimations show an increase of LCOE ? averaged over the whole period ? with respect to the reference open cycle scenario of 20% for Pu management scenario and around 35% for both transmutation scenarios. The main contribution to LCOE is the capital costs of new facilities, quantified between 60% and 69% depending on the scenario. An uncertainty analysis is provided around assumed low and high values of processes and technologies.

Breakers of advanced glycation end products restore large artery properties in experimental diabetes

Glucose and other reducing sugars react with proteins by a nonenzymatic, posttranslational modification process called nonenzymatic glycation. The formation of advanced glycation end products (AGEs) on connective tissue and matrix components accounts largely for the increase in collagen crosslinking that accompanies normal aging and which occurs at an accelerated rate in diabetes, leading to an increase in arterial stiffness. A new class of AGE crosslink “breakers” reacts with and cleaves these covalent, AGE-derived protein crosslinks. Treatment of rats with streptozotocin-induced diabetes with the AGE-breaker ALT-711 for 1–3 weeks reversed the diabetes-induced increase of large artery stiffness as measured by systemic arterial compliance, aortic impedance, and carotid artery compliance and distensibility. These findings will have considerable implications for the treatment of patients with diabetes-related complications and aging.

Inhibition of advanced glycation endproduct formation by acetaldehyde: Role in the cardioprotective effect of ethanol

Epidemiological studies suggest that there is a beneficial effect of moderate ethanol consumption on the incidence of cardiovascular disease. Ethanol is metabolized to acetaldehyde, a two-carbon carbonyl compound that can react with nucleophiles to form covalent addition products. We have identified a biochemical modification produced by the reaction of acetaldehyde with protein-bound Amadori products. Amadori products typically arise from the nonenzymatic addition of reducing sugars (such as glucose) to protein amino groups and are the precursors to irreversibly bound, crosslinking moieties called advanced glycation endproducts, or AGEs. AGEs accumulate over time on plasma lipoproteins and vascular wall components and play an important role in the development of diabetes- and age-related cardiovascular disease. The attachment of acetaldehyde to a model Amadori product produces a chemically stabilized complex that cannot rearrange and progress to AGE formation. We tested the role of this reaction in preventing AGE formation in vivo by administering ethanol to diabetic rats, which normally exhibit increased AGE formation and high circulating levels of the hemoglobin Amadori product, HbA1c, and the hemoglobin AGE product, Hb-AGE. In this model study, diabetic rats fed an ethanol diet for 4 weeks showed a 52% decrease in Hb-AGE when compared with diabetic controls (P < 0.001). Circulating levels of HbA1c were unaffected by ethanol, pointing to the specificity of the acetaldehyde reaction for the post-Amadori, advanced glycation process. These data suggest a possible mechanism for the so-called “French paradox,” (the cardioprotection conferred by moderate ethanol ingestion) and may offer new strategies for inhibiting advanced glycation.

Comparison of potency of inhaled beclomethasone and budesonide in New Zealand: retrospective study of computerised general practice records

Objective To determine whether inhaled budesonide and beclomethasone are equipotent in the treatment of asthma in primary care.

Monophyly and extensive extinction of advanced eusocial bees: Insights from an unexpected Eocene diversity

Advanced eusociality sometimes is given credit for the ecological success of termites, ants, some wasps, and some bees. Comprehensive study of bees fossilized in Baltic amber has revealed an unsuspected middle Eocene (ca. 45 million years ago) diversity of eusocial bee lineages. Advanced eusociality arose once in the bees with significant post-Eocene losses in diversity, leaving today only two advanced eusocial tribes comprising less than 2% of the total bee diversity, a trend analogous to that of hominid evolution. This pattern of changing diversity contradicts notions concerning the role of eusociality for evolutionary success in insects.

Expediting the transfer of evidence into practice: building clinical partnerships*

A librarian/clinician partnership was fostered in one hospital through the formation of the Evidence-based Practice Committee, with an ulterior goal of facilitating the transfer of evidence into practice. The paper will describe barriers to evidence-based practice and outline the committee's strategies for overcoming these barriers, including the development and promotion of a Web-based guide to evidence-based practice specifically designed for clinicians (health professionals). Educational strategies for use of the Web-based guide will also be addressed. Advantages of this partnership are that the skills of librarians in meeting the needs of clinicians are maximized. The evidence-based practice skills of clinicians are honed and librarians make a valuable contribution to the knowledgebase of the clinical staff. The knowledge acquired through the partnership by both clinicians and librarians will increase the sophistication of the dialogue between the two groups and in turn will expedite the transfer of evidence into practice.