The impact of user charges on patient choice of healthcare services in Ireland

This research assesses the impact of user charges in the context of consumer choice to ascertain how user charges in healthcare impact on patient behaviour in Ireland. Quantitative data is collected from a subset of the population in walk-in Urgent Care Clinics and General Practitioner surgeries to assess their responses to user charges and whether user charges are a viable source of part-funding healthcare in Ireland. Examining the economic theories of Becker (1965) and Grossman (1972), the research has assessed the impact of user charges on patient choice in terms of affordability and accessibility in healthcare. The research examined a number of private, public and part-publicly funded healthcare services in Ireland for which varying levels of user charges exist depending on patients’ healthcare cover. Firstly, the study identifies the factors affecting patient choice of privately funded walk-in Urgent Care Clinics in Ireland given user charges. Secondly, the study assesses patient response to user charges for a mainly public or part-publicly provided service; prescription drugs. Finally, the study examines patients’ attitudes towards the potential application of user charges for both public and private healthcare services when patient choice is part of a time-money trade-off, convenience choice or preference choice. These services are valued in the context of user charges becoming more prevalent in healthcare systems over time. The results indicate that the impact of user charges on healthcare services vary according to socio-economic status. The study shows that user charges can disproportionately affect lower income groups and consequently lead to affordability and accessibility issues. However, when valuing the potential application of user charges for three healthcare services (MRI scans, blood tests and a branded over a generic prescription drug), this research indicates that lower income individuals are willing to pay for healthcare services, albeit at a lower user charge than higher income earners. Consequently, this study suggests that user charges may be a feasible source of part-financing Irish healthcare, once the user charge is determined from the patients’ perspective, taking into account their ability to pay.

Randomized Trial for a Mobile Health Approach to Increase Uptake of Cervical Cancer Screening in Tanzania

Background: Largely due to low availability and uptake of screening in low- and middle-income countries, cervical cancer is the second ranked cancer among women in these countries. This is a tragedy because cervical cancer is one of the most preventable carcinomas. This thesis will investigate behaviour change methods, which capitalize on the recent exponential increase in ownership of mobile phones in Tanzania, to increase uptake of cervical cancer screening (CCS) in the Kilimanjaro region of Tanzania. Objectives: 1) To evaluate the effectiveness of behaviour change messages delivered via short message service (SMS) on the uptake of CCS in the Kilimanjaro region; 2) to evaluate the effectiveness of a transportation eVoucher on the uptake of CCS in the Kilimanjaro region; 3) to explore characteristics associated with CCS uptake in the Kilimanjaro region; and 4) to determine the attitudes towards and perceived benefit of behaviour change SMS messages and eVouchers intended to increase uptake of CCS. Methods: In the Kilimanjaro Region, 853 women participated in a randomized controlled trial. Baseline data was collected through self-report through systematic stratified random sampling. Participants were randomized to one of three groups: a control group, a group receiving behaviour change messages delivered via SMS, or a group receiving a travel eVoucher and identical SMS as the SMS group. A fieldworker recorded participants attending screening at the CCS clinics and administered a post-screening survey. The follow-up period was two months from the time of the participant’s enrolment. Logistic regression (both for the combined and stratified data sets) was used to determine associations between the behaviour change interventions, baseline characteristics and cervical cancer screening uptake. Results: All participants receiving SMS messages (SMS or eVoucher group) were more likely to attend cervical cancer screening in comparison with the control group. 83% of participants who attended screening shared the information contained in the messages with others. Conclusions: Behaviour change messages delivered via SMS and transportation eVouchers have the potential to increase uptake of cervical cancer screening in the Kilimanjaro region of Tanzania. Harnessing this potential will require implementing these interventions alongside other methods to achieve maximum impact.

Task sharing within a managed clinical network to improve child health in Malawi

BACKGROUND: Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.

PRESENTATION OF THE HYPOTHESIS: Managed clinical networks have been found to improve equity of care in rural districts and to ensure that the correct care is provided as close to home as possible. A network for paediatric care in Malawi with mentoring of non-physician clinicians based in a district hospital by paediatricians based at the central hospitals will establish and sustain clinical referral pathways in both directions. Ultimately, the plan envisages four managed paediatric clinical networks, each radiating from one of Malawi's four central hospitals and covering the entire country. This model of task sharing within four hub-and-spoke networks may facilitate wider dissemination of scarce expertise and improve child healthcare in Malawi close to the child's home.

TESTING THE HYPOTHESIS: Funding has been secured to train sufficient personnel to staff all central and district hospitals in Malawi with teams of paediatric specialists in the central hospitals and specialist non-physician clinicians in each government district hospital. The hypothesis will be tested using a natural experiment model. Data routinely collected by the Ministry of Health will be corroborated at the district. This will include case fatality rates for common childhood illness, perinatal mortality and process indicators. Data from different districts will be compared at baseline and annually until 2020 as the specialists of both cadres take up posts.

IMPLICATIONS OF THE HYPOTHESIS: If a managed clinical network improves child healthcare in Malawi, it may be a potential model for the other countries in sub-Saharan Africa with similar cadres in their healthcare system and face similar challenges in terms of scarcity of specialists.

Biodistribution of the Radiopharmaceutical Technetium- 99m-Sodium Phytate in Rats After Splenectomy

Drugs and surgery can interfere with the biodistribution of radiopharmaceuticals and data about the effect of splenectomy on the metabolism of phytate-Tc-99m are scarce. This study aimed at evaluating the interference of splenectomy on phytate-Tc-99m biodistribution and liver function in rats. The SP group rats (n=6) underwent splenectomy. In group C (control) the animals were not operated on. After 15 days, all rats were injected with 0.1mL of Tc-99m-phytate via orbital plexus (0.66MBq). After 30 minutes, liver samples were harvested, weighed and the percentage of radioactivity per gram (%ATI-g) was determined by a Wizard Perkin-Elme gama counter. The ATI%-g in splenectomized rats (0.99±0.02) was significantly higher than in controls (0.4±0.02), (p=0.034). ALT, AST and HDL were significantly lower in SP rats (p= 0.001) and leukocytosis was observed in SP rats. In conclusion, splenectomy in rats changed the hepatic biodistribution of Tc-99m-phytate and liver enzimatic activity

Hallux rigidus: Arthroplasty or arthrodesis. What technique produces better results?

Hallux rígidus (HR) affects the first metatarsophalangeal joint (MTPJ) between 35% and 60% of the population over 65 years and there are multiple ways of treatment. Depending on the radiological stage where you find the deformity determines the procedure to be performed; in the early stages cheilectomy techniques and corrective osteotomy is performed while the more advanced ratings, the surgeon chooses destructive techniques considered as arthrodesis and arthroplasty. This final of degree project aims to focus on 1 MTPJ destructive techniques to clarify which of the procedures generates better results by a number of parameters; outcomes of the American Orthopaedic Foot scale and Ankle Society Hallux metatarsophalangeal Interphalangeal-scale (AOFAS), range of motion (ROM) of the 1ºAMTF, radiological classification. As for the implant arthroplasty technique, this article offers information on material and design that generates better relating to patient characteristics such as age, inflammatory joint diseases, viability and durability of the implant results. The conclusion from this review is that the values obtained in the arthrodesis according AOFAS decrease due to loss of mobility, but both techniques have similar values of effectiveness and concludes with the decision that the technique used is determined taking into account various factors and patient characteristics. Keywords: Hallux rígidus; (Hallux Rígidus) and surgery treatment; Hallux Rígidus arthrodesis; Hallux Rígidus arthroplasty; Hallux Rígidus (arthroplasty and arthrodesis).

Aumento de coroa clínica

O sorriso não se baseia apenas em factores dentários relacionados com a cor, a forma ou o alinhamento dos dentes na arcada, mas implica também a presença de tecidos periodontais saudáveis e com um contorno gengival harmónico. Este trabalho tem como objectivo abordar as diversas técnicas de aumento de coroa clínica, enunciar as vantagens e indicações das mesmas, bem como comparar as técnicas cirúrgicas com as ortodônticas. Para tal foi realizada uma pesquisa bibliográfica recorrendo aos motores de busca da Pubmed e b-on, utilizando como palavras-chave: crown lengthening, biological width, crown lengthening AND surgery e crown lengthening AND orthodontic extrusion. Dos 539 artigos encontrados, foram seleccionados 28 que correspondiam aos critérios de inclusão por nós estabelecidos. Critérios de inclusão: meta-análises, ensaios clínicos randomizados e revisões sistemáticas publicadas em Português, Inglês e Espanhol nos últimos 12 anos. De acordo com a literatura, podemos verificar que o aumento de coroa clínica está indicado em várias situações clínicas tais como: cáries infra-gengivais, fracturas radiculares, resolução de alguns problemas estéticos, como o sorriso gengival, principalmente em casos de erupção passiva alterada e assimetrias das margens gengivais. Este aumento pode ser realizado por técnicas cirúrgicas (gengivectomia e retalho de reposicionamento apical), técnicas ortodônticas (extrusão ortodôntica com ou sem fibrotomia) ou através da combinação de ambas.

Sexual functioning in people with stable chronic diseases

Backgound - In developed countries people are living longer and the incidence of chronic disease (CD) is increasing. CD and its treatments can have a negative impact on sexual functioning and sexual satisfaction. Objective - To explore and to compare sexual function and sexual satisfaction in people with stable chronic diseases.

Relação supervisiva e desenvolvimento da identidade profissional: acompanhamento das práticas clínicas dos estudantes de enfermagem

Este estudo centrou-se num Curso de Licenciatura em Enfermagem e teve como objetivo compreender a influência da relação supervisiva no desenvolvimento da identidade profissional dos estudantes. Os eixos estruturantes que suportam esta investigação e que concorrem para a definição do seu objeto de estudo articulam-se em torno da relação supervisiva, do desenvolvimento de competências profissionais e do desenvolvimento da identidade pessoal e profissional em contexto clínico. A formação desenvolvida através da prática clínica destina-se a preparar indivíduos de acordo com a atual realidade socioprofissional, onde os sujeitos, independentemente da singularidade de cada um, desenvolvem saberes adquiridos em sala de aula. Quando comparada com o espaço escolar, a aprendizagem em contexto clínico é condicionada por fatores que se caraterizam por maior imprevisibilidade e obriga frequentemente o estudante a confrontar-se com situações únicas e impares. A identidade dos estudantes torna-se assim construída e vivida a partir de um conjunto de dimensões que ocorrem no decurso das vivências clínicas. Metodologicamente optou-se por um estudo etnográfico no âmbito do paradigma qualitativo, numa abordagem longitudinal segundo a lógica do estudo de caso. A natureza dos dados a recolher englobou ainda o recurso a procedimentos de natureza quantitativa. Como técnica de recolha de dados recorremos à observação participante, entrevistas semiestruturadas e questionários. O estudo desenvolveu-se numa Escola Superior de Enfermagem da Zona Norte do país e fizeram parte da população 69 estudantes de uma turma de segundo ano, quatro tutores e um professor. O plano de estudo da referida escola está organizado de forma a que a aprendizagem dos estudantes seja progressivamente integradora de saberes interligando a componente teórica com a componente prática. Assim, os ensinos clínicos estão distribuídos entre o 2º e o 4º ano. Da análise e discussão dos dados e subsequentes conclusões ressalta que, quer a relação supervisiva, quer os contextos clínicos, foram influenciadores do desenvolvimento de competências profissionais, bem como da identidade pessoal e profissional dos estudantes. Verificamos que os dois contextos clínicos estudados – medicina e cirurgia – favoreceram o desenvolvimento de competências distintas, no entanto complementares. Tornou-se visível que, os supervisores do contexto de medicina, possuidores de uma visão holística da profissão de enfermagem, promoveram nos estudantes uma visão integradora do doente, resultante de uma contínua atitude reflexiva sobre a Pessoa Humana. Por sua vez, no contexto de cirurgia, caraterizada por intervenções mais invasivas e mais centradas no tratar, as competências mais valorizadas pelos tutores, embora que de uma forma não verbalmente assumida, foram do domínio técnicocientífico, com especial relevo pelas competências instrumentais.

Biodistribution of the Radiopharmaceutical Technetium- 99m-Sodium Phytate in Rats After Splenectomy

Drugs and surgery can interfere with the biodistribution of radiopharmaceuticals and data about the effect of splenectomy on the metabolism of phytate-Tc-99m are scarce. This study aimed at evaluating the interference of splenectomy on phytate-Tc-99m biodistribution and liver function in rats. The SP group rats (n=6) underwent splenectomy. In group C (control) the animals were not operated on. After 15 days, all rats were injected with 0.1mL of Tc-99m-phytate via orbital plexus (0.66MBq). After 30 minutes, liver samples were harvested, weighed and the percentage of radioactivity per gram (%ATI-g) was determined by a Wizard Perkin-Elme gama counter. The ATI%-g in splenectomized rats (0.99±0.02) was significantly higher than in controls (0.4±0.02), (p=0.034). ALT, AST and HDL were significantly lower in SP rats (p= 0.001) and leukocytosis was observed in SP rats. In conclusion, splenectomy in rats changed the hepatic biodistribution of Tc-99m-phytate and liver enzimatic activity

Large Morgagni Hernia in an Adult Patient

A 70-year-old woman presented to the emergency department with symptoms of a lower respiratory infection. A chest x-ray showed enlargement of the mediastinal space. The patient was admitted with a respiratory tract infection and started on antibiotic treatment. A computed tomography (CT) scan of the thorax revealed a large diaphragmatic hernia with stomach, large intestine and caudal pancreas lodged in the thoracic cavity. After the antibiotic treatment, the patient became asymptomatic and surgery repair was declined. Morgagni hernia is an uncommon type of congenital diaphragmatic hernia, which may be asymptomatic until late in life or may be present acutely with life threatening conditions.

Funduplicatura de Nissen laparoscópico en el tratamiento de la enfermedad por reflujo gastroesofágico. Hospital Vicente Corral Moscoso. Cuenca, 1997-2008

Introducción: Alrededor del 25 a 50% de sujetos con enfermedad por reflujo gastroesofágico tienen enfermedad persistente progresiva, en ellos, la intervención quirúrgica constituye la mejor opción y el único recurso capaz de restaurar la barrera gastroesofágica. La funduplicatura de Nissen de elección, se realiza por laparoscopía desde febrero de 1997 en nuestro hospital. Objetivo: describir aspectos demográficos y clínicos de pacientes sometidos a funduplicatura de Nissen laparoscópico en el hospital Vicente Corral Moscoso. Método: análisis descriptivo y retrospectivo de videos e historias clínicas en estadística y cirugía de las funduplicaturas de Nissen laparoscópico. Resultados: de febrero 1997 a julio 2008, se realizaron 58 funduplicaturas, en 36 hombres y 22 mujeres, con un promedio de 42 años. Síntomas predominantes; pirosis, regurgitación, dolor abdominal y disfagia. Diagnosticados por: endoscopía digestiva alta y serie esófagogastroduodenal en todos. Com - plicaciones posoperatorias inmediatas: íleo 9, disfagia 5, retención urinaria 4. Tiempo operatorio promedio: 181 minutos en 1997, 102 minutos en 2008. Estancia hospitalaria: 4 días. 49 pacientes recibieron alimentación en 24 horas. No hubo conversiones ni mortalidad. Conclusiones: la cirugía laparoscópica en el tratamiento de ERGE va en aumento y constituye un tratamiento eficaz a largo plazo. Pero los cirujanos debemos también examinar los éxitos, los errores, las complicaciones y limitaciones de estas aplicaciones a largo plazo y con más variables estudiadas.

Practical considerations in the management of proton-pump inhibitors

Proton-pump inhibitors (PPIs) are one of the most active ingredients prescribed in Spain. In recent decades there has been an overuse of these drugs in both outpatient clinics and hospitals that has lead to a significant increase in healthcare spending and to an increase in the risk of possible side effects. It is important for health professionals to know the accepted indications and the correct doses for the use of these drugs. On the market there are different types of PPI: omeprazole, pantoprazole, lansoprazole, rabeprazole and esomeprazole. Omeprazole is the oldest and most used PPI, being also the cheapest. Although there are no important differences between PPIs in curing diseases, esomeprazole, a new-generation PPI, has proved to be more effective in eradicating H. pylori and in healing severe esophagitis compared to other PPIs. In recent years the use of generic drugs has spread; these drugs have the same bioavailability than the original drugs. In the case of PPIs, the few comparative studies available in the literature between original and generic drugs have shown no significant differences in clinical efficacy.

Impacto da relação entre médico veterinário e proprietário no tratamento recebido por felinos domésticos

Dissertação de Mestrado Integrado em Medicina Veterinária

Impacto do maneio clínico da Diabetes mellitus canina e felina na qualidade de vida do cuidador e do paciente

Dissertação de Mestrado Integrado em Medicina Veterinária