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Biomedical subjects

R Feldman

Publications and source records attributed to R Feldman.

At least 19 recordsLinked to original sources
PubMed2006

Primary health care for refugees and asylum seekers: a review of the literature and a framework for services.

OBJECTIVES: This paper aims to provide a framework for primary health care services to meet the recognized health needs of refugees and asylum seekers that can be used in planning and evaluating services for this group. REVIEW: Primary care services for refugees and asylum seekers are reviewed and presented in terms of a tripartite framework of gateway, core and ancillary services. Gateway services facilitate entry into primary care by identifying unregistered patients and carrying out health assessments. They are typically undertaken by nurse-led outreach services and specialist health visitors. Core services provide full registration and may be provided by dedicated practices or by mainstream practices, with or without additional support. Ancillary services are those that supplement and support core services' ability to meet the additional health needs of this group. They include language and information services, close links with community-based organizations, specialist mental health services and services for survivors of torture and organized violence, as well as targeted health promotion and training of health workers. CONCLUSIONS: The framework can be used for education and training, planning and commissioning, and to provide criteria for comparison and evaluation. The paper suggests that a lack of published evaluations and reports about interventions for refugees and asylum seekers constrains further policy development that could build on the strengths of such interventions. It also stresses the importance of ancillary services to successful mainstream provision.

Community Health Nursing↗
PubMed2005

Relations between parents' interactive style in dyadic and triadic play and toddlers' symbolic capacity.

Play has a major role in the evaluation and treatment of young children referred to mental health clinicians. The present study examined parental correlates of preschoolers' symbolic play during dyadic and triadic play interactions. Boys' play contained more aggressive themes, and girls' contained more nurturing themes. Mothers displayed more caring themes during play with both sons and daughters, and fathers displayed more repair and construction themes. Mothers' and fathers' facilitative- creative interaction style in dyadic play predicted the level of the child's symbolic play. Co-parenting style marked by cooperation and autonomy predicted symbolic play during a triadic family session. Child intelligence predicted symbolic play beyond the parent's style during triadic but not dyadic interactions. The findings have implications for early intervention directed at increasing symbolic play in young children.

Adult↗
PubMed2005

Aortic root infection in a prosthetic valve demonstrated by gallium-67 citrate SPECT.

A 70-year-old man presented with 6 weeks of worsening low back pain, fever, sweating, and weight loss with known severe lumbosacral osteoarthritis. His history included CABG in 1992, porcine aortic valve replacement, and permanent pacemaker implantation in 2002. CT of the chest, abdomen, and pelvis did not demonstrate a cause for the symptoms. Blood cultures grew penicillin-sensitive enterococcus and he was referred for evaluation of possible osteodiskitis or epidural abscess. Gallium planar imaging demonstrated increased activity in the lumbar spine, suspicious for the presence of infection, and activity was noted in the mid mediastinum as well. SPECT clearly showed increased Ga-67 activity in the region of the aortic root, suspicious for infection. A perivalvular aortic root abscess was subsequently demonstrated by transesophageal echo. This case illustrates the value of Ga-67 chest SPECT in patients with prosthetic valves for detection of endocarditis.

Aged↗
PubMed2005

Outcomes of electrically stimulated gracilis neosphincter surgery.

OBJECTIVES: To examine patient quality of life (QoL) and long-term costs of electrically stimulated gracilis neosphincter surgery (ESGNS). DESIGN: Independently conducted prospective case-comparison study of patients at the Royal London Hospital (RLH), plus a cross-sectional study of outcomes of ESGNS performed at three other UK centres. PARTICIPANTS: Cases were patients who underwent ESGNS at the participating hospitals during a 5-year period from 1977. Comparisons were made with two groups of people with similar bowel disorders who did not undergo ESGNS. INTERVENTION: ESGNS is a procedure designed to improve bowel function for people living with severe faecal incontinence or stomas. It involves transposition of the gracilis muscle to form a neo-anal sphincter. The transposed muscle is electrically stimulated via an electronic pulse generator implanted beneath the skin of the abdomen. MAIN OUTCOME MEASURES: Clinical success and symptomatic outcomes of surgery. Generic, domain and condition specific measures of QoL. Comparative costs to the NHS of ESGNS and conventional alternatives. RESULTS: At 3 years after surgery approximately three-quarters of patients still had functioning neosphincters. At this stage, bowel-related QoL and continence improved by more than 20% for nearly two-thirds of RLH patients. However, ongoing bowel evacuation difficulties occurred in half of those with good continence outcomes. QoL improvements were maintained in the smaller group of RLH patients who had reached 4 and 5 years of follow-up, although at this stage the proportion with failed neosphincters had increased. The RLH findings were supported by those from the three other UK centres. No significant changes in QoL were observed in the comparison groups during the follow-up period. The mean cost of patient care at RLH, was 23,253 pounds. In the other three centres, the estimated mean cost of the intervention per patient was 11,731 pounds, reflecting fewer planned operations and repeat admissions. Costs of patient care for those with stomas who did not undergo ESGNS were estimated at 2125 pounds per patient-year and for those who remained with severe faecal incontinence, 442 pounds per patient-year. For patients with prior faecal incontinence, a decision to refer to ESGNS resulted in a cost-effectiveness ratio, estimated over 25 years of follow-up, of between 30,000 pounds and 40,000 pounds per quality-adjusted life-year (QALY) gained, depending on centre. The choice of stoma for these patients resulted in a slightly higher cost than ESGNS. For those with prior stoma, referral to ESGNS resulted in a cost-effectiveness ratio of between 5000 pounds and 15,000 pounds per QALY gained, depending on the centre. Cost-effectiveness ratios of around 30,000 pounds per QALY gained are generally regarded to be reasonably attractive in the UK NHS context. CONCLUSIONS: Although ESGNS is a major procedure associated with a high rate of long-term failure and bowel evacuation difficulty, it could be considered as an option at the extreme end of the treatment spectrum for refractory faecal incontinence. A strategy to refer patients for ESGNS would be regarded as cost-effective for patients already with stoma, whilst on the margin of cost-effectiveness for patients initially being managed conservatively.

Anal Canal↗
PubMed2004

Primary parental preoccupation: circuits, genes, and the crucial role of the environment.

Parental caregiving includes a set of highly conserved behaviors and mental states that may reflect both an individual's genetic endowment and the early experience of being cared for as a child. This review first examines the mental and behavioral elements of early parental caregiving in humans. Second, we consider what is known about the neurobiological substrates of maternal behaviors in mammalian species including some limited human data. Third, we briefly review the evidence that specific genes encode proteins that are crucial for the development of the neural substrates that underlie specific features of maternal behavior. Fourth, we review the emerging literature on the "programming" role of the intrauterine environment and postnatal caregiving environment in shaping subsequent maternal behavior. We conclude that there are critical developmental windows during which the genetically determined microcircuitry of key limbic-hypothalamic-midbrain structures are susceptible to early environmental influences and that these influences powerfully shape an individual's responsivity to psychosocial stressors and their resiliency or vulnerability to various forms of human psychopathology later in life.

Environment↗
PubMed2003

Neuronal control of heart rate in isolated mouse atria.

A novel mouse isolated atrial preparation with intact postganglionic autonomic innervation was used to investigate the neuronal control of heart rate. To establish whether autonomic activation was likely to alter heart rate by modulating the hyperpolarization-activated current (If), the L-type Ca2+ current (ICa,L), or the ACh-activated K+ current (IK,ACh), the effects of nerve stimulation (right stellate ganglion or right vagus, 1-30 Hz) and autonomic agonists (0.1 microM norepinephrine or 0.3 microM carbachol) on heart rate were investigated in the presence of inhibitors of these currents, cesium chloride (Cs+, 1 mM), nifedipine (200 nM), and barium chloride (Ba2+, 0.1 mM), respectively. The positive chronotropic response to stellate ganglion stimulation was reduced by approximately 20% with Cs+ and nifedipine (P < 0.05), whereas the heart rate response to norepinephrine was only reduced with Cs+ (P < 0.05). Ba2+ attenuated the decrease in heart rate with vagal stimulation and carbachol by approximately 60% (P < 0.05). These results are consistent with the idea that sympathetic nerve stimulation modulates If to increase heart rate in the mouse. Activation of ICa,L also appears to contribute to the sympathetic heart rate response. However, the decrease in heart rate with vagal stimulation or carbachol is likely to result primarily from the activation of IK,ACh.

Animals↗
PubMed2003

The possible macrophage role in seminal fluid.

The present report was designed to study the macrophage role and their association with percentage of spermatozoa showing DNA native, morphologically normal sperm and occurrence of antibody-coated spermatozoa. Human sperm samples from 31 patients were used in this study. All samples were evaluated for standard semen parameters according to World Health Organization criteria. The sperm heads with abnormal versus normal chromatin structure were specified as orange-red versus green by Acridine Orange method. Macrophage concentration was assessed with Neutral Red in Neubauer hemocytometer. The technique for the determination of sperm bound antisperm antibodies was sperm mixed antiglobulin reaction. In our study the presence of antisperm antibodies in associated to macrophages concentration (p < 0.05). The log of phagocytic cells were highly correlated with an increase of spermatozoa showing DNA denaturation (p < 0.05). The log of phagocytic cells were highly correlated with an increase of spermatozoa showing DNA denaturation (p < 0.05). There isn't significative association between the log macrophage concentration and morphologically normal sperm (p: 0.414). Thus, the present study further emphasizes the importance of immunosurveillance of the macrophages, and the contribution at the semen quality for the success of the fertilization.

Acridine Orange↗
PubMed2001

The QUinapril Ischemic Event Trial (QUIET): evaluation of chronic ACE inhibitor therapy in patients with ischemic heart disease and preserved left ventricular function.

Angiotensin-converting enzyme inhibitors improve endothelial function, inhibit experimental atherogenesis, and decrease ischemic events. The Quinapril Ischemic Event Trial was designed to test the hypothesis that quinapril 20 mg/day would reduce ischemic events (the occurrence of cardiac death, resuscitated cardiac arrest, nonfatal myocardial infarction, coronary artery bypass grafting, coronary angioplasty, or hospitalization for angina pectoris) and the angiographic progression of coronary artery disease in patients without systolic left ventricular dysfunction. A total of 1,750 patients were randomized to quinapril 20 mg/day or placebo and followed a mean of 27 +/- 0.3 months. The 38% incidence of ischemic events was similar for both groups (RR 1.04; 95% confidence interval 0.89 to 1.22; p = 0.6). There was also no significant difference in the incidence of patients having angiographic progression of coronary disease (p = 0.71). The rate of development of new coronary lesions was also similar in both groups (p = 0.35). However, there was a difference in the incidence of angioplasty for new (previously unintervened) vessels (p = 0.018). Quinapril was well tolerated in patients after angioplasty with normal left ventricular function. Quinapril 20 mg did not significantly affect the overall frequency of clinical outcomes or the progression of coronary atherosclerosis. However, the absence of the demonstrable effect of quinapril may be due to several limitations in study design.

Adult↗
PubMed2001

Do HMOs have monopsony power?

OBJECTIVE: To determine whether health maintenance organizations (HMOs) have monopsony power in the markets for ambulatory care and inpatient hospital services. DATA SOURCES: A pooled time-series of data on all HMOs operating in the United States from 1985 through 1997. Information reported to InterStudy on HMO market areas and enrollment is linked to financial data reported to state regulators and county characteristics from the Area Resource File (ARF). STUDY DESIGN: We use a two-stage design to test for the existence of monopsony power. First, we estimate regression equations for the prices paid by HMOs for ambulatory visits and inpatient hospital days. The key independent variable is a measure of the importance of an individual HMO as a buyer of ambulatory care or hospital services. Second, we estimate regressions for the utilization of ambulatory visits and inpatient hospital days per HMO enrollee, as a function of HMO buying power and other variables. PRINCIPAL FINDINGS: Increased HMO buying power is associated with lower price and higher utilization of hospital services. Buying power is not related to ambulatory visit price or utilization per member. CONCLUSIONS: Our findings are not consistent with the monopsony hypothesis. They suggest that managed care organizations have contributed to a welfare-increasing breakup of hospital monopoly power. The role of HMOs as buyers of ambulatory services is more complex. We discuss possible reasons why buying power may not affect price or utilization of ambulatory visits.

Ambulatory Care↗
PubMed2001

Cultural perspective on work and family: dual-earner Israeli-Jewish and Arab families at the transition to parenthood.

Parents' functioning in the work and family roles was examined in traditional and modern societies at the transition to parenthood. Participants were 162 dual-earner Israeli-Jewish and Arab families, who were interviewed and observed in dyadic and triadic interactions. Arab parents reported better adaptation to work following the first childbirth, and the triadic family process in Jewish families was more cohesive. Child care arrangements, part-time employment, easier infant temperament, and lower separation anxiety predicted maternal readaptation to work. Traditional sex-role attitudes, career centrality, full-time employment, and marital satisfaction predicted fathers' work adaptation. Parents' family focus, marital satisfaction, and responsive parenting correlated with a cohesive triadic process. Discussion considered the impact of nuclear- and extended-family living arrangements on the emerging work and family roles in young couples.

Adult↗
PubMed2001

Diagnoses and interactive patterns of infants referred to a community-based infant mental health clinic.

OBJECTIVES: To describe the distribution of symptoms and diagnoses in a community-based infant mental health clinic and to compare play and feeding interactions of referred and nonreferred infants. METHOD: The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC 0-3) was used to diagnose 113 referred infants (60% were boys). Thirty additional dyads were matched with 30 nonreferred dyads. Feeding, play interactions, and home environment were compared. RESULTS: Two peaks of referral were found: 0 to 6 and 12 to 18 months. The main reasons for referral were eating problems, sleep problems, aggressive behavior, irritability, and maternal depression. The most common DC 0-3 diagnosis was a combination of primary infant disorder, parent-child relationship disorder, and parental psychopathology. Mothers of referred children provided lower levels of sensitivity, support, and structuring of the interaction, and less optimal home environment. The dyadic relationship showed a lower degree of mutuality and higher negative exchanges. Feeding interactions elicited more negative interactions than play. CONCLUSIONS: Infants referred by community health workers showed less optimal mother-infant interactions and had less optimal environment, compared with nonreferred dyads. Symptoms of emotional distress in infancy are best apprehended when assessed in multi-institutional contexts and formulated in a multiaxial approach.

Affective Symptoms↗
PubMed2001

Diatheses and stressors in borderline pathology of childhood: the role of neuropsychological risk and trauma.

OBJECTIVE: To determine the relative contributions of neuropsychological deficits and psychosocial stressors to the presence of borderline pathology in children. METHOD: The subjects were 86 school-age children (75 males, 11 females) referred for psychiatric day treatment. Thirty-five of the children met criteria for borderline pathology. Data on psychosocial risk factors were obtained for each child from a questionnaire completed by members of the child's clinical team and were based on interviews with parents and children, as well as reports from schools and social agencies. Neuropsychological measures included computerized versions of the Wisconsin Card Sorting Test and the Continuous Performance Test. RESULTS: Both deficits in executive function and psychological trauma made significant and independent contributions to the variance in borderline pathology. Inclusion of both sets of risk factors produced a model that explained 48% of the variance in borderline diagnosis. CONCLUSIONS: Both environmental risks and neurobiological vulnerability should be taken into account to understand the etiology of borderline pathology in children.

Borderline Personality Disorder↗
PubMed2001

Who uses flexible spending accounts: effects of employee characteristics and employer strategies.

BACKGROUND: Many large employers offer flexible spending accounts (FSAs) to shelter their employees' out-of-pocket medical expenses from taxes and thereby to encourage the purchase of health insurance policies with higher cost sharing. However, very little empirical research has examined the individual employee's decision to contribute to an FSA. OBJECTIVES: To estimate equations for the probability that single employees with no dependents and employees with family health insurance coverage will contribute to FSAs, and the amounts contributed by those with FSAs. RESEARCH DESIGN: An observational study of randomly-selected employees in 15 Minnesota firms matched with information on the strategies those firms use to promote FSAs. Measures of FSA participation were regressed on expected health care spending, employee socio-demographics, and employer strategies. SUBJECTS: 779 single employees with no dependents and 679 employees with family coverage. RESULTS: Education beyond high school increases the probability that both types of subjects will contribute to FSAs, with marginal effects ranging from 16 to 48 percent. The FSA contribution rate for families doubles when the family's marginal federal income tax rate increases from 15 to 28 percent. Employer strategies to encourage participation are also effective in promoting FSAs. CONCLUSIONS: FSAs are used mainly by high-income and highly-educated workers. We question whether this is an equitable use of the income tax code.

Choice Behavior↗
PubMed2001

Pfiesteria: review of the science and identification of research gaps. Report for the National Center for Environmental Health, Centers for Disease Control and Prevention.

In connection with the CDC National Conference on Pfiesteria, a multidisciplinary panel evaluated Pfiesteria-related research. The panel set out what was known and what was not known about adverse effects of the organism on estuarine ecology, fish, and human health; assessed the methods used in Pfiesteria research; and offered suggestions to address data gaps. The panel's expertise covered dinoflagellate ecology; fish pathology and toxicology; laboratory measurement of toxins, epidemiology, and neurology. The panel evaluated peer-reviewed and non-peer-reviewed literature available through June 2000 in a systematic conceptual framework that moved from the source of exposure, through exposure research and dose, to human health effects. Substantial uncertainties remain throughout the conceptual framework the panel used to guide its evaluation. Firm evidence demonstrates that Pfiesteria is toxic to fish, but the specific toxin has not been isolated or characterized. Laboratory and field evidence indicate that the organism has a complex life cycle. The consequences of human exposure to Pfiesteria toxin and the magnitude of the human health problem remain obscure. The patchwork of approaches used in clinical evaluation and surrogate measures of exposure to the toxin are major limitations of this work. To protect public health, the panel suggests that priority be given research that will provide better insight into the effects of Pfiesteria on human health. Key gaps include the identity and mechanism of action of the toxin(s), the incomplete description of effects of exposure in invertebrates, fish, and humans, and the nature and extent of exposures that place people at risk.

Animals↗
PubMed2001

A demand-side view of risk adjustment.

This paper analyzes the efficient allocation of consumers to health plans. Specifically, we address the question of why employers that offer multiple health plans often make larger contributions to the premiums of the high-cost plans. Our perspective is that the subsidy for high-cost plans represents a form of demand-side risk adjustment that improves efficiency. Without such subsidies (and in the absence of formal risk adjustment), too few employees would choose the high-cost plans preferred by high-risk workers. We test the theory by estimating a model of the employer premium subsidy, using data from a survey of large public employers in 1994. Our empirical analysis shows that employers are more likely to subsidize high-cost plans when the benefits of risk adjustment are greater. The findings suggest that the premium subsidy can accomplish some of the benefits of formal risk adjustment.

Community Participation↗
PubMed2001

Disenrollment from Medicare HMOs.

BACKGROUND: Since the program's inception, there has been great interest in determining whether beneficiaries who enter and subsequently leave Medicare health maintenance organizations (HMOs) are more or less costly than those remaining in fee-for-service (FFS) Medicare. OBJECTIVES: To examine whether relatively high-cost beneficiaries disenroll from Medicare HMOs (disenrollment bias) and whether disenrollment bias varies by Medicare HMO market characteristics. In addition, we compare rates of surgical procedures and hospitalizations for ambulatory care-sensitive conditions for disenrollees and continuing FFS beneficiaries. DESIGN: Cross-sectional analysis of 1994 Medicare data. PARTICIPANTS AND METHODS: Medicare beneficiaries were first sampled from the 124 counties with at least 1000 Medicare HMO enrollees. From this pool, HMO disenrollees and a sample of continuing FFS beneficiaries were drawn. The FFS beneficiaries were assigned dates of "pseudodisenrollment." Expenditures and inpatient service use were compared for 6 months after disenrollment or pseudodisenrollment. RESULTS: The HMO disenrollees were no more likely than the continuing FFS beneficiaries to have positive total expenditures (Part A plus Part B) or Part B expenditures in the first 6 months after disenrollment. However, disenrollees were more likely to have Part A expenditures. Among beneficiaries with spending, disenrollees had higher total and Part B expenditures than continuing FFS beneficiaries. Moreover, the disparity in total and Part B spending between disenrollees and continuing FFS beneficiaries increased with HMO market penetration. Although Part A spending was higher for disenrollees with spending, it was not sensitive to changes in market share. The HMO disenrollees received more surgical procedures and were hospitalized for more of the ambulatory care-sensitive conditions than the FFS beneficiaries. CONCLUSIONS: On several measures, Medicare HMOs experienced favorable disenrollment relative to continuing FFS beneficiaries as recently as 1994, which increased as HMO market share increased.

Aged↗