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PubMed2004

Penetrating the "black box": financial incentives for enhancing the quality of physician services.

This article addresses the impact of financial incentives on physician behavior, focusing on quality of care. Changing market conditions, evolving social forces, and continuing organizational evolution in health services have raised societal awareness and expectations concerning quality. This article proceeds in four parts. First, the authors place financial incentives in the context of broader forces shaping the quality of physician services. Second, the article reviews the literature on financial incentive effects on physician behavior. Third, a simple net income maximization model of physician choices is presented, from which are derived formal hypotheses regarding the effect of financial incentives on physician choices of quality per unit of physician service and the quantity of services per patient. The model is extended qualitatively to offer further hypotheses and research directions. Finally, gaps and limitations of the model and of the extant empirical research are articulated, and additional researchable questions are posed.

Attitude of Health Personnel↗
PubMed2025

Diffusely metastatic glioblastoma with FGFR3::TACC3 fusion: cell-free DNA fragmentation analyses and molecular characterization of matched primary and metastatic tumor sites.

Extracranial metastasis of IDH-wildtype glioblastoma is very rare and poorly understood at the molecular level. We report a case of FGFR3::TACC3 fusion IDH-wildtype glioblastoma in a 61-year-old male, whose preoperative blood sample showed highly aberrant cfDNA fragmentation patterns, which could be suggestive of early systemic dissemination, undetected by standard-of-care imaging of his body. Eleven months post-resection and adjuvant therapy, he developed widespread extracranial metastases. Comprehensive molecular profiling of matched primary and metastatic tumors revealed broadly conserved genomic, transcriptomic, and copy number landscapes, with the metastasis harboring an additional ERCC6 deletion and enriched expression of receptor tyrosine kinase signaling genes. These findings provide rare insight into the genetic continuity and evolution underlying IDH-wildtype glioblastoma metastasis.

Humans↗
PubMed2005

Pharmacogenomics and clinical biomarkers in drug discovery and development.

The fields of pathology and clinical pharmacology are in an era of rapid evolution, reflecting continuous technological advancements in molecular diagnostics focused on improving drug efficacy and reducing toxicity. The discovery and refinement of the human genome sequence, further understanding of epigenetic events, and the expansion of proteomics research combined with emerging technologies such as functional imaging, biosensors, and sophisticated computational biology are having an unprecedented impact on the pharmaceutical industry. This review focuses on the discovery and development of DNA-based gene sequence tests and RNA-based gene expression profiles as applied to the prediction of response, resistance, and toxicity of both new and existing anticancer, cardiovascular, and anti-inflammatory drugs. This review will also consider the potential of emerging biomarkers designed to assist in the clinical development of these agents.

Biomarkers↗
PubMed1997

Programmed cell death in prokaryotes.

Programmed cell death (PCD), also referred to as apoptosis, is a cellular "suicide" mechanism, based on information from its own internal metabolism, environment, developmental history, and genome. This system was described in eukaryotes continuously along evolution, through amoebae, nematodes, insects, and animals. PCD is essential for the proper development or function of a cell system, organ, or survival of the organism as a whole. Research in the last 2 decades has shown that the life cycle of several prokaryotic organisms display developmental programs, similar to metazoan differentiation, that is part of their adaptation to stressful environments. These include warmer cell formation and differentiation in Caulobacter cereus, sporulation in Bacillus and Streptomyces, heterocyst formation in Anabaena, development of bacteroids in Rhizobium, the formation of multicellular fruiting bodies and sporulation in Myxobacteria, and the formation of nonculturable, but viable, cells in various Gram-negative bacteria. Moreover, and more significantly, the photosynthetic bacteria Rhodobacter capsulatus were shown to release nucleoprotein particles designated "gene transfer agent (GTA)" as they enter the stationary phase. GTAs contain DNA of 3.6 x 10(6) molecular weight, representing all parts of the genome, and they may be taken up by other strains of R. capsulatus, and complement mutants. We postulate that these various modes of stress adaptations in bacteria are prokaryotic manifestation, and possibly the phylogenetic precursor, of the eukaryotic phenomenon, programmed cell death, and therefore we propose to designate it "proapoptosis". In addition to their function, apoptosis and proapoptosis share various mechanistic programmed features, including DNA fragmentation and packaging, cell shrinkage, degradation of RNA, proteolysis and synthesis of new proteins, and the involvement of reactive oxygen species.

Apoptosis↗
PubMed2000

Leukemia relapse reconsidered from the molecular aspect.

Relapse, a major obstacle in the treatment of acute leukemia, is essentially caused by re-growth of residual leukemia cells, frequently accompanied by resistance to chemotherapy. Comparative studies of clones both at initial diagnosis and at subsequent relapse have indicated that phenotype and karyotype are frequently changed at relapse. This can be recognized as the result of negative selection by chemotherapy in a heterogeneous population. Furthermore, complex molecular alterations that include the loss of as well as the acquisition of mutations are noticed by comparing multiple genes associated with leukemia, suggesting a continuous genetic evolution. Studies on leukemia relapse have thus served as a model of clonal progression, which can be serially observed, including selection by chemotherapy, induction of resistant phenotype, and genetic alteration.

Antineoplastic Agents↗
PubMedDate not supplied

Cancer therapy--the 21st century.

This century has seen a dramatic increase in the modalities available to prevent, control, or cure cancer. Dr. Rosenthal, Professor of Medicine at Harvard Medical School, reflects on the progress in cancer management made in the 20th century and predicts a continuing rapid evolution for the 21st century.

Humans↗
PubMed1999

[Laparoscopy and hysteroscopy in Müllerian duct malformations: usefulness and reproductive results].

Determine the type and the possibility of corrective surgery, reproductive results of infertility patients with Müllerian malformations. The clinic and the laparoscopic and hysteroscopic evaluation were performed to 40 patients with Müllerian anomalies and infertility history analyzing the reproductive results. The uterine septum was present in 23/40 patients (57.5%), bicornual uterus in 6/40 (15%), didelfus uterus 5/40 (12.5%), arcuate uterus 4/40 (10%), unicorn uterus 2/40 (5%). After septum resection we had 13 pregnancies (56.5%). 2 abortions, 4 already delivered and 7 continue normal evolution with on twin case. Strassman metroplasty by laparotomy was performed in 4 cases of bicornual uterus achieving pregnancy in two cases. In one didelfus uterus, a salpingoclasy of the smaller horn was done as an alternative. Of the arcuated uterus, the small septum was removed. Of the unicorn uterus, one pregnancy was lost in the first trimester and the other one reach the term date. Our data show that the endoscopic procedures can perform the correct diagnosis of the Müllerian anomalies and of course the best surgical treatment improving the fertility rates.

Female↗
PubMed1992

The future for healthcare capital investments.

Hospitals have entered into a new era of capital planning. A number of factors will influence hospital buying behavior now that the Medicare capital regulations are being implemented. As purchasing responsibility for additional departments is continually folded into hospitals' central purchasing function there will be increased opportunities for group contracts. As resources shrink and demand for services increases, GPOs will be relied upon for their expertise and financial finesse. The emphasis will be on boosting the use of group contracts among existing members, rather then seeking additional members in a shrinking hospital market. Through effective purchasing, it is generally recognized that a hospital can recover and keep, at best, 5-10 percent of the cost of all purchased goods and services. Group purchasing organizations need to develop better strategies of cooperation with vendors, distributors and hospitals to help providers control capital costs. In this challenging environment, GPOs will aggressively target markets other than acute care as the source of their future growth, just as healthcare facilities are branching out. To accommodate changing needs, the strongest GPOs will continue their evolution into structures more like alliances, offering an array of other cooperative and support programs beyond the purchase of goods and services.

Capital Expenditures↗
PubMed1984

Health education: perspective for PAs.

Health Education is a valid part of the PA's armamentarium which should be developed to maintain pace with the continuing role evolution of PAs. The Health Belief Model is useful as a means of understanding how patients are motivated to accept health-promoting behavioral and life-style changes. The PA, according to his or her own unique interests, experience, and ingenuity, must develop plans and methods for implementation of specific interventions, but the five priority actions delineated by the Surgeon General can serve as a basis. These include the areas of smoking cessation, alcohol and drug management, nutritional guidance, and the management of psychosocial stress. The authors provide a table of references in these areas.

Health Education↗
PubMedDate not supplied

[Echography in minimally invasive surgery].

Thanks to the great development of laparoscopic surgery and his continuous technical evolution, echography plays more and more important role in the pre- and intraoperative diagnosis. In the hepato-pancreatic pathology the use of the laparoscopic echography reduces clearly the role of laparotomic exploration. In laparoscopic surgery of rectal-colon, the echography is more specific and sensitive in compared with pre-operative MR and CT to individualize liver metastasis, to locate them. This allows the treatment of such lesions through the cryosurgery. In pancreatic lesions such method plays a non releasable role in tumors staging, giving essential elements to the surgeon to operate and for a better definition of operative strategy. Also in the adrenal masses surgery, laparoscopic echography reveals very useful especially in the anatomical structures identification (i.e. renal vein and entrance of the left adrenal vein) in the patients already operated or obese. In the preoperative study of rectal tumors the use of rotating and transrectal probes allows to define the degree of infiltration of the lesion and to perform a mini-invasive treatment through endoscopic transanal microsurgery with the radiochemotherapy. Thus echography in mini-invasive surgery has an unreplaceable role both in diagnosis as in evaluation of the parameter of therapeutical approach.

Adrenal Gland Neoplasms↗
PubMed2001

The only thing certain: large changes lurk for case management's future.

The question has never been whether health care will change. Its evolution is continual, and predictions about its future often are about as accurate as 1930s science fiction. Even so, several trends already have emerged that some experts claim provide an interesting glimpse of what's to come--both in case management and in the industry at large.

Aged↗
PubMed1994

[A comparative analysis of two historical approaches to the formation of the modern clinical medicine].

From the perspective of research methodology, it may be said to exist two kinds of different historical approaches with regards to the formation of modern clinical medicine at the turn of the nineteenth century. One is to explain this in terms of the agency or structure that is associated with research topic. This historical view assumes that the Western scientific rationalism is characterized by the unity of Western tradition and its evolution as continuity. Its main focus is given either on how French revolution and war affected the growth of clinical medicine and the hospital reform movement or on how Paris Clinical School contributed to the birth of modern clinical medicine. The other is, according to Michel Foucault, to analyze how medical discourses are related to social (institutional) practices. Following Canguilhem's history of concepts, Foucault traces the historical development of the concept of disease. Elizabeth A Williams, another proponent of this method, conceptualizes the eighteenth-century medicine as three different medical discourses--anthropology, physiology and philosophical medicine, and analyzes how their structural fragmentation were transformed into the modern establishment of clinical medicine in the nineteenth century. ...

Clinical Medicine↗
PubMedDate not supplied

Asthma pathophysiology and the scientific rationale for combination therapy.

The clinical and scientific description of asthma has been undergoing an evolution of continuous revision during the past 10 years. This disorder has been recognized as a complex entity with interplay between genetic, environmental, and allergenic factors resulting in a significant component of inflammation of the airway. Recent directions in therapy differ in taking either the broad-based antagonist or the specific mediator antagonist approach. This review highlights some of the scientific evidence of the operative pathophysiological events and reviews their applicability to the rationale for broad-based combination asthma therapy.

Asthma↗
PubMed1992

The surgical management of osseous defects associated with endosteal hydroxyapatite-coated and titanium dental implants.

As more and more patients choose implant therapies it will be incumbent upon the dentists placing, restoring, and maintaining endosseous implants to be armed with the most current information. There is a need for further research to answer the many significant questions in the management of osseous defects associated with dental implants. Some of these questions include: Which grafting materials yield the greatest repair? If resorbable materials (for example, DFDB) are not replaced by bone, are residual defects and peri-implant tissues similar to those which existed prior to osseous grafting procedures? If so, perhaps the combination of a nonresorbable graft like HA with DFDB may yield the wound-healing potential of both materials; for example, osseoinduction by DFDB and the benefits of a radiographic marker and defect filler provided by HA. Can reintegration occur on previously pathologically exposed implant surfaces? Do biodegradable barriers yield significant GTR, and do they resorb predictably? Is complete detoxification of the infected HA-coated surface possible or necessary for regeneration to occur? Which chemotherapeutic modality detoxifies HA-coated surfaces best clinically and at the histologic level? Or should infected HA coatings be removed before attempting implant repair? Are regenerative techniques (for example, GTR) predictable enough to treatment plan for them when we know there will be residual osseous defects after placing fixtures in their most ideal prosthetic position? If so, what defect types resolve most predictably following surgical correction? Should barriers be used in conjunction with grafting when placing 2-stage blade implants to generate bone in the slot preparation coronal to the shoulder of the blade? It is evident from the growing popularity and acceptance of implant therapies that these and other questions will need to be answered to continue the evolution of the science of this discipline. This author would encourage practitioners to keep abreast of the current research and developments in this field as new techniques, materials, and therapies are in a constant state of flux.

Alveolar Bone Loss↗
PubMed2006

Changing physician prescribing behaviour.

Didactic approaches to educating physicians and/or other health professionals do not produce changes in learner behaviour. Similarly, printed materials and practice guidelines have not been shown to change prescribing behaviour. Evidence-based educational approaches that do have an impact on provider behaviour include: teaching aimed at identified learning needs; interactive educational activities; sequenced and multifaceted interventions; enabling tools such as patient education programs, flow charts, and reminders; educational outreach or academic detailing; and audit and feedback to prescribers. Dr. Jean Gray reflects over the past 25 years on how there has been a transformation in the types of activities employed to improve prescribing practices in Nova Scotia. The evolution of Continuing Medical Education (CME) has resulted in the creation of the Drug Evaluation Alliance of Nova Scotia (DEANS) program, which is one exemplar of an evidence-based educational approach to improving physician prescribing in that province. Key words: Evidence-based, education, prescribing.

Drug Prescriptions↗
PubMed2006

[Gastric cancer and Helicobacter pylori: an interdisciplinary point of view].

Gastric carcinogenesis involves a slow but continuous, stepwise evolution from superficial gastritis to glandular atrophy, metaplasia, dysplasia, and finally, to adenocarcinoma. In 1994, the International Agency for Research on Cancer defined Helicobacter pylori (H. pylori) as a group I carcinogen. Evidence supporting a causal association has been demonstrated by epidemiological data as well as by experimental animal models. The process of carcinogenesis, which may well extend over decades, provides an excellent opportunity for prevention or early detection of the events preceding development of the neoplasm. This is especially true because, at present, H. pylori can be readily treated. Despite this, the prognosis for gastric cancer is poor and, in most industrialised countries, the survival is only 10% after 5 years from diagnosis. The sole exception is Japan where this malignancy is often identified at an early stage when cure by radical surgery is more probable.

Adenocarcinoma↗
PubMedDate not supplied

New diagnostic and screening possibilities in the stenobliterative lesions of the deep visceral vessels.

The evolution and continuous improvement of the ultrasonic diagnostic devices allows an hemodynamic and morphological exploration of the deep abdominal vessels that until now seemed to be precluded to non invasive diagnostic techniques. For example, the angiodynography today advantageously substitutes classical urographic investigation during the initial screening of the hypertensive patients suspected of stenotic lesions of the renal arteries. In fact the ecocolordopplersonography allows not only a morphological evaluation of the parenchyma and of the renal vascular tree, but also supplies a quantitative measurement of the blood flow through the renal artery. Still more important are the possibilities offered by these devices in the study of the acute or chronic intestinal ischemia, in which until now a sure diagnosis was only possible using invasive techniques. Performing a study of the mesenteric vascularization urgently, sometimes is possible a decisive demonstration of an ischemic pathology where the clinical abdominal picture provides only uncertain diagnostic elements.

Abdomen↗