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Identifying prenatal environmental factors that have genuinely causal effects on psychopathology is an important research priority, but it is crucial to select an appropriate research design. In this review we explain why and what sorts of designs are preferable and focus on genetically informed/sensitive designs. In the field of developmental psychopathology, causal inferences about prenatal risks have not always been based on evidence generated from appropriate designs. We focus on reported links between maternal smoking during pregnancy and offspring attention-deficit/hyperactivity disorder or conduct problems. Undertaking a systematic review of findings from genetically informed designs and “triangulating” evidence from studies with different patterns of bias, we conclude that at present findings suggest it is unlikely that there is a substantial causal effect of maternal smoking in pregnancy on either attention-deficit/hyperactivity disorder or conduct problems. In contrast, for offspring birth weight (which serves as a positive control) findings strongly support a negative causal effect of maternal smoking in pregnancy. For maternal pregnancy stress, too few studies use genetically sensitive designs to draw firm conclusions, but continuity with postnatal stress seems important. We highlight the importance of moving beyond observational designs, for systematic evaluation of the breadth of available evidence and choosing innovative designs. We conclude that a broader set of prenatal risk factors should be examined, including those relevant in low- and middle-income contexts. Future directions include a greater use of molecular genetically informed designs such as Mendelian randomization to test causal hypotheses about prenatal exposure and offspring outcome.
Integration in health care is a key goal of health reform in United States and England. Yet past efforts in the 1990s to better integrate the delivery system were of limited success. Building on work by Bevan and Janus on delivery integration, this article explores integration through the lens of economic theories of integration. Firms generally integrate to increase efficiency through economies of scale, to improve their market power, and resolve the transaction costs involved with multiple external suppliers. Using the United States and England as laboratories, we apply concepts of economic integration to understand why integration does or does not occur in health care, and whether expectations of integrating different kinds of providers (hospital, primary care) and health and social services are realistic. Current enthusiasm for a more integrated health care system expands the scope of integration to include social services in England, but retains the focus on health care in the United States. We find mixed applicability of economic theories of integration. Economies of scale have not played a significant role in stimulating integration in both countries. Managerial incentives for monopoly or oligopoly may be more compelling in the United States, since hospitals seek higher prices and more leverage over payers. In both countries the concept of transaction costs could explain the success of new payment and budgeting methods, since health care integration ultimately requires resolving transaction costs across different delivery organizations.
To assess the strength of the relationships between serum carotenoids and three self-reported dietary intake instruments often used to characterize carotenoid intake in studies of diet and disease.
Participants completed a Diet History Questionnaire (DHQ), two 24 h dietary recalls (24HR), a fruit and vegetable screener and a fasting blood draw. We derived dietary intake estimates of α-carotene, β-carotene, cryptoxanthin, lutein, zeaxanthin and lycopene from each diet instrument and calculated sex-specific multivariate correlations between dietary intake estimates and their corresponding serum values.
Montgomery County, Maryland, USA.
Four hundred and seventy women and men aged 40–69 years in the National Cancer Institute's Observing Protein and Energy Nutrition (OPEN) Study.
Serum carotenoids correlated more strongly with the DHQ (r = 0·34–0·54 for women; r = 0·38–0·56 for men) than with the average of two recalls (r = 0·26–0·47 for women; r = 0·26–0·40 for men) with the exception of zeaxanthin, for which the correlations using recalls were higher. With adjustment for within-person variation, correlations between serum carotenoids and recalls were greatly improved (r = 0·38–0·83 for women; r = 0·42–0·74 for men). In most cases, correlations between serum carotenoids and the fruit and vegetable screener resembled serum–DHQ correlations.
Evidence from the study provides support for the use of the DHQ, a fruit and vegetable screener and deattenuated recalls for estimating carotenoid status in studies without serum measures, and draws attention to the importance of adjusting for intra-individual variability when using recalls to estimate carotenoid values.
In a relatively short time, regulation has become a significant and distinct feature of how modern states wish to govern and steer their economy and society. Whereas the former ‘dirigiste’ state used to be closely related to public ownership (e.g. hospitals), planning (volume and capacity planning) and centralised administration (e.g. fixed prices and budgets), the new regulatory state relies mainly on the instrument of regulation to achieve its objectives. In this paper, we wish to relate the rise of the ‘regulatory state’ to the path-dependent trajectories and institutional legacies of discrete European health-care systems. For this purpose, we compared the Dutch corporatist social health insurance system, the strongly centralised National Health Service (NHS) of England and federal regionalised NHS system of Italy. Comparing these three different health-care systems suggests that it is indeed possible to identify a general trend towards the rise of the regulatory state in health care in the last two decades. However, although the three countries examined in this paper face similar problems of multilevel governance of networks of third-party payers and providers, each system also gives rise to its own distinct regulatory challenges.
This article presents a cross-national analytical framework for understanding current attempts to reform medical governance – in particular, those by third parties to control the practice of medicine. The framework pays particular attention to the ways in which institutions shape policy reform. The article also outlines the main comparative findings of case studies of selected reforms and associated processes of negotiations in Denmark, Germany, Italy and the United Kingdom. These four countries were selected because they are characterised by theoretically interesting variations in the institutional contexts of medical governance. The analysis suggests that although all the four countries have pushed for more control over the way in which doctors practise medicine, in response to similar imperatives, each country differs in the path it has taken. More specifically, the instruments and techniques brought to bear in each case vary considerably and are directed by a country's political institutions towards a unique path.
Dietary intake of long-chain n-3 PUFA has been reported to decrease several markers of lymphocyte activation and modulate monocyte susceptibility to apoptosis. However, most human studies examined the combined effect of DHA and EPA using relatively high daily amounts of n-3 PUFA. The present study investigated the effects of increasing doses of DHA added to the regular diet of human healthy volunteers on lymphocyte response to tetradecanoylphorbol acetate plus ionomycin activation, and on monocyte apoptosis induced by oxidized LDL. Eight subjects were supplemented with increasing daily doses of DHA (200, 400, 800, 1600 mg) in a TAG form containing DHA as the only PUFA, for 2 weeks each dose. DHA intake dose-dependently increased the proportion of DHA in mononuclear cell phospholipids, the augmentation being significant after 400 mg DHA/d. The tetradecanoylphorbol acetate plus ionomycin-stimulated IL-2 mRNA level started to increase after ingestion of 400 mg DHA/d, with a maximum after 800 mg intake, and was positively correlated (P < 0·003) with DHA enrichment in cell phospholipids. The treatment of monocytes by oxidized LDL before DHA supplementation drastically reduced mitochondrial membrane potential as compared with native LDL treatment. Oxidized LDL apoptotic effect was significantly attenuated after 400 mg DHA/d and the protective effect was maintained throughout the experiment, although to a lesser extent at higher doses. The present results show that supplementation of the human diet with low DHA dosages improves lymphocyte activability. It also increases monocyte resistance to oxidized LDL-induced apoptosis, which may be beneficial in the prevention of atherosclerosis.
Italy has a national health service (SSN) dating to 1978. Italy's
system of government is characterized by a rather high degree of
decentralization of power, and the health system is likewise
decentralized. Most of the responsibilities for health care have
been ceded to the regions. The state retains only limited
coordinating and supervisory powers. The state has a financial
responsibility for the national health service, but state
contributions are limited and expenditures in excess of this made by
the region must be financed from other sources. Health reforms of
1992–93 aimed at making the regions more sensitive to the need to
control aggregate expenditure and to monitor measures to promote efficiency,
quality, and citizen-patient satisfaction. The diffusion of individual
health technologies has been relatively uncontrolled in many regions
in Italy, although tight central constraints on capital spending have
contained diffusion of new technology. Regulation of placement of
services is a planning function and is the responsibility of both the
Ministry of Health and the regions. Health technology assessment
(HTA) activities have been expanding since the early 1990s, but these
activities tend to be untargeted, uncoordinated, and without
priorities. Nonetheless, the principal actors in the SSN at national,
regional, and local levels are becoming more sensitive to the need to
apply criteria of clinical and cost-effectiveness and to be more
rigorous in deciding what services to guarantee. There are reasons to
be guardedly optimistic about the future of HTA in Italy.
The accelerated aging of unplasticized Cellophane film specimens was conducted at tempe:atures ranging from 80 to 150 °C in a dry, forced-air convection oven for various periods of time. Colorimetric evaluation showed increasing discoloration which could be partially reversed by rinsing in deionized water. The infrared spectra of samples aged within this temperature range show the same changes, dependent upon aging time. This indicates that the species formed in the films at temperatures above and below the boiling point of water are the same, and that the moisture content of the films may affect the reaction rate, but not the mechanisms. The observed data in the visible region fit the standard pseudofirst-order kinetics model and are in excellent agreement with those determined for both the color change of cotton and the UV absorbance of Cellophane under similar conditions.
While otitis media is perhaps the most common disease of childhood that receives medical attention, there is little agreement concerning the efficacy of the medical and surgical therapies employed to try to alleviate its symptoms or hasten its natural resolution. Because various surgeries including adenoidectomy, myringotomy, and insertion of tympanostomy tubes are frequently involved in the treatment of otitis media with effusion (OME), it is likely the most expensive condition being managed in national terms.
In an attempt to elucidate the most appropriate management of this condition, a meta-analysis was attempted to the 12 randomized control trials of surgical treatments for OME in children, published between 1966 and 1990. Heterogeneity both in the populations and comparisons studied and in the out comes presented made meta-analysis an inappropriate method for clarifying this area of clinical uncertainty. Important elements in the design of randomized control trials that should be included in future studies of treatment for OME are therefore discussed.
Iodide glasses presently being investigated suffer from their poor glass forming abilities, thermal instabilities and general lack of chemical durability. Glasses in the Cd-As-I and Cd-As-Ge-I systems are investigated in this study for the purpose of developing water-resistant, thermally stable iodide glasses and optical fibers. Differential scanning calorimetry(DSC) showed that glasses in these systems have glass transition temperature(Tg) values above 300°C. Devitrification of glasses during cooling and reheating can be suppressed by incorporating small amount of Ge atoms into ternary Cd-As-I glasses. They are transparent up to 14μm in the infrared region with excellent durability against liquid water at 90°C.
This article begins by sketching out the constitutional arrangements in Italy for the distribution of powers among different levels of government. The more important characteristics of the health system are then examined in some detail, the aim being to provide a sufficient basis for understanding the analysis of technology policy which follows later. The mechanisms used for funding medical technology are next described, after which data available on the diffusion of medical equipment are illustrated. Medical technology policies at the national and regional level are examined and an attempt made to appraise their effectiveness. The article concludes with a brief analysis of the possible role played by private medicine in the diffusion of medical technology in ltaly.
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