Limited Healthcare System Research Articles

Nurses' Experience with Caring for COVID-19 Patients in a Negative Pressure Room Amid the Pandemic Situation

The purpose of this study was to explore nurses' experience with caring for COVID-19 patients in a negative pressure room amid the spread of the pandemic. This study was a qualitative research, and focus group interviews were used to collect data. Three focus groups comprising 19 nurses were interviewed from February 17 to 25, 2021. All interviews were recorded and transcribed verbatim with the consent of the participants. The verbatim transcripts were scrutinized using thematic analysis. Two main themes emerged from the analysis: 'Struggling in an isolated space' and 'Limitations of nursing infrastructure and system'. The nurses caring for COVID-19 patients experienced anxiety and fear about the infection, physical exhaustion, emotional burnout, and a sense of duty as a nurse. They also acknowledged the lack of guidelines, increased task and burden, limitations of nursing care, and the demand for improving the limitations of the nursing system. The results of this study demonstrate that nurses caring for COVID-19 patients encounter physical and emotional problems within the limited healthcare system. The study suggests that comprehensive interventions are needed for nurses. Furthermore, detailed guidelines, strengthening of nursing personnel, and improvements to the nursing system are vital to effectively cope with the pandemic. The government and medical institutions should be aware of the needs of nurses and what they are going through, and make efforts to improve the quality of life of healthcare workers and create a safe healthcare environment.

Supervised Machine Learning Models for Prediction of COVID-19 Infection using Epidemiology Dataset.

COVID-19 or 2019-nCoV is no longer pandemic but rather endemic, with more than 651,247 people around world having lost their lives after contracting the disease. Currently, there is no specific treatment or cure for COVID-19, and thus living with the disease and its symptoms is inevitable. This reality has placed a massive burden on limited healthcare systems worldwide especially in the developing nations. Although neither an effective, clinically proven antiviral agents' strategy nor an approved vaccine exist to eradicate the COVID-19 pandemic, there are alternatives that may reduce the huge burden on not only limited healthcare systems but also the economic sector; the most promising include harnessing non-clinical techniques such as machine learning, data mining, deep learning and other artificial intelligence. These alternatives would facilitate diagnosis and prognosis for 2019-nCoV pandemic patients. Supervised machine learning models for COVID-19 infection were developed in this work with learning algorithms which include logistic regression, decision tree, support vector machine, naive Bayes, and artificial neutral network using epidemiology labeled dataset for positive and negative COVID-19 cases of Mexico. The correlation coefficient analysis between various dependent and independent features was carried out to determine a strength relationship between each dependent feature and independent feature of the dataset prior to developing the models. The 80% of the training dataset were used for training the models while the remaining 20% were used for testing the models. The result of the performance evaluation of the models showed that decision tree model has the highest accuracy of 94.99% while the Support Vector Machine Model has the highest sensitivity of 93.34% and Naïve Bayes Model has the highest specificity of 94.30%.

Postgraduate palliative care education and curricular issues in Central Asia, Eastern and South-Eastern Europe: Results from a quantitative study

Introduction. The WHO Europe Office, together with the European Association for Palliative Care, is supporting the development of an interdisciplinary core curriculum for health care professionals in the European Region, which is to be given to the countries as a recommendation. Material and methods. Between April and September 2018, a research journey to Central Asia, Eastern and South-Eastern Europe took place. It covered two main tasks: collecting quantitative data using a survey and collecting qualitative data by conducting on-site interviews. This article contains the quantitative part. Experts in palliative care education in 23 countries were invited to fill out a questionnaire. The data received from 23 questions were statistically evaluated by IBM SPSS Statistics 25. Results. 27 surveys received from 21 countries were evaluated. In one-third of the surveyed countries, there is still no postgraduate training in palliative care. The main barriers to the development of educational work are limited political interest, followed by limited educational structures, missing curricula, lack of trainers and the limited healthcare system. For 92.6% of all respondents, a WHO-recommended interdisciplinary postgraduate core curriculum would help promote palliative care in their country. Conclusion. There is a high need for postgraduate education in general and the intended core curriculum in particular. The results of the survey, along with those from the interviews in a later second part of the publication, are essential for the development of a core curriculum.

Crisis management strategies of hospitals during the pandemic

HintergrundDie SARS-CoV-2-Pandemie hat weltweit zu erheblichen Einschränkungen der medizinischen Versorgung geführt. Wir beschreiben bisherige Entwicklungen sowie Maßnahmen, die von März bis Mai 2020 zur Aufrechterhaltung der Versorgung ophthalmologischer Patienten an bettenführenden Augenkliniken beigetragen haben.MethodenLiteraturrecherche über PubMed, eigene Daten, klinikübergreifende Umfrage.ErgebnisseDurch die rasche Umsetzung von Hygienemaßnahmen und Anpassung der „standard operating procedures“ (SOP) zur Minimierung des Infektionsrisikos sowie die Fokussierung auf Notfälle und dringliche Indikationen bei gleichzeitiger Aussetzung elektiver Behandlungen konnte eine kontinuierliche Versorgung ophthalmologischer Patienten aufrechterhalten werden.SchlussfolgerungTrotz der Herausforderung einer erheblichen Verlagerung medizinischer Ressourcen während der SARS-CoV-2-Pandemie sind medizinisch dringlich notwendige ophthalmologische Behandlungen an Kliniken der Maximalversorgung gewährleistet. Anhand derzeit verfügbarer Daten kann allerdings nicht ausgeschlossen werden, ob es während der Pandemie auch zu Verzögerungen bei der Behandlung von Notfallpatienten gekommen ist.

Chloroquine and Hydroxychloroquine for the Prevention or Treatment of COVID-19 in Africa: Caution for Inappropriate Off-label Use in Healthcare Settings.

The novel severe acute respiratory syndrome-coronavirus-2 pandemic has spread to Africa, where nearly all countries have reported laboratory-confirmed cases of novel coronavirus disease (COVID-19). Although there are ongoing clinical trials of repurposed and investigational antiviral and immune-based therapies, there are as yet no scientifically proven, clinically effective pharmacological treatments for COVID-19. Among the repurposed drugs, the commonly used antimalarials chloroquine (CQ) and hydroxychloroquine (HCQ) have become the focus of global scientific, media, and political attention despite a lack of randomized clinical trials supporting their efficacy. Chloroquine has been used worldwide for about 75 years and is listed by the WHO as an essential medicine to treat malaria. Hydroxychloroquine is mainly used as a therapy for autoimmune diseases. However, the efficacy and safety of CQ/HCQ for the treatment of COVID-19 remains to be defined. Indiscriminate promotion and widespread use of CQ/HCQ have led to extensive shortages, self-treatment, and fatal overdoses. Shortages and increased market prices leave all countries vulnerable to substandard and falsified medical products, and safety issues are especially concerning for Africa because of its healthcare system limitations. Much needed in Africa is a cross-continental collaborative network for coordinated production, distribution, and post-marketing surveillance aligned to low-cost distribution of any approved COVID-19 drug; this would ideally be piggybacked on existing global aid efforts. Meanwhile, African countries should strongly consider implementing prescription monitoring schemes to ensure that any off-label CQ/HCQ use is appropriate and beneficial during this pandemic.

650-P: Safety and Effectiveness of Recombinant Human Insulin Insugen in Real-World Clinical Setting

Background: As the burden of diabetes is increasing dramatically, the demand of insulin is also on rise, affordable access to insulin remains a challenge, particularly in Low and Mid income countries. For that reason, recombinant human insulin (rHI) formulations are considered to be effective alternatives to insulin analogues in countries with limited healthcare systems and resources. Continuing patient education and support programmes with rHI are critical role players in improving the access and overall disease management. Objective: This is a non-interventional study to observe the safety and effectiveness of Recombinant Human insulin in a real world population with type 2 (T2DM) diabetes mellitus from Indian perspective. Methodology: Out of 10426 diabetes patients who were enrolled in patient support program i.e “Insulin Therapy Assistance Program (iTAP)”, 5691 patients were initiated with various formulations of rHI (Insugen R, N, 30/70 and 50/50). Insulin therapy was initiated in T2DM patients with A1C > 7%. HbA1c, FPG and PPG values were recorded at baseline and follow up of 3, 6 and 9 months. Results: The Figure 1, 2, 3 depict the baseline and follow up of FBG, PPG and HbA1c respectively. Figure 1. Change in FPG (*p<0.05). Figure 2. Change in PPG (*p<0.05). Figure 3. Change in HbA1c (*p<0.05). Conclusion: In the current study, various formulations of rHI were well tolerated and resulted in significant reduction of HbA1c, FPG and PPG when aided with patient support program. Considering the economic impact of diabetes patients in taking insulins, human insulin become an alternative option in comparison to analogues which are expensive. Early initiation of insulin therapy can prevent or delay diabetes complications. Access to affordable insulin therapy is the key success factor while considering Insulin Therapy. Disclosure P. Raj: Employee; Self; Biocon. P. J: None. D.C. Mathew: None. C. Biswas: None. S. Nethra: None.

LO53: Emergency department visits for hyperglycemia: through the eyes of the patient

Introduction: Patients with poorly-controlled diabetes often visit the emergency department (ED) for treatment of hyperglycemia. While previous qualitative studies have examined the patient experience of diabetes as a chronic illness, there are no studies describing patients’ perceptions of ED care for hyperglycemia. The objective of this study was to explore the patient experience regarding ED hyperglycemia visits, and to characterize perceived barriers to adequate glycemic control post-discharge. Methods: This study was conducted at a tertiary care academic centre in London, Ontario. A qualitative constructivist grounded theory methodology was used to understand the experience of adult patient partners who have had an ED hyperglycemia visit. Patient partners, purposively sampled to capture a breadth of age, sex, disease and presentation frequency were invited to participate in a semi-structured individual interview to probe their experiences. Sampling continued until a theoretical framework representing key experiences and expectations reached sufficiency. Data were collected and analyzed iteratively using a constant comparative approach. Results: 22 patients with type 1 or 2 diabetes were interviewed. Participants sought care in the ED over other options because of their concern of having a potentially life-threatening condition, advice from a healthcare provider or family member, or a perceived lack of convenient alternatives to the ED based on time and location. Participants’ care expectations centred around symptom relief, glycemic control, reassurance and education, and seeking referral to specialist diabetes care post-discharge. Finally, perceived system barriers that challenged participants’ glycemic control included affordability of medical supplies and medications, access to follow-up and, in some cases, the transition from pediatric to adult diabetes care. Conclusion: Patients with diabetes utilize the ED for a variety of urgent and emergent hyperglycemic concerns. In addition to providing excellent medical treatment, ED healthcare providers should consider patients’ expectations when caring for those presenting with hyperglycemia. Future studies will focus on developing strategies to help patients navigate some of the barriers that exist within our current limited healthcare system, enhance follow-up care, and improve short- and long-term health outcomes.

Blockchain-based electronic healthcare record system for healthcare 4.0 applications

Modern healthcare systems are characterized as being highly complex and costly. However, this can be reduced through improved health record management, utilization of insurance agencies, and blockchain technology. Blockchain was first introduced to provide distributed records of money-related exchanges that were not dependent on centralized authorities or financial institutions. Breakthroughs in blockchain technology have led to improved transactions involving medical records, insurance billing, and smart contracts, enabling permanent access to and security of data, as well as providing a distributed database of transactions. One significant advantage of using blockchain technology in the healthcare industry is that it can reform the interoperability of healthcare databases, providing increased access to patient medical records, device tracking, prescription databases, and hospital assets, including the complete life cycle of a device within the blockchain infrastructure. Access to patients’ medical histories is essential to correctly prescribe medication, with blockchain being able to dramatically enhance the healthcare services framework. In this paper, several solutions for improving current limitations in healthcare systems using blockchain technology are explored, including frameworks and tools to measure the performance of such systems, e.g., Hyperledger Fabric, Composer, Docker Container, Hyperledger Caliper, and the Wireshark capture engine. Further, this paper proposes an Access Control Policy Algorithm for improving data accessibility between healthcare providers, assisting in the simulation of environments to implement the Hyperledger-based eletronic healthcare record (EHR) sharing system that uses the concept of a chaincode. Performance metrics in blockchain networks, such as latency, throughput, Round Trip Time (RTT). have also been optimized for achieving enhanced results. Compared to traditional EHR systems, which use client-server architecture, the proposed system uses blockchain for improving efficiency and security.

'If you can't see a dilemma in this situation you should probably regard it as a warning': a metasynthesis and theoretical modelling of general practitioners' opioid prescription experiences in primary care.

The prescribing of opioids has increased internationally in developed countries in recent decades within primary and secondary care. The majority of patients with chronic non-malignant pain (CNMP) are managed by their general practitioner (GP). Recent qualitative studies have examined the issue of opioid prescribing for CNMP from a GP viewpoint. The aim of this study is to identify and synthesise the qualitative literature describing the factors influencing the nature and extent of opioid prescribing by GPs for patients with CNMP in primary care. MEDLINE, Embase, PsycINFO, Cochrane Database, International Pharmaceutical Abstracts, Database of Abstracts of Reviews of Effects, CINAHL and Web of Science were systematically searched from January 1986 to February 2018. The full text of included articles was reviewed using the Critical Appraisal Skills Programme (CASP) tool for qualitative research. The papers were coded by two researchers and themes organised using Thematic Network Analysis. Themes were constructed in a hierarchical manner, basic themes informed organising themes which informed global themes. A theoretical model was derived using global themes to explain the interplay between factors influencing opioid prescribing decisions. From 7020 records, 21 full text papers were assessed, and 13 studies included in the synthesis; 9 were from the United States, 3 from the United Kingdom and 1 from Canada. Four global themes emerged: suspicion, risk, agreement and encompassing systems level factors. These global themes are inter-related and capture the complex decision-making processes underlying opioid prescribing whereby the physician both consciously and unconsciously quantifies the risk-benefit relationship associated with initiating or continuing an opioid prescription. Recognising the inherent complexity of opioid prescribing and the limitations of healthcare systems is crucial to developing opioid stewardship strategies to combat the rise in opioid prescription morbidity and mortality.

Abstract P360: Potential Need for Expanded Clinical- and Community-based Pharmacologic Treatment and Lifestyle Modification Services Under the 2017 Hypertension Guideline

Objective: Describe the effects of the 2017 Hypertension Guideline (HTN GL) compared to JNC-7 guideline on recommended blood pressure (BP) treatment status among US adults and identify the potential need for expanded clinical- and community-based BP management services. Methods: Analyze data from 2011-2014 National Health and Nutrition Examination Survey, with analytic sample of 10,031 aged ≥18 years. Results: The new HTN GL reclassifies 32.3 million US adults as newly hypertensive and recommends BP-related treatment for 133.7 million adults, including 4.9 million newly recommended pharmacologic therapy and 50.5 million newly recommended lifestyle modifications alone. An estimated 1.1 million adults newly recommended to initiate pharmacologic treatment and 20.6 million adults newly recommended lifestyle modification alone report not having established healthcare linkages. Application of the new HTN GL affects some groups significantly more than others in being reclassified as having hypertension or being newly recommended to initiate BP treatment. This includes adults aged 18-64 years and males, two groups who historically have limited access to or low utilization of healthcare services for hypertension management. In addition, 3.6 million of the 4.9 million US adults who are newly recommended pharmacologic treatment and 36.4 million of the 50.5 million of those newly recommended lifestyle modification alone, are overweight or obese. Conclusions: The new HTN GL results in millions of additional US adults being recommended for lifestyle modification to manage their BP and a smaller proportion for pharmaceutical treatment. With many of those individuals not having established linkages to healthcare, these results can aid in translating the new HTN GL into clinical practice and public health programs necessary to meet the increased demand for services. Expanded clinical and public health resources are likely to be required to manage the additional millions of US adults recommended to newly initiate pharmacologic treatment and/or lifestyle modification, including many who previously had only limited healthcare system interaction. Community-based prevention strategies can aid in addressing this added burden on the health care system.

Rituximab versus the modified Ponticelli regimen in the treatment of primary membranous nephropathy: a Health Economic Model.

Membranous nephropathy is among the most common causes of nephrotic syndrome worldwide, with a high healthcare burden. Treatment using the modified Ponticelli regimen (mPR) has remained the standard of care for decades, but newer therapies such as rituximab offer promising results with reduced side effects. The cost of this treatment, however, is perceived as a barrier to widespread use, especially in resource limited healthcare systems. We developed a decision-analytic model to estimate the cost-effectiveness of rituximab versus the mPR from the perspective of the National Health Service in the UK over a 1 year, 5 year and lifetime horizon. Primary outcome is the cost-effectiveness of rituximab versus mPR at 5years post-treatment. Secondary outcomes are cost-effectiveness at 1 and 10years post-treatment and over a lifetime. At 1-year post-treatment, rituximab therapy dominates mPR. At 5years post-treatment, rituximab therapy is cheaper than the Ponticelli regimen but at a loss of 0.014 quality-adjusted life years (QALYs) with an incremental cost-effectiveness ratio (ICER) of £95 494.13. Over a lifetime, rituximab remains the cheaper option with an incremental cost of -£5251.03 but with a reduced quality of life (incremental QALY of -0.512) giving an ICER of £10 246.09. Our analysis indicates that rituximab has the potential to be a cost-effective treatment in the short and medium terms despite the high single-dose cost. This evaluation suggests that further research is warranted and highlights the need for a high-quality clinical trial to confirm the efficacy and cost-effectiveness of rituximab versus the current standard of care.

Design and baseline data from a PCORI-funded randomized controlled trial of family-centered tailoring of diabetes self-management resources

This article describes the methodology, recruitment, participant characteristics, and sustained, intensive stakeholder engagement for Project ACE (Achieving control, Connecting resources, Empowering families). Project ACE is a randomized controlled trial of children and youth ages 8–16 with type 1 diabetes evaluating the impact of tailored self-management resources on hemoglobin A1c (A1c) and quality of life (QOL). Despite strong evidence that controlling A1c reduces long-term complications, <25% of US youth with type 1 diabetes meet A1c targets. Many interventions are efficacious in improving A1c and QOL for these youth, whose families often struggle with the substantial demands of the treatment regimen. However, most such interventions are ineffective in the real world due to lack of uptake by families and limited healthcare system resources. Project ACE is a multi-site trial designed to improve diabetes outcomes by tailoring existing, evidence-based interventions to meet families' needs and preferences. We hypothesize that this family-centered approach will result in better A1c and QOL than usual care. Project ACE has recruited and randomized 214 eligible 8–16year old youth and their parents. The 9-month intervention consisted of 4 group sessions tailored to families' self-management barriers as identified by a validated instrument. Outcomes including A1c and QOL for parents and youth will be assessed for 1year after the intervention. Stakeholder engagement was used to enhance this trial's recruitment, retention and integration into routine clinical care. Findings will inform implementation and dissemination of family-centered approaches to address self-management barriers.Trial Registration Number: NCT02024750Trial Registrar: Clinicaltrials.gov, https://clinicaltrials.gov/ct2/show/NCT02024750

"All I Need Is Help to Do Well": Herbs, Medicines, Faith, and Syncretism in the Negotiation of Elder Health Treatment in Rural Ghana.

This qualitative research sought answers to questions about how elders in Agate, Ghana, coped with the challenges of illness in a rural village and in particular how they negotiated treatment for their illnesses within a flawed and limited healthcare system. In our study, 22 of 28 interviewees used all methods available to them (biomedical approaches [doctors and/or hospitals and/or doctor-prescribed medications], herbs, over-the-counter medicines [i.e., acetaminophen painkillers], and faith-based methods [praying/fasting/laying of hands/holy food and/or water]) in attempts to heal their illnesses. A syncretism existed in the negotiation of treatment options. All participants in our study used some form of what we term "Treatment Blending" (TBL), the use by a single participant of more than one of the aforementioned treatment methods for illness. Our research also revealed a widespread use of multiple spiritual systems (at the same time) and practitioner overlap (visiting a doctor, a traditional healer, and/or Christian pastor). Elders, in multiple cases, demonstrated the daily practice of one religion while seeking healing through another framework. TBL among our participants was a reflection of the lives elders lead in which illness and healing cannot be separated from the spiritual, the idea of an omnipresent God who is the ultimate "doctor," and ancient African traditions of herbs and rituals that possess deeper meaning for both physical and psychological healing and well-being. This ran parallel with the syncretism of religion itself in Ghana and suggests possible related paths through which to improve the healthcare system for elders in rural Ghana utilizing local faith-based groups and the elders themselves to assist.

An economic analysis of the limits of market based reforms in the English NHS.

BackgroundOver the past three decades, a limited range of market like mechanisms have been introduced into the hierarchically structured English National Health Service (‘NHS’), which is a nationally tax funded, budget limited healthcare system, with access to care for all, producing structures known as a quasi market. Recently, the Health and Social Care Act 2012 (‘HSCA’) has been enacted, introducing further market elements. The paper examines the theory and effects of these market mechanisms.MethodsUsing neo-classical economics as a primary theoretical framework, as well as new institutional economics and socio-legal theory, the paper first examines the fundamental elements of markets, comparing these with the operation of authority and resource allocation employed in hierarchical structures. Second, the paper examines the application of market concepts to the delivery of healthcare, drawing out the problems which economic and socio-legal theories predict are likely to be encountered. Third, the paper discusses the research evidence concerning the operation of the quasi market in the English NHS. This evidence is provided by research conducted in the UK which uses economic and socio-legal logic to investigate the operation of the economic aspects of the NHS quasi market. Fourth, the paper provides an analysis of the salient elements of the quasi market regime amended by the HSCA 2012.ResultsIt is not possible to construct a market conforming to classical economic principles in respect of healthcare. Moreover, it is not desirable to do so, as goals which markets cannot deliver (such as fairness of access) are crucial in England. Most of the evidence shows that the quasi market mechanisms used in the English NHS do not appear to be effective either. This finding should be seen in the light of the fact that the operation of these mechanisms has been significantly affected by the national political (i.e. continuingly hierarchical) and budgetary context in which they are operating.ConclusionThe organisational structures of a hierarchy are more appropriate for the delivery of healthcare in the English NHS.

Assessment of Acute Trauma Care Training in Kenya

An Acute Trauma Care (ATC) course was adapted for resource-limited healthcare systems based on the American model of initial care for injured patients. The course was taught to interested medical personnel in Kenya. This study undertook a survey of the participants' healthcare facilities to maximize the applicability of ATC across healthcare settings. The ATC course was conducted three times in Kenya in 2006. A World Health Organization (WHO) Needs Assessment survey was administered to 128 participants. The data were analyzed qualitatively and quantitatively. Ninety-two per cent had a physician available in the emergency department and 63 per cent had a clinical officer. A total of 71.7 per cent reported having a designated trauma room. A total of 96.7 per cent reported running water, but access was uninterrupted more often in private hospitals as opposed to public facilities (92.5 vs 63.6%, P = 0.0005). Private and public employees equally had an oxygen cylinder (95.6 vs 98.5%, P > 0.05), oxygen concentrator (69.2 vs 54.2%, P = 0.12), and oxygen administration equipment (95.7 vs 91.4%, P > 0.05) at their facilities. However, private employees were more likely to report that "all" of their equipment was in working order (53 vs 7.9%, P < 0.0001). Private employees were also more likely to report that they had access to information on emergency procedures and equipment (64.4 vs 33.3%, P = 0.001) and that they had learned new procedures (54.8 vs 25.4%, P = 0.002). Despite a perception of public facility lack, this survey showed that public institutions and private institutions have similar basic equipment availability. Yet, problems with equipment malfunction, lack of repair, and availability of required information and training are far greater in the public sector. The content of the ATC course is valid for both private and public sector institutions, but refinements of the course should focus on varying facets of inexpensive and alternative equipment resources. Furthermore, the implementation of this course should create a setting that advocates, promotes, and investigates resources. The WHO survey can guide future research in understanding impediments to implementing essential trauma care courses for resource limited healthcare systems.

The Late Effects Clinic in action: For survivors of childhood malignancy

Background. Long-term survivors of childhood malignancy are a newly emergent patient group with a unique but wide range of survivorship issues. There are rising demands for long-term, medical follow-up and social support for this potentially vulnerable group. These demands stem from improving survival rates and the progressively increasing incidence of late physical, psychological and social sequelae. Case-studies and Discussion. The ideal method to facilitate this long-term follow-up is unclear, and faces the problems of health-care system limitations coupled with the paucity of outcomes-based research to guide evidence-based, clinical practice. We discuss how the Late Effects Clinic operates in our institution: optimising the involvement of the multi-disciplinary medical and allied health care teams to meet the physical and psychological needs of long-term survivors, and to assist with the social issues surrounding survivorship. This model involves a co-operative team approach, thereby alleviating the sole responsibility from general practitioners or individual physicians with a restricted realm of expertise. We present three case reports illustrating the value of a formal late effects follow-up programme, and demonstrating the integration of the Late Effects Clinic into medical practice.

Peritoneal dialysis in Mexico

While Mexico has the thirteenth largest economy, a large portion of the population is impoverished. About 90% of the population is Mestizo, the result of the admixture of Mexican Indians and Spaniards, with the Indigenous peoples concentrated in the southeastern region. Treatment for end-stage renal disease (estimated 268 patients per million population) is largely determined by the limited healthcare system and the individual's access to resources such as private insurance ( approximately 15%) and governmental sources ( approximately 85%). With only 5% of the gross national product spent on healthcare and most treatment providers being public health institutions that are often under severe economic restrictions, it is not surprising that many Mexican patients do not receive renal replacement therapy. Mexico uses proportionately more peritoneal dialysis than other countries; 1% of the patients are on automated peritoneal dialysis, 19% on hemodialysis and 80% on CAPD. Malnutrition and diabetes, important risk factors for poor outcome, are prevalent among the patients in CAPD programs.

Concurrent gonococcal and chlamydial infection: how best to treat.

Clinicians treating concurrent gonococcal and chlamydial infections have a variety of drugs to choose from. Neisseria gonorrhoeae is adept at developing resistance and the choice of antibiotic must be dictated to some extent by the patterns of resistance in the locality of the clinician. In contrast, resistance of Chlamydia trachomatis to some classes of drugs has been shown in vitro but does not appear to be clinically important at present. The success of treatment depends on patient compliance with the drug administration schedule. With these organisms, which can be carried asymptomatically, many patients are unlikely to comply with courses of antibiotics. Although single-dose therapy with azithromycin is available and established for chlamydial genital infection, it is more expensive and difficult to justify in a cash limited Healthcare system, and its efficacy for treating concurrent gonococcal infection requires further study. In patients where compliance is likely to be of concern, its use may be justified. Another major deterrent for completing antibiotic courses is the adverse effect profile. Most of the available drugs cause only minor adverse effects, in particular gastrointestinal. Ofloxacin has a better profile than doxycycline but is considerably more expensive. Newer fluoroquinolones, found to be effective in vitro, are being assessed in clinical studies. However, more evidence is required before recommending these over the tried and tested therapies.