Regional Specialty Research Articles

Financing the treatment of chronic pain: models for risk-sharing among pain medicine physicians, health care payers, and consumers.

Chronic pain patients are among a growing group of medically underserved Americans. Despite increasing public awareness about pain and widespread legislative activity that is focusing on the needs of pain patients, there remain significant roadblocks in bringing the expertise of Pain Medicine specialists to these unfortunate people. This paper explores how the managed care revolution has impacted the practice of Pain Medicine in the United States. The dissolution of many prominent multi-disciplinary pain treatment centers has been paralleled by the evolution of pain management as an area of interest by several competing medical specialty societies. Despite this fragmentation, the American Academy of Pain Medicine continues to grow and to promote the needs of Pain Medicine specialists and their patients. The advantages and disadvantages of various practice patterns for Pain Medicine specialists is explored against a backdrop of discussions about: (1) the problems currently faced by chronic pain patients; (2) the role of organized Pain Medicine in helping patients to access and finance care; and (3) the future of American health care and the new responsibilities that will bring to physicians. Finally, we have some specific recommendations for pain medicine specialists about: (1) sharing risk; (2) exerting individual leadership; and (3) simplifying one's professional life in the new health care environment, that we hope will enable them to continue caring for as many chronic pain patients as possible. It is opined that the development of sophisticated regional specialty networks is the best model to accomplish this task in the future.

Producer constructions of quality in regional speciality food production: a case study from south west England

Within the context of recent concerns over potential health threats from BSE, E.Coli and genetically modified organisms, food quality is of increasing importance in contemporary British society. Thus food producers, retailers and government institutions are engaged in an attempt to reassure consumers that their food is of high quality and safe to consume. Yet, the concept of `quality’ is one which is contested, constructed and represented differently by diverse actors operating within a variety of regulatory and market arenas. The aim of this paper is to focus on one set of actors who interact to construct notions of quality within a niche market arena, namely small producers of regional speciality food products (SFPs) in the south west of England. It emerges that, despite new regulatory frameworks and consumer concerns, producers usually define quality in terms of product specification and attraction rather than through official certification schemes or association with region of origin. Food quality, however defined by producers, is essentially self-regulated and constructed within the context of maintaining stable relationships between producers and buyers. Furthermore, marketing is based on low-cost methods which demand a high personal input of time and energy from the entrepreneur. Quality, therefore, must be understood as a contested notion which is constructed by actors attempting to build stable and lasting networks between themselves and others within the market arena.

Niche Markets and Regional Speciality Food Products in Europe: Towards a Research Agenda

Set within the context of recent rural restructuring in developed market economies, the authors examine the potential of niche markets for speciality food products (SFPs) to contribute towards rural development in peripheral (lagging) regions. Drawing on elements of regulation theory, actor-network approaches, and consumption studies, niche markets for SFPs are conceptualised as the outcomes of the intersecting activities of networks of producers, consumers, and institutions. On the basis of this conceptualisation and preliminary empirical evidence from a European research project, it is suggested that unique configurations of networks at local and regional levels, and their relationships to cxtralocal networks, will contribute to the success or failure of regional SFPs in promoting endogenous development. It is also argued that a focus on particular products, markets, and regions is required to gain a holistic understanding of the complex and contested network relationships through which niche markets for SFPs are constructed.

Trauma centres: a British perspective.

Trauma centres: a British perspective.

Collecting the evidence: the nursing management of intravenous therapy

Objectives: This study was prompted by the need to identify and measure the impact of change on the existing roles and responsibilities of nurses with reference to the management of intravenous (IV) therapy in terms of activity and workload, standards of care, scope of practice and risk management. Design: a study was designed to include: • an activity analysis to identify changes in nursing workload • a small research-based project to examine clinical practice • a risk management exercise to identify ‘the harm’. Setting: a large acute teaching hospital with regional specialities. Participants: key representatives from research, audit, resource management, education and training and clinical practice worked in partnership to inform an evidence-based approach to support practice. Findings: evidence-based practice can be enhanced by combining traditional researchmethods, findings from service evaluation, audit and risk management exercises. Discussion: the use of local data, specific research findings and the expertise of practitioners, managers, educators and researchers can be combined to underpin safer, more clinically and cost-effective approaches to the nurse management of IV therapy.

Job descriptions for Regional Representatives and Specialty Tutors

Job descriptions for Regional Representatives and Specialty Tutors

Perspective: committed to excellence.

Perspective: committed to excellence.

A comparison of two methods of dietary assessment in peritoneal dialysis patients

Objective: To conduct a comparison of two methods of dietary assessment in patients on peritoneal dialysis. Design: Comparative, cross-sectional study of two methods of dietary assessment (3-day diet diary and 24-hour recall). Data was collected simultaneously by a single experienced dietitian. Each assessment was coded and analyzed blind. Setting: Regional speciality peritoneal dialysis training unit. Patients: In this study, 30 peritoneal dialysis patients recruited prospectively and consecutively as they attended for out-patient assessment of dialysis adequacy. Age range was 22 to 77 years. Patients were excluded if unwell, younger than 18 years, or had peritonitis. Outcome measures: Total energy and protein intakes from both methods were compared. Protein intakes from both methods were compared with the protein catabolic rate generated from urea kinetics. Data obtained from both methods were compared using paired t tests, linear regression, and Bland and Altman techniques. Results: There were no significant differences in the mean daily protein (72.4 g v 76.6 g) and total energy (1757 kcals (7.35 MJ) v. 1897 kcals (7.94 MJ)) intakes determined by the two methods. Positive correlations were seen between the measurements for protein intake ( r = .58, P = .0026) energy intake ( r = .78, P < .00001), with mean differences of .066 g/kg/d (SD .38) 2.04 kcal/kg/day (SD 6.67), respectively. For both methods there was a similar positive correlation between dietary protein intake and protein catabolic rate. A 24-hour recall was more likely to result in successful collection of data (29 of 30) than 3-day diet diaries (25 of 30) and was less time consuming. Conclusion: These two methods of determining dietary protein and energy intake do not differ significantly in the information they provide. The relative success in obtaining completed records of intake, the shorter time taken and the opportunity for patient education and assessment of other nutrition related factors has led to the adoption of the 24-hour recall method in our institution.

高温条件下におけるオオムギ品種の表面温度の比較

Regional specialities of world wide barley cultivars under high temperature conditions were studied, using surface temperatures of plant canopy measured by an infrared thermometer. A total of 274 barley cultivars consisting of 5 north American cvs, 11 north African cvs, 19 Chinese cvs, 37 Ethiopian cvs, 35 south west Asiatic cvs, 30 Japanese cvs, 30 Korean cvs, 21 Nepalese cvs, 18 Turkish cvs, and 68 European cvs were randomly taken from the stocks preserved in the Barley Germplasm Center of Okayama University.Under nearly zero stress conditions on cloudy days, differences (Ts-Ta) between canopy surface temperatures (Ts) of barley cultivars and ambient air temperatures (Ta) decrease with increasing air temperatures and water vapor pressure deficits, having very high correlation coefficients. On the other hand, under higher air temperature and dry conditions on clear afternoons, Japanese cvs, south west Asiatic cvs, and Nepalese cvs maintained low surface temperatures, but barley cultivars from higher latitudes such as European cvs had the tendency to increase surface temperatures. These imply that the former cvs have the ability to change energy dissipation rates in response to changes in energy absorption but the latter cvs have a limited ability to change the rates of some energy loss mechanisms such as transpiration. Barley cultivars in the habitats with higher annual air temperature and more annual precipitation generally tended to have greater ability to moderate leaf temperatures.

Referrals of patients by family physicians to consultants: a survey of the Israeli Family Practice Research Network.

We aimed to analyse factors influencing referral of patients by primary care physicians to specialist consultants at the beginning of the era of direct access to specialists in Israel. We carried out a study of referrals by family physicians to specialists over a continuous period of 3 months. Twenty-four certified family physicians filled in a questionnaire detailing referrals during the study period. All patients were referred for consultation to a specialist at regional speciality clinics or hospital out-patient departments. Ten physicians met the study conditions. In 1140 of 10896 (10.5%) visits, patients were referred to specialist consultants. The percentage of referral ranged from 7.4 to 15.9%. The difference between the physicians with the lowest and highest rates of referral was statistically significant (P < 0.0001). The variance in referral rates was not explained by significant differences in physician or practice variables. The types of specialists to whom the most referrals were made were orthopaedic surgeons, ophthalmologists, dermatologists, ear, nose and throat, general surgeons and plastic surgeons. There was a significant correlation between the type of specialist and the age of the patient. Older patients were referred more frequently to urologists, cardiologists and ophthalmologists, while younger patients were referred more frequently to ear, nose and throat specialists and gynaecologists (P < 0.01). The results of this study can be used as an aid for decision makers in the health services for determining policy. Direct access to some specialties might be appropriate, but not to all. Adoption of a policy based on these findings could lead to reduced health care costs by reducing the burden on hospital emergency rooms. It might also increase patient satisfaction in that the patients will have greater freedom of choice. On the other hand, more appropriate training of family physicians and more extensive self- and peer-quality assurance will increase the primary physician's knowledge and ability to diagnose and treat a broad range of problems and improve the level of care.

Tempo Diet

This paper weaves together several conceptual threads between time, food production and consumption habits. In a context of fast food and ready-to-eat meals, it advances an environmental argument for rediscovering the joys and culinary pleasures of local foods and regional specialities, as well as the need for finding time once again for unhurried social eating.

"Tarogato" as a Regional Instrument

The designation t6rogatd refers to two different instruments: one was a pre-19th century instrument, the other was one consummated at the end of the 19th century. The first was called Kegeloboe by Curt Sachs' and was understood to denote all woodwind instrument types which existed with double reed in Asia and the Near East. On the frequency of its use in the Near East, see also Farmer's book on Islam.2 In Hungary it was first used as defined by Schalmey, e.g. in the Latin glossary of Murmelius (no. 2490) in 1533,3 and this use prevailed in the 17th-18th centuries. The Ottomans appeared in this part of Europe in those centuries. They brought along this Schalmey-type, together with lots of other instruments, which was named in Hungarian tarogat6. This became the favourite instrument of the soldiers in camp during one of the first Hungarian wars of liberation after the 150year-long Ottomanoccupation, and of its leader Ferenc Rdk6czi, whose figure is highlit by a wide repertory of songs. That is why the t6rogat6 as an instrument is closely related to the stock of Raik6czi songs. So far, then, it is not a regional speciality but an instrument type which was brought to Hungary by the Ottomans: a conical woodwind instrument with holes, employing a double reed. The other type displays the regional specificity developed in the 19th century. In the first half of the 19th century, the original instrument was still in use in the region. There were artists including Andras Szuk4 who

Epidemiology of nosocomial infections: 10-month experience in one hospital

We analyzed data on nosocomial infections obtained from the worldwide and Mexican medical literature and from the monitoring system at Regional Specialties Hospital No. 25 in Nuevo León, Mexico. We found a considerably higher incidence of hospital-acquired infections among patients in intensive care units. The urinary and respiratory tracts were the predominant sites of nosocomial infection. The principal causative organisms were the gram-negative bacilli, particularly Enterobacteriaceae, and some nonfermenting microorganisms, such as Pseudomonas species. An increase also was noted in the isolation of coagulase-negative staphylococcus, particularly related to infections from foreign objects such as catheters and prostheses. Analysis of the antimicrobial resistance patterns of 1045 bacterial strains, particularly those from the Enterobacteriaceae family, isolated at our hospital from November 1991 to August 1992 revealed that resistance to cefotaxime and amikacin is not a significant problem, even though these drugs have been used in the hospital for more than 10 years. The incidence of nosocomial infections can be reduced through control measures such as epidemiologic monitoring systems, adherence to isolation procedures, the rational use of antimicrobial agents, and the use of susceptibility tests to determine bacterial resistance patterns in the hospital environment.

A regional specialty policy for pressure sores

A survey of pressure sores in Mersey's geriatric units revealed almost universal access to high technology equipment but limited availability of specialist skills and knowledge. Many wounds were treated with toxic or inappropriate agents. Consequently a regional specialty policy for pressure sores, incorporating a tissue viability formulary, was introduced. A second audit investigated its effects.The prevalence, grade, ages and anatomical sites affected were very similar in the two studies. Patients receiving a pressure sore risk assessment increased, from 157/170 (92%) to 186/187 (99.5%) ( p &lt;0.0005). Prior to the introduction of the policy 74/272 (27%) pressure sores had an unsuitable cleanser, cavity filler or dressing compared with 51/309 (16%) subsequently ( p &lt;0.005).This regional specialty audit has improved the management of pressure sores in 10 units.

D-Day and Geography

When the Allied forces landed on the beaches of Normandy early on the morning of 6 June 1944, they launched the most massive military undertaking of World War II. Since then those beaches have borne the code names Utah, Omaha, Gold, Juno, and Sword, the components of Operation Overlord, which is popularly known as D-day. The landings set the stage for the beginning of the end of German occupation of France. The operation was both enormous and complex. Counting combat troops and personnel involved in administrative and logistical support, between 2.6 and 2.7 million individuals participated. Published print, video, and filmed material on the events of the spring and summer of 1944 proliferated in Great Britain, France, and the United States before and after the fiftieth anniversary of D-day. The focus of this article is the crucial role of weather and tides, physical-geographic factors fundamental to the choice of the invasion date. Situated between Brittany and the western part of the Paris Basin, the Normandy peninsula is rimmed by sand or pebble beaches backed by cliffs that give way to a pastoral landscape of farms and villages. Irregular hills are separated by marshland and several small rivers. Scattered forests contain mixed stands of oak, chestnut, and beech. The countryside is a patchwork of old earthworks and hedgerows, known locally as bocage, that protect livestock and crops from the bone-chilling Atlantic winds. A characteristic landscape west of Rouen, bocage is an irregular patchwork of low trees and thick, high hedges alternating with small fields or meadows and pastures. Much of the fighting took place in the bocage. These hedges, four to five feet high and almost as thick, were capable of stopping a tank, and frequently did, until an American soldier hit on the idea of attaching steel blades on the front of his tank to uproot the tangled vegetation. Fields contain corn, buckwheat, and barley, and pastures are covered with wildflowers in the spring. Fruit orchards abound; apples yield the regional specialties -- cider and Calvados. Seaweed and kelp are gathered to use as fertilizer on the local farms, which are underlain by rocky soil. The soils are thin, comprising sand, limestone, marl, chalk, and, in places, flint. Although the interior exhibits some upwarping, the coasts are somewhat lower but rimmed with steep, eroded cliffs, especially in the eastern portion. The location of Normandy, both as a gateway to the continent and an exit from the European mainland to the British Isles, has seemed to invite military incursions throughout history. The D-day operations were the most recent of actions that are rooted in antiquity. In 1940 Germany overran France with frightening rapidity. The need for a cross-channel invasion to liberate France was recognized, and Prime Minister Winston Churchill noted in the fall of 1941 that it would occur when the tide turned more strongly in favor of the Allies. Stalin had been urging the opening of a second front soon after Germany invaded the Soviet Union. In January 1943, at the Casablanca conference, a committee was formed to devise a plan for Operation Overlord, the code name chosen for what was to become the Normandy landings. In 1944 what was probably the most ambitious amphibious invasion of modern times was launched in Normandy. Success or failure of the operation hinged on suitable weather conditions. Thus selecting the date of the assault required the talents of the most skilled meteorologists available. The 1942 landings in North Africa provided some lessons for a large-scale amphibious operation. The problem there, as for Normandy, concerned the limitations of long-range forecasting. A universally accepted technique to predict weather accurately for more than one or two days did not, and does not, exist. American meteorologists had been working on five-day forecasts, but the British had found such forecasts to be of little value. …

Regional specialities

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A Regional Specialty Policy for Pressure Sores

A Regional Specialty Policy for Pressure Sores

Genetic services in the context of DNA probes: what do they cost?

We describe results from the first year of a three year economic evaluation of genetic services in the context of DNA probes provided at three genetic centres in Great Britain. The analysis so far has concentrated on the costs of providing DNA diagnostic services. Estimates are given of the total costs of providing DNA probe services at each of the three centres, together with information for assessing the cost implications of future developments in these services. DNA probe services are likely to be funded as a Regional specialty. This paper concludes that relative to other developing medical technologies and as an investment by Regions, DNA probe services are inexpensive. An appraisal of the benefits to be derived from DNA probe services is still to be undertaken.

The Kentucky Diabetes Control Program and the feasibility of the pyramidal model for public health intervention in diabetes mellitus.

The Kentucky Diabetes Control Program was the first statewide program to use an indirect, "pyramidal" model to achieve desired changes in health care delivery for diabetes. This model leverages the expertise of sub- specialists through regional sub specialty teams (RDTs) of allied health professionals to primary health professionals for use with their patients. It has the advantage of yielding geometric increases in the numbers of patients affected while utilizing the existing primary care system. The model was implemented throughout Kentucky over four years and now includes an admin istrative core, two subspecialty resource centers, and 18 RDTs, with a registered nurse and dietitian in each. During its first five years of operation, the program providedformal, continuing education in diabetes to 16, 035 health professionals. They, in turn, provided formal patient education to 20, 866 patients and family members. These results suggest the feasi bility of the indirect, pyramidal model as afunctional public health intervention in diabetes.

The regional specialty adviser.

The regional specialty adviser.