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By K. Ningal. Cottey College.

Insurance for high-cost sick- care is thus a self-reinforcing process which invests the providers of care with the control of increasing resources buy actos 30mg otc. But like all other such remedies discount actos 15mg free shipping, capitation enlarges the iatrogenic fascination with the health supply. In England the National Health Service has tried, albeit unsuccessfully, to ensure that cost inflation will be less plagued by conspicuous flimflam. The need was assumed to be finite and quantifiable, the ballot box the best place to decide the total budget for health, and doctors the only ones able to determine the resources that would satisfy the need of each patient. But need as assessed by medical practitioners has proved to be just as extensive in England as anywhere else. The fundamental hope for the success of the English health-care system lay in the belief in the ability of the English to ration supply. Until about 1972 they did so, in the opinion of an author who surveyed British health economics, "by means in their way almost as ruthless but generally held to be more acceptable than the ability to pay. But this stern commitment to equality prevented only those astounding misallocations for prestigious gadgetry which provided an easy starting point for public criticism in the United States. Since 1972 the Health Service in Britain has undergone a traumatic change, for complex economic and political reasons. The initial success of the Health Service and the present unique disarray in the system make predictions for the future impossible. Yet curiously, England is also one of the few industrialized countries where the life expectancy of adult males has not yet declined, though the chronic diseases of this group have already shown an increase similar to that observed a decade earlier across the Atlantic. The number of physicians and hospital days per capita seems to have doubled between 1960 and 1972, and costs to have increased by about 260 percent. The Russians, for instance, limit by decree mental disease requiring hospitalization: they allow only 10 percent of all hospital beds for such cases. The proportion of national wealth which is channeled to doctors and expended under their control varies from one nation to another and falls somewhere between one-tenth and one-twentieth of all available funds. Excepting only the money allocated for treatment of water supplies, 90 percent of all funds earmarked for health in developing countries is spent not for sanitation but for treatment of the sick. From 70 percent to 80 percent of the entire public health budget goes to the cure and care of individuals as opposed to public health services. All countries want hospitals, and many want them to have the most exotic modern equipment. The poorer the country, the higher the real cost of each item on their inventories. As to cost, the same is true of the physicians who are made to measure for these gadgets. The education of an open-heart surgeon represents a comparable capital investment, whether he comes from the Mexican school system or is the cousin of a Brazilian captain sent on a government scholarship to study in Hamburg. It is clearly a form of exploitation when four-fifths of the real cost of private clinics in poor Latin American countries is paid for by the taxes collected for medical education, public ambulances, and medical equipment. But the exploitation is no less in places where the public, through a national health service, assigns to physicians the sole power to decide who "needs" their kind of treatment, and then lavishes public support on those on whom they experiment or practice. Once President Frei of Chile had started on one palace for medical spectator-sports, his successor, Salvador Allende, was forced to promise three more. The prestige of a puny national team in the medical Olympics is used to intensify a nationwide addiction to therapeutic relationships that are pathogenic on a level much deeper than mere medical vandalism. Only in China at least, at first sight does the trend seem to run in the opposite direction: primary care is given by nonprofessional health technicians assisted by health apprentices who leave their regular jobs in the factory when they are called on to assist a member of their brigade. The achievements in the Chinese health sector during the late sixties have proved, perhaps definitively, a long- debated point: that almost all demonstrably effective technical health devices can be taken over within months and used competently by millions of ordinary people. Despite such successes, an orthodox commitment to Western dreams of reason in Marxist shape may now destroy what political virtue, combined with traditional pragmatism, has achieved. The bias towards technological progress and centralization is reflected already in the professional reaches of medical care. China possesses not only a paramedical system but also medical personnel whose educational standards are known to be of the highest order by their counterparts around the world, and which differ only marginally from those of other countries. Most investment during the last four years seems to have gone towards the further development of this extremely well qualified and highly orthodox medical profession, which is getting increasing authority to shape the over-all health goals of the nation. University-trained personnel instruct, supervise, and complement the locally elected healer. This ideologically fueled development of professional medicine in China will have to be consciously limited in the very near future if it is to remain a balancing complement rather than an obstacle to high-level self-care. But there is no reason to believe that cost increases in pharmaceutical, hospital, and professional medicine in China are less than in other countries. For the time being, however, it can be argued that in China modern medicine in rural districts was so scarce that recent increments contributed significantly to health levels and to increased equity in access to care. But the fundamental reason why these costly bureaucracies are health-denying lies not in their instrumental but in their symbolic function: they all stress delivery of repair and maintenance services for the human component of the megamachine,79 and criticism that proposes better and more equitable delivery only reinforces the social commitment to keep people at work in sickening jobs. The war between the proponents of unlimited national health insurance and those who stand up for national health maintenance, as well as the war between those defending and those attacking all private practice, shifts public attention from the damage done by doctors who protect a destructive social order to the fact that doctors do less than expected in defense of a consumer society.

Monitor Include dementia in basic health Institute surveillance for early Develop advanced monitoring community information systems dementia in the community systems health Survey high-risk population Monitor effectiveness of groups preventive programmes 10 order 15mg actos with visa. Support more Conduct studies in primary Institute effectiveness and Extend research on the causes research health-care settings on the cost effectiveness studies for of dementia prevalence purchase 30mg actos visa, course, outcome community management of Carry out research on service and impact of dementia in the dementia delivery community Investigate evidence on the prevention of dementia a Based on overall recommendations from The world health report 2001 (32). Caregivers of patients with Alzheimer s disease: a qualitative study from the Indian 10/66 Dementia Research Network. Association of apolipoprotein E allele e4 with late-onset familial and sporadic Alzheimer s disease. Predictive value of apolipoprotein E genotyping in Alzheimer s disease: results of an autopsy series and an analysis of several combined studies. Alzheimer s disease in the National Academy of Sciences-National Research Council Registry of Aging Twin Veterans. Prevalence of Alzheimer s disease and vascular dementia: association with education. Head trauma as a risk factor for Alzheimer s disease: a collaborative re-analysis of case-control studies. Synergistic effects of traumatic head injury and apolipoprotein-epsilon 4 in patients with Alzheimer s disease. Depressed mood and the incidence of Alzheimer s disease in the elderly living in the community. Atherosclerosis, apolipoprotein E, and prevalence of dementia and Alzheimer s disease in the Rotterdam Study. Smoking and risk of dementia and Alzheimer s disease in a population-based cohort study: the Rotterdam Study. Midlife vascular risk factors and Alzheimer s disease in later life: longitudinal, population based study. Methodological issues in population-based research into dementia in developing countries. Prevalence of Alzheimer s disease and dementia in two communities: Nigerian Africans and African Americans. Incidence of dementia and Alzheimer disease in 2 communities: Yoruba residing in Ibadan, Nigeria, and African Americans residing in Indianapolis, Indiana. Is mental health economics important in geriatric psychiatry in developing countries? According to the Brazilian 2000 census, there remainder are in the hands of a private system. Primary are 10 million people aged 65 years and over, correspond- care is provided primarily by the Family Health Programme, ing to about 6% of the whole population. It is predicted in which health professionals go to the patient s home for that by 2050 the elderly population will have increased by periodic health evaluation and management; however, this over 300%, whereas the population as a whole will have in- programme covers only 40% of the population. Brazil has also one of the highest (geriatricians, psychiatrists and neurologists) see referred rates of urbanization in the world with almost one third of patients as outpatients and inpatients. Long-term care is the whole population living in only three metropolitan ar- scarce and is mostly provided by religious organizations eas (So Paulo, Rio de Janeiro and Belo Horizonte), as well for those with severe disability and limited family support. Dementia in Brazil Brazilian Psychiatric Association has a Geriatric Psychia- is still a hidden problem and there is little awareness of it. Several regional nongovernmental organizations are relatively advantaged because of the means-tested work to support people with dementia and their caregivers; non-contributory pension benets for older Brazilians, in- these are united in a federation Federao Brasileira de troduced in the 1990s. Carers experi- ter medical care and low fertility have made the elderly ence signicant burdens and health strain. India has of carers are female and around 50% are spouses who are over one billion people, 16% of the world s population: it themselves quite old. People with dementia are often ne- is estimated that the growth in the elderly population is glected, ridiculed and abused. In this project, a exible, stepped-care intervention According to a recent consensus, the prevalence of de- was adopted to empower the carers with knowledge and mentia in India is 1. The context of the large population and demographic transition, intervention was implemented by locally trained home the total numbers are estimated to more than treble in the care advisers under supervision. The public decreasing the stress of looking after a person with demen- health and socioeconomic implications are enormous. There is a need to make dementia a public the role of caregivers are also working and cannot spend health priority and create a network of home care advisers as much time caring for the elderly. Dementia is considered to provide supportive and educational interventions for the as a normal part of ageing and is not perceived as requiring family caregivers through the primary health-care system medical care. According to United Nations es- are poor, so that many elderly people who retire do not re- timates, it is likely that the gure of 0. Recently the Federal Government has the whole population) people over 60 years of age in 2000 introduced a contributory pension scheme, but in the past will have more than trebled by 2040 (1. No effective alternatives have is being piloted only among certain Federal civil servants.

Pleural malignancy Cystic brosis Pneumonia Aetiology Sarcoidosis The most common cause of pleurisy is infection actos 15 mg sale, related Traumatic Penetrating chest wounds to an underlying bacterial or viral pneumonia cheap actos 15 mg line. Pleurisy Rib fractures canalsobeafeatureofpulmonaryembolism,pulmonary Oesophageal rupture Iatrogenic Subclavian cannulation infarction, malignancy and connective tissue diseases Positive pressure ventilation such as rheumatoid arthritis. Pleural aspiration Oesophageal perforation during endoscopy Clinical features Lung biopsy Sharp, well-localised pain, worse on inspiration or coughing,andapleuralrubheardonauscultation. Investigations Chest X-ray shows the visceral pleura as a thin line with Macroscopy absent lung markings beyond. Fibrinous exudate is seen over the pleural surfaces and there is variable exudation of uid. Aimed at identication and treatment of the underlying r If the pneumothorax is >20%, particularly if the pa- cause. Nonsteroidalanti-inammatorydrugsandparac- tient has underlying lung disease or is signicantly etamol are used for analgesia. If after a few days disease and embolism the drain continues to bubble and the pneumothorax persists this indicates a bronchopleural stula, i. Denition r Pleurectomy is indicated in recurrent pneumotho- Respiratory failure is dened as a fall in the arterial oxy- racesorfor bronchopleural stulae that fail to close gen tension below 8 kPa. Aetiology/pathophysiology The opposition of lung to the raw area on the chest r Type I failure, sometimes called acute hypoxaemic wall causes the surfaces to adhere to one another. Other signs include required, preferably before patients are completely ex- the use of accessory muscles of respiration, tachypnoea, hausted (see Table 3. With time the arteries undergo a and <8kPa when stable with polycythaemia, nocturnal proliferative change leading to irreversible pulmonary hypoxaemia, peripheral oedema or pulmonary hyper- circulationchanges. Patients increase in blood viscosity and predisposes to must have stopped smoking (for safety reasons), and an thrombosis. Investigations Prognosis Blood gas monitoring is the most important initial in- Fifty per cent of patients with severe chronic breathless- vestigation to establish the type of failure and will dictate ness die within 5 years, but in all stopping smoking is the the mode of oxygen therapy. Pulmonary embolism Pathophysiology Following a pulmonary embolus there is a reduction in Denition the perfusion of the lung supplied by the blocked vessel. Thrombus within the pulmonary arteries causing lack Ventilation perfusion mismatch occurs, leading to hy- of lung perfusion. Production of surfactant also stops if perfu- or uncommonly from the heart embolises to the lungs. Infarct is rare (only occurring in around Prevalence 10% of cases) as the lung is also supplied by the bronchial Common. Aetiology The causes of thrombosis can be considered according Clinical features to Virkhow s triad: The result of a pulmonary embolism depends on the size r Disruptioninbloodowparticularlystasis:Prolonged and number of the emboli. Pleural inam- 1 In massive pulmonary embolism, there is haemody- mationresultsinapleuralfrictionrubandalow-grade namic compromise which may require resuscitative pyrexia. With large emboli, thrombolysis or surgical Clinical signs of a deep vein thrombosis may also be thrombectomy with cardiac bypass may be life-saving. For small or moderate Blood enters the pulmonary vasculature and thus there emboli subcutaneous low molecular weight heparin is is congestion proximal to the blockage. Therapy is converted to warfarin after 48 hours (for 3 Repair results in the formation of a white scar. Lifelong war- farin may be indicated depending on the underlying Microscopy cause, or in recurrent embolism. Typical features include haemorrhage (due to extravasa- 3 If anti-coagulants are unsuccessful or contraindicated tion of blood), loss of cell architecture, cellular inltra- a lter may be inserted into the inferior vena cava to tion and occasionally necrosis. Atelectasis and areas of hypoperfusion may be seen, and large emboli may cause Pulmonary hypertension an elevated hemidiaphragm and enlarged proximal pul- Denition monary arteries. A ventilation perfusion (V/Q) scan is Aetiology usually diagnostic, but is less helpful if the chest X-ray Pulmonary hypertension may be secondary to a variety is abnormal. This in turn raises r Right ventricular strain pattern T wave inversion the pulmonary capillary and arterial pressures (left in leads V1 V4. A similar syndrome is associated with Management sytemic lupus erythematosus, scleroderma and Ray- Treatment is aimed at the underlying cause. The result is a de- disease may benet from oxygen therapy to reduce crease in the lumen of the vessels and hence an increased the vasoconstrictor effect of hypoxia. Progressive fail- r Long-term intravenous infusion of epoprostenol ure of the right side of the heart occurs which is called (prostacyclin) improves the outcome of patients with cor pulmonale. The administra- tion of bosentan (a nonselective endothelin receptor Clinical features antagonist) may also be benecial in patients with Dyspnoea, syncope and fatigue are common. Symptoms primarypulmonaryhypertensionalthoughlong-term of the underlying cause and of right ventricular failure follow-up data are not yet available.