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Introduction: Improving pain management in the ED might be attained by adequate teaching of medical students. We assessed the skills in pain treatment of ED physicians who teach the students. Methods: All physicians working in an ED who provide elective training to undergraduate medical students from the Ghent University were asked to complete a questionnaire consisting of vignette patient cases concerning acute pain management of abdominal colic pain, and non-traumatic abdominal pain. Results: Thirty two physicians completed the cases. In the renal colic case 91% of the respondents proposed a NSAID as first line treatment. Butylhyoscine was still suggested by 18%. After initial failure of analgesia 31% administered a strong opioid. In biliary colic pain NSAIDs and butylhyoscine were proposed as first line analgesics by 59% and 31% respectively. In second line, butylhyoscine would be given by 22%. The patient case with right fossa abdominal pain would initially be treated with acetaminophen by 81%. Thirteen % of the respondents would not give further analgesia if the first line treatment was insufficient. Conclusion: Our results indicate that adherence by teachers to evidence based guidelines of acute pain management is insufficient. Therefore improving knowledge and skills in pain management of the teachers should receive more attention.

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The influence of hypovolemia (removal of 30% of the blood volume) on the pharmacokinetics and pharmacodynamics of etomidate was investigated in the rat. Chronically instrumented animals were randomly allocated to either a control (n = 9) or a hypovolemia (n = 9) group, and etomidate was infused (50 mg/kg/h) until isoelectric periods of 5 s or longer were observed in the electroencephalogram. The changes observed in the electroencephalogram were quantified using aperiodic analysis in the 2.5- to 7.5-Hz frequency band and used as a surrogate measure of hypnosis. The righting reflex was used as a clinical measure of hypnosis. The etomidate dose that had to be infused to reach the electroencephalographic endpoint was almost 40% lower (p.01) in the hypovolemic animals than in the control animals. This difference could be attributed to a decrease in clearance (-20%; p =.06) and distribution volume (-30%; p.01) of etomidate. Protein binding was similar in both groups. To investigate changes in end organ sensitivity during hypovolemia, the electroencephalographic effect-versus-effect-site concentration relationship was studied. The effect-plasma concentration relationship was biphasic, exhibiting profound hysteresis in both hypovolemic and control animals. Semiparametric minimization of this hysteresis revealed similar equilibrium half-lives in both groups, and the biphasic effect-concentration relationship was characterized nonparametrically by descriptors. With these descriptors, a slightly increased potency of etomidate during hemorrhage was observed. The concentration at the return of righting reflex was 16% (p.05) lower in the hypovolemic animals. In conclusion, an increased hypnotic effect of etomidate was observed during hypovolemia that is mainly attributed to pharmacokinetic changes. Our data also suggest a small increase in central nervous system sensitivity for etomidate in hypovolemic animals.

OBJECTIVE: To compare the expression of adhesion molecules on intestinal intra-epithelial (IEL) and lamina propria T cells (LPL) from ileum and colon, in patients with Crohn's disease (CD) versus healthy controls, with special reference for the alpha E beta 7 integrin. METHODS: IEL and LPL were obtained from 18 CD patients and 20 controls by enzymatic extraction, and subsequently characterized by flow cytometry for CD3, CD4, CD8, CD25, LFA-1 alpha (CD11a), CD44, alpha 4 and alpha E beta 7 integrin. RESULTS: In LPL of controls, a decreased CD4/CD8 ratio was noted in ileum compared to colon. This regional difference was accompanied by a higher expression of alpha E beta 7 integrin in ileum versus colon. In LPL from left hemicolon of CD patients, a decreased CD4/CD8 ratio was noted versus controls. alpha E beta 7 expression on T cells of LPL did not discriminate CD from controls. However, an overexpression of this beta 7 integrin member was observed on CD25+ T cell subsets from lamina propria of left hemicolon, in CD versus controls. Moreover, in IEL, profound alterations in alpha E beta 7 integrin were observed in CD, compared to controls. A decreased expression of alpha E beta 7 was noted in IEL of ileum of CD patients. This was also apparent in non-inflamed mucosa. CONCLUSION: The observed changes of alpha E beta 7 integrin expression in CD patients versus controls are of pathogenic relevance, especially the decreased expression of alpha E beta 7 in IEL of non-inflamed CD mucosa. This may be one of the earliest events in the pathogenesis of this disease

BACKGROUND: The fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil. METHODS: A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. RESULTS: The results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations. CONCLUSIONS: The results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.

There are few comprehensive studies available on barriers encountered from the initial seeking of healthcare through to the resolution of the health problem; in other words, on access in its broad domain. For Colombia and Brazil, countries with different healthcare systems but common stated principles, there have been no such analyses to date. This paper compares factors that influence access in its broad domain in two municipalities of each country, by means of a cross-sectional study based on a survey of a multistage probability sample of people who had had at least one health problem within the last three months (2163 in Colombia and 2155 in Brazil). The results reveal important barriers to healthcare access in both samples, with notable differences between and within countries, once differences in sociodemographic characteristics and health needs are accounted for. In the Colombian study areas, the greatest barriers were encountered in initial access to healthcare and in resolving the problem, and similarly when entering the health service in the Brazilian study areas. Differences can also be detected in the use of services: in Colombia greater geographical and economic barriers and the need for authorization from insurers are more relevant, whereas in Brazil, it is the limited availability of health centres, doctors and drugs that leads to longer waiting times. There are also differences according to enrolment status and insurance scheme in Colombia, and between areas in Brazil. The barriers appear to be related to the Colombian system's segmented, non-universal nature, and to the involvement of insurance companies, and to chronic underfunding of the public system in Brazil. Further research is required, but the results obtained reveal critical points to be tackled by health policies in both countries.

INTRODUCTION: Health system reforms are undertaken with the aim of improving equity of access to health care. Their impact is generally analyzed based on health care utilization, without distinguishing between levels of care. This study aims to analyze inequities in access to the continuum of care in municipalities of Brazil and Colombia. METHODS: A cross-sectional study was conducted based on a survey of a multistage probability sample of people who had had at least one health problem in the prior three months (2,163 in Colombia and 2,167 in Brazil). The outcome variables were dichotomous variables on the utilization of curative and preventive services. The main independent variables were income, being the holder of a private health plan and, in Colombia, type of insurance scheme of the General System of Social Security in Health (SGSSS). For each country, the prevalence of the outcome variables was calculated overall and stratified by levels of per capita income, SGSSS insurance schemes and private health plan. Prevalence ratios were computed by means of Poisson regression models with robust variance, controlling for health care need. RESULTS: There are inequities in favor of individuals of a higher socioeconomic status: in Colombia, in the three different care levels (primary, outpatient secondary and emergency care) and preventive activities; and in Brazil, in the use of outpatient secondary care services and preventive activities, whilst lower-income individuals make greater use of the primary care services. In both countries, inequity in the use of outpatient secondary care is more pronounced than in the other care levels. Income in both countries, insurance scheme enrollment in Colombia and holding a private health plan in Brazil all contribute to the presence of inequities in utilization. CONCLUSIONS: Twenty years after the introduction of reforms implemented to improve equity in access to health care, inequities, defined in terms of unequal use for equal need, are still present in both countries. The design of the health systems appears to determine access to the health services: two insurance schemes in Colombia with different benefits packages and a segmented system in Brazil, with a significant private component.

Summary The Public-Private Mix for Directly Observed Treatment, Short Course (PPM-DOTS) programme has been hailed as a success story in international cooperation. However, the evidence emerging from a range of sources suggests that this confidence may be motivated more by a desire to eulogize participation by private providers per se rather than on evidence of impact in terms of the cases treated. This review of literature has therefore been triggered by the need for a sober assessment of the progress of the strategy of PPM-DOTS to date, and queries the extent to which tuberculosis control is embedded in sustainable national tuberculosis control programmes. Our concerns over PPM-DOTS relate to three factors: Firstly, there is growing doubt about the stewardship role of the state in LICs to adequately supervise the private for-profit sector. There is evidence from some regions that the current arrangements further weaken what remains of the public health system. Secondly, the nature of the private for-profit sector, which in most settings is highly diverse, requires a coherent national health system absent in many cases; this fragments tuberculosis control, and undermines the long-term sustainability of PPM-DOTS. Thirdly, the complex nature of partnerships and the frequent lack of adequate public sector supervision are leading to a rise in multidrug resistance as reported from many regions.