Are bad health and pain making us grumpy? An empirical evaluation of reporting heterogeneity in rating health system responsiveness

This paper considers the influence of patients’ characteristics on their evaluation of a health system’s responsiveness, that is, a system’s ability to respond to the legitimate expectations of potential users regarding non-health enhancing aspects of care (Valentine et al. 2003a). Since responsiveness is evaluated by patients on a categorical scale, their selfevaluation can be affected by the phenomenon of reporting heterogeneity (Rice et al. 2012). A few studies have investigated how standard socio-demographic characteristics influence the reporting style of health care users with regard to the question of the health system’s responsiveness (Sirven et al. 2012, Rice et al. 2012). However, we are not aware of any studies that focus explicitly on the influence that both the patients’ state of health and their experiencing of pain have on the way in which they report on system responsiveness. This paper tries to bridge this gap by using data regarding a sample of patients hospitalized in four Local Health Authorities (LHA) in Italy’s Emilia-Romagna region between 2010 and 2012. These patients have evaluated 27 different aspects of the quality of care, concerning five domains of responsiveness (communication, social support, privacy, dignity and quality of facilities). Data have been stratified into five sub-samples, according to these domains. We estimate a generalized ordered probit model (Terza, 1985), an extension of the standard ordered probit model which permits the reporting behaviour of respondents to be modelled as a function of certain respondents’ characteristics, which in our analysis are represented by the variables “state of health” and “pain”. Our results suggest that unhealthier patients are more likely to report a lower level of responsiveness, all other things being equal, while patients experiencing pain are more likely to make use of the extreme categories of responsiveness, that is, to choose the category “completely dissatisfied” or the category “completely satisfied”. These results hold across all five domains of responsiveness

Mediatori dei conflitti in ambito sanitario

Fino a qualche decennio fa, il modello di gestione dei conflitti sociali basato sul controllo da parte di un’autorità centrale sulle azioni di individui subordinati e l’applicazione di sanzioni in caso di violazione delle norme era pressochè universalmente accettato (Arielli & Scotto, 2003). Soltanto nei primi anni sessanta questo modello è stato messo in discussione, soprattutto nel campo delle relazioni industriali. A partire da quel momento si è registrata una crescente attenzione verso modelli interattivi di assunzione delle decisioni e di risoluzione delle controversie (Valdambrini, 2008). La mediazione risulta essere la pratica più distante dal processo giudiziale in quanto si distingue da esso e dagli altri metodi ADR (conciliazione, negoziazione, arbitrato) soprattutto per l’assenza di potere cogente da parte del mediatore che non solo non emette giudizi, assegna risarcimenti o applica sanzioni, ma - in molti casi - nemmeno suggerisce possibili soluzioni ai confliggenti. Il contesto professionale sanitario risulta essere un settore in cui l’utilizzo di tali pratiche è appena agli inizi. Un aspetto interessante è che questo ritardo non è una caratteristica italiana, riconducibile a dinamiche culturali restie nell’accogliere pratiche innovative. L’introduzione della gestione costruttiva dei conflitti nei contesti sanitari è un fenomeno recente anche nei paesi anglosassoni, dove pratiche come la mediazione vantano qualche decennio di attività (Robson & Morrison, 2003). Nel 2005 la Regione Emilia-Romagna ha promosso un progetto di formazione volto ad inserire nei percorsi di reclamo/denuncia aziendali soggetti in grado di esercitare la funzione di mediatori dei conflitti fra utenti e operatori. Nel giro di tre anni sono stati formati 67 mediatori dei conflitti attraverso 3 corsi di formazione. I mediatori sono tuttora presenti in tutte le aziende sanitarie regionali e in alcune strutture private accreditate, nonché in alcune realtà extra-regionali. Il Dott. Ragazzi ha seguito fin dall’inizio il progetto lavorando a stretto contatto con tutti gli attori organizzativi interessati (responsabili del progetto a livello regionale e aziendale, mediatori, formatori, medici legali, responsabili Uffici Relazioni con il Pubblico, personale medico e infermieristico, etc.) e intervenendo in modo significativo nelle varie fasi progettuali: valutazione del progetto formativo, monitoraggio dell’attività in azienda, supervisione e riprogrammazione della funzione organizzativa di mediazione dei conflitti. Con una lucida espressione Robson e Morrison (2003) definiscono la sanità come un “sistema adattabile complesso” caratterizzato da «collegamenti fluidi, regole flessibili che si affidano alla storia del sistema, cambiamento costante, un volume di dati enorme e cicli di risposte multipli, ma accesso limitato alle informazioni di altri». Il candidato ha dunque accompagnato l’evoluzione della comunità di pratica dei mediatori dei conflitti (Wenger, 1998) in un contesto caratterizzato da una ‘complessa indefinitezza organizzativa’ e composto da attori sociali mossi da dinamiche distanti e contrastanti a livello di potere, valori, culture professionali, interessi economici e di sistema. L’approccio del candidato di fronte alla situazione descritta è stato dunque quello dell’action research che si pone l'obiettivo non tanto di approfondire conoscenze teoriche, ma di utilizzare le conoscenze a disposizione per analizzare una pratica messa in atto da un attore sociale in un contesto composto da altri attori sociali in cui è incluso il ricercatore stesso con lo scopo di introdurre, nella pratica stessa, dei cambiamenti migliorativi, documentando i processi e le dinamiche osservate e offrendosi al sistema come specchio in cui osservarsi e comprendersi (Zucchermaglio & Alby, 2006)

Anti-diabetic combination therapy with pioglitazone or glimepiride added to metformin on the AGE-RAGE axis: a randomized prospective study

Introduction: The ratio between advanced glycation end products (AGEs) and soluble form of receptor (s-RAGE) has been proposed as a risk marker for renal and cardiovascular diseases. The aim of this study was to evaluate in the diabetes condition the influence of two different oral anti-diabetic treatments on the AGE/ s-RAGE ratio, during a 5-year observation period. Methods: Seventy-three patients with type 2 diabetes mellitus were randomly assigned to a drug therapy with pioglitazone or glimepiride, combined to metformin. Each subject was evaluated at baseline and after 5 years of treatment. Results: In both groups s-RAGE levels did not significantly vary, while the levels of AGE and AGE/s-RAGE were both significantly reduced, basal compared to 5-year values. Within pioglitazone group, as well within glimepiride group, significant variations (D, as difference between 5 years of treatment minus basal) were observed for AGE (D= ˗21.1±13.4 μg/ml, P<0.001 for pioglitazone; D= ˗14.4±11.4 μg/ml, P<0.001 for glimepiride) and in AGE/s-RAGE (D= -0.037±0.022 μg/pg, P<0.001 for pioglitazone; D= -0.024±0.020μg/pg, P<0.001 for glimepiride), suggesting an average decrease of the parameters by more than 50% in both treatments. Pioglitazone was more effective than glimepiride in reducing AGE/s- RAGE ratio after 5 years of therapy. Conclusion: These data can help to explain the benefits of oral anti-diabetic therapy in relation to the reduction of cardiovascular risk, as suggested by variations in AGE/s-RAGE ratio as biochemical marker of endothelial function; in particular, treatment with pioglitazone seems to offer greater long-term benefit on AGE-RAGE axis

In Vivo and Ex Vivo Confocal Microscopy for Dermatologic and Mohs Surgeons

Confocal microscopy is a modern imaging device that has been extensively applied in skin oncology. More specifically, for tumor margin assessment, it has been used in two modalities: reflectance mode (in vivo on skin patient) and fluorescence mode (on freshly excised specimen). Although in vivo reflectance confocal microscopy is an add-on tool for lentigo maligna mapping, fluorescence confocal microscopy is far superior for basal cell carcinoma and squamous cell carcinoma margin assessment in the Mohs setting. This article provides a comprehensive overview of the use of confocal microscopy for skin cancer margin evaluation

Fluorescence confocal microscopy for pathologists

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TERT Promoter Mutations in Papillary Thyroid Microcarcinomas

Small papillary thyroid carcinomas have contributed to the worldwide increased incidence of differentiated thyroid cancer observed over the past decades. However, the mortality rate has not changed over the same period of time, raising questions about the possibility that thyroid cancer patients, especially those with small tumors, are overdiagnosed and overtreated. Molecular prognostic marker able to discriminate aggressive thyroid cancers from those with an indolent course would be of great relevance to tailor the therapeutic approach and reduce overtreatment. Mutations in the TERT promoter were recently reported to correlate strongly with aggressiveness in advanced forms of thyroid cancer, holding promise for a possible clinical application. The occurrence and potential clinical relevance of TERT mutations in papillary thyroid microcarcinomas (mPTCs) is currently unknown. This study aimed to analyze the occurrence of two TERT promoter mutations (-124C>T and -146C>T) and their potential association with unfavorable clinical features in a large cohort of mPTCs

The Moss Macromitrium Richardii (Orthotrichaceae) with Sporophyte and Calyptra Enclosed in Hymenaea Resin from the Dominican Republic

Abstract Dominican amber is an important source for Early Miocene bryophytes. We report the moss Macromitrium richardii Schwägr., an extant representative of the Orthotrichaceae, from the Dominican amber collection of the American Museum of Natural History. This species is currently a widespread Neotropical epiphyte. The specimen includes several gametophytes and sporophytes, and represents the first fossil record of Orthotrichaceae. Alongside the Macromitrium shoots we observed several fragments of the liverworts Cheilolejeunea antiqua and Frullania sp. The unusual thermal behavior of the resin sample initially led to doubts about the Miocene age of the specimen, but chemical analyses of the Hymenaea resin provides evidence that the specimen represents a highly oxidized sample of Miocene Dominican amber rather than an artificially thermally-treated subfossil resin (copal). Our inclusion demonstrates the exceptional preservation potential of tree resin, but our observations also suggest that provenance (including any possibility that a modern resin has been thermally treated to make it appear older) should be scrutinized when single pieces with atypical thermal behavior and exceptionally well-preserved extant morphotypes come to light

Mediterranean Diet and Red Yeast Rice Supplementation for the Management of Hyperlipidemia in Statin-Intolerant Patients with or without Type 2 Diabetes

Lipid profile could be modified by Mediterranean diet (MD) and by red yeast rice (RYR). We assessed the lipid-lowering effects of MD alone or in combination with RYR on dyslipidemic statin-intolerant subjects, with or without type 2 diabetes, for 24 weeks. We evaluated the low-density lipoprotein (LDL) cholesterol level, total cholesterol (TC), high-density lipoprotein (HDL) cholesterol, triglyceride, liver enzyme, and creatinine phosphokinase (CPK) levels. We studied 171 patients: 46 type 2 diabetic patients treated with MD alone (Group 1), 44 type 2 diabetic patients treated with MD associated with RYR (Group 2), 38 dyslipidemic patients treated with MD alone (Group 3), and 43 dyslipidemic patients treated with MD plus RYR (Group 4). The mean percentage changes in LDL cholesterol from the baseline were -7.34±3.14% (P0.05). No significant increase in AST, ALT, and CPK levels was observed in all groups. Our results indicate that MD alone is effective in reducing LDL cholesterol levels in statin-intolerant patients with a presumably low cardiovascular risk, but associating MD with the administration of RYR improves patients’ LDL cholesterol levels more, and in patients with type 2 diabetes

Intercalibration of the barrel electromagnetic calorimeter of the CMS experiment at start-up

Calibration of the relative response of the individual channels of the barrel electromagnetic calorimeter of the CMS detector was accomplished, before installation, with cosmic ray muons and test beams. One fourth of the calorimeter was exposed to a beam of high energy electrons and the relative calibration of the channels, the intercalibration, was found to be reproducible to a precision of about 0.3%. Additionally, data were collected with cosmic rays for the entire ECAL barrel during the commissioning phase. By comparing the intercalibration constants obtained with the electron beam data with those from the cosmic ray data, it is demonstrated that the latter provide an intercalibration precision of 1.5% over most of the barrel ECAL. The best intercalibration precision is expected to come from the analysis of events collected in situ during the LHC operation. Using data collected with both electrons and pion beams, several aspects of the intercalibration procedures based on electrons or neutral pions were investigated

Benefit analysis. Assessing the cost of blackouts in case of attack. Evaluation based on Italian and Polish case studies

RT 52; This report provides an economic quantification of the benefits of implementing security standards, expressed in terms of avoided costs of blackouts. The evaluation considers specifically the blackouts described in the Italian and Polish trials, employing a mixed methodology relying on the “production function” approach for the non-household sector, while an econometric method based on survey data (stated preferences) is used for household consumers. With reference to non-households, a separate evaluation is carried on for the electricity industry. The results show that the costs of blackout are substantial, either for household and non-household consumers, and largely exceed the damage suffered by the utilities ue to lost sales. Finally, since for non-households only losses in production are considered, we provide, in a separate section, three case studies demonstrating that some industries can suffer relevant additional blackout cost