The future prospects of Lithuanian family physicians: a 10-year forecasting study

BACKGROUND: When health care reform was started in 1991, the physician workforce in Lithuania was dominated by specialists, and the specialty of family physician (FP) did not exist at all. During fifteen years of Lithuania's independence this specialty evolved rapidly and over 1,900 FPs were trained or retrained. Since 2003, the Lithuanian health care sector has undergone restructuring to optimize the network of health care institutions as well as the delivery of services; specific attention has been paid to the development of services provided by FPs, with more health care services shifted from the hospital level to the primary health care level. In this paper we analyze if an adequate workforce of FPs will be available in the future to take over new emerging tasks. METHODS: A computer spreadsheet simulation model was used to project the supply of FPs in 2006–2015. The supply was projected according to three scenarios, which took into account different rates of retirement, migration and drop out from training. In addition different population projections and enrolment numbers in residency programs were also considered. Three requirement scenarios were made using different approaches. In the first scenario we used the requirement estimated by a panel of experts using the Delphi technique. The second scenario was based on the number of visits to FPs in 2003 and took into account the goal to increase the number of visits. The third scenario was based on the determination that one FP should serve no more than 2,000 inhabitants. The three scenarios for the projection of supply were compared with the three requirement scenarios. RESULTS: The supply of family physicians will be higher in 2015 compared to 2005 according to all projection scenarios. The largest differences in the supply scenarios were caused by different migration rates, enrolment numbers to training programs and the retirement age. The second supply scenario, which took into account 1.1% annual migration rate, stable enrolment to residency programs and later retirement, appears to be the most probable. The first requirement scenario, which was based on the opinion of well-informed key experts in the field, appears to be the best reflection of FP requirements; however none of the supply scenarios considered would satisfy these requirements. CONCLUSION: Despite the rapid expansion of the FP workforce during the last fifteen years, ten-year forecasts of supply and requirement indicate that the number of FPs in 2015 will not be sufficient. The annual enrolment in residency training programs should be increased by at least 20% for the next three years. Accurate year-by-year monitoring of the workforce is crucial in order to prevent future shortages and to maintain the desired family physician workforce

Effect of sitagliptin on cardiovascular outcomes in type 2 diabetes

BACKGROUND: Data are lacking on the long-term effect on cardiovascular events of adding sitagliptin, a dipeptidyl peptidase 4 inhibitor, to usual care in patients with type 2 diabetes and cardiovascular disease. METHODS: In this randomized, double-blind study, we assigned 14,671 patients to add either sitagliptin or placebo to their existing therapy. Open-label use of antihyperglycemic therapy was encouraged as required, aimed at reaching individually appropriate glycemic targets in all patients. To determine whether sitagliptin was noninferior to placebo, we used a relative risk of 1.3 as the marginal upper boundary. The primary cardiovascular outcome was a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina. RESULTS: During a median follow-up of 3.0 years, there was a small difference in glycated hemoglobin levels (least-squares mean difference for sitagliptin vs. placebo, -0.29 percentage points; 95% confidence interval [CI], -0.32 to -0.27). Overall, the primary outcome occurred in 839 patients in the sitagliptin group (11.4%; 4.06 per 100 person-years) and 851 patients in the placebo group (11.6%; 4.17 per 100 person-years). Sitagliptin was noninferior to placebo for the primary composite cardiovascular outcome (hazard ratio, 0.98; 95% CI, 0.88 to 1.09; P<0.001). Rates of hospitalization for heart failure did not differ between the two groups (hazard ratio, 1.00; 95% CI, 0.83 to 1.20; P = 0.98). There were no significant between-group differences in rates of acute pancreatitis (P = 0.07) or pancreatic cancer (P = 0.32). CONCLUSIONS: Among patients with type 2 diabetes and established cardiovascular disease, adding sitagliptin to usual care did not appear to increase the risk of major adverse cardiovascular events, hospitalization for heart failure, or other adverse events

Intracellular distribution of nontargeted quantum dots after natural uptake and microinjection

Leona Damalakiene,1 Vitalijus Karabanovas,2 Saulius Bagdonas,1 Mindaugas Valius,3 Ricardas Rotomskis1,21Biophotonics Group, Laser Research Center, Faculty of Physics, 2Biomedical Physics Laboratory, Institute of Oncology, 3Proteomics Center, Institute of Biochemistry, Vilnius University, Vilnius, LithuaniaBackground: The purpose of this study was to elucidate the mechanism of natural uptake of nonfunctionalized quantum dots in comparison with microinjected quantum dots by focusing on their time-dependent accumulation and intracellular localization in different cell lines.Methods: The accumulation dynamics of nontargeted CdSe/ZnS carboxyl-coated quantum dots (emission peak 625 nm) was analyzed in NIH3T3, MCF-7, and HepG2 cells by applying the methods of confocal and steady-state fluorescence spectroscopy. Intracellular colocalization of the quantum dots was investigated by staining with Lysotracker&amp;reg;.Results: The uptake of quantum dots into cells was dramatically reduced at a low temperature (4&amp;deg;C), indicating that the process is energy-dependent. The uptake kinetics and imaging of intracellular localization of quantum dots revealed three accumulation stages of carboxyl-coated quantum dots at 37&amp;deg;C, ie, a plateau stage, growth stage, and a saturation stage, which comprised four morphological phases: adherence to the cell membrane; formation of granulated clusters spread throughout the cytoplasm; localization of granulated clusters in the perinuclear region; and formation of multivesicular body-like structures and their redistribution in the cytoplasm. Diverse quantum dots containing intracellular vesicles in the range of approximately 0.5&amp;ndash;8 &amp;micro;m in diameter were observed in the cytoplasm, but none were found in the nucleus. Vesicles containing quantum dots formed multivesicular body-like structures in NIH3T3 cells after 24 hours of incubation, which were Lysotracker-negative in serum-free medium and Lysotracker-positive in complete medium. The microinjected quantum dots remained uniformly distributed in the cytosol for at least 24 hours.Conclusion: Natural uptake of quantum dots in cells occurs through three accumulation stages via a mechanism requiring energy. The sharp contrast of the intracellular distribution after microinjection of quantum dots in comparison with incubation as well as the limited transfer of quantum dots from vesicles into the cytosol and vice versa support the endocytotic origin of the natural uptake of quantum dots. Quantum dots with proteins adsorbed from the culture medium had a different fate in the final stage of accumulation from that of the protein-free quantum dots, implying different internalization pathways.Keywords: endocytosis, internalization, carboxyl, lysosome, protein corona, multivesicular body-like structures, ring-like vesicles, green fluorescent protein, pathway, saturatio

Ten years of primary care reform in Lithuania: comparing the task profiles of primary care doctors in 1994 and GPs in 2004.

Background: Since its independence in 1990 Lithuania is transforming health care from the previous Soviet system to a decentralised social insurance based system with a strong emphasis on primary care. Doctors have been re-trained to become GPs with a gatekeeping position. GPs can either work as employees in the public centres or in their own private practice, contracted to the system. Family medicine residency programmes have been developed. Health centres have been modernised and new centres have been established. This paper is an evaluation of changes between 1994 and 2004 with respect to the profile of specific tasks provided by Lithuanian primary care doctors to their patients. Methods: In 1994 and 2004 identical questionnaires have been completed by random samples of primary care physicians about the following services: minor surgical procedures, management and follow up of diseases, and prevention and health education. Data entry, processing, and analysis were carried out using SPSS software. Results: In 1994 the response among district doctors was 333 (87%) and among primary care paediatricians 262 (87%). In 2004 the response among GPs was 298 (73%). Nowadays GPs aresignificantly more involved than primary care doctors 10 years ago in the provision of most medical procedures considered in the questionnaire. Similarly, GPs were significantly more involved in the treatment of a number of diseases, though not with all diseases considered. With respect to prevention no increase was found. Despite the improvements overall, the current position of GPs in Lithuania in the aspects considered is still clearly behind the position of GPs in western Europe in 1994. Conclusions: GP task profiles are more comprehensive now than they were 10 years ago, but continued efforts and time will be needed to reach the profile of provision of GPs in western European countries. (aut.ref.

Primary care in a post-communist country 10 years later: comparison of service profiles of Lithuanian primary care physicians in 1994 and GPs in 2004.

OBJECTIVES: The study aimed, firstly, to assess changes in the service profile of primary care physicians between 1994, when features of the Soviet health system prevailed, and 2004, when retraining of GPs was completed. Secondly, to compare service profiles among current GPs, taking into account their positions before being retrained. METHODS: A cross-sectional repeated measures study was conducted among district therapists and district pediatricians in 1994 and GPs in 2004. A questionnaire was used containing identical items on the physicians' involvement in curative and preventive services. The response rates in both years were 87% and 73%, respectively. RESULTS: In 2004, physicians had much more office contacts with patients than in 1994. Modest progress was made with the provision of technical procedures. Involvement in disease management was also stronger in 2004 than in 1994, particularly among former pediatricians. Involvement in screening activities remained stable among former therapists and increased among former pediatricians. At present, GPs who used to be therapists provide a broader range of services than ex pediatricians. GPs from the residency programme hold an intermediate position. CONCLUSIONS: Lithuanian GPs have taken up new tasks but variation can be reduced. The health care system is still in the midst of transition. (aut. ref.

Organizational and structural changes in PHC centres during health care reform in Lithuania.

Background: The increasing health care inequalities and morbidity, inefficient payment system challenged to a new health care reform with its priority primary health care after Lithuania’s independence in 1990. Former district doctors have been re-trained to become GPs and former policlinics have been modernized and decentralized. The private medicine was introduced. This paper is an evaluation of structural and organizational changes in PHC centres between 1994 and 2004. Research question: Are PHC centres better organized after PHC reform? Are there any differences between private and public PHC centres in 2004? Methods: In 1994 and 2004 identical questionnaires have been completed by random samples of primary care physicians about the: workload, working arrangement, practice equipment. Data entry, processing and analysis were carried out using SPSS software. Results: In 1994 the response among district doctors was 333 (87%) and among primary care pediatricians 262 (87%). In 2004 the response among GPs was 298 (73%). The number of the patients per GP decreased in 2004, but the number of office contacts, consultations by phone and workload increased in 2004. There were more equipment items in 2004. The number of home visits decreased in 2004. The distance of PHC centres were longer and there were less possibility to make an advanced appointment for a consultation in 1994. Comparing private and public PHC centres there were some differences: more patients per GP in public practice, but normal working hours higher in private PHC centres. The public PHC centres had more equipment. Conclusions: PHC centres are better organized then they were ten years ago. Private PHC centres have less equipment and less patients per GP, but private GPs have more time for their patients. Continued efforts, finance and time will be needed to reach the organization principles of western European countries