Access Problems (access + problem)

Distribution by Scientific Domains

Selected Abstracts

Pediatrics Access Problems in hemodialysis with a permanent central venous catheter

J. Muscheites
Hemodialysis is a common treatment of chronic renal failure, also in childhood. Due to the high standard of technique there are only few contraindications for this treatment at present. Limitations are given by the vessel access. But in the last years, hemodialysis has been made practicable by the permanent central venous catheter, however, with more problems. As an example for potential complications in the treatment with the permanent catheter we present an unusual case report about a twenty-one- year-old girl suffering from chronic renal failure due to reflux nephropathy, Prader-Willi- syndrome, myelonatrophia of undetermined origin with spastic diplegia of the legs, and increasing sphincter ani dysfunction. We started the renal replacement therapy when the girl was 15 years old. It was not possible to create an AV fistula due to very small vessels. Two Gore-Tex ® implants were clotted in absence of thrombophilia. Afterwards, the hemodialysis was performed by a permanent central venous catheter. The catheter had to be changed 15 times. The reasons for changing the catheter were problems of flow during hemodialysis due to clotting, dislocations, spontaneous removing of the catheter by herself, and infections. Altogether a sepsis occurred four times. The first transplantation failed due to a rupture of the transplanted kidney. A second transplantation was not possible because of the high BMI. Intermittently, the girl was treated with peritoneal dialysis (PD) in the hospital, because the PD couldn't be done at home due to different reasons. Only on weekends could the girl go home. The PD had to be finished after 6 months due to a severe psychotic syndrome. The girl died at age 21, caused by a sepsis following the 15th change of the catheter. A huge problem of frequent catheter changing is the limited availability of vessel accesses , the limits of treatment by hemodialysis. [source]

Direct adsorption of low-density lipoprotein and lipoprotein(a) from whole blood: Results of the first clinical long-term multicenter study using DALI apheresis,

T. Bosch
Abstract Direct adsorption of lipoproteins (DALI) is the first low-density lipoprotein (LDL)-apheresis technique by which atherogenic LDL and lipoprotein(a) (Lp(a)) can be selectively removed from whole blood without plasma separation. The present study was performed to evaluate the efficacy, selectivity and safety of long-term DALI apheresis. Sixty-three hypercholesterolemic coronary patients were treated by weekly DALI sessions. Initial LDL-cholesterol (C) plasma levels averaged 238 ± 87 mg/dl (range 130,681 mg/dl). On average, 34 sessions (1,45) were performed processing 1.5 patient blood volumes. The primary aim was to acutely reduce LDL-C by ,60% per session. To this end, three different adsorber sizes could be employed, i.e., DALI 500, 750, and 1,000, which were used in 4, 73, and 23% of the 2,156 sessions, respectively. On average, 7,387 ml of blood were processed in 116 min per session. This resulted in the following mean acute changes: LDL-C 198 , 63 mg/dl (,69%), Lp(a) 86 , 32 mg/dl (,64%), triglycerides 185 , 136 mg/dl (,27%). HDL-C (,11%) and fibrinogen (,15%) were not significantly influenced. The mean long-term reduction of LDL-C was 42% compared to baseline while HDL-C slightly increased in the long run (+4%). The selectivity of LDL removal was good as recoveries of albumin, immunoglobulins, and other proteins exceeded 85%. Ninety-five percent of 2,156 sessions were completely uneventful. The most frequent adverse effects were hypotension (1.2% of sessions) and paresthesia (1.1%), which were probably due to citrate anticoagulation. Access problems had to be overcome in 1.5%, adsorber and hardware problems in 0.5% of the sessions. In this multicenter long-term study, DALI apheresis proved to be an efficient, safe, and easy procedure for extracorporeal LDL and Lp(a) elimination. J. Clin. Apheresis 17:161,169, 2002. © 2002 Wiley-Liss, Inc. [source]

Access to energy services by the poor in India: Current situation and need for alternative strategies

V. S. Ailawadi
Abstract Poor and inadequate access to clean, reliable and affordable energy is now considered a major concern for sustainable development. India houses about a third of the world's population without access to electricity and about 40% of those without access to modern energy. This article considers India's challenge in this area, examines the energy access situation, and analyses measures pursued to improve it. The article argues that the current focus on rural electrification is unlikely to resolve the energy access problem, due to the low penetration of electricity in the energy mix of the poor. The article also argues that strategies based on energy market reform, promotion of renewable technologies and correct price signals are unlikely to succeed in changing the situation, as acceptance of this policy prescription is rather low. Instead, a bottom-up, holistic, long-term approach is suggested that integrates energy access with economic development, and relies on selective market intervention, local resources and local governance. [source]

The End of an Era: What Became of the "Managed Care Revolution" in 2001?

Cara S. Lesser
Objective. To describe how the organization and dynamics of health systems changed between 1999 and 2001, in the context of expectations from the mid-1990s when managed care was in ascendance, and assess the implications for consumers and policymakers. Data Sources/Study Setting. Data are from the Community Tracking Study site visits to 12 communities that were randomly selected to be nationally representative of metropolitan areas with 200,000 people or more. The Community Tracking Study is an ongoing effort that began in 1996 and is fielded every two years. Study Design. Semistructured interviews were conducted with 50,90 stakeholders and observers of the local health care market in each of the 12 communities every two years. Respondents include leaders of local hospitals, health plans, and physician organizations and representatives of major employers, state and local governments, and consumer groups. First round interviews were conducted in 1996,1997 and subsequent rounds of interviews were conducted in 1998,1999 and 2000,2001. A total of 1,690 interviews were conducted between 1996 and 2001. Data Analysis Methods. Interview information was stored and coded in qualitative data analysis software. Data were analyzed to identify patterns and themes within and across study sites and conclusions were verified by triangulating responses from different respondent types, examining outliers, searching for disconfirming evidence, and testing rival explanations. Principal Findings. Since the mid-1990s, managed care has developed differently than expected in local health care markets nationally. Three key developments shaped health care markets between 1999 and 2001: (1) unprecedented, sustained economic growth that resulted in extremely tight labor markets and made employers highly responsive to employee demands for even fewer restrictions on access to care; (2) health plans increasingly moved away from core strategies in the "managed care toolbox"; and (3) providers gained leverage relative to managed care plans and reverted to more traditional strategies of competing for patients based on services and amenities. Conclusions. Changes in local health care markets have contributed to rising costs and created new access problems for consumers. Moreover, the trajectory of change promises to make the goals of cost-control and quality improvement more difficult to achieve in the future. [source]

Preliminary Results from the Use of New Vascular Access (Hemaport) for Hemodialysis

J Ahlmén
One of the most important factors for an optimal chronic hemodialysis is a well- functioning vascular access. Still the A-V-fistula is the best alternative. When repeated failures arise new access alternatives are needed. The Hemaport combines a PTFE-graft with a percutaneous housing of titan. Starting and stopping the dialysis session is simple and needle-free. The first clinical experiences are presented. Thirteen patients (m-age 60 years) in 6 centres had used the Hemaport system. Out of 11 functioning devices 7 were placed on the upper arm and 4 were located on the thigh. The total days in observation were 2.156 days with 769 dialysis sessions performed. Six patients had used the Hemaport system for more than 6 months. Mean blood flow was 364, range 100,450 ml/min with a mean venous and arterial pressure of 100 mm Hg, range 30,250, and 16 mm Hg respectively, range , 140 to + 259. Thrombosis interventions have been required in 14 percent to obtain a functioning vascular access. Two patients contributed with more than half of these events. Mechanical or pharmacological thrombolysis can be performed through the Hemaport dialysis lid without open surgery. Six implants have been removed and in 5 of these cases a new Hemaport was implanted. The reasons for removing the device were related to insufficient vascular flow, thrombosis, and/or infection. In patients with repeated access problems, a new vascular access (Hemaport) has been clinically used for about 1 year. By its design, Hemaport offers a novel approach. [source]

Resource management model and performance evaluation for satellite communications

Axel Jahn
Abstract Efficient resource management is mandatory to achieve maximum system capacity for next generation communications systems. Resource management deals with the available spectral band, time, power, and space for a transmission signal. It includes (i) the frequency planning, (ii) the selection of transmit power, and (iii) the assignment of the channels and access nodes to the users. The paper presents a generalized notation as well as graph algorithms for resource management problems. Impairment graphs can be used for frequency planning, whereas flow graphs are suitable for channel access problems. To evaluate the performance of the resource management, service criteria (such as blocking or the carrier to interference ratio C/I) or efficiency criteria (bandwidth requirements) can be derived from the graphs. The resource management techniques are applied to satellite networks with non-geostationary orbits yielding time-variant network topologies. As a simple example, the channel assignment and capacity optimization of the EuroSky Way system are shown. Furthermore, a comparison of fixed, dynamic and hybrid channel allocation schemes (FCA, DCA, HCA) for a typical MEO satellite scenario is given. Satellite diversity and its impact on bandwidth requirement and transmission quality is also examined. Finally, it is shown how spread spectrum systems can be investigated with the presented tools. Copyright © 2001 John Wiley & Sons, Ltd. [source]

The geographies of crisis: exploring accessibility to health care in Canada

There is increasing concern in Canada that the health care system is in a state of crisis. It is argued that reductions in federal government transfers to the provinces have resulted in a health care system characterized by under-funding in key areas and policy decisions based more on provincial fiscal concerns than the health needs of their constituents. Provincial governments have responded to reduced levels in federal funding by undertaking aggressive restructuring tactics such as the closure of hospitals and the deinsuring of medical services from provincial health plans. The end result of this restructuring, as argued by the media, consumer groups and indeed some health researchers, is a state of crisis' (i.e., lower levels of accessibility, long waiting lists, overcrowding in hospitals and increasing costs of medication). One crisis theme often mentioned is that fiscal decisions of various kinds are reducing economic and geographic accessibility, one of the five principles of the Canada Health Act (CHA) that defines the very essence of the Canadian health care system. Using data from the 1998-99 National Population Health Survey (NPHS), this paper explores the extent to which an accessibility crisis exists within the Canadian health care system by examining access to health care services and the barriers encountered in trying to access services in each of the ten provinces. The results show that approximately 6.0 percent of Canadians report access problems, with values ranging from 4.5 percent in Newfoundland to 8.3 percent in Manitoba. Regional variations in barriers to accessing care were also observed. In particular, geographic accessibility appears to be a main barrier to care in Atlantic Canada while economic accessibility emerges as a main barrier to care in Western Canada. We discuss these findings in the context of the current debates on the Canadian health care system ,crisis'. De plus en plus de Canadiens s'inquiétent que leur systéme de soins de santé soit en état de crise. On défend l'idée selon laquelle la réduction des paiements de transfert aux provinces par le gouvernement fédéral serait responsable de l'état d'un systeme de santé caractérisé par un sous-financement dans les domaines-clés et des décisions politiques de santé basées, non pas sur les besoins des membres de la société canadienne, mais sur la fiscalité provinciale. Les gouvernements provinciaux ont réagi à la réduction du financement fédéral par une tactique de restructuration agressive (fermeture d'hôpitaux et retrait de services médicaux des programmes d'assurance de santé provinciaux). Selon les médias, les groupes de consommateurs et même les chercheurs en soins de santé, cette restructuration a eu pour effet un système en état de ,crise' (diminution de l'aecès aux services, longues fetes d'attente, hôpitaux surchargés, augmentation des coûts des médicaments etc). Un des thèmes récurrent est celui des décisions flscales de toutes sortes qui entraînent une baisse de l'accessibilité financière et géographique. Cette accessibilité est pourtant un des cinq principes de la Loi canadienne sur la santé définissant l'essence même du système de santé au Canada. Utilisant les données tirèes de l'Enquête nationale sur la santé de la population, 1998-99 et examinant l'accès aux services de santé et les obstacles rencontrés dans les 10 provinces canadiennes, cet article évalue dans quelle mesure une crise d'accessibilité existe au sein du système de santé canadien. Les résultats démontrent qu'environ 6.0 pour cent des Canadiens ont rencontré des problèmes d'accessibilité, avec des variantes allant de 4.5 pour cent à Terre-Neuve jusqu'à 8.3 pour cent au Manitoba. On observe aussi des variantes régionales dans les obstacles rencontrés. L'accessibilité géographique en particulier semble un obstacle mqjeur dans les régions de l'Atlantique, alors que l'accessibilite financière semble être un obstacle majeur dans l'Ouest du Canada. Ces résultats sont présentés dans le contexte des débats actuels sur l'existence dune, ,crise' dans le système de santé au Canada. [source]

Agreement on Trade-Related Aspects of Intellectual Property Rights and Access to Medication: Does Egypt Have Sufficient Safeguards Against Potential Public Health Implications of the Agreement

Heba Wanis
The implementation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement) in Egypt raised concerns over public health implications, resulting from pharmaceutical patents, especially because the Egyptian pharmaceutical industry is heavily dependent on generic production. The current level of global competition in the pharmaceutical market, together with the lack of local pharmaceutical research, threaten the industry, and, as a result, access to affordable medication is expected to be impaired. Determinants of access to medicines are analysed. An epidemiological overview of the most prevalent diseases in Egypt has been done in light of the results of surveys about changes in medicine prices and availability, to speculate about potential limitations in access to medicines. Considering domestic pharmaceutical pricing and marketing regulations, which are mainly concerned with affordability, together with the flexibilities in the TRIPS Agreement, short-term solutions to potential access problems will be possible. Egypt has the necessary theoretical safeguards against negative implications of the TRIPS Agreement on access to treatment. However, this does not necessarily mean that these safeguards will be implemented in a way that will protect against the implications of patent protection on medicines in the long term. [source]

Public dental service utilization among adults in South Australia

L Luzzi
Abstract Background:, Longitudinal patterns of public dental service use may reflect access issues to public dental care services. Therefore, patterns of dental service use among South Australian adult public dental patients over a 3½-year period were examined. Methods:, Public dental patients (n = 898) initially receiving a course of emergency dental care (EDC) or general dental care (GDC) at baseline were followed for up to 3½ years. Patient clinical records were accessed electronically to obtain information on dental visits and treatment received at those visits. Results:, Some 70.7 per cent of EDC and 51.3 per cent of GDC patients returned for dental treatment post-baseline. EDC patients returned within a significantly shorter time period post-baseline, received significantly more courses of care and were visiting more frequently than GDC patients. A greater proportion of EDC patients received oral surgery, restorative, endodontic and prosthodontic services, but fewer received periodontic services. EDC patients received significantly more oral surgery and fewer preventive services per follow-up year, on average, than GDC patients. Large proportions of EDC (52.4 per cent) and GDC (63.8 per cent) patients who returned sought emergency care post-baseline. Conclusions:, Patients appeared to be cycling through emergency dental care because of lack of access to general care services, highlighting access problems to public dental care. [source]