The new market in health care: prospects for managed care in Australia

Most developed countries are experiencing, or moving at full speed, to implement new forms of health delivery based in part on capitation arrangements and stronger accountability of health service providers. Proposals for introduction of capitation or managed care have been advanced in Australia but have attracted strong opposition from the medical profession. This paper reviews the policy issues surrounding the introduction of managed care, including how Australia's current institutional forms may evolve into managed care provision.

Designing a funding system for rehabilitation services. Part 1: Rationale and recent developments

Part 1 of this paper presents a critical review of several aspects of risk-sharing in rehabilitation that need to be taken into account in designing a funding system. It argues the case for the development of a new rehabilitation payment system separate from both the acute care casemix system and funding arrangements for long-term residential care. The paper then outlines a number of recent developments in the United States and in Australia that draw attention to the need for such a separate system, and details the current provisions for funding rehabilitation in Victoria. An analysis of existing rehabilitation classification systems is given to set the scene for proposing further developments, which are taken up in part 2 of the paper (to be published in the next issue of Australian Health Review).

Designing a funding system for rehabilitation services. Part 2: Policy objectives and options for achieving efficiency and quality of care

This paper examines the objectives of a funding policy for rehabilitation services. A casemix funding system comprises two sets of instruments: a classification system and a payment system. Attention is given to identifying which policy objectives are best pursued through each of these instruments. The paper then analyses the effect of various instruments on creating incentives for efficiency and quality, and assesses policy options with regard to their capacity for dealing with the heterogeneity of rehabilitation patients and controlling various forms of gaming. In conclusion, the paper canvasses four major areas warranting consideration in advancing policy: the use of a blended payment system; dealing with functional gain; the development of an information base; and the focus on designated rehabilitation units.

Medicare: where to now?

Although it is now more than ten years since Medicare was introduced, Medicare is still a relevant response to ensuring access to health care. However, marginal improvements to Medicare are needed in three areas. First, in terms of bureaucratic issues, rational development of health policy suffers from problems associated with the contemporary division of Commonwealth and State responsibilities. Secondly, more sophisticated methods for priority-setting, which take account of both the technical and allocative efficiency issues, are needed. Finally, Medicare needs to be enhanced by improving its ability to meet the diverse and varying needs of patients with long-term illnesses: improvement in 'coordinated care' is necessary. Approaches to meeting these needs are canvassed.

Managing myoclonus secondary to anoxic encephalopathy through EMG biofeedback

Biofeedback has traditionally been used in the context of relaxation therapy along with stress management. Some recent studies have looked to extend the applicability of biofeedback by using it as a didactic tool for neuromotor rehabilitation. The present case is one in which an anoxic head-injury patient was unable to participate in transfers owing to a severe myoclonic condition. The patient was trained using an autogenic relaxation procedure along with EMG biofeedback modality to reduce the myoclonus and therefore participate actively with stand pivot transfers.

Levy-Reid hypothesis

The inconsistencies in the research findings looking to test for the Levy-Reid hypothesis on the relationship between hand posture and laterality have been accounted for in various ways. Some authors (Cohen, 1991; Weber and Bradshaw, 1981) have suggested that existing methodologies for experimentally establishing laterality of language functioning are unreliable. To overcome this constraint, we have taken Halsey, Blauenstein, Wilson, and Wills' (1980) suggestion of using cerebrovascular accident (CVA) patients in which laterality of expressive speech has been established incontrovertibly. We examined 74 CVA subjects assessing hand posture, handedness, and side of stroke. Our findings lend support for Levy-Reid, nevertheless further examination of the hypothesis using a cross-cultural sample underscores the impact education and culture have on hand posture.

An unusual case of sundown syndrome subsequent to a traumatic head injury

An unusual case of sundown syndrome is here reported, in which a bilingual patient would involuntarily change languages at sunset. Numerous theories have been advanced in attempting to account for sundowning. Cameron has suggested that nocturnal delirium was based on an inability to maintain a spatial image without the assistance of repeated visualization. Kral and Wolanin and Phillips have argued for a more psychogenic account, by stating that psychosocial stressors may, in concert with impaired cognitive functioning, account for sundowning. The present case concerns a 42-year-old white male who in January 1989 suffered a closed head injury. A thorough personal history as well as a detailed examination of the patient's daily activities allowed us to account for the unusual manner in which the sundowning manifested itself. The uniqueness of this case allows us to underscore both the psychological as well as environmental and neurological factors involved in sundowning. Thus, we have as a consequence been able to synthesize the seemingly disparate accounts of both Cameron and more recent published literature.

Biopsy diagnosis of familial Alexander's disease

A 26-year-old woman presented with headaches, incoordination and a cerebellar mass (1982). The CT scan revealed dilated ventricles and a hypodense space-occupying lesion adjacent to the fourth ventricle. Neuronal loss, gliosis and masses of Rosenthal fibers were seen in biopsy. There was no evidence of neoplasm. A second biopsy 2 years later was similar to the original specimen. A diagnosis of Alexander's disease was suggested. Later that year the patient's 11-year-old brother manifested a clinical picture initially diagnosed as brainstem glioma, but whose biopsy was characteristic of Alexander's disease. There has been a gradual deterioration of these siblings over the past 6 years (1986-1991). No evidence of neoplasm has appeared.

Ossified mucin-secreting choroid plexus adenoma: case report

This is the first report of a fully documented case of an ossified mucin-producing benign choroid plexus tumor. This was a chance finding in a man who complained only of posttraumatic low back discomfort. The ossification of the tumor appears to have been therapeutic. Mucin production may be a defense mechanism.

Hospital role delineation: the technology and the politics

Regulated health systems are under increasing pressure to improve the efficiency of their hospital provision. One approach is to have more coordinated hospital provision through hospital role delineation. This short communication proposes the use of Diagnosis Related Groups as part of the role delineation process. However, the role delineation process is not solely a technical one: it requires a blend of technical and political decisions. Political aspects of the role delineation process are also reviewed.

Methods to establish priorities for health care

There is no right way to rank health care projects or patients requiring treatment. Different people or interests, either explicitly or implicitly, adopt different criteria: medical, economic, ethical, or political. This paper discusses the nature of these criteria and presents some strategies for improving our processes for setting priorities for health care expenditure.

Effects of collateral blood vessel ligation and electrical conditioning on blood flow in dog latissimus dorsi muscle

Utilization of skeletal muscle as a myocardial substitute requires it to undergo two major modifications: mobilization to the site of action and adaptation to continuous activity. We have examined the effects of collateral blood vessel ligation, which would accompany mobilization, on blood flow in control and electrically conditioned canine latissimus dorsi (LD) muscle. Blood flows were measured at rest and during a vigorous isometric fatigue test. In 22 control muscles, electrical stimulation during the fatigue test resulted in a sevenfold increase in muscle blood flow (0.26 +/- 0.18 ml/g/min at rest, 1.69 +/- 0.84 ml/g/min during stimulation). No difference was detected in flow to distal and proximal portions of the muscle. In three muscles where collateral vessels were ligated immediately before measurement of blood flow, flow in the proximal portion of the muscle was not significantly different from control, but in the distal portion, stimulation failed to elicit an increase in flow (0.12 +/- 0.13 ml/g/min at rest, 0.16 +/- 0.07 ml/g/min during stimulation). In animals allowed a 3-week recovery period following collateral vessel ligation, stimulation-induced increases in blood flow were detected but remained lower than control. Muscles which had been conditioned by continuous electrical stimulation for 6-7 weeks at 2 or 10 Hz generated less peak isometric tension than controls (peak tension = 4.5 +/- 1.7 kg control, 2.4 +/- 0.7 kg following 2 Hz conditioning, 1.6 +/- 0.4 kg following 10 Hz conditioning). However, these muscles demonstrated an increased resistance to fatigue.(ABSTRACT TRUNCATED AT 250 WORDS)

Slow recovery of central axons in acrylamide neuropathy

To study the differential vulnerability of central versus peripheral axons, we observed serial changes in conduction over comparable segments of central and peripheral axons of the primary sensory neuron in 17 rats with acrylamide neuropathy using somatosensory evoked potentials. Central conduction abnormalities persisted even after peripheral conduction and clinical abnormalities had recovered. Morphometric studies showed prompt restoration of the largest-diameter fibers in the peripheral nerve after clinical recovery but persistent or even more severe loss of large- and medium-sized fibers in the cervical gracile tract. This finding suggests that recovery from central-peripheral distal axonopathy begins in the largest peripheral axons, perhaps even at the expense of central axons, and that clinical recovery can occur at a time when central conduction remains abnormal. The selective central axonopathy found in certain chronic degenerative disorders may be a consequence of this slow central recovery process associated with chronic or intermittent metabolic derangements.

Epstein-Barr virus infection complicated by acute rhabdomyolysis

A patient presented with infectious mononucleosis complicated by acute rhabdomyolysis following physical exertion. This infrequent complication should be identified and treated quickly to prevent serious sequelae of rhabdomyolysis, which may include renal failure and disseminated intravascular coagulation.

Power output of skeletal muscle ventricles in circulation: short-term studies

Skeletal muscle ventricles (SMVs) were constructed from preconditioned latissimus dorsi muscles in eight dogs and then connected to each animal's systemic arterial circulation in short-term experiments. The lengths of time that SMVs could produce hemodynamic work as left ventricular assist devices were recorded. After 4 hr of continuous pumping at approximately 55 beats/min, six of eight SMVs were able to generate systolic pressures of 128 +/- 23 mm Hg and flows of 340 +/- 31 ml/min, representing 20 +/- 4% of the animals' cardiac output. After 8 hr of continuous pumping, five of the eight SMVs generated pressures of 110 +/- 15 mm Hg and flows of 308 +/- 88 ml/min, or 15 +/- 7% of the animals' cardiac output. The stroke work produced by the SMVs was intermediate between that of the animals' left and right ventricles. Although the SMVs were stimulated to contract at only about one-third the heart rate, the power output of the SMVs approximated that of the right ventricles because of the greater stroke work of the SMVs. Two SMVs functioned as LVADs for 14 hr. Deterioration in SMV function eventually occurred. In each case, however, complications such as anemia, hypoxia, and hypotension, which are inherent to prolonged short-term experiments of this type, contributed to the deterioration of SMV function. The results presented here suggest that skeletal muscle has the potential to directly support the circulation; however, the length of time such muscle pumps are capable of functioning has yet to be determined.

Abnormal deposits of chromium in the pathological human brain

Three patients presented with encephalopathies: an undiagnosed degenerative disease of the brain, a degenerative cerebral disease in a patient with a myeloma but without a myelomatous deposit in the CNS and a malignant astrocytoma. Perivascular pallidal deposits (vascular siderosis) containing chromium, phosphorus and calcium plus sometimes traces of other elements were present in the three cases. Such deposits were present in the pallidal parenchyma and around vessels in the cerebellum in one case. Calcium and phosphorus are always present in any CNS calcification but the presence of chromium has not been reported. Chromium and its compounds (ingested, injected or inhaled) are toxic to humans and animals in trace doses. Approximately 900 cases of chromium intoxication have been reported and usually have had dermatological or pulmonary lesions (including cancer) but there is no report of involvement of the CNS. Sublethal doses of chromium nitrate injected intraperitoneally in rats and rabbits results in the presence of chromium in the brain. A thorough investigation was made to find the source of the chromium in these patients. Chromium was found to be present in trace amounts in the radiological contrast agents administered to these patients and in the KCl replacement solution and in mylanta, an antacid, given to one case. The evidence that chromium induced pathological changes in these three brains is circumstantial but shows that chromium can penetrate the human brain. This study indicates that vascular siderosis found in the brains of the majority of middle-aged and elderly humans is not simply an anecdotal pathological curiosity, but that it can serve as a route of entry for toxic products into the brain.

Early application of pedicled omentum to the acutely traumatised spinal cord

Placement of the intact omentum upon a recently traumatised spinal cord was found to be effective in lessening motor and neuroelectrical dysfunction in a group of cats. It was theorised that the beneficial effect of omental transposition was due to the establishment of a dynamic equilibrium between production of vasogenic oedema from the injured cord and its absorption through omental pathways. Removing vasogenic oedema at the omental/spinal cord interface is hypothesised to stabilise a rising tissue pressure within the cord during the acute phase of injury and at a later date to decrease scar formation at the injury site.