Heterogeneity in physician's job preferences in a dual practice context - Evidence from a DCE.

Many countries are facing challenges in recruiting and retaining physicians, particularly in regions where the public and private sectors compete for doctors. Understanding the factors influencing physicians' job choices can help inform policies aimed at attracting and retaining this valuable workforce. This study aims to elicit the strength of physicians' preferences regarding various job-related aspects, including earnings, time flexibility, discussion of clinical cases, frequency of facilities and equipment updates, training opportunities and autonomy in decision making. To achieve this, a Discrete Choice Experiment (DCE) was administered to 697 physicians. Each participant completed a series of eight choice tasks, where they had to choose between two hypothetical jobs differing in these attributes with levels mirroring positions in the public and private sectors in Portugal. The resulting choices were analysed using mixed logit, generalized multinomial logit and latent classes models to account for diverse unobserved variations in physicians' preferences and to explore preference heterogeneity across different observable characteristics. Jobs that offered more autonomy and training opportunities were strongly preferred, as physicians would require additional compensation to work with reduced autonomy (equivalent to 28.62% of gross income) or less frequent training (equivalent to 22.75%). This study also shows that the ranking of the job characteristics is similar between physicians working exclusively in the public sector and those engaged in dual practice. Nevertheless, public sector physicians place more emphasis on the availability of frequent training possibilities and frequent updates of facilities and equipment compared to their counterparts in dual practice. These findings contribute to existing knowledge by highlighting the significance of non-monetary attributes and shedding light on the preferences of physicians across various employment scenarios. They offer valuable insights for policy development aimed at influencing physicians' allocation of time between sectors.

Dance of the Sugar: Two Case Reports of Chorea Associated With Nonketotic Hyperglycemia.

Hyperglycemia-induced chorea/ballism is a rare clinical entity that often occurs in the setting of nonketotic hyperglycemia due to poor glycemic control in elderly patients with a diagnosis of type 2 diabetes mellitus (DM). This condition is typically characterized by hemichorea/hemiballism and unique brain imaging findings in the contralateral basal ganglia. Treatment involves the correction of blood glucose, and most cases resolve without additional therapy. Here we report two cases of this condition in which patients with type 2 DM presented with nonketotic hyperglycemia and typical neuroimaging findings. Although rare, clinicians should be aware of this condition in patients with diabetes who present with sudden abnormal movements since its prompt diagnosis and treatment often lead to a favorable outcome.

Should we adjust health expenditure for age structure on health systems efficiency? A worldwide analysis.

INTRODUCTION: Healthcare expenditure, a common input used in health systems efficiency analyses is affected by population age structure. However, while age structure is usually considered to adjust health system outputs, health expenditure and other inputs are seldom adjusted. We propose methods for adjusting Health Expenditure per Capita (HEpC) for population age structure on health system efficiency analyses and assess the goodness-of-fit, correlation, reliability and disagreement of different approaches. METHODS: We performed a worldwide (188 countries) cross-sectional study of efficiency in 2015, using a stochastic frontier analysis. As single outputs, healthy life expectancy (HALE) at birth and at 65 years-old were considered in different models. We developed five models using as inputs: (1) HEpC (unadjusted); (2) age-adjusted HEpC; (3) HEpC and the proportion of 0-14, 15-64 and 65 + years-old; (4) HEpC and 5-year age-groups; and (5) HEpC ageing index. Akaike and Bayesian information criteria, Spearman's rank correlation, intraclass correlation coefficient and information-based measure of disagreement were computed. RESULTS: Models 1 and 2 showed the highest correlation (0.981 and 0.986 for HALE at birth and HALE at 65 years-old, respectively) and reliability (0.986 and 0.988) and the lowest disagreement (0.011 and 0.014). Model 2, with age-adjusted HEpC, presented the lowest information criteria values. CONCLUSIONS: Despite different models showing good correlation and reliability and low disagreement, there was important variability when age structure is considered that cannot be disregarded. The age-adjusted HE model provided the best goodness-of-fit and was the closest option to the current standard.

A case report of platypnea-orthodeoxia syndrome: an interplay of pressure and blood flow.

BACKGROUND: Platypnea-orthodeoxia syndrome is a rare condition characterized by onset or worsening of dyspnoea with orthostatism (platypnea) and arterial desaturation (orthodeoxy) that is relieved by returning to a recumbent position. An acute event causing a change in the pressure relationships inside the cardiac chambers can lead to the diagnosis of a previously undiagnosed cardiac anomaly, as the following case illustrates. CASE SUMMARY: A previously asymptomatic 80-year-old female patient was admitted in our hospital with a sudden onset ischaemic stroke. Initial evaluation, including 12-lead electrocardiogram and transthoracic echocardiogram, was unremarkable. During hospital stay, she develops pulmonary embolism, after which she complains of positional dyspnoea that develops upon sitting up, accompanied with refractory hypoxaemia that reverts on recumbent position. Transoesophageal echocardiogram revealed an interatrial septum with an exuberant hyperdynamic movement, and an abundant passage of contrast from the right atrium to the left, even without performing the Valsalva manoeuvre, compatible with an important patent foramen ovale. A percutaneous closure was performed, and patient has been symptom-free since then. DISCUSSION: This is a case illustrates how an anomaly that has been present for 80 years can suddenly manifest itself with an array of different symptoms that can make the diagnosis challenging. A high degree of clinical suspicion is crucial for an accurate diagnosis and definitive treatment.

Colorectal cancer: comparative analysis of clinical and pathological characteristics in patients aged above and below 45 years of age and impact on prognosis / Câncer colorretal: análise comparativa das características clínicas e anatomopatológicas em doentes com idade superior e inferior a 45 anos de idade e impacto no prognóstico

Introduction: Colorectal cancer, in Portugal, presents as the second most common cancer and of cancer death cause. CRC is a disease of the elderly; however, there has been an increase of incidence in younger patients and doubts have emerged about its behavior, characteristics and prognosis in this group. Methods: In this study, we have evaluated a sample of 512 patients diagnosed with colorectal cancer submitted to surgical treatment in the period between January 1st, 2005 and January 1st, 2010, through a comparative clinical, pathological and survival analysis of patients under and over 45 years old (Groups I and II respectively). Results: Group I patients accounted for 5.5% of the sample. There was a predominance of males and the most common site was the left colon in both age groups. In the younger group, the histological type presents with a predominance of tumors with a mucinous component and with signet ring cells (p = 0.001), however, there was no difference in terms of overall survival and disease-free survival. Conclusion: In this study, colorectal cancer at younger ages shows similar characteristics to those of older patients.

Introdução: O Câncer Colorectal (CCR), em Portugal, constitui o segundo câncer mais frequente em termos de incidência e de mortalidade. É uma doença do idoso, no entanto, tem-se observado um aumento da incidência em pacientes mais jovens, tendo surgido dúvidas acerca do seu comportamento, características e prognóstico neste grupo etário. Métodos: 512 pacientes com diagnóstico de CCR operados entre Janeiro de 2005 e Janeiro de 2010 foram avaliados através da análise comparativa das características clínicas, anatomopatológicas e sobrevida em indivíduos com idade inferior e superior a 45 anos (Grupo I e II respetivamente). Resultados: Os pacientes do Grupo I representaram 5,5% da amostra. Houve predomínio do gênero masculino e o local mais frequente foi o cólon esquerdo em ambos os grupos. No grupo mais jovem, relativamente ao tipo histológico ocorreu predomínio significativo de tumores com componente mucinoso e células em anel de sinete (p = 0,001), mas sem diferença ao nível da sobrevida global e sobrevida livre de doença. Conclusão: Neste estudo, o CCR em idades mais jovens revelou características semelhantes às dos pacientes mais idosos.

Leukocytoclastic Vasculitis with Systemic Involvement Associated with Ciprofloxacin Therapy: Case Report and Review of the Literature.

A 71-year-old woman presented with constitutional signs and lower extremity palpable purpura after being prescribed a four-day course of 500 mg of ciprofloxacin two times daily for a gastrointestinal infection. She was admitted for inpatient treatment. During the third hospital day, she presented with an episode of abundant hematemesis while her skin lesions remained unchanged. Upper endoscopy revealed multiple lesions consistent with vasculitis and histological examination of the skin biopsy disclosed a leukocytoclastic vasculitis. The patient was successfully treated with prednisone following ciprofloxacin discontinuation. Complete resolution of the lesions on drug withdrawal strongly suggested drug toxicity, which was further supported by a score of 8 in the Naranjo Adverse Drug Reaction Probability Scale. Awareness that the development of skin and gastrointestinal lesions following administration of ciprofloxacin may be a manifestation of ciprofloxacin-induced vasculitis can help early detection, treatment, and lead to an overall good prognosis.