Primary Health Care for Universal Health Coverage? Contributions for a Critical Anthropological Agenda.

Forty years after the Alma-Ata declaration, the WHO has reaffirmed its commitment to Primary Health Care (PHC). We argue that this renewed interest in PHC is being coopted by the neoliberal agenda on health via its application to Universal Health Coverage (UHC) reforms as part of the Sustainable Development Goals (SDGs). We offer an overview of classic anthropological studies on PHC, and more recent ones on UHC, as a way to propose some research foci and a set of questions for emerging critical anthropological research. Lastly, we suggest the careful reading of five recently published articles in Medical Anthropology.

Intercapitalist Maneuvers and the ICD-10 Transition: The Instrumental Role of the State in the Corporate Governance of U.S. Health Care.

In 2015, the United States transitioned to the ICD-10-CM/PCS, a comprehensive updated coding system for medical reimbursement. This transition was part of a larger move toward value-based reimbursement in U.S. health care and required nearly 2 decades of planning. As an unfunded mandate from Congress, it created a substantial financial burden for many groups within the health sector. This article traces the ICD-10 transition using the concept of the corporate governance of health care, attending to the role the state plays in mediating intercapitalist maneuvers. The ICD-10 was not a simple top-down declaration originating in a neutral state. Rather, it was produced and modified through lobbying efforts on the part of various stakeholders who, along with their competitors, would be affected by the transition in differential ways. The health information technology industry, in particular, stood to gain the most from this transition, at the expense of other capitalist players. An examination of the intercapitalist maneuevers behind the ICD-10 transition demonstrates that even when corporate powers govern U.S. health care, the role of the state should not be written off as inconsequential but rather interrogated and analyzed in relation to the corporate interests with which it is entangled.

Hepatic encephalopathy: a neurochemical, neuroanatomical, and neuropsychological study.

Hepatic encephalopathy (HE) is normally diagnosed by neuropsychological (NP) tests, which are not very specific and do not reveal the underlying pathology. Magnetic resonance imaging (MRI) and spectroscopy (MRS) of the brain offer alternative and possibly more specific markers for HE. These methods were applied in conjunction with NP testing in order to determine their usefulness in the identification of HE and to understand the pathogenesis of HE more clearly. MR imaging and spectroscopy examinations, in addition to a battery of 15 NP tests, were administered to investigate 31 patients awaiting liver transplantation and 23 healthy controls. MR image intensities from the globus pallidus region were calculated and normalized to those of the thalamus. Absolute concentrations and ratios with respect to creatine (Cr) of several metabolites were computed from MR spectra. The MR data were correlated with the results of NP tests. The patients showed impairment in NP tests of attention and visuospatial and verbal fluency. In T1-weighted MRI, the relative intensity of the globus pallidus with respect to that of the thalamus region was significantly elevated in patients and correlated(negatively) with three NP tests (Hooper, FAS, and Trails B). The absolute concentrations of myo-inositol (mI) and choline (Ch) were significantly reduced in three brain regions. In addition, the absolute concentrations of glutamine (Gln) and combined glutamate and glutamine (Glx) were increased in all three locations, with Gln increase being significant in all areas while that of Glx only in the occipital white matter. In summary, this study partially confirms a hypothesized mechanism of HE pathogenesis, an increased synthesis of glutamine by brain glutamate in astrocytes due to excessive blood ammonia, followed by a compensatory loss of myo-inositol to maintain astrocyte volume homeostasis. It also indicates that the hyperintensity observed in globus pallidus could be used as complementary to the NP test scores in evaluating the mental health of HE patients.

Adding another spectral dimension to 1H magnetic resonance spectroscopy of hepatic encephalopathy.

PURPOSE: To evaluate a localized two-dimensional correlated magnetic resonance spectroscopic (L-COSY) technique in patients with hepatic encephalopathy (HE) and healthy subjects, and to correlate the cerebral metabolite changes with neuropsychological (NP) test scores. MATERIALS AND METHODS: Eighteen minimal hepatic encephalopathy (MHE) patients and 21 healthy controls have been investigated. A GE 1.5-T magnetic resonance (MR) scanner was used in combination with a body MR coil for transmission and a 3-inch surface coil for reception. A 27-mL voxel was localized by three slice-selective radio frequency (RF) pulses (90 degrees-180 degrees-90 degrees) in the anterior cingulate region. The total duration of each two-dimensional L-COSY spectrum was approximately 25 minutes. The NP battery included a total of 15 tests, which were grouped into six domains. RESULTS: MR spectroscopic results showed a statistically significant decrease in myo-inositol (mI) and choline (Ch) and an increase in glutamate/glutamine (Glx) in patients when compared to healthy controls. There was also an increase in taurine (Tau) in patients. The NP results indicated a significant correlation between motor function assessed by NP tests and mI ratios recorded using two-dimensional L-COSY. CONCLUSION: The study demonstrated the feasibility of evaluating the two-dimensional L-COSY sequence in a clinical environment. The results showed additional cerebral metabolites that can be measured with the technique in comparison to one-dimensional study.

Breast core-needle biopsy: clinical trial of relaxation technique versus medication versus no intervention for anxiety reduction.

PURPOSE: To evaluate effectiveness of oral anxiolytic medication versus relaxation technique for anxiety reduction in women undergoing breast core-needle biopsy (CNB). MATERIALS AND METHODS: The institutional review board reviewed and approved the study. Informed consent was obtained from 143 consecutive women scheduled for breast CNB. Women were randomized as follows: no anxiety intervention (usual care group), relaxation therapy with an audiotape of classical music and ocean sounds during CNB (relaxation group), and 0.5-mg of alprazolam administered orally 15 minutes before CNB (medication group). Anxiety before, during, and 24 hours after the procedure was assessed with State-Trait Anxiety Inventory and self-reported visual analog scale from 0 (no anxiety) to 10 (worst anxiety). Data analysis was performed with statistical software. Descriptive statistics were computed for all variables. Group differences were determined with analysis of variance. Differences in mean values were assessed with Bonferroni multiple comparison procedure. Categorical demographic differences were assessed with chi(2) statistic. RESULTS: Preprocedural State-Trait Anxiety Inventory scores indicated that women were not inherently anxious: usual care group, score of 44.63; relaxation group, 45.74; and medication group, 49.1. Scores represented significantly elevated anxiety for women in all three groups when compared with the normative value of 35.12 (P < .0001), with no statistically significant differences between the scores of the three groups. Women in medication group reported significant reductions in anxiety (-44%) from levels determined before the procedure to levels determined during the procedure (P = .02) and significant reduction during the procedure when compared with changes in usual care (+15%) and relaxation (-8%) groups (P = .02). Women in all three groups reported significant reduction in anxiety from levels determined before the procedure to levels determined at 24 hours after it (P < .0001). There was no significant difference (P = .95) in 24-hour postprocedural anxiety levels among the three groups. CONCLUSION: Use of oral anxiolytic medication before breast CNB can significantly reduce anxiety women experience during the procedure.

Imaging-Guided Core Needle Biopsy of the Breast: Study of Psychological Outcomes.

The objective of this study was to evaluate and document pain and psychological distress related to imaging-guided core needle biopsy (CNB) of the breast. This prospective study of 52 consecutive patients undergoing CNB of the breast assessed anxiety, pain, acute stress disorder, and activities of daily living both preprocedure and at 24 hours, 5 days, and 30 days postprocedure. Survey instruments included the State-Trait Anxiety Inventory (STAI), a visual analog pain scale, the SF-36 Physical Functioning Scale, and DSM IV criteria for acute stress disorder. Preprocedure the mean scores for self-reported levels of state and trait anxiety were 47.11 (SD = 13.53) and 37.71 (SD = 11.24), respectively. At 24 hours postprocedure, the mean score for self-reported state anxiety was 38.74 (SD = 17.77), a significant reduction from the preprocedure level reported by patients (p < 0.005). Further reductions in state anxiety levels were reported at 5 and 30 days postprocedure. The mean scores for state anxiety fell within the normal range at 30 days postprocedure (mean 32.75, SD = 10.97). However, at 5 days post-CNB, patients with confirmed malignancies reported significantly more anxiety than patients without malignancies (p = 0.002). This difference was not present at 30 days post-CNB (p = 0.17). Patients reported average pain scores of 2.0 (on a scale of 0-10) during the biopsy. This decreased to 1.3 at 24 hours, 0.3 at 5 days, and 0.2 at 30 days. Reported symptoms of acute stress related to the procedure significantly increased over the period between the 5-day interview and the 30-day interview. One (2%) patient reported avoidance of thoughts about CNB 5 days postprocedure and 5 (12%) patients reported this at 30 days postprocedure (p < 0.05). Patients undergoing CNB reported significant levels of state anxiety which were greatest at the time of biopsy. A significant decrease was observed at 24 hours postprocedure, despite the fact that biopsy results were not available to the patients. Self-reported levels of anxiety for the group, regardless of biopsy results, fell within the normal range by 30 days. Further research and interventions are recommended to address the management of anxiety for patients undergoing CNB.