Biomedical subjects
W L Toffler
Publications and source records attributed to W L Toffler.
Using the nicotine patch to stop smoking.
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Principles of clinical medicine: an interdisciplinary integrated 2-year longitudinal course.
In keeping with the Report of the Panel on the General Professional Education of the Physician (Association of American Medical Colleges 1984), Oregon Health Sciences University (OHSU) School of Medicine is in the midst of revising its curriculum. After a 4-year process, the Curriculum Committee mandated development of the Principles of Clinical Medicine course, a 2-year longitudinal course integrating input from both basic and clinical science departments. We describe the steps leading to the course's implementation, its administrative and organizational structure, the evaluation of student performance, teacher training, course curriculum, and the use of interdisciplinary teaching. This course embodies many of the changes called for in the AAMC Report and serves as a model for interdisciplinary education.
Second-trimester abortion.
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Health promotion and early disease detection among medical school faculty.
BACKGROUND: Medical school faculty members influence students' health promotion beliefs by their patient care activities and personal health habits. We characterized the medical school environment by defining faculty's health promotion and early disease detection attitudes and practices. The data disclose faculty needs and suggest a new paradigm to alter medical students' health promotion beliefs and care patterns. METHODS: An observational study of all academic faculty was conducted at a medical school using self-report survey data collected with a confidential questionnaire. The survey instrument assessed faculty demographics, 27 behaviors, and 23 beliefs concerning health promotion. RESULTS: Eighty-four percent of faculty (575 of 683) responded. Although agreement was moderate to good between lifestyle beliefs and personal behaviors, the concordance between personal adherence to and beliefs concerning the recommended physical examinations and laboratory tests was only fair (kappa 0.21 to 0.40). CONCLUSION: Faculty's health promotion and disease detection beliefs and behaviors were inconsistent. Observing this discrepancy may relate to students' establishment of attitudes and practices. Modifying faculty's personal behaviors and altering the medical school environment might enhance students' commitment toward preventive care.
Principles of clinical medicine: a multidisciplinary, integrated, two-year longitudinal curriculum.
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Impact of the presence of a third-year medical student on gross charges and patient volumes in 22 rural community practices.
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Use of a group objective structured clinical examination with first-year medical students.
PURPOSE: To evaluate the implementation of a quarterly group objective structured clinical examination (GOSCE) to assess the patient-evaluation abilities of a medical school class. METHOD: The study subjects were 94 first-year students participating in the Principles of Clinical Medicine course at the Oregon Health Sciences University School of Medicine in 1992-93. To create the GOSCE, the authors modified the format of the quarterly objective structured clinical examination by making each standardized-patient station the site of an interaction between a standardized patient and a group of four or five students. The GOSCE's reliability, content and face validity, and expense were evaluated. Student feedback was obtained using a structured questionnaire. RESULTS: Performances varied both among the five stations of the GOSCE and among the 23 student groups: the mean percentage of items performed correctly per station was 83%, with a range of 73-97%. The reliability of the GOSCE's stations was low, with intraclass correlations during the three consecutive quarters of .29, .05, and .12. Despite no prior experience with this type of testing, the students' mean rating of the GOSCE's appropriateness was 3.8 (on a Likert scale of 1, poor, to 5, excellent), compared with 2.5 for the appropriateness of the written examination also used for quarterly assessment. The expense of the GOSCE was much less than the costs reported for the OSCE format. CONCLUSION: The use of the quarterly GOSCE favorably influenced the students, faculty, and curriculum. The GOSCE format made possible the assessment of a large number of students' abilities, without the time and expense needed to evaluate students individually.
Characteristics and perceptions of nicotine patch users.
BACKGROUND: Although transdermal nicotine patches are frequently prescribed to aid in smoking cessation, little information exists about their use in general medical practice. In clinical studies, nicotine patches have been found to be effective when used in conjunction with nonpharmacologic interventions, such as physician counseling and follow-up visits. This study examines the characteristics and perceptions of patients regarding treatment with nicotine patches. METHODS: Patients filling or refilling prescriptions for a nicotine patch at 17 pharmacies were asked to complete a questionnaire. RESULTS: Seventy-six questionnaires were returned. Thirty-six percent of the respondents first learned about the nicotine patch from the media, 32% from friends, family, or co-workers, and 25% from their physicians. Most respondents (87%) had requested the patch, whereas only 9% had been asked by their prescriber to try the patch. Most of the surveyed smokers were highly motivated to quit, and 86% smoked at least one pack per day. Eighty percent indicated they had received a clear message from their physicians to quit, 56% said their physician had counseled them about relapse, and 55% had follow-up arranged. A quit date had been set by 37%, and only 24% reported the use of self-help materials. Approximately one half of smokers (54%) who had started using the patch indicated that they continued to smoke. CONCLUSIONS: Most respondents were good candidates for the nicotine patch based on how much they smoked and their motivation to quit. Direct-to-consumer advertising may have influenced many smokers to request treatment with the patch. Physicians should recognize that some persons may use the patch as a "quick fix," as very few respondents used the number of nonpharmacologic interventions that have proved useful in nicotine patch clinical trials. Physicians should follow the progress of patch users to ensure that they completely stop smoking during treatment.
Hopes and concerns of a first-year medical school class.
To assess the hopes and concerns of first-year medical students, the 1991 Oregon Health Sciences University (OHSU) Medical School class was surveyed during orientation. Using qualitative research methods, student responses were grouped into general categories. The most common 'hopes' were to provide personal care and develop relationships with patients, to attain self-fulfillment, and to enjoy the personal challenge and variety of medicine. Common 'concerns' were family issues, outside intervention into medicine, and loss of self. The hopes and concerns of this class revolve primarily around personal issues, rather than issues relating to their local community or to society. This information may be useful in student counselling and curriculum development. Further research is necessary to evaluate changes in this class's attitudes over time. The methodology of this study may be useful in the evaluation of the attitudes of subsequent first-year medical school classes at OHSU, and at other institutions.
Estrogen replacement therapy for reducing cardiovascular disease.
The Council on Scientific Affairs of the California Medical Association presents the following inventory of items of progress in general and family practice. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, and scholars to stay abreast of these items of progress in general and family practice that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on General and Family Practice of the California Medical Association, and the summaries were prepared under its direction.
Failure of insulin treatment in obese patients with non-insulin-dependent diabetes mellitus.
A number of experts recommend the use of insulin for patients with non-insulin-dependent diabetes mellitus (NIDDM) who fail to respond to diet, exercise, and oral hypoglycemics, even when the patient is morbidly obese. This article describes the use of insulin in two obese patients with NIDDM whose obesity worsened following the institution of insulin therapy. In some cases the risk for increased obesity and its complications following the institution of insulin may offset the potential benefits of insulin therapy itself. There are two main drawbacks associated with insulin therapy in these patients. First, from a medical point of view, insulin has a lipogenic effect and may actually contribute to weight gain, hyperinsulinemia, and increased insulin resistance in obese patients with NIDDM. Second, from a behavioral point of view, the institution of insulin therapy may shift the patient's and physician's focus from the preferred lifestyle adjustments to the numerous details associated with insulin use and monitoring. Since weight gain and sedentary activity are themselves risk factors for coronary artery disease, the benefits of decreased blood glucose levels should be balanced against the risk of increased weight gain in these patients.
Comparative cytologic yield and quality of three Pap smear instruments.
BACKGROUND: Various sampling techniques of the cervix have established false negative rates ranging from 18% to 45%. A number of studies suggest that this false negative rate can be reduced by sampling techniques that are associated with higher yields of endocervical cells. METHOD: This study enrolled 301 women, each of whom had a Pap smear obtained using three different sampling instruments (a cervical brush, a plastic spatula, and a cotton swab) in random order. RESULTS: The cervical brush yielded a better endocervical sample than either of the other instruments (P < .001), and there was no difference between the swab and spatula. In addition, the recovery of endocervical cells increased with each additional sample taken, regardless of instrument used (P < .001), although the difference in yield between the second and third samples was not significant. CONCLUSIONS: To enhance the yield of endocervical cells in Pap smear sampling, consideration should be given to using the cervical brush routinely as a sampling instrument and to taking more than one sample per screening.
Vaginal PO2 in healthy women and in women infected with Trichomonas vaginalis: potential implications for metronidazole therapy.
We measured the PO2, pH, and temperature in the vaginal canals of nine patients with symptomatic Trichomonas vaginitis and those of 10 healthy women. The patients included eight women with primary infections caused by metronidazole-susceptible strains and one refractory case that resulted from infection with a metronidazole-resistant Trichomonas vaginalis. The median vaginal PO2, pH, and temperature in the patient group were 1 mm Hg, 6, and 37.3 degrees C respectively; these medians were 1 mm Hg, less than or equal to 4.5, and 37.2 degrees C in the healthy group. These data show that vaginal environment is anaerobic or microaerophilic (it has reduced oxygen tension). Because the activity of metronidazole is reduced under aerobiosis, the vaginal environment should enhance the biologic activity of the drug.
Learning about students' attitudes toward entering medical careers.
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The immunogenicity and safety of intradermal hepatitis B vaccine.
BACKGROUND: One of the chief barriers to a greater use of hepatitis B vaccine is the high cost of the vaccine itself. A number of small research trials have shown that an adequate immune response can be induced at a much lower cost by administering one tenth of the vaccine using an intradermal technique. The purpose of this study was to ascertain whether these results could be replicated in a larger clinical trial. METHODS: Vaccine recipients included health care providers, police officers, and firefighters. Recipients were given 0.1 mL of plasma-derived hepatitis B vaccine intradermally on days 1, 30, and 180. Antibody response was measured on day 210, with seroconversion defined as a sample-to-negative (S/N) ratio of greater than or equal to 10. Any local and systemic side effects were documented. RESULTS: Six hundred sixteen individuals completed the vaccination series, and seroconversion occurred in 534 (86.7%). The rate of seroconversion in those younger than 40 years was 91.2% and in those 40 years and older was 75.1%. The mean S/N ratio was 154.9 (range 0 to 620) and decreased with increasing age (r = -.25, P = .0001). Side effects were largely limited to local reactions. CONCLUSIONS: The results support the use of the intradermal technique as a cost-effective alternative to the intramuscular route in individuals younger than 40 years. The intradermal technique may be used in older individuals if titers are obtained to assure seroconversion. Because of the restricted availability of the plasma-derived vaccine used in this study, similar trials with recombinant vaccine should be undertaken.
Dorsal penile nerve block for newborn circumcision.
Dorsal penile nerve block with lidocaine is safe and effective for reducing the pain associated with newborn circumcision. Administering the anesthesia adds little time or expense to the overall routine. Complications are minor, limited to local bleeding and hematoma formation. Family physicians performing circumcision should be prepared to use penile nerve block and to advocate it to parents who choose newborn circumcision.
A new treatment of nocturnal enuresis.
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