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PubMed2005

Accreditation council on graduate medical education technical skills competency compliance: urologic surgical skills.

BACKGROUND: In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents' surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program. STUDY DESIGN: We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection. RESULTS: Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained. CONCLUSIONS: Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance.

Accreditation↗
PubMed2005

Evaluating immediate and long-range effect of a geriatric clerkship using reflections and ratings from participants as students and as residents.

This article describes a longitudinal study developed to assess perceived usefulness of a mandatory geriatric clerkship from the perspective of junior students completing the newly initiated program in 1998-1999 and 1999-2000 and these same students as second- or third-year residents. End-of-clerkship student evaluations were compared with follow-up resident surveys of those same students to identify the utility of information provided and strengths and weaknesses of the initial course experience. Students participated in hospice, outpatient clinics, nursing homes, and transitional care venues during their clerkship experience at the Donald W. Reynolds Department of Geriatrics, College of Medicine, University of Arkansas for Medical Sciences. Two hundred eighty-five student evaluations were collected, and 143 resident surveys were returned. Quantitative and qualitative data from students and residents corroborated each other in identifying strengths and weaknesses of the clerkship. Hospice information was successfully incorporated into residency practice. In contrast, outpatient clinic, nursing home, and transitional care segments of the clerkship were perceived as inadequate. Survey responses validated faculty changes that were initiated in the following years. These changes use settings and patients that more accurately mirror those seen in typical resident encounters.

Adult↗
PubMedDate not supplied

Long-term care insurance comes to Japan.

Japan has moved decisively toward "socialization of care" for the frail elderly by initiating public, mandatory long-term care insurance (LTCI) on 1 April 2000. The LTCI program covers both institutional and community-based caregiving. Everyone age forty and older pays premiums. Everyone age sixty-five and older is eligible for benefits based strictly on physical and mental disability, in six categories of need. Benefits are all services, with no cash allowance for family care, and are generous, covering 90 percent of need. Long-term costs seemed not to be a major consideration in program design. Consumers can choose the services and providers they want, including use of for-profit companies.

Adult↗
PubMed2004

Governmental policies and measures regulating nitrogen and phosphorus from animal manure in European agriculture.

This paper discusses governmental policies and measures that regulate the use of animal manure in the European Union (EU-15). Systematic intervention by governments with European agriculture in general started at the end of the 19th century. Major changes in governmental policies on agriculture followed after the establishment of the EU and its Common Agricultural Policy (CAP) in 1957. Environmental side effects of the large-scale intensification of agricultural production were addressed following the reform of the CAP and the implementation of various environmental regulations and directives from the beginning of the 1990s. The Nitrate Directive approved in 1991 has exerted, as yet, the strongest influence on intensive livestock production systems. This directive regulates the use of N in agriculture, especially through its mandatory measures to designate areas vulnerable to nitrate leaching and to establish action programs and codes of good agricultural practice for these areas. These measures have to ensure that for each farm the amount of N applied via livestock manure shall not exceed 170 kg x ha(-1) x yr(-1). These measures have large consequences, especially for countries with intensive animal agriculture, including The Netherlands, Belgium, Denmark, and Ireland. The mean livestock density in these countries is between 1.5 and 4 livestock units/ha, and the average amounts of N in animal manure range from 100 to 300 kg/ha of agricultural land. More than 10 yr after approval of the Nitrate Directive, there appears to be a delay in the implementation and enforcement in many member states, which reflects in part the major complications that arise from this directive for intensive livestock farming. It also reflects the fact that environmental policies in agriculture have economic consequences. The slow progress in the enforcement of environmental legislations in agriculture combined with the increasing public awareness of food safety, animal welfare, and landscape maintenance call for a more fundamental change in EU agriculture.

Agriculture↗
PubMed1994

Establishment of a tissue bank for fetal stem cell transplantation.

STUDY OBJECTIVE: To analyse the yield of fetal liver tissue in first trimester abortions and to evaluate the number of nucleated cells obtained from each fetal liver during the sixth to twelfth week of gestation. DESIGN: Prospective descriptive study: LOCATION: University Hospital. MATERIAL: Women seeking abortion during a 12 month period 1992/1993. RESULTS: Out of 1271 women seeking abortion, 152 were asked whether they were willing to donate fetal tissue for fetal transplantation. Of these women, 105 (69%) accepted the proposal and underwent a modified low suction vacuum curettage. Fetal liver tissue was obtained in 61 (58%) of these procedures. The frequency at which tissue was retrieved was strongly related to gestational age and rose from 29% in week 6 to 79% in the tenth to twelfth week of gestation. The mean number of nucleated cells obtained from each fetal liver demonstrated a concomitant increase with gestational age, rising from 16 to 43 x 10(6) per liver during these weeks of gestation. Of the 61 cases in which fetal liver was obtained, four subjects were shown to be abnormal by laboratory analyses and 11 did not alter the mandatory follow-up appointment. This left 46 cases for use in the program of fetal to fetal transplantations. CONCLUSIONS: Most women seeking abortion seem to be in favor of the idea of fetal tissue donation for the treatment of other fetuses. The possibility of obtaining fetal liver tissue and the number of fetal stem cells retrieved are closely correlated to gestational age. A tissue bank appears to facilitate the operation of a fetal to fetal stem cell transplantation program.

Attitude to Health↗
PubMedDate not supplied

Prematures with and without regressed retinopathy of prematurity: comparison of long-term (6-10 years) ophthalmological morbidity.

Forty-two ex-prematures having had regressed forms of retinopathy of prematurity (ROP) during the neonatal period were compared with 42 matched non-ROP ex-premature controls at ages 6 to 10 years. The overall incidence of ophthalmologic problems was 55% in the ROP and 36% in the non-ROP group. Strabismus, amblyopia, and refraction anomalies occurred more frequently in the ROP group. In this group, a significantly greater number of children had decreased vision in one or both eyes compared to the non-ROP group. Although the incidence of ophthalmologic problems in the ROP group was considerably higher, the incidence in the non-ROP group still turned out unexpectedly high. this implicates that non-ROP very low birth weight neonates should also be considered to be at a greatly increased risk for later visual problems. Regular ocular examinations, mandatory for the ROP group, thus should be included in follow-up programs of non-ROP very low birthweight neonates as well.

Amblyopia↗
PubMed1999

[Postgraduate education in surgery].

During the past 100 years, specialization and differentiation in medicine have developed rapidly. As a field of culture, medical science has progressively been deprived of the philosophical and ethical elements that are the most important part of the practice of medicine. New technology has improved surgical techniques for curing diseases but often the patient as a whole human being has been lost sight. Before imparting super-specialized knowledge and techniques to postgraduate medical students, a global standard of primary care, understanding, and sympathy for the patient must be provided. No super-specialty that does not also fulfill the minimum requirements for general, fundamental medical and surgical knowledge and techniques will be accepted and respected by the majority of people. So-called straight residency training in super-specialties starting immediately after medical school must cease. A residency program of several years including primary-care training for general surgery is mandatory to educate well-balanced "surgical specialists." Such a curriculum must be developed and constantly revised in response to social needs.

Education, Medical, Graduate↗
PubMed2000

External quality assessment of urine analysis in Europe. Results of a round table discussion during the symposium 'From uroscopy to molecular analysis', Seeon, Germany, September 18-20, 1999.

Interlaboratory surveys on urine quantities have only recently been introduced in several European countries. Representatives of 10 European countries exchanged their experiences during an international urinalysis meeting held in September 1999. Although still not mandatory in most areas, more than 5000 laboratories participated in external quality assessment programs in the countries represented. Qualitative (test strips and microscopic morphology) as well as quantitative chemical and immunochemical quantities were included. The maximal allowable deviations are reported as well as methods used to determine target values. Consensus scales up to reference methods were applied. The participants agreed that quality criteria need to be defined separate from those already existing for plasma/serum analytes. Besides higher biological variables and different medical needs, less standardisation of methods to quantify urine constituents was observed as a major cause of higher interlaboratory differences.

Europe↗
PubMed2004

Updated European recommendations for the clinical use of HIV drug resistance testing.

In most European countries, HIV drug resistance testing has become a routine clinical tool. However, its practical implementation in a clinical context is demanding. The European HIV Drug Resistance Panel was established to make recommendations to clinicians and virologists on this topic and to propose quality control measures. The panel recommends resistance testing for the following indications: i) drug-naive patients with acute or recent infection; ii) therapy failure, including suboptimal treatment response, when treatment change is considered; iii) pregnant HIV-1-infected women and paediatric patients with detectable viral load when treatment initiation or change is considered; and iv) genotype source patient when post-exposure prophylaxis is considered. In addition, for drug-naive patients with chronic infection in whom treatment is to be started, the panel suggests that resistance testing should be strongly considered and recommends testing the earliest sample for drug resistance if suspicion of resistance is high or prevalence of resistance in this population exceeds 10%. The panel does not favour genotyping over phenotype, however it is anticipated that genotyping will be used more often because of its greater accessibility, lower cost and faster turnaround time. For the interpretation of resistance data, clinically validated systems should be used to the greatest extent possible. It is mandatory that laboratories performing HIV resistance tests take regular part in quality assurance programs. Similarly, it is necessary that HIV clinicians and virologists take part in continuous education and meet regularly to discuss problematic clinical cases. Indeed, resistance test results should be used in the context of all other clinically relevant information for predicting therapy response. The panel also encourages the timely collection of epidemiological information to estimate the impact of transmission of resistant HIV and the prevalence of HIV-1 non-B subtypes in the different European countries.

Anti-HIV Agents↗
PubMed1988

Contributions of family violence research to criminal justice policy on wife assault: paradigms of science and social control.

Criminal justice policy on family violence has evolved over the past two decades, informed by political activism as well as theory and research from divergent and often competing perspectives. Experimental research on mandatory arrest of men who assault female partners, policy research on special prosecution programs, and the development of treatment programs for men who batter, typify the strategies for applying criminal sanctions to family violence. However, other critical research on family violence has not been integrated into criminal justice policy, limiting policy development and intervention strategies to practices which reflect contemporary models of sanctions and social control. The limited contributions of family violence research to criminal justice policy reflect competing paradigms of social science, the challenge of family violence cases to the normative processes and the social organization of the criminal courts, and divergent perspectives on social control of offenders in family and stranger violence cases. Strategies for an integrated policy development process are suggested.

Criminal Law↗
PubMed1982

Continuing medical education: 1960s to the present.

Since the 1960s, continuing medical education (CME) has undergone a period of reappraisal of its effectiveness and consideration of alternatives to the traditional teaching model. In this paper the authors discuss three proposals that were developed out of these concerns: the establishment of a national plan, a process program model based on the identified needs of physicians, and the use of mandatory continuing education as part of a relicensing/recertification procedure. The problems and controversies in each of these areas are explored. Recommendations for changes in CME are discussed and summarized into three areas: organizational needs, programmatic needs, and physician needs. The authors attempt to point out the general agreement in these recommendations as well as the difficulty of achieving any uniform or orderly change in the future.

Certification↗
PubMed2002

Prevalence of spina bifida and anencephaly during the transition to mandatory folic acid fortification in the United States.

BACKGROUND: In 1992, the United States Public Health Service recommended that all women of childbearing age consume 400 microg of folic acid daily. The Food and Drug Administration authorized the addition of synthetic folic acid to grain products in March 1996 with mandatory compliance by January 1998. The impact of these public health policies on the prevalence of neural tube defects needs to be evaluated. We sought to determine the prevalences of spina bifida and anencephaly during the transition to mandatory folic acid fortification. METHODS: Twenty-four population-based surveillance systems were used to identify 5,630 cases of spina bifida and anencephaly from 1995-99. Cases were divided into three temporal categories depending on whether neural tube development occurred before folic acid fortification (January 1995 to December 1996), during optional fortification (January 1997 to September 1998), or during mandatory fortification (October 1998 to December 1999). Prevalences for each defect were calculated for each time period. Data were also stratified by programs that did and did not ascertain prenatally diagnosed cases. RESULTS: The prevalence of spina bifida decreased 31% (prevalence ratio [PR] = 0.69, 95% confidence interval [CI] = 0.63-0.74) from the pre- to the mandatory fortification period and the prevalence of anencephaly decreased 16% (PR = 0.84, 95% CI = 0.75-0.95). Stratification by prenatal ascertainment did not alter results for spina bifida but did impact anencephaly trends. CONCLUSIONS: The decline in the prevalence of spina bifida was temporally associated with folic acid fortification of US grain supplies. The temporal association between fortification and the prevalence of anencephaly is unclear.

Anencephaly↗
PubMed1997

Doping control in sports--a perspective from the 1996 Olympic Games.

Doping-control (DC) procedures, particularly as used at the 1996 Olympic Games, are described, and the role of pharmacists in DC is discussed. DC procedures must be strict and precisely followed to avoid contamination of samples, the appearance of bias, and breaches in security and confidentiality. The process of selecting athletes for testing can be random, nonrandom, or a combination of the two. Escorts are used to notify athletes of their selection, verify their identity, and accompany them to the DC station. When urine specimens are obtained for DC, the voiding process must be directly observed. The specimen is checked for pH and specific gravity and then processed for shipping to a laboratory to be analyzed for banned substances. Medication histories are also obtained, giving athletes the opportunity to declare any substance that has been taken for legitimate medical purposes. Laboratory analysis involves screening and confirmation phases. During the Atlanta Games, roughly 50 pharmacists participated in the DC program as escorts or technical officers. It is logical to involve pharmacists in DC programs because they can develop and conduct drug-testing protocols; educate athletes, coaches, and trainers about drug use and abuse; and help ensure the safe and effective use of medications. Sophisticated doping-control procedures have been developed for athletic competitions, and pharmacists have much to offer DC programs.

Doping in Sports↗
PubMedDate not supplied

Alabama laws on drug testing in the work place.

Alabama law related to employee work place drug testing consists of the newly enacted drug free work place program, the workers' compensation law and the unemployment compensation law. These laws contain specific requirements relating to the performance of employee drug testing. Physicians will play a key role in the management, supervision and implementation of employer drug testing programs and should become familiar with state and federal laws and regulations pertaining to the operation of those programs.

Alabama↗
PubMedDate not supplied

Medicaid managed care and children: an overview.

In recent years, states have increasingly turned to managed care arrangements for financing and delivering health services to Medicaid beneficiaries. In 1996, approximately 40% of all Medicaid recipients were enrolled in some form of managed care. The rapid escalation of managed care in this population has been fueled by states' desire to slow the growth of Medicaid expenditures and by the trend toward managed care enrollment in the private health insurance industry. The effect of managed care on cost containment in the Medicaid program may be limited, however, because 85% to 90% of Medicaid managed care enrollees are women of childbearing age and children, who together account for 69% of Medicaid recipients, but only 26% of program costs. Nonetheless, the increase in managed care enrollment in this population may have a profound impact on health service delivery and health outcomes for U.S. children, approximately 20% of whom received health benefits through the Medicaid program in 1995. In the future, the proportion of Medicaid-eligible children enrolled in managed care will likely increase as a result of recent legislation that relaxed the requirement that states seek federal approval prior to mandating managed care enrollment for Medicaid beneficiaries. More states are relying on fully capitated arrangements as the preferred type of managed care for Medicaid recipients, despite the relative lack of experience many of these plans have in serving this low-income population. Moreover, managed care organizations have few incentives to enroll chronically or disabled children with higher-than-average expected costs. Without mechanisms in place that adequately adjust capitated rates to account for these higher-cost enrollees, managed care organizations may lose money, and children with the greatest health care needs may be underserved. As mandatory managed care enrollment for Medicaid recipients increases nationwide, states should carefully monitor changes in program costs and quality as well as implications for the delivery of pediatric health services and health outcomes.

Adult↗
PubMed2004

Reporting instruction for radiology residents.

RATIONALE AND OBJECTIVES: To determine the amount of formal instruction and evaluation about reporting given to radiology residents in the U.S.A., to document report generation methods and to quantify the performance of physician coding. MATERIALS AND METHODS: E-mail requests with links to a web-based, anonymous survey were sent to program directors of all accredited radiology residencies in the USA. Demographic questions included university or private affiliation, number of residents, geographic location, and number of hospitals covered. Subject-specific items covered the amount of didactic instruction, formal evaluation of reports, and use of structured reports. A didactic activity index (DAI) was calculated as the sum of answers to domain-specific questions and tested for relation to demographic variables. We also asked about dictation methods and International Classification of Diseases (ICD) or Common Procedural Terminology (CPT) coding of examinations by radiologists. RESULTS: Of the 191 active radiology residencies, 151 (79%) completed the survey. Responses for hours of didactic instruction in reporting given more than a 4-year residency were distributed as follows: 0-1 = 40%, 2-4 = 46%, >4 = 14%. The percentage of resident reports formally graded was distributed as follows: 0-1 = 82%, 2-4 = 8%, >4 = 10%. The extent to which faculty-designed, structured reports were used by residents was distributed as follows: none = 16%, minimal = 25%, few = 17%, some = 33%, most = 9%. The DAI was normally distributed with a mean of 14.8 and a standard deviation of 2.4. Military programs had higher DAIs than university residencies (P = .03). There was no significant relation between any other program demographic variables and the DAI (P > .05). A substantial number of programs reported that physicians performed coding for some or most studies: ICD-9 = 30%, CPT = 26%. The dominant method for report generation was human transcription in 79% followed by speech recognition at 19%. Speech recognition penetration (departments reporting use of the technology for at least some dictation) was estimated to be 38%. CONCLUSION: In 86% of sampled radiology residencies, trainees receive no more than one hour of didactic instruction in radiology reporting per year. An aggregate measure of didactic activity about interpretative reporting was identical across all program demographic variables except that military residencies seemed to do slightly more than those located at universities.

Data Collection↗
PubMedDate not supplied

Evaluating livestock system environmental performance with whole-farm nutrient balance.

As a part of the USEPA's concentrated animal feeding operation (CAFO) final rule, all CAFOs are required to develop and implement a nutrient management plan (NMP). The USEPA's emphasis on better management of nutrients appropriately targets a critical environmental issue associated with animal production. The concentration of animals in livestock feeding operations, often separate from feed grain production, requires importing of substantial quantities of feed nutrients. Due to the inefficiencies of nutrient utilization in livestock production, quantities of nitrogen (N) and phosphorus (P) in manure greater than can be utilized in local crop production often result. With the focus of the USEPA's NMP rules on internal farm manure management planning, nutrient concentrations resulting from animal concentration may not be adequately addressed by compliance with the USEPA rules alone. A review of two mandatory and two voluntary nutrient management strategies is made by comparing whole-farm nutrient balance for a case-study beef cattle feedlot. The results suggest that voluntary BMPs, such as modification to animal feeding program and exporting of manure, can have greater environmental benefits (30-60% reduction in P accumulation for case-study farm) than mandatory NMPs and buffers (5-7% reduction in P accumulation for case-study farm) for a typical beef cattle feedlot. Whole-farm nutrient balance procedures can also be valuable for reviewing the nutrient performance of livestock systems.

Animal Feed↗

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