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The worsening of the health status of northern populations is a matter of concern to scientists in many countries. International collaboration aimed at using international experience in the field of circumpolar health may speed up the research, making it more effective for solving problems of medical science and public health in the North.
"The study compares determinants of internal and international migration intentions, drawing upon interview data from a sample of adults in Ilocos Norte, a largely rural province in the Philippines. A regression model is applied to test the relative determinants of intentions to migrate to Manila and to Hawaii. The study is based on a value-expectancy model of migration decision making. The results document the importance of subjective expectations related to the attainment of different values and goals in Manila and Hawaii."
Point-of-care international normalized ratio (POC INR) testing is increasingly used to monitor anticoagulant therapy. This study assessed patient satisfaction with registered nurse--managed POC INR testing in a primary care internal medicine practice. One hundred eighty-seven of the first 216 (87%) patients using the program responded to the survey. The respondents were surveyed for satisfaction after they had experienced the nurse-managed POC INR system at the Mayo Clinic, Rochester, Minnesota, for one month. Eighty-eight percent of patients indicated that they were very satisfied or satisfied with the POC INR system. The authors conclude that nurse-managed POC INR testing is quick, convenient, less painful, and more satisfying for patients compared with traditional venipuncture and telephone follow-up.
The 1985-1986 National Study of Internal Medicine Manpower asked directors of residency and fellowship programs about their plans to change the size of their programs in the near future. The vast majority (71% to 76%) of the directors expected their programs to remain about the same size for the next couple of years. For fellowship directors, this reflects a decline in the number planning to increase their program size since 1976-1977 from 32% to 18%. Directors of programs that are principal affiliates of medical schools are more likely to plan a decrease, while Veterans Administration directors are more likely to plan an increase in program size. The reason residency directors cited most frequently as important to their plans to increase program size was a perceived shortage of internists. Fellowship directors most frequently cited the need for fellows in clinical research. Stipend availability was the most important factor that influenced plans to decrease program size. Overall, residency and fellowship directors planned to increase the size of their programs around 1%. Program directors and others in the internal medicine community should consider how they can change the stipend availability, admissions criteria, and other incentives to channel trainees into the areas of greatest potential need and demand for the profession.
The International Health Regulations (IHR), the only global regulations for infectious disease control, have not been significantly changed since they were first issued in 1951. The World Health Organization (WHO) is currently engaged in a process to modernize the IHR. This article reviews WHO's draft revised IHR and recommends new reforms to improve global health, which include (1) a robust mission, emphasizing the WHO's core public health purposes, functions, and essential services; (2) broad scope, flexibly covering diverse health threats; (3) global surveillance, developing informational networks of official and unofficial data sources; (4) national public health systems, setting performance criteria, measuring outcomes, and holding states accountable; (5) human rights protection, setting science-based standards and fair procedures; and (6) good governance, adopting the principles of fairness, objectivity, and transparency. The WHO should ensure state compliance with health norms and generous economic and technical assistance to poorer countries. An important issue for the international community is how sovereign countries can join together to make global health work for everyone, the poor and the wealthy alike.
Fellowship programs in general internal medicine should be designed to train outstanding academic internists to serve as future faculty and leaders in the field. Although programs may vary widely in their specific components, all should share a number of characteristics and goals. In this document, the Society of General Internal Medicine outlines basic principles and guidelines for fellowship training, states that its own PCIM Directory will explicitly require that programs indicate how they conform to them, and indicates its interest in considering a formal fellowship accreditation process in the future.
OBJECTIVE: To survey the extent to which internal medicine housestaff experience abuse and discrimination in their training. DESIGN: Through a literature review and resident focus groups, we developed a self-administered questionnaire. In this cross-sectional survey, respondents were asked to record the frequency with which they experienced and witnessed different types of abuse and discrimination during residency training, using a 7-point Likert scale. PARTICIPANTS: Internal medicine housestaff in Canada. MEASUREMENTS AND MAIN RESULTS: Of 543 residents in 13 programs participating (84% response rate), 35% were female. Psychological abuse, as reported by attending physicians (68%), patients (79%), and nurses or other health workers (77%), was widespread. Female residents experienced gender discrimination by attending physicians (70%), patients (88%), and nurses (71%); rates for males were 23%, 38%, and 35%, respectively. Females reported being sexually harassed more often than males, by attending physicians (35% vs 4%, p < .01), peers (30% vs 6%, p < .01), and patients (56% vs 18%, p < .01). Physical assault by patients was experienced by 40% of residents. Half of the residents surveyed reported racial discrimination and homophobic remarks in the workplace, perpetrated by all groups of health professionals. CONCLUSIONS: Psychological abuse, gender discrimination, sexual harassment, physical abuse, homophobia, and racial discrimination are prevalent problems during residency training. Housestaff, medical educators, allied health workers, and the public need to work together to address these problems in the training environment.
A technic for reconstruction of the internal carotid artery after resection of carotid aneurysms is presented. Reconstruction is performed over an internal shunt using a vein or Dacron patch. Total interruption of cerebral circulation is usually less than three minutes. The technic is described in detail. Oculoplethysmographic and phonoangiographic follow-up studies demonstrate normal carotid flow.
Three ampouled preparations of interleukin-1 alpha (IL-1 alpha) and three ampouled preparations of interleukin-1 beta (IL-1 beta) were evaluated by 13 laboratories in six countries for their suitability to serve as international standards for these materials. The preparation were assayed in in vitro and in vivo bioassays, radioreceptor assays and immunoassays. On the basis of the results reported here, with the agreement of participants in the study and with the authorization of the Expert Committee on Biological Standardization (ECBS) of the World Health Organization (WHO), one of the preparations of IL-1 alpha and one of the preparations of IL-1 beta were established as international standards for these materials. Further, since the relative activities of IL-1 alpha and IL-1 beta were dependent upon the assay systems used, it was decided that reference should be made to units of IL-1 alpha activity or IL-1 beta activity rather than to IL-1 activity.
A 66-year-old man presented with right cerebellar infarction and ischemic lesions in the left dorsal thalamus and right upper parietal lobe. Angiography showed occlusion of the right internal carotid artery proximal to an ipsilateral proatlantal artery type I, 70% stenosis of the left internal carotid artery, and aplasia of both posterior communicating arteries. The carotid occlusion was successfully treated by thrombendarterectomy. Persistence of a proatlantal artery is a rare condition. In relation to the 38 literature reports on proatlantal arteries, this case demonstrates the clinical significance of a persistent proatlantal artery in the evolution of atypical ischemic cerebrovascular disease.
A cross comparison of environmental programmes of major International Organisations reveals a convergent tendency. A relatively small number of priority areas for action have been identified, in the domain of pollution prevention and control, natural resource management, and quality of life in human settlements. Policy development in each of the priority areas requires specific scientific research efforts. The dialogue between policy-makers and scientists raises some problem, relative, inter alia, to the independence of science and to the practical need to act before various environmental threats become irretrievable. A rational sharing of tasks between International Organisations could work towards greater effectiveness.
A selected candidate international reference preparation of timothy grass (Phleum pratense)-pollen extract was studied together with two other freeze-dried timothy pollen allergenic extracts in a multinational study. The collaborators used RAST inhibition, histamine release, quantitative immunoelectrophoresis (crossed immunoelectrophoresis/crossed radioimmunoelectrophoresis and rockets), isoelectric focusing, and other methods. The total allergenic potencies measured in RAST inhibition were evaluated for validity of linearity and parallel-line response. The relative concentrations of some important individual allergenic components were measured. The relative potencies for the total allergenic activity and the timothy components studied in each preparation were expressed relative to the selected candidate. This preparation was established in 1983 by the World Health Organization expert committee on biologic standardization as the international standard for timothy grass-pollen extracts with assigned units of 100,000 IU per ampule.
A selected candidate international standard preparation of birch (Betula verrucosa)-pollen extract was studied together with other birch-pollen extracts in a multinational study involving 20 laboratories in 11 countries. The biologic activity of the extract had previously been demonstrated in quantitative skin prick testing. The study methods comprised RAST inhibition, histamine release, quantitative immunoelectrophoresis, isoelectric focusing, and other methods. The results from RAST inhibition were calculated as parallel-line assays with statistical tests for linearity and parallelism. Analysis of variance was applied to test the significance of differences between potency estimates. In all assay methods, the candidate standard could be used to assign relative potencies to other birch-pollen extracts. The candidate standard was adequately stable during 36 months of storage at or below 5 degrees C. On the basis of this study, the World Health Organization has established the preparation as the International Standard for birch-pollen extract with assigned units of 100,000 IU per ampule.
The present situation, needs and potential for the veterinary research and diagnostic laboratories in Latin America and the Caribbean are presented based upon the evaluation of their scientific personnel. The following conclusions were arrived at. (a) The economic crisis in countries of Latin America and the Caribbean has seriously affected veterinary services in general and the diagnostic and research laboratories in particular. (b) Policies need to be reviewed regarding the hiring of new and young scientific personnel in order to replace those retiring, and to define the number and type of working posts needed for the proper operation of the laboratories. (c) Policies need to be reviewed to define the salaries for the scientific personnel of the diagnostic and research laboratories; the only way to retain qualified personnel is through competitive salaries. (d) At present there is more stability among the scientific personnel, especially in those laboratories considered as reference laboratories for the Network; this gives more reliability and guarantees the continuity of their programs and services. (e) Policies need to be reviewed in relation to the publication of scientific information. Latin America journals that have appeared regularly and are well indexed in the international bibliographic services need to be identified and promoted as cited journals for the dissemination of scientific information generated in Latin America and the Caribbean. Diagnostic and research institutions' presentations at national or international congresses should subsequently be published in scientific journals. (f) Evaluation methodology as stated in this review can be used to help identify reliable laboratories with top-quality personnel.
OBJECTIVE: To determine the opinion of current residents and recent graduates of internal medicine training programs regarding an additional mandatory year of residency training. METHODS: A survey was made of 2,000 associate members of the American College of Physicians from five geographic regions. RESULTS: Of 917 respondents, 70.3% thought a fourth year of training would impact negatively on their choice of a career in internal medicine, and 82.9% believed a mandatory fourth year should not be required of residents choosing a subspecialty career. Furthermore, 58.1% of physicians surveyed thought a mandatory fourth year would discourage individuals from pursuing subspecialty careers. If a mandatory fourth year of training were required, 50.7% respondents indicated that it should consist of ambulatory training in a number of general fields, while 49.6% physicians believed the training should focus on one or two subspecialty fields. CONCLUSIONS: A mandatory fourth year of training is not supported by residents and recent graduates of the programs surveyed.
BACKGROUND: The aim of this study was to evaluate the outcome and flow dynamics of the lambda graft configuration, relative to a second arterial graft. METHODS: From 1998 to 2000, 47 patients (mean age 55.5 +/- 4.7 years) with triple-vessel disease underwent arterial revascularization using the lambda graft. The in situ left internal mammary artery (LIMA) and right internal mammary artery (RIMA) were anastomosed to the left anterior descending (LAD) and obtuse marginal arteries, respectively. In 21 patients (group I) presenting proximal or middle-third LAD or right coronary (RC) arterial stenoses, the lambda graft was constructed by anastomosing the distal LIMA, as a free LIMA graft, to the RC and proximally to the in situ RIMA. In the other 26 patients (group II) presenting with middle-distal third LAD or RC arterial stenoses, the radial artery (RA) was used to construct the lambda graft. All patients underwent transthoracic echo color Doppler before and after an adenosine test at 1 week and 3 months after operation. RESULTS: There were no hospital deaths. Overall, 47 lambda grafts were constructed. There was no difference between baseline and maximal flows and coronary flow reserve (CFR) between groups. CFR at IMA stems increased in both groups within 3 months versus 1 week [(LIMA)CFR = 2 +/- 0.3 vs 2.3 +/- 0.3 (p = 0.002) and (RIMA)CFR = 2.2 +/- 0.4 vs 2.5 +/- 0.3 (p = 0.009) in group I, and (LIMA)CFR = 2.12 +/- 0.33 vs 2.4 +/- 0.35 (p = 0.005) and (RIMA)CFR = 2.17 +/- 0.32 vs 2.52 +/- 0.26 (p = 0.001) in group II]. At 3 months versus 1 week, the (RIMA)diameter(i) (mm) at rest was 1.69 +/- 0.32 versus 1.48 +/- 0.2 (p = 0.015) in group I and 1.66 +/- 0.3 versus 1.47 + 0.2 (p = 0.01) in group II. At 6 +/- 2.4 months, all patients were free of angina. CONCLUSIONS: These data, almost identical for free LIMA and RA to RIMA using the lambda graft, demonstrate that RIMA flow reserve is adequate for multiple coronary anastomoses irrespective of the second arterial graft.
An ampouled preparation of acute phase serum rich in serum amyloid A protein (SAA) was evaluated in seven laboratories in six countries for its suitability to serve as the international standard for immunoassay of SAA. A variety of different immunoassays were used. On the basis of the results reported here and with the authorization of the Expert Committee on Biological Standardization of the World Health Organization (WHO) this preparation (coded 92/680) was established as the first international standard of SAA.
The optimal assessment of cancer pain includes a detailed description of pain characteristics and classification by both syndrome and likely mechanisms. In the clinical setting, the interpretation of this information is aided by knowledge of the available clinical experiences on these aspects of the pain. Unfortunately, existing data are limited. There have been few large surveys of cancer pain characteristics and syndromes, and comparative data from patients in different parts of the world are entirely lacking. To better define the characteristics of cancer pain syndromes the Task Force on Cancer Pain of the International Association for the Study of Pain (IASP) conducted a prospective, cross-sectional, international, multicenter survey of pain specialists and their patients. From a total of 100 clinicians who described themselves as cancer pain practitioners in the IASP membership directory, 51 agreed to participate in the survey and a total of 58 provided data. These clinicians resided in 24 countries and evaluated a total of 1095 patients with severe cancer pain mostly requiring opioid medication, using a combination of patient-rated and observer-rated measures. The patient-rated scales comprised a pain intensity measure chosen from the brief pain inventory. The observer-rated information included demographic and tumor-related data, and responses on checklists of pain syndromes and pathophysiologies. Patients were heterogeneous in terms of demographics and tumor-related information. More than 76% had a Kamofsky performance status score < or = 70. Almost one-quarter of the patients experienced two or more pains. A large majority of the patients (92.5%) had one or more pains caused directly by the cancer; 20.8% of patients had one or more pains caused by cancer therapies. The average (SD) duration of pain was 5.9 (10.5) months. Approximately two-thirds of patients (66.7%) reported that the worst pain intensity during the day prior to the survey was > or = 7 on a 10-point numeric scale. The factors that were univariately associated with higher pain intensity included the presence of breakthrough pain, somatic pain or neuropathic pain, age younger than 60 years, and lower performance status score. A multivariate model suggested that the presence of breakthrough pain, somatic pain, and lower performance status were the most important predictors of intense pain. Pains that were inferred by the treating clinician to be nociceptive and due to somatic injury occurred in 71.6% of the patients. Pains labeled nociceptive visceral were noted in 34.7% and pains inferred to have neuropathic mechanisms occurred in 39.7%. In a broad classification, the major pain syndromes comprised bone or joint lesions (41.7% of patients), visceral lesions (28.1%), soft tissue infiltration (28.3%), and peripheral nerve injuries (27.8%). Twenty-two types of pain syndromes were most prevalent. Large differences in the diagnosis of breakthrough pain by clinicians of different countries suggest that this phenomenon is either defined or recognized differently across countries. These data confirm, in segment of the cancer population experiencing severe pain, in different parts of the world, that cancer pain characteristics, syndromes and pathophysiologies are very heterogeneous. Predictors of worsening pain can be identified. The data provide a useful context for the interpretation of pain-related information acquired in both clinical and research settings. They suggest the need for future studies and the potential usefulness of a written checklist for cancer pain syndromes and pathophysiologies.