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PubMedDate not supplied

The role of the telephone in providing prenatal care.

To assess the role of telephone services in the health care of pregnant women, we evaluated the pregnancy healthline, Info-Grossesse (IG). We assessed the population of users, the reasons for their use, their reactions to the program, and their willingness to participate in follow-up surveys. During a 44-month period, there were 3,589 calls from women who were (or thought they were) pregnant. Overall, about half the calls related to teratogen information services, whereas the other half were for more general pregnancy-related information. Although women calling about medications were slightly older than the others, there were no major differences between groups defined by the primary reason for a call. Overall, about 17% of calls required a referral for formal risk counseling, with referrals most likely for calls about medications. Based on responses to a satisfaction questionnaire completed by over 80% of those asked to participate, IG decreased concerns for and answered all the questions of about three quarters of the respondents. Over 85% of eligible callers provided information on the outcome of their pregnancies, indicating that collecting these follow-up data is an acceptable and feasible program component. This study suggests that a pregnancy healthline such as IG can reach women worried about their pregnancies and that it can, thereby, reduce adverse conditions of pregnancy associated with "unnecessary" concerns or "inappropriate" use of services.

Adult↗
PubMed2005

Challenges in motivating treatment enrollment in community syringe exchange participants.

Participants of syringe exchange programs (SEPs) exhibit high rates of substance use disorder but remain extremely ambivalent about seeking treatment. This study evaluated the effectiveness of motivational interviewing (MI) for encouraging SEP participants to enroll in substance abuse treatment. New opioid-dependent registrants to the Baltimore Needle Exchange Program (BNEP) (n =302) completed the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), and the Addiction Severity Index (ASI) and were randomly assigned to one of three treatment referral conditions: (1) MI, (2) job readiness (JR) (attention control), or (3) standard referral. Participants in each condition who expressed interest in treatment were referred to a treatment readiness group that provided further encouragement and referral to programs that were accepting new admissions. Participants were observed for 1 year following the intervention. The results showed that 10.9% of study participants enrolled in substance abuse treatment, although no condition effects were observed. White participants and those diagnosed with major depression were most likely to enter treatment. The results suggest that a single motivational interview is insufficient to motivate changes in treatment seeking in this population, whereas the identification of predictors of treatment enrollment is worthy of further investigation.

Adult↗
PubMedDate not supplied

Organization of wound healing services: the Danish experience and the importance of surgery.

Thomas K. Hunt is a general surgeon. Through his basic wound healing research and clinical work with wound patients he has been a great inspiration for my work in wound healing. In order to fulfill Dr. Hunt's vision, the clinical wound healing arena must be organized in an optimal way, and this article focuses on different options. Multidisciplinary wound care teams or centers focusing on all types of problem wounds have proved to be most effective at providing treatment and care for patients with problem wounds. The ultimate model is an outpatient clinic and an inpatient ward joined within a departmental structure, which represents an integrated part of an accepted national expert program on wound healing. Different types of center models can be established with different advantages and disadvantages. Currently, the wound care arena is being organized in Denmark and the model is described in this article. Of all specialties involved in treatment of wounds, surgery is of vital importance. "Wound healing is the keystone on which surgery is founded" (Thomas K. Hunt). This has long been understood in relation to acute wounds, while the importance of surgery in the treatment of chronic wounds has been less widely recognized. Surgical procedures directly related to the wound consist of debridement of all types of problem wounds and, in more specialized procedures such as skin transplantation, different types of flap constructions, bone surgery, and tendo-Achilles lengthening. Arterial reconstruction is a type of surgery that indirectly, through improved tissue perfusion, improves healing of problem wounds. This study concludes that multidisciplinary specialized wound healing concepts integrated into the national health care system as accepted expert functions would be the ideal way to organize wound healing to best benefit patients and society. Emphasis is on the importance of surgical procedures in wound healing and care. The models described can be applied with minor adjustments to both industrialized and developing countries.

Denmark↗
PubMed1991

Variable low dose rate irradiation (131I-anti-CEA) and integrated low dose chemotherapy in the treatment of nonresectable primary intrahepatic cholangiocarcinoma.

Previous experience using 131I anti-CEA antibody, which irradiates at a variable low dose rate in combination with a multimodality treatment program, has demonstrated acceptable toxicity and response in primary intrahepatic cholangiocarcinoma. In attempting to improve therapy, Cis-platin was added to the prior regimen. Induction therapy was unchanged. One month later, chemotherapy was given (doxorubicin, 15 mg, 5-fluorouracil, 500 mg, plus Cis-platin, 20 mg/M2) followed the next day by outpatient administration of 20 mCi 131I anti-CEA by i.v. bolus. Five days later, 10 mCi was administered. The latter regimen (chemotherapy plus 20 + 10 mCi 131I anti-CEA) was repeated every 2 months using polyclonal antibodies derived from different species (rabbit, pig, baboon, and horse). Twenty-four patients (29% with prior chemotherapy and/or metastases) were prospectively treated according to this regimen. Toxicity was limited to hematologic toxicity and was manifested by thrombocytopenia and leukopenia (17% and 4% grade 4, respectively, according to RTOG toxicity criteria). Tumor remission was evaluated by CT volumetric analysis and demonstrated a 14% response rate for the induction portion of therapy, 24% for the radioimmunoglobulin portion of treatment, and 50% remission rate when all subsequent tumor volumes were compared to the pre-treatment volume (entire program). The median survival for the entire group of patients was 10.1 months. This result is superior to previously reported trials and, in comparison to our previous study (10.1 vs 6.5 months median survival), further advancement in protocol design appears to have been made. In view of the rarity of this disorder, a randomized trial is not possible and strict statistical analyses cannot be made. The mechanism of 131I-anti-CEA variable low dose irradiation and chemotherapy interaction is discussed as well as further potential modifications for treatment improvement.

Adenoma, Bile Duct↗
PubMed1997

Common cancers--genetics, origin, prevention, screening: Parts I and II.

Carcinogenesis is a stepwise process that occurs through mutations of cancer-related genes. Five or more genes must be mutated before malignant transformation occurs in most adult cancers; in some childhood cancers as few as two mutated genes may be sufficient. A rare inherited mutation of a critical gene may predestine cancer to occur in one or more sites. This germline mutation is present in virtually every cell in the body, except half of the germ cells, which do not contain the mutated gene in their haploid chromosome set. These and other genes have been used to piece together a puzzle of regulatory systems that govern cell division and proliferation, as well as apoptosis or programmed cell death. Mutations of these genes result not only in increased cell proliferation but also in diminished cell death. Most genetic changes that occur during carcinogenesis are not inherited or germline. They are acquired after birth and are called somatic mutations. A somatic mutation affects only the mutated cell and its progeny. Each time a cell divides, there is a chance of somatic mutation, and therefore there always is a low, background risk for cancer and other malignant lesions. A far more prevalent cause of cancer-related death in the United States is environmental exposure. Such exposure causes somatic mutations of cancer-related genes through direct damage to DNA or through alteration of proliferation or cell death, which enhances the baseline risk for mutation. As carcinogenesis becomes understood, interventions may be designed that selectively interfere in important steps. Screening for cancer is based on the premise that one can treat a patient for a cancer that has not spread from its primary site. Nevertheless, cancer screening is controversial and often confusing. Issues of costs, risks versus benefits, physical time and effort, and patient compliance all affect the clinician's view of screening, often to the extent that the true value of this approach to cancer control is underappreciated and underutilized. A clinician should consider the following questions when assessing the priority, scope, and intensity of cancer screening. Is the cancer an important public health problem? Can preclinical stages be detected and cured? Are effective screening tests available? Are the tests feasible and acceptable? Have screening programs reduced cancer-specific mortality? Is the screening program cost effective? Is screening generally recommended? There is clear-cut evidence of benefit from screening for cancer of the cervix, breast, colon and rectum, and skin and some specific genetic syndromes. Evidence of survival benefit from screening for prostate cancer is lacking, although prostate specific antigen screening is widely used. Screening for lung and ovarian cancer is ineffective.

Adult↗
PubMed1988

Infant orthotopic cardiac transplantation.

Infant orthotopic cardiac transplantation has been recently applied to various forms of congenital heart disease with encouraging short-term results. Between June 1986 and September 1987 we evaluated 16 infants for orthotopic cardiac transplantation. Fourteen had hypoplastic left heart syndrome, one had endocardial fibroelastosis with aortic atresia, and one had anomalous pulmonary arterial origin of the left main coronary. Eight families accepted the treatment program and eight families refused (two because of associated anomalies and six on philosophical grounds). Of the eight patients who were candidates for orthotopic cardiac transplantation, one died 6 hours after diagnosis, one was allowed to die after 60 days because of acquired neurologic complications, and another had congenital cytomegalic virus infection. The remaining five patients (four with hypoplastic left heart syndrome, one with anomalous pulmonary arterial origin of the left main coronary) had orthotopic cardiac transplantation. The operation was performed with absorbable polydioxanone suture with deep hypothermia and circulatory arrest in four neonates for hypoplastic left heart syndrome (average time 47 minutes) and bicaval cannulation and continuous bypass in one 11-month-old infant for anomalous origin of the left main coronary. In-house retrieval was used in all. One neonate died of complications as a result of pretransplant donor heart dysfunction and size discrepancy, whereas the remaining three neonates and one infant survived and are home 23 months, 12 months, and 8 months (the patients with hypoplastic left heart syndrome) and 17 months (the patient with anomalous origin of the left main coronary) postoperatively. Triple-drug immunosuppression included cyclosporine, azathioprine, and prednisone. Rejection was diagnosed by clinical evaluation of child activity and monocyte cell cycle analysis from peripheral blood samples without myocardial biopsies. Routine echocardiograms, electrocardiograms, and chest x-ray films were not helpful. Six episodes of rejection were successfully treated in four patients. Twelve-month postoperative catherization in one patient (hypoplastic left heart syndrome) showed appropriate graft growth, no aortic or pulmonary anastomotic strictures, normal right and left ventricular function, and no coronary artery disease. We conclude that infant orthotopic cardiac transplantation is an acceptable procedure for severe forms of untreatable congenital heart disease. The excellent short-term results warrant continued application of orthotopic cardiac transplantation.

Acute Kidney Injury↗
PubMed1996

Inner-city older blacks have high levels of functional disability.

OBJECTIVES: To describe the frequency and severity of functional problems in two groups of noninstitutionalized inner-city blacks aged 70 years and older contrasted with results from appropriate groups of white and black older adults and with the goals of the Healthy People 2000 program. DESIGN: Cross-sectional descriptive study. SETTING: Community-based samples. PARTICIPANTS: A population-based sample of 416 older adults living in a 3.5-square mile catchment area in north St. Louis (NSL), Missouri, and a sample of 197 older residents living in public housing in East St. Louis (ESL), Illinois. MEASUREMENTS: Health status, preventive health activities, health services utilization, and risks for progressive frailty were assessed by self report and observation using well validated, standardized instruments. Whenever possible, comparison data were derived from national datasets, original samples used to validate the measures, and other useful comparison groups. RESULTS: The NSL sample had somewhat better health status and risk for progressive disability than the ESL sample. However, compared with national or regional reference groups using age-gender adjustments, both study groups demonstrated increased levels of dependence in intermediate activities of daily living, restricted activity days, inability to walk one-half mile without assistance, reported poor vision, living alone, and limited income compared with both older whites and blacks, and increased levels of worsening health, inability to perform heavy work around the house, never walking a mile or more, and currently unmarried versus whites with variable decrements versus blacks. Contrasted with other comparison groups, the two samples had increased body fat; consistent decrements in gait speed, timed chair stands, timed one-leg balance, and frequency of preventive exercise; and lower levels of dental care; results relative to physician visits and hospital days were mixed. They also had high levels of measured visual and hearing impairments, unmet needs for home delivered meals, and problems with false teeth. Deficiencies compared with the goals of Healthy People 2000 were large. CONCLUSIONS: The special attributes of inner-city blacks, including poverty and access to and acceptance of remedial programs, will have to be considered if the goals of Healthy People 2000 are to be met in this important and growing segment of older Americans. 44:0000-0000, 1996.

Activities of Daily Living↗
PubMed1996

Total hip and knee replacement treatment programs: a report using consensus.

Physical therapists may use varied treatment protocols for the acute care of patients with to hip or knee replacements. The purpose of this study was to develop, via consensus, a standardized treatment program for patients receiving total hip or knee replacement for primary osteoarthritis. Eighteen clinicians nationwide participated in a three-round consensus process. In Round 1, over 80% of the panel identified exercise, transfers, ambulation, and discharge criteria as the important treatment categories. In Round 2, they reviewed the preliminary physical therapy treatment program and recommended additional exercise regimes. In Round 3, 76% of the panel accepted the final total hip replacement program while 70% of the panel accepted the total knee replacement program. Using the consensus development process, physical therapists may begin to define their treatment programs which is fundamental to establishing a baseline standard of care.

Hip Prosthesis↗
PubMed1986

A mental health center's influence in a county jail.

A case study that describes the process of establishing mental health services in the medium-sized Howard County (Maryland) jail is presented. Built in 1878, the county jail provided virtually no rehabilitative services to its inmates until 1972. At that time, personnel from the Howard County Bureau of Mental Health began to gain access to the jail, establish rapport with the jail staff, assess the mental health needs of the inmates, and implement various programs to meet these needs. Implementation and development of services are described for the 12-year span between 1972 and 1984. The concept of providing community-based services has been accepted and incorporated into the value system and structure of the jail. It is concluded that the viability of programs depended upon interactions among continuation of strong leadership for each component of the rehabilitation program, acceptance of the value of these services by the jail administration and staff, and availability of community resources. The linkage between the jail and community agencies is discussed.

Community Mental Health Services↗
PubMedDate not supplied

Alcoholic patients' decisions about halfway houses. What they say, what they do.

Because of the important role of halfway houses in the recovery of many alcoholic patients, patients' attitudes toward accepting placement in a halfway house were studied in a state hospital's alcohol rehabilitation program. Verbal intentions to accept or not to accept placement were measured at the beginning and again toward the end of the program sequence. Both assessments showed a strong correlation with the patients' actual behaviors. The relationships between intentions and ultimate choices were moderated both by the amount of time between observations and, independently of the passage of time, by the subjects' experience with or knowledge about halfway houses. Changes over the course of the program were mostly positive (favorable toward going and actually doing so). These shifts mainly involved the people who had been initially undecided about placement in a halfway house. Amount of time spent in the rehabilitation program was unrelated to patients' initial intentions toward going and had little bearing on their final decisions.

Alcoholism↗
PubMed2005

[Is the semen analysis a reliable test?].

The semen analysis is one, if not the most, important and widely used clinical laboratory test to evaluate the fertility potential of the male. However, recent reports have suggested that the semen analysis is unreliable. Quality control in the andrology laboratory is often seen as problematic, and many laboratories do not routinely employ QC procedures in semen testing. Quality assurance is an often overlooked and unappreciated aspect of overall quality laboratory performance. External proficiency testing programs in andrology are not universally accepted, and the results from the few programs currently available demonstrate huge variations between laboratories. Numerous different standards and criteria are being used by andrology laboratories, making it difficult if not impossible to compare results from one laboratory to another. However, reliable semen analyses can be obtained by following several recommendations: (1) all laboratories performing the semen analysis should adopt universally accepted performance standards and criteria, (2) all laboratories performing this test should participate in external proficiency testing programs, (3) andrology laboratories should implement effective internal quality control and quality assurance programs to ensure that the results reported are accurate and reproducible, and (4) physicians should only refer their patients to, or accept semen analysis results from, laboratories that have stringently followed these recommendations.

Clinical Laboratory Techniques↗
PubMed1993

Will universal health insurance assure universal access to ongoing primary care for adults?

OBJECTIVE: To assess the impact of current public insurance status (Medicare and Medicaid) and hypothetical payment levels of a new insurance program on physician acceptance of adult primary care patients desiring continuing care. METHOD: Survey of 175 primary care physicians in a medium-sized city and six surrounding counties in North Carolina. MAIN OUTCOME MEASURE: Likelihood of accepting new continuing care patients covered by Medicare, Medicaid, or a hypothetical health insurance system mandated to cover the uninsured. RESULTS: The response rate was 80%; 86% of the respondents were accepting new patients with private insurance. Of the remaining physicians, 72% were not accepting new continuing care patients covered by Medicaid and 55% were not accepting patients who paid via Medicare assignment alone. Seventy-nine percent of respondents were unlikely to accept new continuing care patients insured by a hypothetical public plan that reimbursed physicians at 60% of reimbursement levels provided by privately insured patients, compared with only 25% who were unlikely to accept patients if the reimbursement was 80% of the private level. CONCLUSIONS: Medicaid and Medicare do not assure access to continuing primary care. Also, physician reimbursement is an important determinant in any new health care system designed to provide universal and consistent access to regular primary care services.

Adult↗
PubMed1987

Screening of subsequent siblings of children who die of sudden infant death syndrome.

Since the value of home apnea monitoring for subsequent siblings (subsibs) of an infant who died of sudden infant death syndrome is uncertain, we describe an evaluation and monitoring program for subsibs. Eighty subsibs were screened in hospital at an average age of 4.6 weeks. The most valuable investigations included history, physical examination, blood gas tests, and four days on an apnea monitor in hospital. Sleep recordings added no decision-making data. Only 23 infants met one of the following criteria for home apnea monitoring: (1) sleep apnea for more than 15 s (either on sleep recording or recognized by apnea alarm), (2) more than 4.5 episodes of apnea per hour of sleep, (3) periodic breathing greater than 24% of sleep time, or (4) severe parental anxiety. Twenty-two infants were monitored until they were aged 6 months and had spent two months apnea free. Twelve had apnea at home. All of the infants survived. Excessive periodic breathing alone did not seem to be a valid reason for home monitoring. Our screening program is simple, acceptable to families, and useful to select a smaller number of subsibs for home apnea monitoring.

Diseases in Twins↗
PubMed1975

Mail-order medicine; An analysis of the Sears Roebuck Foundation's Community Medical Assistance Program.

Of the 625 rural communities that originally applied to the Sears Roebuck Foundation's Community Medical Assistance Program, 253 were accepted. One hundred sixty-three went on to build clinics, and 132 had physicians at the time of follow-up. From the standpoint of physician coverage of the community once a clinic had been built, the rate of physician availability was 78 percent, The communities' success in recruiting and retaining physicians was compared against 13 variables; none was significantly related to the recruitment, and only two--numbers of service clubs and distance to nearest physician--were related to retention.

Community Health Services↗
PubMed2000

Cadaver profile at university of Stellenbosch Medical School, South Africa, 1956-1996.

Data on 1,698 cadavers donated during the period 1956-1996 were obtained from files of the Department of Anatomy and Histology at the University of Stellenbosch Medical School, Tygerberg Hospital, South Africa, to project a profile of the characteristics of those accepted on the program for dissection. A breakdown of the data also provided information on the profile of donors belonging to different population groups. Donors to our program were predominantly male (68%) and predominantly colored, which in South Africa identifies those of mixed heritage (63%). The average age of death was 55 years (range 15-98). Donors belonging to the white population group had the highest female : male ratio. Circulatory disorders accounted for most deaths in the white population group (48%), whereas cancer was the leading cause of death in the colored and black population groups ( approximately 25%). Pulmonary tuberculosis accounted for 13% deaths in the colored population group, 14% of deaths in the black population group, but only 0.5% of deaths in the white population group. Cervical cancer and breast cancer accounted for approximately one-third of cancer deaths in women, with cervical cancer more common in colored and black female donors and breast cancer more common in white female donors. The cadaver profile in general reflects the health status of the different population groups in South Africa. The profiles of the colored and black groups reflect that of disadvantaged population groups (a high prevalence of infectious disease; relatively young populations), whereas the white donor profile is that of a privileged population group (a high prevalence of degenerative disease; aging population).

Adolescent↗
PubMed1981

The economics of cancer prevention and detection: getting more for less.

Economics has been described as the science of allocating scarce resources. Given the magnitude of the cancer problem and the obvious impracticality of eliminating every carcinogen or screening every person for every disease, our success in preventing cancer will depend greatly on our ability to use available resources efficiently. This paper will illustrate the principles of economics applied to the early detection of cancer of the lung, breast, colon, and cervix. The objective is to deliver the highest benefit possible. The available options include choice of the population to be screened (e.g., ages and risk factors), the tests to be used, and the frequency of examinations. The issues to be considered in making these choices include the expected benefits of early detection, the risks and side effects of the tests, the acceptibility of the program, the costs of the tests, the consequences of false positives, changes in therapy, and decrease in disability and lost earnings. The final choice of an "optimal" early detection protocol requires estimating and comparing these and other outcomes. This is a question of expectations and values; there is no "correct" answer or "best" program. These issues also have implications for the feasibility and prospects for third-party reimbursement for cancer prevention activities.

Adult↗
PubMed1989

Development of a computer-based instructional system in pharmacokinetics: efficacy in clinical pharmacology teaching for senior medical students.

The teaching of pharmacokinetics is acknowledged to be a key aspect of the core curriculum in clinical pharmacology and therapeutics, but is also widely acknowledged to be a very difficult part of the curriculum to teach. In order to assess the potential efficacy of interactive computer instruction in clinical pharmacokinetics we have developed a prototype computer-based instructional package. The courseware contains a comprehensive learning system including tutorial, simulation, and problem solving components. To determine the efficacy of this approach we randomly assigned senior medical student volunteers enrolled in the fourth year clinical pharmacology and therapeutics course to receive conventional teaching in clinical pharmacokinetics and/or adjuctive teaching using the computer-based instructional system. There was a high degree of acceptance of the program and over the short term of the trial those students using the computer program scored significantly higher [35%, P less than 0.05] on the mid-term pharmacokinetics quiz. The data suggests that a computerized instructional system in pharmacokinetics may significantly improve the teaching of clinical pharmacokinetics to medical students.

Computer-Assisted Instruction↗