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Preventing lead poisoning in New York City: priorities for lead abatement in housing.

The major challenge for lead poisoning prevention programs is to increase the availability of lead-safe housing as quickly as possible. The approach proposed by the City of New York maximizes the impact of the limited resources available to address this problem. The approach, however, is based on an assumption that in the short-term, modest lead hazard reduction measures such as restoring surfaces to an intact condition is adequate for most units and that more extensive abatement should be reserved for the relatively fewer units in which there is a high risk of exposure of lead-poisoned children reside. Ideally, this plan would be implemented with voluntary efforts to abate lead hazards when other renovation or remodeling occurs or when dwellings are vacant and more extensive abatement work can be performed at lower cost and without the attendant difficulty of abating occupied units. Approaches ranking hazards and implementing varying levels of hazard reduction must be fully evaluated and modified as new information becomes available. The specific criteria used to rank hazards should be evaluated to determine what measures best differentiate risk. Given the magnitude of the problem and the numerous obstacle--lack of funding, limited trained workers, and limited technical knowledge--it will probably take years, if not decades, to abate lead hazards in all the dwellings in which they exist. We must not be deterred, however, from beginning this effort in the communities and dwellings that need intervention the most: deteriorated, older housing units in which young children reside. In major urban centers such as New York City the greatest lead hazards will generally be found in areas where poverty is greatest. Thus, every effort must be made to ensure that adequate resources are available to improve housing in the communities in greatest need.

Child↗

Multicenter evaluation of Reflotron direct dry-chemistry assay of high-density lipoprotein cholesterol in venous and fingerstick specimens.

The Reflotron HDL Cholesterol test (Boehringer Mannheim GmbH) directly separates and analyzes high-density lipoprotein (HDL) cholesterol in plasma collected with EDTA in an integrated dry-reagent system suitable for alternative site testing of lipoproteins. We describe a multicenter evaluation of this test by two US and six European laboratories experienced in lipid analysis. Each laboratory compared the Reflotron with the same conventional wet-chemistry method, Boehringer phosphotungstate-Mg2+ precipitation with enzymatic cholesterol assay. Imprecision was within accepted guidelines, with CVs of < or = 8% for fresh and frozen plasmas (median CV 1.7-3.9%) and for lyophilized sera (median CV 3.8-4.7%), similar to those of the conventional method. Results of linear-regression analysis were as follows: Reflotron HDL Cholesterol = 1.03 conventional - 3.9 mg/L, r = 0.987. The Reflotron results were somewhat low in the two US laboratories, demonstrating the need for general standardization of methods for measuring HDL cholesterol. Results from capillary fingerstick plasma agreed well with those from venous-derived plasma; capillary = 1.04 venous + 4.5 mg/L, r = 0.967. The system is relatively insensitive to interference from hemoglobin (< or = 0.75 g/L), ascorbic acid (< or = 0.3 g/L), bilirubin (< or = 50 mg/L), cholesterol (< or = 3.5 g/L), and triglycerides (< or = 4 g/L). The relative ease of operation and the rapid availability of results (within 90 s for plasma collected in EDTA) make the method appropriate for use by well-trained, but not necessarily technical, operators in the physician's office or other alternative sites.

Aminopyrine↗

Innovations and advances in brachytherapy.

The treatment of cancer with radioactive sources using topical molds and intracavitary radium showed the efficacy of brachytherapy long before external radiation therapy became common practice. Brachytherapy is progressing in several clinical directions that reflect technological innovation as well as changes in medical care which combine to provide significant advances in the practice of brachytherapy today. A major change in brachytherapy, the development of high intensity sources, promoted clinical and technologic innovations in high dose-rate brachytherapy. Pulse dose-rate brachytherapy is the use of these sources to treat a target by using pulses of radiation for several minutes each hour with the same overall time and total dose as low dose-rate treatment. Recent novel approaches of using radiotherapy for prevention of restenosis in coronary and peripheral vessels has interested laboratory and clinical researchers. Most of the work toward new source material for brachytherapy centers around intravascular applications. Technology to support brachytherapy continues to advance rapidly. The interaction between images from diverse modalities and the various phases of the treatment planning is the basis of enhanced treatment planning procedures. Optimization in brachytherapy entails calculating the source strengths or source dwell times to satisfy a set of dose criteria to achieve the best dose distribution for a brachytherapy implant. Progress in computerization and calculation modeling has promoted this technical advance. Education and training in brachytherapy indications and techniques is mandatory to maintain high standards of brachytherapy practice.

Animals↗

[Psychological characteristics of unsuccessful pilot trainees].

Some pilot trainees can not pass flight examinations and are obliged to give up their flight training because of their insufficient technical skills. We investigated their results of group Rorschach test (a multiple-choice test with ink blots which are similar to those for face-to-face Rorschach test). Subjects were 20 male pilot trainees (F (fail) group: mean age 22.6 +/- 1.5 years) who were obliged to give up their flight trainings between 1985 and 1996 because of their insufficient technical skills. The control group was made up of 125 male pilot trainees (P (pass) group: mean age 22.4 +/- 1.7 years) who were the successful classmates of the unsuccessful trainees. We investigated the differences of the results of group Rorschach test given for employment screening between the two groups. All results of the scores in group Rorschach test were within normal limits both in P group and F group. There, however, were following significant differences between the two groups: (1) F group showed more Key- responses than P group (F group: 4.9 +/- 2.1 P group: 3.4 +/- 2.0, p<0.01). (2) F group showed more k responses than P group (F group: 0.2 +/- 0.4 P group: 0.02 +/- 0.1, p<0.01). (3) P group showed more FC' responses than F group (F group: 1.4 +/- 1.0 P group: 2.2 +/- 1.2, p<0.01). (4) F group showed more cF responses than P group (F group: 1.6 +/- 1.2 P group: 1.0 +/- 0.9, p<0.05). (5) P group showed higher form level than F group (F group: 120.6 +/- 15.8 P group: 128.2 +/- 12.6, p<0.05). The pilot trainees in F group were suggested to have vulnerability to be nervous and anxious in an inexperienced situation, to decline their ability to cope objectively and effectively with a new situation, and to increase desire for dependence upon others.

Adaptation, Psychological↗

Development of a rating system for surgeons' non-technical skills.

BACKGROUND: Analyses of adverse events in surgery reveal that many underlying causes are behavioural, such as communication failure, rather than technical. Non-technical (i.e. cognitive and interpersonal) skills are not addressed explicitly in surgical training. However, surgeons need to demonstrate these skills, which underpin their technical excellence, to maximise patient safety in the operating theatre. This paper describes the method used to identify surgeons' non-technical skills, and the development of a skills taxonomy and behavioural rating system to structure observation and feedback in surgical training. METHODS: Cognitive task analyses (critical incident interviews) were conducted with 27 consultant surgeons in general, cardiac and orthopaedic surgery. The interviews were coded and a multidisciplinary group of surgeons and psychologists used an iterative process to develop a skills taxonomy. This was supported by data gathered from an attitude survey, literature review, analysis of surgical mortality reports and observations in theatre. RESULTS: Five categories of non-technical skills were identified, including situation awareness, decision making, task management, leadership and communication and teamwork. This provided a structure for a prototype skill taxonomy (v1.1), which comprised 14 non-technical skill elements. Observable behaviours (markers) indicative of good and poor performance were developed for each element by 16 consultant surgeons to form a prototype behaviour rating system. CONCLUSIONS: The prototype skills taxonomy and behaviour rating system are grounded empirically in surgery. The reliability of the system is currently being tested using standardised scenarios. If this evaluation proves successful, the system could be used to structure feedback and guide non-technical skills training.

Consultants↗

[Different methods of percutaneous desobstruction of peripheral arteries].

Chronic arterial occlusion of the iliac and femoro-popliteal vessels has been considered, until recently, to be a contraindication to percutaneous transluminal angioplasty. However, recent advances in radiological and catheterisation equipment and the introduction of new methods of recanalisation (laser, mechanical devices) have increased the therapeutic possibilities. The immediate and long-term results of iliac recanalisation are usually excellent with conventional angioplasty methods. The success rate of recanalisation of the femoro-popliteal segments is about 80% irrespective of the method used, the failure rate increasing with the length of the occlusion. However, the long-term patency rate is poor, about 50%. These methods of percutaneous recanalisation are technically difficult and require special training and sophisticated equipment. The indications should be carefully evaluated in a pluridisciplinary manner taking into account the potential clinical benefits, the technical difficulties, the risks and other therapeutic possibilities.

Angioplasty, Balloon↗

[Opinion of family and community medicine resident physicians in Spanish hospitals].

OBJECTIVE: To find out the opinions of Family and Community medicine interns concerning various aspects of their teaching during their period of hospital training. DESIGN: Crossover study. SITE. Within hospitals. PARTICIPANTS: Family and Community Medicine residential interns in Spanish hospitals. MAIN MEASUREMENTS AND RESULTS: Out of the questionnaires returned by mail, 78.4% thought that their hospital training was adequate; 83.6% believed they were well enough trained to practise professionally; 76% considered that their hospital's technical equipment had been useful for their training; 66% felt they had sufficient back-up from the staff; 60% contributed to scientific statements or publications; 59% thought that their centre's library was inadequately equipped; and 45.4% stated that their pay as interns, or in the future as specialists, was too low. CONCLUSIONS: Family and Community Medicine interns' current training is in general satisfactory. Certain aspects, such as stocking libraries, salaries and contributions to scientific reports should be improved.

Adult↗

Quality in the technical performance of screening flexible sigmoidoscopy: recommendations of an international multi-society task group.

BACKGROUND: Flexible sigmoidoscopy (FS) is a complex technical procedure performed in a variety of settings, by examiners with diverse professional backgrounds, training, and experience. Potential variation in technical quality may have a profound impact on the effectiveness of FS on the early detection and prevention of colorectal cancer. AIM: We propose a set of consensus and evidence based recommendations to assist the development of continuous quality improvement programmes around the delivery of FS for colorectal cancer screening. RECOMMENDATIONS: These recommendations address the intervals between FS examinations, documentation of results, training of endoscopists, decision making around referral for colonoscopy, policies for antibiotic prophylaxis and management of anticoagulation, insertion of the FS endoscope, bowel preparation, complications, the use of non-physicians as FS endoscopists, and FS endoscope reprocessing. For each of these areas, continuous quality improvement targets are recommended, and research questions are proposed.

Antibiotic Prophylaxis↗

[Trends in the teaching of epidemiology in Brazil].

The teaching of epidemiology in Brazil began in the 1920s and has always been connected to public health. The 1970s witnessed an expansion in the number of graduate-level courses in epidemiology. The 1980s were characterized by "social epidemiology," which incorporated the social sciences and their methods into epidemiology; the second half of the decade was marked by the development of biostatistical techniques. Currently, the definition of guidelines for the teaching of epidemiology in Brazil depends on careful reflection regarding a number of issues, among which are the reformulation or elimination of medical residency programs in preventive medicine, social medicine, and collective health; the creation of masters and doctoral programs exclusively in epidemiology; the conflict between a theoretical emphasis and a technical emphasis; and the development of strategies to strengthen new instructional groups that are being created in teaching institutions in less developed regions of the country. A positive trend is that teaching institutions are working more closely with health services, both for training personnel and for providing technical support in planning, organizing, and evaluating health programs. Regarding the teaching of health service professionals, successful training depends on how well teachers can provide in-service training that ties students' learning to real work situations, where the application of theories can be understood in the natural context of real problems.

Brazil↗

[Technic of flexible cystoscopy].

After brief training, flexible cystoscopy allows complete investigation of the vesical cavity in the surgeon's office. In particular, this technique facilitates the examination of the anterior wall and the base of the bladder. The low flow rate of the irrigating channel prohibits the use of this technique in cases with severe haematuria.

Cystoscopes↗

Semiquantitative mercury determination in fish: a tool for poisoning prevention.

Human exposure to mercury intoxication through contaminated fish ingestion has been well studied, mainly among Japanese population. The Brazilian population, particularly in the Amazon region, is now in focus due to findings of fish contamination. Major health impacts caused by mercury affect mostly people who have a regular fish diet. A continuous checking for mercury content in the most consumed fish could prevent human intoxication. A simple, non-instrumental method to allow a continuous checking of the mercury content in fish was developed. Based on this method, we are proposing a prevention action where community agents can be trained to perform fish analysis. Technical Schools and Universities located nearby the affected areas would be in charge of quality control programs for the fish analysis as well as for the selection, training and update for operators.

Animals↗

Training of A3-A3 side-to-side anastomosis in a deep corridor using a box with 6.5-cm depth: technical note.

BACKGROUND: Cerebral revascularization in the deep surgical field is technically challenging. Especially, side-to-side anastomosis like A3-A3 could be technically more difficult compared with end-to-side anastomosis. To improve surgeon's dexterity and maneuverability in the deep surgical field, the authors developed an easily accessible and well-simulating training system using prosthetic tubes and a box. METHODS: Two prosthetic tubes (silicon tube, 1.2 mm in diameter) are mounted in parallel on the bottom of 6.5-cm-deep emptied 'tissue paper box.' The orifice of the box is restricted to 2 x 2 cm to simulate a deep and narrow surgical corridor. Using bayonet-shaped micro needle holder and forceps, the side-to-side anastomosis of the tubes is performed with 10-0 nylon under operative microscope. RESULTS: Prosthetic tubes well simulated real A3-A3 anastomosis. From the standpoint of technical difficulty, this training system needed slightly higher level of dexterity compared with real A3-A3 anastomosis because of narrower and deeper surgical corridor, and the wall of prosthetic tube was slightly thicker and more inflexible. After this training, the surgical technique in real A3-A3 anastomosis was improved. CONCLUSIONS: This training system worked well to ease the transition from anastomosis in shallow surgical field to deep and narrow surgical field. The prosthetic tube we used approximates real A3 relatively well, and the ease in setting up this system enabled repeated practice, which resulted in steep learning curve of the technique.

Aged↗

[Ophthalmologic ultrasound diagnosis--current training programs in Germany, Austria, Switzerland].

In these three countries the application of diagnostic ultrasound in ophthalmology is restricted, with few exceptions, only to institutions having access to in-patients. This situation is based on the organization of medical care and does not depend on the technical evolution of the equipment. Consequently the annual rate of trainees in ophthalmic ultrasound is relatively low, but a comprehensive training programme is needed in this field. The requisite training subjects are described. They include a technical and a clinical programme for both pulse-echo (A, B, M, D mode) and Doppler techniques as applied for biometry as well as for tissue and vascular examination. Some data are given regarding training facilities, aids and courses in the three countries. The concept and organization of a 5-day course (Bonn/Würzburg Course, Directors: W. Buschmann/H.G. Trier) is described in greater detail. For ophthalmic ultrasonography, testing and calibration of system parameters both for equipment and transducers is necessary for obtaining reliable and reproducible results. Examples are given for the organization of technical training in the practical course. The 1981 guidelines of the "Kassenärztliche Bundesvereinigung", Cologne, are discussed. These regulations define minimum requirements for both ultrasonic training and equipment in the FRG. Finally, a few controversial aspects of the teaching (quality assurance, role of biometry) are mentioned.

Austria↗

[Training before departure of volunteers during nutritional emergencies. From inception to evaluation].

Predeparture training is rarely undertaken within emergency nongovernmental organizations. Although field-training is considered as the only real school, the technical requirements are increasingly more constraining. To cope with this problem, the technical officers of Action contre la faim planned a predeparture training project based on self-instruction of any volunteer leaving for a nutritional emergency mission. The project began in 1994. Six self-instruction sessions were produced to enable volunteers to learn. To improve the quality of work, this framework encouraged creativity, constant research and motivation. The training supervisor accompanied the volunteers and put them in simulated situations where various tools were made available to them. A series of measures have been used to improve this basic training: 1) a training contract meant to make the volunteer responsible for his training; 2) better programming to ensure adequate relay from one volunteer to the next; 3) an apprentice report covering the first 15 days of the volunteer's integration into the field, thereby providing important feed-back to the supervisor; 4) an evaluation of the monthly report and an interview-grid used to follow the volunteer in the short and medium-term; 5) and an evaluation form completed by the volunteer which enables the updating of sessions and simulated situations. This initiative has made us aware of the importance of following the volunteers at all stages: this can increase the volunteer's efficiency and their fidelity to the non-governmental organization. Currently, the main objective is to gain the support of qualified technical coordinators who will be the most important factor in continuous training.

Creativity↗

Establishing an endoscopy unit for surgical training.

Gastrointestinal endoscopy is slowly returning to the core of surgical resident training. The intent is to integrate endoscopy into the mainstream of surgical education such that it will be approached and used the same as any of the many diagnostic and therapeutic tools at the surgeon's disposal. The current feeling is that although endoscopy should be intimately incorporated into training, there is a level of technical expertise required such that a dedicated teaching experience must be provided. This education must be directed by a surgeon experienced in endoscopy; we should not abdicate this responsibility to others. The training program should be founded on education, clinical practice, and research, with technical skills to begin in PGY 2 or PGY 3 and be incorporated throughout the remainder of training. Quality assurance should be monitored closely but not separately from that of the surgical service. Certification of the resident should not depend on numbers, nor be specifically singled out from the body of surgery. There is adequate patient demand to establish the endoscopy unit under the supervision of a surgeon, either as a separate unit or as part of the surgical clinic. However, as the number of endoscopic procedures performed approaches 600 per year, a fully dedicated endoscopy room and full-time gastrointestinal assistant technician are required. The most efficient method of postsedation recovery is through coordination with an ambulatory surgery unit or postoperative recovery room. The current standard for equipment is video endoscopy in order to provide the most efficient method for surgical training.

Digestive System Surgical Procedures↗

Objective assessment of gynecologic laparoscopic skills using the LapSimGyn virtual reality simulator.

BACKGROUND: Safe realistic training and unbiased quantitative assessment of technical skills are required for laparoscopy. Virtual reality (VR) simulators may be useful tools for training and assessing basic and advanced surgical skills and procedures. This study aimed to investigate the construct validity of the LapSimGyn VR simulator, and to determine the learning curves of gynecologists with different levels of experience. METHODS: For this study, 32 gynecologic trainees and consultants (juniors or seniors) were allocated into three groups: novices (0 advanced laparoscopic procedures), intermediate level (>20 and <60 procedures), and experts (>100 procedures). All performed 10 sets of simulations consisting of three basic skill tasks and an ectopic pregnancy program. The simulations were carried out on 3 days within a maximum period of 2 weeks. Assessment of skills was based on time, economy of movement, and error parameters measured by the simulator. RESULTS: The data showed that expert gynecologists performed significantly and consistently better than intermediate and novice gynecologists. The learning curves differed significantly between the groups, showing that experts start at a higher level and more rapidly reach the plateau of their learning curve than do intermediate and novice groups of surgeons. CONCLUSION: The LapSimGyn VR simulator package demonstrates construct validity on both the basic skills module and the procedural gynecologic module for ectopic pregnancy. Learning curves can be obtained, but to reach the maximum performance for the more complex tasks, 10 repetitions do not seem sufficient at the given task level and settings. LapSimGyn also seems to be flexible and widely accepted by the users.

Clinical Competence↗

The GLBT Health Access Project: a state-funded effort to improve access to care.

The Gay, Lesbian, Bisexual, and Transgender (GLBT) Health Access Project is a unique public-private collaboration working to eliminate barriers to health care for the GLBT community, foster development of comprehensive, culturally appropriate health promotion policies and health care services for GLBT people and their families, and expand appropriate data collection on GLBT health. Funded by the Massachusetts Department of Public Health, the project developed community standards of practice for provision of quality health care services to GLBT clients. A health access training curriculum was developed and technical assistance was offered to health care providers implementing the standards, which cover personnel, clients' rights, intake and assessment, service delivery and planning, confidentiality, and community outreach and health promotion. Training participants (324 individuals from 89 agencies) reported positive though not statistically significant changes in attitude.

Community Health Planning↗

[The hygienic assessment of the organization of the vocational study practice of students training for the job of power-generating unit operator].

The study is carried out with schoolchildren from the educative and industrial complex of energetics (two classes with total 60 students) at the age of 17-18, from the Technical College of Energetics "V. Pick"--Sofia. They are trained for the profession "operator on power aggregates". The investigation is performed during the educative and industrial practice of the students in the Heat Power Station "Tr. Kostov" and the Heat Power Station "Sofia", as well as in the training shop of the technical college. Studies are made on: the functional adaptation of the organism through the reactivity of the CNS, some analysers, the cardiovascular system and the sympathetic-adrenal system, haemopoiesis; the factors of the educative and industrial environment; working/professional maturity of the students; health status of the adolescents. The results of the examination show low effectiveness of the education and industrial training in the Heat power station or low daily and annual exposure, leading to monotony, hypodynamia especially when working in second shift. It is recommended the education and industrial practice in the secondary special schools and technical colleges to be carried out in training shops, educative and industrial workshops and at standardization of the environmental factors and organization of rational regime of work and rest.

Adaptation, Physiological↗