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PubMed2000

Investment in a rural residency program: a case study.

Rural hospitals have used numerous strategies over the past several decades to recruit and retain physicians. These have included providing physicians economic incentives, immigration status, professional and technical support and establishing rural training tracks (RTT) in family practice residency programs. This paper presents the experience of an isolated rural region in southwestern New York state that has employed each of these strategies in the past decade. Success as measured by the change in size of the medical staff, hospital operating margins, admissions and employment occurred only after the emphasis changed from meeting hospital needs to physician needs. Pivotal to this strategy was the nurturing and development of an RTT. Investment in the residency program required strong leadership to ensure the political, financial and operational commitment of its affiliated hospital. In addition, the RTT required an affiliation with a financially viable, full-service hospital, a strong on-site chief of service, family physicians who performed cesarean sections, midlevel providers and practitioners dedicated to the mission of teaching.

Career Choice↗
PubMed1993

Catch-up growth during adolescence.

Various chronic diseases and malnutrition cause growth failure in childhood and adolescence; following recovery, catch-up growth may occur. The extent to which growth failure can be compensated for depends on the timing, severity and duration of the growth failure, as well as on the aetiology and pathogenesis of the disease restricting growth and development. There are three types of catch-up growth. In type 1, when growth restriction ceases, growth occurs to such an extent that the height deficit is rapidly eliminated. Once the original growth curve is attained, growth proceeds normally. In type 2, when growth restriction ceases, there is a delay in growth and somatic development. However, growth continues for longer than usual, compensating for the growth arrest. Type 3 is a mixture of types 1 and 2, and all three types may be complete or incomplete. Two factors make it difficult to record catch-up growth during adolescence: the large variability in timing, expression and duration of pubertal growth and somatic development, and the relationship between the measurement error and the increase in growth observed within a defined time period. To avoid data collection and analysis problems, prospective and long-term study design should be considered. Ideally, data collection should be started in the prepubertal period and continue until final adult height is reached. High technical standards and well-trained personnel should be used. A variety of parameters should be assessed to obtain different dimensions of the growth process and pubertal development.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2000

Perceptions of and constraints upon pregnancy-related referrals in rural Rajasthan, India.

Mortality associated with complications of pregnancy and childbirth remains disproportionately high in the developing world. This paper reports on a study into the reasons for the poor uptake of referrals to specialist medical units in a group of 276 women in a rural area in the state of Rajasthan, India. Of the 276 cases that were referred, 242 (88%) of the women failed to attend for specialist consultation. In-depth personal interviews were conducted and a series of focus group discussions was held with the women and with their spouses and spouses' mothers. A range of geographic, cultural, socio-economic and medico-administrative factors was identified as influencing decisions to attend referral units. Recommendations for improving uptake include improving facilities at referral units, providing additional training for healthcare staff (covering technical, managerial and behavioural aspects) and in counselling techniques, a better defined role for traditional birth attendants, improved understanding of the mother's needs by her family (particularly the spouse and his mother) and increasing public awareness of the importance of referral. Finally, there is the requirement that women are encouraged to realize and understand their own needs.

Adolescent↗
PubMed2004

Participation of African social scientists in malaria control: identifying enabling and constraining factors.

OBJECTIVE: To examine the enabling and constraining factors that influence African social scientists involvement in malaria control. METHODS: Convenience and snowball sampling was used to identify participants. Data collection was conducted in two phases: a mailed survey was followed by in-depth phone interviews with selected individuals chosen from the survey. FINDINGS: Most participants did not necessarily seek malaria as a career path. Having a mentor who provided research and training opportunities, and developing strong technical skills in malaria control and grant or proposal writing facilitated career opportunities in malaria. A paucity of jobs and funding and inadequate technical skills in malaria limited the type and number of opportunities available to social scientists in malaria control. CONCLUSION: Understanding the factors that influence job satisfaction, recruitment and retention in malaria control is necessary for better integration of social scientists into malaria control. However, given the wide array of skills that social scientists have and the variety of deadly diseases competing for attention in Sub Saharan Africa, it might be more cost effective to employ social scientists to work broadly on issues common to communicable diseases in general rather than solely on malaria.

Adult↗
PubMed2006

The diffusion of effective behavioral interventions project: development, implementation, and lessons learned.

Implementation of evidence-based HIV/STD prevention interventions can play an important role in reducing HIV and sexually transmitted diseases. This article describes the development, implementation, and lessons learned of the Diffusion of Effective Behavioral Interventions (DEBI) project, a strategy funded by the Centers for Disease Control and Prevention to diffuse evidence-based, group- and community-level HIV/STD prevention interventions to health departments and community-based organizations nationwide. The article specifically provides an overview of the rationale, description, and theoretical foundation of the project; a review of marketing efforts, including assessment of interests, needs, and capacities relative to the project; a description of project products, their purpose, approach employed to develop them, and their use by implementers; a description of the project's training coordination functions and activities; technical assistance issues; an overview of process and outcome evaluation components; new developments in response to feedback; and a discussion of future directions for DEBI. Project successes and challenges are addressed to inform future efforts to diffuse prevention interventions.

Diffusion of Innovation↗
PubMed2001

[Communication related to pesticides use in a rural area of the state of Rio de Janeiro, Brazil].

OBJECTIVE: To assess communications aspects related to pesticide use in a rural area of the Rio de Janeiro state, Brazil. METHODS: The study was carried out in the area of São Lourenço stream. It was based on methodological triangulation comprising: semi-structured interviews and observation of a local population sample (about 600 inhabitants); structured questionnaire to collect data on the local community; and records of lectures given by argonomic engineers, pesticides traders and other public service professionals. RESULTS AND DISCUSSION: This study pointed out to the historical misinformation on pesticides in rural areas; the emphasis on technical language in educational and training activities available which constitutes a barrier for rural workers knowledge acquisition and empowerment; and the industry/commerce's pressure to legitimate pesticide trading, reinforcing the existing communication process, resulting in unfavorable inclusion of the rural worker into a broader market economy.

Brazil↗
PubMed2003

[Cooperation between an NGO and "host" states in the control of leprosy in Latin America].

The proliferation of nongovernmental organizations (NGOs) can be considered the result of the inability of the current democratic system to perform all the tasks desired by its citizens. Although NGOs often do quite positive work, they tend to diminish governmental power and are capable of interfering in the internal affairs of other countries. In this context, there are efforts to control their activities, and this control can produce both negative effects (blocking the defense of human rights) and positive ones (correcting the lack of coordination in the work by NGOs). NGOs working with the control of leprosy have a long history of cooperation with "host" states in Latin America. In the worst cases they work in a vacuum left by the state. In a country like Brazil, where the government prioritizes the control of Hansen disease and community participation in the political process - NGOs generally work "in harmony" with national authorities. The most useful contribution to state efforts has been the technical and financial support for training health personnel, supervision, and awareness-raising campaigns. Thus, the NGO becomes "quasi-governmental" in performing its tasks.

Brazil↗
PubMedDate not supplied

Assessment of a scenario-based approach to facilitating critical thinking among paramedic students.

INTRODUCTION: Paramedic practice is shifting from [direct] on-line medical control to protocol-driven care initiated on the paramedic's judgment of the patient's problem(s). Teaching in most paramedic training programs remains grounded in technical rationality. This does not adequately prepare practitioners for current day practice. Medical conditions often present as ill-defined problems. To deal with these situations, practitioners need problem solving and reflective-thinking skills. Methodologies incorporating the use of these skills in a contextual situation similar to actual practice may help paramedics develop these skills. HYPOTHESIS: This study sought to determine the impact of written scenario exercises in the context of clinical problems as a means of learning in order to foster higher level thinking skills and self-directed tendencies. It involved three hypotheses: 1) Post-test scores would correlate with scores attained on the traditional, multiple choice, final examination; 2) Post-test scores would correlate with scores on the critical thinking sub-test of the final examination; and 3) Scores would be better on the post-test compared to the pre-test. METHODS: This two year, longitudinal, prospective study was conducted with 55 paramedic students using a pre- and post-test. Post-test scores were compared with final examination scores and scores of the subset of higher level thinking questions within that examination using the Pearson r-test. The relationship between the pre- and post-test scores was analyzed using a one-tailed dependent t-test. Post-hoc analysis of the variables of age, experience, and education was conducted using one-way analysis of variance. RESULTS: The correlation between post-test scores with final examination scores was positive and modestly significant. There was no correlation of post-test scores with sub-test scores. Comparison of pre- and post-test scores was significant. Effects for age, experience, and education were not significant statistically. CONCLUSIONS: Using written scenarios increases ability to utilize reflective thinking and self-directed tendencies. However, this ability may not be demonstrated consistently on traditional written examinations. A multi-site study using large numbers and a control group or alternative methods appears to be indicated to demonstrate more accurate effects of the methodology.

Adult↗
PubMed1999

[An epidemiological study of health care seeking behavior by children under the age of 5 years at hospital emergency services in Togo].

The functioning and efficacy of pediatric emergency services are currently being questioned in many Northern countries, as well as in the South, for example in North Africa. Reference is often made to unjustified medical emergencies in the face of an influx of patients with benign problems who come from socially disadvantaged families. In the university and regional hospitals in three regions in Togo, we compared three categories of under-5 patients: children sent to "day-time" emergency services after triage done by health personnel; those sent to the "ordinary consultation"; and children brought after hours by their family (without referral by a health professional in 92% of cases) and seen in the "after-hours" emergency service. Serious tropical pathology (cerebral malaria, malaria, sickle cell disease) is mainly seen in emergency consultations, in which high hospitalization rates are noted (83% during the day, 67% at night) and a lethality of 3.4%. One cannot therefore use terms such as "false emergencies", "felt" and "medically unjustified" and the pediatric supervisor for the research considered that recourse to after-hours emergency services was justified in 75% of cases. Families using night services have higher educational levels than those sent to day emergency services, the mother's educational level being the main factor associated with certain characteristics of health seeking behavior (duration of symptoms prior to arrival at hospital, recourse to modern medical drugs). There is often a long delay before recourse to hospital: only 45% of children seen after hours and half of those who died came the 1st or 2nd day of the illness. Self-medication at home is usual but recourse to tradi-practitioners appears rare (4%). Several solutions can be envisaged and should be linked: strengthening of the first level of care, technical improvements in emergency services, training of tradi-practitioners in the recognition and referral of emergency cases, improvement of reception practices at the hospital level, prophylactic and preventive measures for tropical diseases.

Age Factors↗
PubMedDate not supplied

[Trans-sternal approach to the cervicothoracic junction].

Cervicothoracic junction and upper thoracic spine down to T4 can be reached through anterior approach via sternotomy. Transsternal approach is the best route to gain access to lesions localized within vertebral bodies of the upper thoracic spine allowing for their resection, interbody fusion and replacement with bone cement. Consecutive modifications of transsternal approach evolved toward less extensive osteotomy from full median sternotomy, through manubriotomy with clavicle resection and partial lateral manubriotomy. Less extensive modifications provide limited lateral exposure of the spine and are more demanding technically. We present two cases of upper thoracic spine tumours operated on through full medial sternotomy. We believe that median sternotomy has several advantages over less extensive modifications: it is technically simple to perform for trained thoracic surgeon, safer as it provides better exposure of the mediastinum and thus sufficient control of great vessels including subclavian ones, gives better exposure of T3, T4 and even T5 vertebral bodies, allows perpendicular sight and attack to anterior surface of the upper thoracic spine and therefore good visualizing of the posterior longitudinal ligament and dura, do not destabilize shoulder girdle nor affect function of the upper limb. Additional caudal exposure of the thoracic spine as down as T5 can be obtained by dissecting a plane between the brachiocephalic vein, vena cava superior and ascending aorta.

Aged↗
PubMedDate not supplied

[Summary of recommendations for a rational implementation of the ministry of health guidelines on the prevention of occupational risks in handling antineoplastic agents].

The Italian Society of Preventive Medicine for Health Care Workers has examined the guidelines recently published by the Italian Ministry of Health for implementation of safe handling practices for antineoplastic drugs and produced recommendations. On the basis of literature data and the field research carried out by the Society, different aspects covering risk assessment, environmental and biological monitoring, workplace and individual protection measures, education and training of health care and technical personnel, health surveillance programs, were focused on. The creation of a single central unit for preparing antineoplastic drugs or at least a drastic reduction in the number of preparation units currently operating in each hospital are the most relevant objectives of both the guidelines and the Society document. This must be accompanied by correct management of technical and organizational measures, improvement of safety and health of personnel involved in different activities and reduction of the number of exposed subjects. Finally the importance is stressed of clear specific mandatory procedures with which to manage and control the different aspects of job organization.

Antineoplastic Agents↗
PubMedDate not supplied

Measurement of HIV-1 p24 antigen by signal-amplification-boosted ELISA of heat-denatured plasma is a simple and inexpensive alternative to tests for viral RNA.

Assessment of HIV-1 RNA concentration is widely used for monitoring antiretroviral therapies. Tests are, however, expensive and require technically advanced equipment and highly trained personnel. Increasing availability of antiretroviral treatment in resource-poor settings calls for simple and inexpensive virus tests. HIV-1 p24 antigen tests were frequently used before the availability of nucleic acid tests (NAT). Two simple modifications, heat-mediated destruction of test-interfering antibodies and increased sensitivity achieved by signal amplification, have shaped the p24 antigen test into a tool that rivals NAT. This improved p24 antigen test, for which all reagents are available from Perkin Elmer Life Sciences, was evaluated in clinical studies in comparison with the most sensitive PCR methods available at a given time. In a prospective study over 4 years, HIV-1 infection among 859 samples from 307 infants born to HIV-positive mothers in Switzerland was detected as sensitively by p24 antigen assay as by PCR for viral DNA or RNA: 100% sensitivity of all methods after 10 days of age; 99.2% diagnostic specificity of p24 after neutralization (RNA, 98.6%). A study conducted in Dar es Salaam (Tanzania) found 123 of 125 samples from 76 PCR-positive infants positive for p24 antigen (sensitivity = 98.7%). In 169 infected Swiss adults with a median CD4+ T-cell count of 140 cells/microliter followed for a median of 2.7 years, p24 at baseline correlated as well as or better than HIV-1 RNA with the ensuing CD4+ T-lymphocyte decline and was independently predictive of progression to clinical AIDS (P = 0.043) and survival (P = 0.032). RNA predicted AIDS (P < 0.005), but not survival (P = 0.19). Another study of first-visit samples from 496 mostly black IVDU in the U.S. with a median CD4+ count of 518 cells/microliter showed equally strong prediction of progression to clinical AIDS for p24 antigen, HIV-1 RNA, and CD4+ T-lymphocyte concentrations at baseline. Treatment-associated changes in p24 and RNA levels in adults and children correlated well in three Swiss studies. The half-life of p24 antigen in the first phase of effective treatment was 1.6 +/- 0.4 days (RNA, 1.7 +/- 0.8). A second, slower decay phase had a half-life of 42 +/- 16 days. One study suggested that a strategy involving a somewhat more frequent testing for p24 antigen permitted detection of viral failures significantly earlier than tests for HIV-1 RNA conducted at 3-month intervals, while at the same time significantly saving on costs. Experience from three studies indicates that the p24 antigen test recognizes viruses of subtypes A-G and O, as well as some recombinant isolates, but leaves open the possibility that some non-B p24 antigens may be suboptimally detected. This improved p24 antigen test provides diagnosis of pediatric HIV infection, prediction of prognosis and treatment monitoring in quality comparable to tests for HIV-1 RNA, but at much lower costs. There is no problem with sample instability and no need for cumbersome nucleic acid extraction. The test is validated for subtype B, but requires further studies for non-B subtypes.

AIDS Serodiagnosis↗
PubMed2005

Total laparoscopic abdominal aortic aneurysms repair.

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.

Aged↗
PubMed2006

Assessment of persistency and bioaccumulation in pesticide registration frameworks within the Organization for Economic Cooperation and Development.

This article describes the results of a survey conducted in 2003 on methods used by different member countries within the Organization for Economic Cooperation and Development (OECD) to evaluate persistent and bioaccumulative pesticides. The objectives were to establish the differences in taking persistence (P) and bioaccumulation (B) into account in the decision-making process and to establish the influence of the assessors' subjectivity to data interpretation and data selection. Fifteen countries participated in the survey, which generated a vast amount of information on decision making, risk assessment, risk classification, and data treatment. Survey results indicated clear differences in approaches to the use of P, B, and toxicity (T) information in scientific risk assessment. Using the same data for 2 different pesticides, several OECD member countries responded differently in classifying both substances as P, B, and T. Differences in regulatory decision-making were also apparent because, based on identical classifications, several OECD member countries adopted different decisions on pesticide registration; recommendations were based, with respect to technical guidance, on data handling, training of assessors, and handling of uncertainty in risk assessment.

Data Collection↗
PubMed2006

[Mesenteric trauma: management in austere environments].

Mesenteric trauma, i.e., injuries located in the bowel or organs supplied by the superior mesenteric artery, can be life-threatening. The incidence of these lesions is low. Most occur as result of blunt and penetrating abdominal trauma due mainly to gunshot wounds or road accidents. Management of these serious injuries can be challenging in the military field hospitals. The major problem in austere environment is the unavailabiity of computerized axial and other tools gene rally used for diagnosis. As an alternative to tomography diagnostic peritoneal lavage can be used with a high sensitivity for the detection of mesenteric trauma. The second difficulty is technical. General surgeons without vasular training or supplies must prepared to suspect and reonstuct lesions of the superior mesenteric available resources.

Humans↗
PubMedDate not supplied

[The role of endoscopic ultrasound in digestive tract diseases in era of advanced techniques of computed tomography].

During the last 20 years endoscopic ultrasound (EUS) has been established as a highly accurate method in the diagnosis of digestive tract diseases. This method enables analysis of the lesions within the bowel wall, pancreas, and biliary system with utmost precision. Good results have also been achieved in evaluation of regional lymphadenopathy in staging of malignant diseases. Principal limitations of this method originate from its low accesibility and technical complexity which requires well trained sinologist and scientific evaluation of results in order to achieve adequate level of skill. Complications occur rarely with numbers comparable to other endoscopic procedures. With new software and hardware device introduced, computerized tomography (CT) (this refers in the first place to multidetector row CT) has been tremendously upgraded approaching the EUS in diagnostic accuracy in mentioned indications, and overcoming it in detection of distant metastases. Implementation of 3D reconstruction techniques allowed CT to enter the area of classic endoscopy, as in the case of virtual gastroscopy and/or colonoscopy. CT is a noninvasive method, very acceptable to majority of patients, and therefore popular and more prevalent compared to EUS. Although comparable in diagnostic accuracy in majority of indications, endosonography retains advance in evaluation of lesions within GI tract wall (including the early stages of carcinoma), detection of small biliary stones and small pancreatic tumors. Moreover, EUS is indespensable in therapeutic indications. Experiences with fine needle aspiration, punctions and drainage of cysts and abscesses, celiac plexus neurolysis and creation of digestive anastomosis confirm its place and value among the minimally invasive procedures which minimize the need for surgical intervention, patients' trauma and treatment costs.

Digestive System Diseases↗
PubMed1991

Intervention program components.

It is evident that those delivering health promotional services need training not only in the technical aspects of their profession, but in terms of enhancement of their organizational and management skills as well. Tasks associated with testing, data analysis, life style prescription, counselling, education, and safe and effective direction of program functions obviously require a multi-faceted staff. Screening and testing of fitness/wellness program clients is designed to identify those who can safely participate with likelihood of achieving their goals. Data from these procedures are used to formulate exercise and nutritional prescriptions and to serve as motivation. Counselling and educational efforts are aimed at servicing special needs of clients, providing motivation, increasing program visibility in the community and at enhancing program adherence. In view of the fact that fitness/wellness programs affect the health of participants and that certain aspects of these programs are hazardous, well worked-out schemes for providing emergency assistance and for otherwise protecting participants from harm must be in line and well-practiced. This need is enhanced by the fact that fitness/wellness programs and those who are associated with them are legally liable for physiological and mechanical accidents that can be traced to negligence.

Body Composition↗
PubMed1990

[A trial of evaluation of cholecystectomy by celioscopic approach. Apropos of 2266 patients].

Facing enthusiasm and critics it is necessary to evaluate new surgical techniques. The aim of our study is to try to evaluate cholecystectomy by laparoscopy. 2266 patients operated on by laparoscopy in France are compared with 3390 patients operated on by laparotomy which were published in 1990 in American surgical revues. Both groups are comparable concerning age of patients and surgical indications. Even if 10% of the patients operated on by laparoscopy needed a laparotomy, the morbidity and the mortality were not significantly different in both techniques. This study allows to conclude that cholecystectomy done by laparoscopy offers the same security to patients than using laparotomy, with in addition a faster and better recovery and a much lower economic cost. However, some problems are not yet resolved, especially the one concerning main bile duct stones and the one concerning the necessity of a special training for these surgical laparoscopic technics.

Adolescent↗