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The 3-year medical school program at McMaster University encourages an approach to learning a physician can apply throughout his or her career. The program has four phases and provides early exposure to relevant clinical material. In phase 3, the basic science phase, the structure and function of organ systems in health and disease are studied. Understanding the mechanisms of disease in order to be able to relate clinical symptoms and signs to physiologic and pathologic processes is emphasized. The four 10-week units deal with groups of organ systems. The "blood and guts" unit teaches the student hematology and gastroenterology through a variety of problem-based methods. Specialists in the relevant scientific disciplines influence selection and construction of the problems presented. The students are evaluated by the faculty tutor on their accomplishment of specific objectives related to their competence in solving biomedical problems.
BACKGROUND: In order to improve the health quality at the Primary care level, the Catalonian Health Authority (Servei Catala de la Salut) has begun a reform of the medical and surgical specialties. In this reform process the Hospital del Mar, Barcelona, Spain, has taken part in the incorporation of several medical and surgical hospital specialists to primary care within its influence area. In this study, we describe the results of the collaboration between Hospital health care and Primary care on rheumatic complaints during one year. METHODS: We carried out a descriptive study of some clinical and epidemiological variables of the population visited during one year (1995), at the Primary care level by the Rheumatologist. Our area has a population of 90,612 people, and its located in Barcelona City, Ciutat Vella Variables of study were collected during the period of time between January and December 1995. The following variables were recorded: age, gender, referral cause, rheumatologic diagnosis, intra-articular and peri-articular corticosteroid injections perform, techniques used for the diagnosis of rheumatic disease, follow-up level Data were statistically analyzed. RESULTS: Visits performed were 2,668 on 1,384 patients. Fifty-two percent were first visits, 48% were follow-up visits (Ratio first visits Nolfow-up visits: 0.57). Fifty-one percent of the patients were > 65 years old. Unspecific polyarthralgias, chronic low back pain, gonalgia and pathology of the shoulder were the most frequent complaints (> 50%). Osteoarthritis and soft-tissue diseases were the most frequent diagnosis with a percentage of 41% and 30.7%, respectively. Connective tissue diseases and spondyloarthropathies had account for 3.8% of global diagnosis. X-ray film has been the commonest technique used for the diagnosis of rheumatic diseases (80.5%). The waiting list for first visit initially has been 5 weeks, and at the end of study it has been 3 weeks. Ten percent of patients had been referred to the Hospital. CONCLUSIONS: Collaboration between Hospital care rheumatology and Primary care, improves the diagnostic quality, as well as it decreases the waiting list and allows the patients' control at the most appropriate care level.
Traditional Native American healing practices are increasingly sought after by Native Americans as well as non-Natives. A series of meetings between traditional Native American healers and the author resulted in dialogues on the Native American worldview and biomedicine. Recommendations arose for how Native American treatment should proceed in the modern world and how to effectively introduce interested non-Natives to Native American healing practices. An approach for bridging cultures to facilitate the interaction of non-Natives with traditional healers was developed. A total of 116 patients were treated by the author in conjunction with traditional Native American healers. More than 80% of patients showed significant, persistent benefits from a time-intensive treatment program. A comparison group consisting of patients from the author's emergency room practice had significantly lower rates of improvement. An intensive program inspired by Native American practices lasting 7 to 10 days can achieve both health benefits and improved cost-effectiveness in the treatment of chronic physical illness. The treatment philosophy underlying this approach is best described as a dynamic energy system. Within this theoretical framework, physical illness, which is viewed as simultaneously spiritual, mental, and physical, can be treated by counseling and ceremony. Due to the interaction and hierarchical nature of these levels, intervention at any one level affects the others.
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A package of integrated programs for calculating pharmacokinetic variables and drug-dosing regimens using a hand-held programmable calculator is described. Twelve pharmacokinetic programs, which were based on previously published pharmacokinetic equations, were developed for use in a HP-41C hand-held calculator (Hewlett-Packard). The programs perform, pharmacokinetic calculations for many drugs, including digoxin, theophylline, phenytoin, nd the aminoglycosides. Also programs for ideal body weight, body surface area, and creatinine clearance calculations are included. Eleven of the 12 programs can be stored in the calculator at any time. Values generated in one program are stored in memory registers and can be recalled directly for use in other programs. The calculator has a continuous memory; therefore, all stored data, programs, and functions are maintained when the calculator is turned off. The integrated calculator programs provide a quick and reliable means of applying pharmacokinetic principles to everyday hospital pharmacy practice.
Integrating family planning programs with local cultures can increase or undermine their effectiveness. Program design and organization will be influenced by kinship and reproductive decision-making, which varies across regions, racial and communal divisions, and religions. Program implementation depends on four aspects of culture: (1) the understanding, acceptance, and continued practice of family planning by clients; (2) the climate in the organizations responsible for fieldwork, which affects the disposition to work and the tasks to be done; (3) the ability and willingness of field implementers to do their work; and (4) the communities in which clients live, including collective attitudes toward family planning and local pressures put on clients to participate. The Indonesian family planning program is a case in which these elements of culture are often positive. Other programs, such as that in Kenya, have a more negative environment for action.
Programs for use with the Apple II Plus microcomputer that generate graphic simulations of various linear and Michaelis-Menten pharmacokinetic models are described. The programs numerically integrate sets of differential equations for appropriate pharmacokinetic models. Multiple oral (or intramuscular), intravenous bolus, or infusion doses (continuous or discontinuous) may be administered in any combination. Doses as well as pharmacokinetic parameters may be changed at the end of each simulated dosing interval. The programs can be easily modified by users familiar with the BASIC programming language and offer an economical approach to pharmacokinetic simulation.
The objectives of this analysis were to assess the probable impacts of vertical and integrated FP/MCH programs on family planning (knowledge, use, and intentions to use), family size preferences, fertility, and mortality (child and infant). The following discussion summarizes and draws conclusions regarding the results of this investigation. The vertical program showed a greater impact on knowledge of family planning than the integrated program. Increases in knowledge between 1975 and 1978 while controlling for social and demographic variables were greater in the vertical than the integrated areas. Multiple classification analysis at both household and village levels showed that the vertical program was a better predictor of knowledge and changes in knowledge than the integrated program. In addition, the vertical program showed consistently higher proportions of women with awareness of family planning among those segments of the population that could have the greatest impact on fertility reduction in the future--namely, the younger women who are either childless or just beginning their childbearing and those with husbands who have little or no education. Neither the vertical nor the integrated FP/MCH program showed an impact on current use or ever use of family planning. The very low levels and changes in levels of these factors between the programs showed almost no difference throughout the selected demographic and socioeconomic groups. In both program areas the proportions of ever use and current use increased substantially with the number of living sons, exceeding 14 percent and 10 percent, respectively, among women with three or more sons. There were virtually no family planning users or ever users among women with no sons. This appears to indicate that "son preference" (documented in the Nepal Fertility Survey) is an important factor affecting the incidence of family planning practice and may be a formidable obstacle to a substantial reduction in fertility. Family limitation generally may not be taken seriously until a couple has produced the desired number of sons. Hence, until the value of sons (perhaps as sources of labor, financial support and security in old age, and as performers of funeral rites for fathers) can be altered it is unlikely that a reduction in fertility beyond certain levels could occur. The vertical program showed a slightly greater impact on future intentions to use family planning than the integrated program.(ABSTRACT TRUNCATED AT 400 WORDS)
Integrated disability management (IDM) programs offer employers a simple, strategic approach to managing health and lost time. However, components of these programs also present potential liabilities under federal, and sometimes, state law. This article reviews the sources of these liabilities and summarizes techniques for minimizing the risk of employers (and managers individually).
BACKGROUND: Preventing cardiovascular disease through community interventions makes theoretical sense but has been difficult to demonstrate. We set out to determine whether a community cardiovascular health program had an impact on mortality. DESIGN: Program evaluation plus ecologic observational analysis of program encounters and mortality rates with external comparisons. SETTING: Franklin County and two comparison counties in rural Maine. PARTICIPANTS: Program encountered >50% of regional adults, broadly distributed by site, gender, and age. INTERVENTIONS: From 1974 to 1994, a community program, integrated with primary medical care and staffed by professional nurses, provided education, screening, counseling, referral, tracking, and follow-up for cardiovascular risk factors. MAIN OUTCOME MEASURES: Age-adjusted mortality rates (total, heart, coronary, cerebrovascular, cancer) for three counties and Maine, plus annual program encounters. RESULTS: Relative to Maine, the Franklin heart disease death rate was 0.97 at baseline (1960-1969; 95% confidence interval, 0.91 to 1.03), 0.91 during the program (0.85 to 0.97), 0.83 during the 11 years of program growth (0.78 to 0.88), but 1.0 during the 10 years of decreasing encounters. Franklin's total death rate was 1.01 at baseline, 0.95 during the program (0.92 to 0.98), and 0.90 during program growth (0.86 to 0. 94). Results were similar for coronary disease, stroke, and cancer. Relative death rates did not fall in either comparison county. Nurse-client encounters totaled 120,280 over 21 years. Relative to Maine, heart disease death rates correlated inversely with program encounters (r = -0.53) but not with unemployment or physician supply. CONCLUSIONS: Integrated with primary medical care, a comprehensive, nurse-mediated community cardiovascular health program in rural Maine has been associated with significant time-dependent and dose-dependent reductions in cardiovascular and total mortality.
In an integrated, dual disorder treatment program delivered at two sites, the authors address numerous barriers to delivering services to dually diagnosed consumers and employ a set of multidimensional indicators to assess outcome. Consumers who received services through the well-implemented, integrated services program for 12 months were functioning better in the community. There was a cost shifting from mental health to drug and alcohol services, as well as a one-third increase in the total costs of care by the end of the first year of treatment. Program implementation issues are described and the clinical management implications for more effectively serving dually diagnosed consumers through integrated treatment programs are discussed.
The Program for Integrated Women's Health Care (PAISM) was launched by the Brazilian Ministry of Health in 1983 as a new and different approach to women's health. Paradoxically, the PAISM also became the first case in which the Brazilian state explicitly proposed and implemented (albeit partially) a program regulating fertility. This raised suspicions as to disguised promotion of birth control. However, a brief analysis of the history of this program and its social significance suggests that the PAISM was a pioneering undertaking (even within the international scenario) in proposing integrated women's health care as opposed to isolated family planning measures. This helps explain why women's movements in Brazil immediately began to struggle to see it properly implemented. The program contained the definition of reproductive health adopted by the World Health Organization in 1988, which was expanded and consolidated in Cairo in 1994 and Beijing in 1995. Consequently, adoption of the PAISM meant a significant step towards recognition of women's reproductive rights, even before gaining the various international forums for struggle.