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PubMed2004

Medical genetics in Peru.

Peru has a growing population characterized by notorious socioeconomic differences. The main health problems are acquired diseases related to sanitary conditions that affect mainly the large segment afflicted by poverty and extreme poverty. The state's health policy does not contemplate any action on congenital or genetic conditions, and genetic services are considered a very low priority. In spite of this, some of the best medical schools have undergraduate and graduate programs in genetics, and there is a growing group of specialists that makes its best to impulse the practice of medical genetics in Peru. Many ethical and legal dilemmas, common to other countries in the region, and derived from social inequality, and political, cultural and religious factors, are also faced in everyday practice.

Congenital Abnormalities↗

PubMed2000

The design, implementation, and acceptance of a primary care-based intervention to prevent depression relapse.

OBJECTIVE: This article describes the conceptual underpinnings, implementation, and participation rates of a twelve-month low-intensity primary care-based intervention to prevent depression relapse. The intervention was designed to address the inherent problems in delivery of effective maintenance treatment in a population based sample of primary care patients. METHODS: Patients at high risk of relapse based on psychiatric history who recovered from depression six to eight weeks after initiation of pharmacotherapy by their primary care physician were eligible; 194 were randomized to receive the intervention. The intervention combined education about depression, motivation-enhancing shared decision-making regarding the use of maintenance pharmacotherapy, and cognitive-behavioral strategies. The program included two visits with a Depression Prevention Specialist working in tandem with the primary care physician at the primary care clinic, with supervision and back up from a consulting psychiatrist, proactive follow-up telephone calls and mailed personalized feedback. RESULTS: Ninety-three percent of patients attended both in-person visits; 97 percent attended one visit. Eighty percent of patients completed all three follow-up telephone calls, and 85 percent returned at least one mailed feedback form; 48 percent returned all four forms. Offered a menu of options for self-management, most patients chose medication as well as a variety of behavioral strategies. At six months, 72 percent ofpatients and at twelve months 62 percent of patients remained on antidepressant medication. CONCLUSIONS: We conclude that it is feasible to integrate a low intensity, twelve-month relapse prevention intervention for depression into a primary care clinic.

Antidepressive Agents↗

PubMed2006

Colposcopy services in the United Arab Emirates.

BACKGROUND: United Arab Emirates (UAE) is a young country with a population of 3 million, an abundant oil wealth, and a high standard of living. There is no organized cervical screening program, but the authorities are planning to introduce one soon. OBJECTIVE: To study the availability and quality of colposcopy services. METHODS: A questionnaire survey of all gynecologists in the major government and private hospitals in the country. RESULTS: Twenty government hospitals offer obstetrics and gynecology services, 11 governments and 4 private hospitals have colposcopy services. Of the 52 specialists performing colposcopy, 8 had adequate training, 3 had formal recognition, and 3 had long-term experience. The number of cases seen per doctor varies from 10 to 100 a year, with a mean and median of 28 and 15, respectively. Three units had the required basic colposcopy equipment for diagnosis and treatment. Only 1 unit performs audit. CONCLUSIONS: Colposcopy service is widely available in many hospitals in the United Arab Emirates, but substantial variation exists in clinical standards and needs more organization and standardization.

Clinical Competence↗

PubMed1999

The role of the transplant advanced practice nurse: a professional and personal evolution.

Rapid changes in health care toward cost-effective managed care have resulted in the evolution of the transplant advanced practice nurse to address the care needs of a specific patient population. This article describes the evolution of this role at one institution. The specific responsibilities of the transplant advanced practice nurse are delineated, and phases of development for the experienced clinical nurse specialist entering the role as a novice nurse practitioner are identified and discussed.

Cost-Benefit Analysis↗

PubMedDate not supplied

Disease management for depression and at-risk drinking via telephone in an older population of veterans.

OBJECTIVES: The purpose of this study was to explore the efficacy in a primary care setting of a telephone-based disease management program for the acute management of depression and/or at-risk drinking. MATERIALS AND METHODS: Veterans (N= 97) with depression and/or at-risk drinking were identified by systematic screening and assessment. Eligible subjects received either telephone disease management (TDM) program or usual care based on random assignment of their clinician. The TDM program consisted of regular contacts with each subject by a behavioral health specialist (BHS) to assist in assessment, education, support, and treatment planning. Symptomatic outcomes were assessed at 4 months. RESULTS: Overall response rates favored those assigned to TDM compared with those assigned to usual care (39.1% responded vs. 17.6%, p= 0.022). Response rates within the separate diagnostic groups also favored TDM, but this was only significant for depressive disorders. CONCLUSIONS: Although the sample size was modest and the sample was limited to veterans, findings strongly suggest that a telephone-based disease management program can improve outcomes for patients with a behavioral health problem. Findings also suggest that a health specialist can focus and manage patients with different diagnoses, thus expanding the role beyond just depression care. TDM may be a viable, low-cost, model for primary care clinicians to deliver manual guideline-adherent behavioral health care, especially in a VA clinical setting.

Aged↗

PubMed1981

Acoustic neurinoma in a population of noise exposed workers.

Regulations from the Occupational Safety and Health Administration require the performance of audiometric tests on workers exposed to potentially hazardous noise levels. These tests are frequently performed by Occupational Hearing Conservationists who have taken a 20-hour course based on recommendations of the Council for Accreditation in Occupational Hearing Conservation. Unless audiograms performed by such personnel are promptly reviewed and appropriate referral to specialists made, significant and potentially life-threatening otic disease may go undetected. This paper reports a series of workers with acoustic tumors initially detected by an Occupational Hearing Conservation Program. It is dangerous to assume that the hearing loss and tinnitus reported by noise-exposed workers is necessarily the result of workplace noise exposure.

Adult↗

PubMed1999

Surveillance of hospital acquired infections: presentation of a computerised system.

Day by day surveillance of hospital acquired infections is a time-consuming activity. Healthcare professionals need powerful computer tools to manage and analyse these data. Such a program must include all the functions needed to manage communication with other programs in order to minimise data entry. Coherence checks are then used to validate data. Automatic production of reports, graphics or tables enables users to quickly obtain timely and representative documents regarding the evolution of specific indicators. The local person in charge for the system must be able to easily modify many parts of the program (data entry screens, calculations, checks, etc.) without any direct intervention from a computer specialist. Using this description, we have created a specific software for the management of this information named NosoCom. The program has been used for four years in France and Belgium. An English release is now available.

Communication↗

PubMed2006

Effect of surgeon specialty on processes of care and outcomes for ovarian cancer patients.

BACKGROUND: For many diseases, specialized care (i.e., care rendered by a specialist) has been associated with superior-quality care (i.e., better outcomes). We examined associations between physician specialty and outcomes in a population-based cohort of elderly ovarian cancer surgery patients. METHODS: We analyzed the Medicare claims, by physician specialty, of all women aged 65 years or older who underwent surgery for pathologically confirmed invasive epithelial ovarian cancer between January 1, 1992, and December 31, 1999, while living in an area monitored by the Surveillance, Epidemiology, and End Results (SEER) program to assess important care processes (i.e., the appropriate extent of surgery and use of adjuvant chemotherapy) and outcomes (i.e., surgical complications, ostomy rates, and survival). All statistical tests were two-sided. RESULTS: Among 3067 ovarian cancer patients who underwent surgery, 1017 patients (33%) were treated by a gynecologic oncologist, 1377 patients (45%) by a general gynecologist, and 673 patients (22%) by a general surgeon. Among patients with stage I or II disease, those treated by a gynecologic oncologist (60%) were more likely to undergo lymph node dissection than those treated by a general gynecologist (36%) or a general surgeon (16%). Patients with stage III or IV disease were more likely to undergo a debulking procedure if the initial surgery was performed by a gynecologic oncologist (58%) than by a general gynecologist (51%) or a general surgeon (40%; P < .001) and were more likely to receive postoperative chemotherapy when operated on by a gynecologic oncologist (79%) or a general gynecologist (76%) than by a general surgeon (62%, P < .001). Survival among patients operated on by gynecologic oncologists (hazard ratio [HR] of death from any cause = 0.85, 95% confidence interval [CI] = 0.76 to 0.95) or general gynecologists (HR = 0.86, 95% CI = 0.78 to 0.96) was better than that among patients operated on by general surgeons. CONCLUSIONS: Ovarian cancer patients treated by gynecologic oncologists had marginally better outcomes than those treated by general gynecologists and clearly superior outcomes compared with patients treated by general surgeons.

Aged↗

PubMed1999

Colorectal cancer screening in general practice. A survey of current practice and attitudes in Victoria.

OBJECTIVE: To determine the views and practices of Victorian general practitioners (GPs) on the early detection of colorectal cancer (CRC). METHODS: A 1995/1996 quantitative mail survey was used to determine GP knowledge and practice in relation to CRC screening and diagnosis in asymptomatic and symptomatic patients. This includes the amount of investigation, the type and process of diagnostic testing and attitudes to CRC screening. RESULTS: GPs are investigating symptomatic patients but few asymptomatic patients. In general, only patients in the increased risk groups are being investigated. Colonoscopy is the most common method of examination. Most GPs prefer faecal occult blood tests (FOBTs) to be interpreted via laboratory and endoscope procedures to be performed by a specialist. CONCLUSION: GPs were unlikely to screen asymptomatic patients unless there is a family or personal history of CRC or adenomatous polyps. Colonoscopy is the preferred practice for examining such patients. The use of FOBTs for screening standard risk asymptomatic patients was lower than recent research recommends. If population screening for CRC is endorsed, professional and public education in CRC tests, particularly for asymptomatic standard risk patients would be required. Patient initiated screening was highly favoured, supporting the need for public awareness programs.

Colorectal Neoplasms↗

PubMedDate not supplied

Planning availability in stroke rehabilitation units.

The sequelae of cerebrovascular diseases constitute, and in the coming years will increasingly constitute, a major health problem. Stroke is already the leading cause of permanent invalidity, the second leading cause of dementia, and the third (on course to become the second) leading cause of death, after cardiovascular diseases and cancer. In view of the aging of the population and of the fact that stroke is strictly age-related, the incidence of stroke, in Italy, looks set to rise progressively over the coming years. In recent years, units have been set up for the specialist inpatient treatment of stroke victims, both in the acute phase (known as stroke units) and in the subsequent rehabilitative phase (stroke rehabilitation units), the aim being to improve both the management of these patients and, as a result, their functional outcome. Health policies and programming will have to take into account the need for more beds in both types of stroke unit.

Health Facility Planning↗

PubMedDate not supplied

Outcome and cost of family physicians' care--pilot study of three diagnosis-related groups in elderly inpatients.

BACKGROUND: Health care analysts have speculated whether a primary-care-based delivery system would improve outcomes and costs for the currently preponderantly specialist-directed United States system. This pilot study compares outcomes and costs of family physicians' care with those of other physicians' care for three diagnosis-related groups (DRGs) and shows the feasibility of a larger scale research program using the Pennsylvania MedisGroups data base. METHODS: A cross-sectional comparison of outcomes and costs of hospital care given by either family physicians or other physicians was conducted using patients aged 65 years and older who were hospitalized during 1990. The study population was 2420 inpatients: 847 with DRG 174 (gastrointestinal bleeding), 628 with DRG 243 (medical back pain), and 945 with DRG 296 (metabolic disorders). Patients were stratified into five admission severity groups for each DRG. Comparison variables were MedisGroups major morbidity classification, in-hospital mortality, mean length of stay, and total charges. RESULTS: The family physician group delivered inpatient care to the elderly with gastrointestinal bleeding at significantly less cost than other physicians without any compromise of effectiveness. There was a similar but less striking trend for medical back pain. Results were variable for metabolic disorders. CONCLUSIONS: The results of this pilot study apply only to the three DRGs in the region at the time investigated. Generalizations should be avoided before additional DRGs are studied throughout the rest of the state. This pilot study demonstrates the feasibility of such research.

Aged↗

PubMed2006

[Preventive medicine in times of a rapid epidemiologic transition in Korea].

Ever since the foundation of the Korean Society for Preventive Medicine in 1947, members of the Society had made remarkable contributions to the public health development and national health promotion. They had played key roles in establishing national health system, improving environmental hygiene, controlling infectious and chronic diseases, promoting family planning, improving industrial and environmental health, and developing health service management. However, the Society had less actively responded to the changes in health service needs of the population that were caused by a rapid epidemiologic transition in last a few decades. Early detection and treatment of chronic diseases including cancer and cardiovascular diseases and risk reduction by the life style modification are major approaches to the contemporary national health problems and they are the core contents of preventive medicine. The author proposed to develop the clinical preventive medicine specialist who will have additional training in clinical medicine for health screening and life style modification to the current preventive medicine training program and thus will be able to provide comprehensive preventive medical services. Another area that the Society may take the initiative is training preventive medicine specialist in the disaster, including bioterrorism, preparedness and management. The Society should be more active in proposing health policy and health service program and also participate collectively in a large scale health research project of the government. These approaches may not only contribute more effectively to the national health promotion but also improve the identity of the Society.

Adolescent↗

PubMedDate not supplied

Preparing public health leaders for the 1990s.

Public health leadership is urgently needed throughout the world. In most local, provincial, and national jurisdictions, such responsibility has been assumed by doctors of clinical medicine, who know much about treatment of disease in individual patients but very little about prevention of disease and promotion of health in populations or the management of health systems. Effective leadership in public health requires a new profession, with generalized education in the basic tools of social analysis, health and disease in populations, promotion of health and prevention of disease, and health care systems and their management. More than 40 distinct scientific subjects have been developed in these fields over the years, and current faculties are qualified to teach them. To provide this education would require about 5 years of academic and field studies, after a bachelor's degree. Schools of public health now train doctoral-level specialists who are prepared in the PhD tradition for academic posts. These schools should also develop educational programs for doctoral-level generalists who are qualified to provide community health leadership at local, provincial, and national levels.

Curriculum↗

PubMed1998

[Endoscopic cholecystectomy as cost assessment--still a learning intervention?].

Economic considerations are putting increasing pressure on surgical departments to avoid intra- and postoperative complications and thus additional costs. Under this aspect, it was investigated whether laparoscopic cholecystectomy is a suitable training intervention for young prospective surgeons. These physicians in advanced training did not have a higher intra- or postoperative complication rate in a preselected patient population than senior physicians or specialists. The additional costs per surgical intervention due to longer operation times required by young physicians were acceptable so that laparoscopic cholecystectomy as a training intervention for young colleagues can be justified.

Cholecystectomy, Laparoscopic↗

PubMed2003

Management of diabetes mellitus complicating pregnancy.

Diabetes mellitus complicates 3-5% of all pregnancies and is a major cause of perinatal morbidity and mortality, as well as maternal morbidity. The availability of a variety of new insulins, the insulin pump, and self-monitoring of blood glucose have revolutionized the care of the pregnancy complicated by diabetes mellitus. However, challenges remain in caring for the pregnant patient with pregestational diabetes. Relatively few women receive preconceptional counseling, and major fetal malformations as a result of poor glucose control before and during the early weeks of gestation have emerged as the major cause of perinatal mortality. When the patient has diabetic vasculopathy, the obstetrician, maternal-fetal specialist, and/or endocrinologist and other members of the health care team must perform a challenging balancing act that promotes fetal health while minimizing maternal risk. As obesity increases in this country and our population becomes more diversified, the rate of gestational diabetes mellitus (GDM) will rise. Although there is controversy regarding which diagnostic standards to use for GDM, there is agreement that excellent blood glucose control, with diet and, when necessary, insulin will result in improved perinatal outcome. Finally, the goal of our educational programs should be not only to improve pregnancy outcome but also to promote healthy lifestyle changes for the mother that will last long after delivery.

Blood Glucose Self-Monitoring↗

PubMed2007

Aetiology in adult patients with bronchiectasis.

BACKGROUND: Bronchiectasis has a number of causes. Their prevalence is not well documented. The aim of this study was to identify aetiology in a population of patients referred to a specialist clinic with symptoms suggestive of bronchiectasis, to determine the proportion of patients in whom knowing the aetiology altered management. In addition we wished to describe in detail those patients who remained idiopathic to facilitate future studies of this group; and establish the diagnosis in those without bronchiectasis. METHODS: A total of 240 consecutive patients referred to the Royal Brompton Hospital with a history of recurrent chest infections, chronic cough and regular sputum production underwent a 3 day program of investigation. RESULTS: A total of 165 patients had bronchiectasis on CT scan, an underlying cause was identified in 122 (74%) and this affected management in 61 (37%). The common aetiologies were: post-infection (52), primary ciliary dyskinesia (17), allergic bronchopulmonary aspergillosis (13), and immune deficiency (11). Fourty-three patients had idiopathic bronchiectasis. They had symmetrical predominant lower lobe disease with onset of chronic chest and sinus symptoms in middle age. CONCLUSION: Full investigation of problematic cases should occur in a specialist centre because results affect management in a third of cases.

Adolescent↗

PubMed2005

Referring patients for consideration of device treatment of sudden cardiac death and heart failure: incorporating evidence-based therapies within the Canadian health care system.

The growing use of the implantable cardioverter defibrillator (ICD) in Canada reflects the impact that primary and secondary prevention trials have had in demonstrating the superiority of the ICD over medical therapy in the prevention of sudden cardiac death in high-risk populations. Currently, there are significant regional disparities in ICD implantation in Canada. These disparities may reflect a lack of regional ICD implant and follow-up programs, and capping of funding for ICDs. In addition to increased funding for ICD systems, more resources are required to perform device implantations and follow patients over the long-term. Potentially eligible patients should be referred to an electrophysiologist for consideration of ICD therapy for the prevention of sudden cardiac death or to an electrophysiologist/ heart failure specialist for the consideration of combination cardiac resynchronization and ICD therapy for the management of refractory heart failure.

Canada↗

PubMed1996

ET nursing education in Australia.

Australia is comparable in size to the United States, but its population is far smaller, approximately 17 million. Australia is technologically advanced and has a high standard of health care, in which ET nursing has always been considered a specialist nursing role. Although Australia is historically linked with England, formation of closer ties with geographic neighbors, such as Southeast Asia, New Zealand, and the Pacific nations, is ongoing. This article describes some relevant aspects of the Australian context and considers the past, present, and expected future trends for ET nurse education in Australia, from the first program in 1971 to current World Council of Enterostomal Therapy-recognized programs teaching students from as far away as Japan, Israel, Singapore, Malaysia, New Zealand, China, Russia, and New Guinea. The content of the programs has progressively broadened in recognition of the expanded scope of practice, and this trend will undoubtedly continue. ET nursing should remain, however, a distinct nursing specialty practice in Australia.

Accreditation↗