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PubMed2001

Adolescent immunization practices: a national survey of US physicians.

BACKGROUND: Adolescent immunization rates remain low. Hence, a better understanding of the factors that influence adolescent immunization is needed. OBJECTIVE: To assess the adolescent immunization practices of US physicians. DESIGN AND SETTING: A 24-item survey mailed in 1997 to a national sample of 1480 pediatricians and family physicians living in the United States, randomly selected from the American Medical Association's Master List of Physicians. PARTICIPANTS: Of 1110 physicians (75%) who responded, 761 met inclusion criteria. OUTCOME MEASURES: Immunization practices and policies, use of tracking and recall, opinions about school-based immunizations, and reasons for not providing particular immunizations to eligible adolescents. RESULTS: Seventy-nine percent of physicians reported using protocols for adolescent immunization, and 82% recommended hepatitis B immunization for all eligible adolescents. Those who did not routinely immunize adolescents often cited insufficient insurance coverage for immunizations. While 42% of physicians reported that they review the immunization status of adolescent patients at acute illness visits, only 24% immunized eligible adolescents during such visits. Twenty-one percent used immunization tracking and recall systems. Though 84% preferred that immunizations be administered at their practice, 71% of physicians considered schools, and 63% considered teen clinics to be acceptable alternative adolescent immunization sites. However, many had concerns about continuity of care for adolescents receiving immunizations in school. CONCLUSIONS: Most physicians supported adolescent immunization efforts. Barriers preventing adolescent immunization included financial barriers, record scattering, lack of tracking and recall, and missed opportunities. School-based immunization programs were acceptable to most physicians, despite concerns about continuity of care. Further research is needed to determine whether interventions that have successfully increased infant immunization rates are also effective for adolescents.

Adolescent↗

PubMed2005

Teaching evidence-based medicine in a managed care setting: from didactic exercise to pharmacopolicy development tool.

OBJECTIVES: To implement a residency-based program for the teaching of evidence-based medicine in an Israeli HMO and to incorporate this effort into the HMO's routine drug policy formulation process. METHODS: Residents and preceptors participating in the family practice residency program in The Leumit Health Fund, 1 of the 4 HMOs operating in Israel, were invited to participate in a workshop for the formulation of guidelines for antibiotic treatment of the common infectious diseases encountered in primary care. The participants were allocated to teams consisting of a preceptor (an attending physician) and a resident physician, with each team choosing a different disease to analyze. Upon completion of the program, a questionnaire was sent to all residents and preceptors who participated in the workshop to evaluate attitudes concerning the outcomes of the program. RESULTS: Guidelines for the treatment of 14 infectious diseases commonly seen in the primary care setting were formulated. The program was accepted by the participants, who ultimately cooperated with the relevant HMO stakeholders in the formulation of official HMO policies for drug prescribing. CONCLUSION: The utilization of family practice residents is a feasible method of formulating in-house clinical practice guidelines for a managed care setting. The program was mutually beneficial for both the residents and for the stakeholders in the HMO.

Communicable Diseases↗

PubMed1988

Economic aspects of clinical decision making: evaluating clinical programs.

The importance of program evaluation is discussed, and issues to consider when designing and conducting program evaluations in the restructuring health-care environment are identified. Program evaluation is carried out for the purpose of supporting specific decisions for individual organizations. Unlike scientific research, program evaluation accepts time as a constraint, and its audience is composed of managers. Considering the likelihood of being fixed-dollar contractors or employees in an era of managed care, professionals must try to understand the cost objectives of management; similarly, managers must understand the patient-care objectives of professionals. Program evaluation can help provide the necessary documentation of a program's impact on the outcome of health care, which influences the total cost of care. Successful program evaluation requires careful planning, and issues related to six steps in the planning process are described: defining the objective of the evaluation, choosing and defining the program to be evaluated, choosing indicator variables, designing the evaluation, presenting the results, and planning follow-through. While program evaluation is too often understood in negative terms, particularly as something done because of external pressure, it is as much a part of management as is directing day-to-day operations or developing a long-range plan.

Decision Making↗

PubMedDate not supplied

Acceptance of an injury-prevention program in rural communities: a preliminary study.

INTRODUCTION: Considerable attention is being addressed to injury prevention. This study addresses the acceptance of a home injury-prevention survey as an injury-prevention tool in rural communities. PURPOSE: The purpose of this study was to evaluate public acceptance of a home injury-prevention survey as a tool to educate and enlighten the public about home injuries. METHODS: All patients with home injuries who came to Wetzel County Hospital Emergency Department were asked if they would participate in a home injury-prevention survey. The study was conducted from 01 May to 01 July 1995. Paramedics were used as interviewers because of the closeness they enjoy with the community. RESULTS: During the study period, 2,104 patients came to the emergency department of Wetzel County Hospital. Of these, 386 sought care because of an injury sustained in their homes. From this group, 23 (5.9%) patients agreed to participate in a home injury-prevention study; 363 (94.1%) refused. CONCLUSION: A home injury-prevention survey alone does not seem to be an effective tool to aid in the reduction of home injuries, because it is not embraced by the general public.

Accidents, Home↗

PubMed1980

The American Board of Surgery in-training examination.

Since 1975, the American Board of Surgery has annually offered a multiple-choice in-training examination to directors of accredited general surgery programs in the United States for administration to residents in their programs. Residents' scores for the total examination and the five body-system categories are provided to program directors, along with normative data for comparison of their residents' performance against that of all examinees. Each year, residents' scores have correlated well with their level of training. Reliability coefficients have verified that the examinations have functioned effectively as test instruments. The increasingly wide use of the examination and its favorable acceptance by program directors have indicated that the examination is making a significant contribution to surgical education in the United States.

Education, Medical, Graduate↗

PubMed2004

[Rehabilitation on effort of low back pain. Functional restoration programs].

Mediocre functional prognosis In industrialised countries, chronic low back pain is the most common cause of disability and work stoppage. Conventional treatments have not reduced the impact of chronic low back pain. Hence new solutions have been searched for. FUNCTIONAL RESTORATION PROGRAMS: These programs consist in heavy and expensive multidisciplinary treatment schedules, lasting from 3 to 6 weeks. The key concepts of these programs are acceptance of pain, treatment of the problem by the patients themselves and a progression contract. POSITIVE RESULTS: Controlled studies published on the percentage of patients returning to work are positive. Maintenance of a job-attached status to the pre-injury employer is often best accomplished by the provision of suitable modified duties. Finally, results of functional restoration programs in term of return-to-work rate probably strongly depend on the social security system of the country in which such programs have been developed.

Chronic Disease↗

PubMed1992

Simultaneous treatment with single-agent chemotherapy and radiation for locally advanced cancer of the head and neck.

A substantial proportion of patients with squamous cell carcinoma of the head and neck have extensive locoregional disease at presentation. While extensive surgical procedures may completely eradicate local disease with acceptable morbidity for smaller tumors, in patients with stage III and IV disease, high local relapse rates and relatively short survival times still characterize the course of the majority of such patients. For patients with locally unresectable disease, the combined use of chemotherapy and radiation has resulted in encouraging data both in terms of local control and survival. Combined-modality programs frequently employ platinum coordination complexes, and standard or hyperfractionated radio-therapy toxicity data suggest that the overall tolerance of such programs is acceptable and, more important, long-term follow-up has shown that function can be largely preserved. In this review we illustrate the experience with combined single-agent chemotherapy and radiotherapy, and discuss the methodologic difficulties of clinical trials in this setting. We describe our experience with combined carboplatin and simultaneous conventional radiation in patients with extensive unresectable locoregional disease. Encouraging results and modest toxicity clearly support further testing with this approach, especially in patients with less advanced and bulky disease.

Aged↗

PubMed1993

Regional and temporal use of avermectins for ruminants in Australia.

The avermectin class of anthelmintics has been available for approximately 4 years (sheep) and 7 years (cattle) in Australia. They are highly efficacious against a very broad spectrum of nematode parasites and certain ectoparasites of livestock. To date there are no field reports of resistance to these compounds in either the cattle or sheep industry, despite the fact that nematode parasites of sheep show high levels of resistance to other broad spectrum anthelmintics. The avermectins have gained rapid acceptance, but their share of the anthelmintic market is less than expected, owing to several factors such as drought and recession of the rural economy. Nevertheless, it can be expected that this class of compounds will assume greater importance, particularly in the sheep industry, when greater awareness of the widespread failure of alternative broad spectrum anthelmintics, and the value of regional worm control programs become accepted by producers.

Animals↗

PubMed1977

A comparison of primary care educational experiences in two urban pediatric settings.

The purpose of this study was to initiate the evaluation of the ambulatory care training programs of the Johns Hopkins Medical Institutions and affiliated programs as resources for primary care education, and to provide input into the development of a primary care educational curriculum. It was determined that these settings fell short of fulfilling an a priori set of educational objectives designed to emphasize primary as opposed to secondary care. Foresight must be exercised in the selection of sites and the design of the clinical practice of an acceptable training program in primary care is desired.

Ambulatory Care↗

PubMed2003

HLAMatchmaker-based strategy to identify acceptable HLA class I mismatches for highly sensitized kidney transplant candidates.

HLAMatchmaker determines HLA compatibility at the level of polymorphic amino acid triplets in antibody-accessible sequence positions. Recent studies have shown that among HLA-DR-matched kidney transplants, the HLA-A,B antigen mismatches which are compatible at the triplet level have almost identical graft survival rates as the zero-HLA-A,B antigen mismatches. This finding provides the basis of a new strategy to identify HLA-mismatched organs that have similar success rates as the zero-HLA-antigen mismatches. This report describes how in conjunction with the Acceptable Mismatch program in Eurotransplant, HLAMatchmaker can expand the pool of potential donors for highly sensitized patients, for whom it is very difficult to find a compatible transplant. Sera from 35 highly sensitized kidney transplant candidates with an average PRA of 96% were screened by lymphocytotoxicity with HLA-typed panels that included cells that were selectively mismatched for one or two HLA antigens for each patient. Acceptable and unacceptable HLA-A,B antigen mismatches were determined from the serum reactivity with the cell panel. HLAMatchmaker analysis was applied to identify additional HLA class I antigens that were matched at the triplet level. For each patient, we calculated the probability of finding a donor (PFD) in the different match categories from HLA gene frequencies in the kidney donor population. The median PFD for a zero-antigen mismatch was 0.025%. Matching at the triplet level increased the median PFD to 0.037% ( P = 0.008). The median PFD was 0.058% for a 0-1-triplet mismatch and 0.226% for a 0-2-triplet mismatch. Serum screening identified acceptable antigen mismatches for 28 of 35 highly sensitized patients, and the median PFD increased to 0.307% for a zero/acceptable antigen mismatch. The application of HLAMatchmaker permitted for 33 patients (or 92%) the identification of additional antigens that were acceptable at the triplet level, and the median PFD for a zero/acceptable triplet mismatch went up to 0.425%. Inclusion of one-triplet mismatches increased the median PFD to 1.112%. Validation studies have shown that patient sera reacted with none of the zero-triplet-mismatched antigens, 8-13% of the one-triplet mismatches, and 12-19% of the two-triplet mismatches. Although most antigens with one or two mismatched triplets appear acceptable to highly sensitized patients, a serum analysis must ascertain that the patient's antibodies do not recognize such mismatched triplets. HLAMatchmaker offers a useful strategy of identifying more donors with acceptable HLA mismatches and could alleviate the problem of accumulation of highly sensitized patients on the transplant waiting list.

Algorithms↗

PubMed1984

A simple computer program for Scatchard plot analysis of hormone receptors including statistical analysis on a low cost desk top calculator.

A simple procedure for the estimations of standard errors in hormone binding parameters derived from Scatchard analysis is proposed by assuming an univariate linear regression statistic model. The complete set of necessary formulae is presented and a practical way for calculation is solved using the binding of human growth hormone to rat adrenal membranes, as a practical example. The comparison between the results obtained by the method proposed and by using a well proved and accepted computer program, shows unequivocally that the differences are practically undistinguishable. The complete program to calculate the Scatchard parameters and their statistical analysis is available on request.

Binding Sites↗

PubMed1999

An algorithm for the assembly of robust physical maps based on a combination of multi-level hybridization data and fingerprinting data.

We have developed an algorithm which combines data obtained from restriction digestion experiments and hybridization experiments to construct robust physical maps of whole chromosomes. The algorithm has been incorporated into a program which accepts hybridization data consisting of an unordered hybridization matrix and fingerprinting data containing band coordinates for each clone. The combined data is used to produce a non-redundant, ordered matrix which can be further reduced to represent a minimum tile coverage of the chromosome. In addition, the method also takes into account multi-level hybridization events which allows for an improved treatment of the hybridization data. The program is evaluated against several other contig building programs using simulated and real data sets. Finally, it is applied to construct a physical map of the 4.1 Mb genome of Ochrobactrum anthropi based on 1387 clones and 70 probes, as well as 624 fingerprints.

Algorithms↗

PubMed1981

Effect of an exercise program on the static balance of deaf children.

Deaf children show subnormal performance on standard tests of static balance. This study investigated the effect of a 10-day exercise program of static balance activities on the static balance ability of severely deaf children. A pretest-posttest control group design was used. The subjects, 49 deaf children, were tested on a force platform in four different stances. The experimental group then participated in a daily exercise program of activities traditionally used to facilitate balance ability. A comparison of the change in steadiness scores between the control and experimental groups revealed no significant difference in static balance ability as measured by degree of sway. However, the length of time that children in the experimental group could stand on one leg increased significantly. The lack of improvement in the amount of sway after use of this widely accepted therapeutic program serves to highlight the need for further investigation of the effect of any exercise program on static balance ability.

Child↗

PubMed2000

Health promotion in the city: a structured review of the literature on interventions to prevent heart disease, substance abuse, violence and HIV infection in US metropolitan areas, 1980-1995.

To achieve its national public health goals, the US must improve the health of low-income urban populations. To contribute to this process, this study reviewed published reports of health promotion interventions designed to prevent heart disease, HIV infection, substance abuse, and violence in US cities. The study's objectives were to describe the target populations, settings, and program characteristics of these interventions and to assess the extent to which these programs followed accepted principles for health promotion. Investigators searched five computerized databases and references of selected articles for articles published in peer-reviewed journals between 1980 and 1995. Selected articles listed as a main goal primary prevention of one of four index conditions; were carried out within a US city; included sufficient information to characterize the intervention; and organized at least 25% of its activities within a community setting. In general, programs reached a diverse population of low-income city residents in a variety of settings, employed multiple strategies, and recognized at least some of the principles of effective health promotion. Most programs reported a systematic evaluation. However, many programs did not involve participants in planning, intervene to change underlying social causes, last more than a year, or tailor for the subpopulations they targeted, limiting their potential effectiveness. Few programs addressed the unique characteristics of urban communities.

HIV Infections↗

PubMed2001

Parent training in head start: a comparison of program response among African American, Asian American, Caucasian, and Hispanic mothers.

The effectiveness of the Incredible Years Parenting Program was evaluated in a low-income sample of Caucasian, African American, Hispanic, and Asian mothers whose children were enrolled in Head Start. Data from two prior intervention studies [Webster-Stratton (1998) Journal of Consulting and Clinical Psychology, 66(5), 715-730; Webster-Stratton et al. (in press) Journal of Clinical Child Psychology] were combined, yielding a sample of 634 families (370 Caucasian, 120 African American, 73 Asian, 71 Hispanic) across 23 Head Start centers. Centers were matched and assigned randomly to either an experimental condition (8-12 weeks of weekly 2-hr parenting classes), or a control condition (the regular Head Start Program without parenting groups). Families in both conditions were assessed using home observations of parent-child interactions and parent reports of parenting style and discipline strategies and child behavior problems in the fall (baseline) and spring (postintervention) of the children's Head Start year. Families were reassessed 1 year later. Following treatment, intervention mothers were observed to be more positive, less critical, more consistent, and more competent in their parenting than were control mothers. Additionally, children of intervention parents were observed to exhibit fewer behavior problems than were control children. Differences in treatment response across ethnic groups were few, and did not exceed the number expected by chance. Parents from all groups reported high satisfaction levels following the parenting program. Results indicate that the Incredible Years Program is accepted by and effective with diverse populations.

Adult↗

PubMed1997

PCR-based screening for cystic fibrosis carrier mutations in an ethnically diverse pregnant population.

As the most common lethal autosomal recessive disorder in North America, cystic fibrosis (CF) is an obvious candidate for general population carrier screening. Although the identification of the causative gene has made detection of asymptomatic carriers possible, the extreme heterogeneity of its mutations has limited the sensitivity of the available DNA screening tests and has called into question their utility when they are applied to patients with no family history of the disease. The purpose of this study was to determine the technical feasibility, patient acceptance and understanding, and psychosocial impact of large-scale CF carrier screening in an ethnically diverse pregnant population. A total of 4,739 pregnant women attending prenatal clinics located in both an academic medical center and a large HMO were invited in person to participate. Of this group, 3,543 received CF instruction and assessments of knowledge and mood, and 3,192 underwent DNA testing for the six most common CF mutations, by means of a noninvasive PCR-based reverse-dot-blot method. Overall participation rates (ranging from 53% at the HMO to 77% at the academic center) and consent rates for DNA testing after CF instruction (>98%) exceeded those of most other American studies. The PCR-based screening method worked efficiently on large numbers of samples, and 55 carriers and one at-risk couple were identified. Understanding of residual risk, anxiety levels, and overall satisfaction with the program were acceptable across all ethnic groups. Our strategy of approaching a motivated pregnant population in person with a rapid and noninvasive testing method may provide a practical model for developing a larger CF screening program targeting appropriate high-risk groups at the national level, and may also serve as a paradigm for population-based screening of other genetically heterogeneous disorders in the future.

Academic Medical Centers↗

PubMed1983

Computer-aided diagnosis of lumbar disc herniation.

A microcomputer was programmed to accept data on the history and physical findings of patients, with low-back pain, suspected of having a herniated lumbar intervertebral disc, then suggest a likely diagnosis, with probability, and make suggestions for further management. Formal decision analytic techniques were used to test for the threshold of diagnostic likelihood that would make the expected value of laminotomy for excision of a herniated disc greater than the expected value of non-surgical management. The program is recursive, using its results to update its data base, and become more "intelligent." In a blinded evaluation, an expert could not detect a significant difference between the output of the computer and the diagnoses and treatment plans of ten clinicians.

Adult↗

PubMed2004

Doping control from a global and national perspective.

The practice of enhancing athletic performance through foreign substances was known from the earliest Olympic games. In 1967, the International Olympic Committee (IOC) established a Medical Commission responsible for developing a list of prohibited substances and methods. Drug tests were first introduced at the Olympic winter games in Grenoble and at the summer games in Mexico City in 1968. In February 1999, the IOC convened the World Conference on Doping in Sport in Lausanne, Switzerland. The Lausanne Declaration on Doping in Sport recommended creation of an International Anti-Doping Agency. The World Anti-Doping Agency (WADA) was formed in Lausanne, Switzerland on the basis of equal representation from the Olympic movement and public authorities. One of the mandates of WADA was to harmonize the Olympic antidoping code and develop a single code applicable and acceptable for all stakeholders. The world antidoping code developed by WADA included creation of several international standards (IS). The purpose of each IS was harmonization among antidoping organizations. The ISs were developed for laboratories, testing, the prohibited list, and for therapeutic use exemptions (TUE). The objective of this manuscript is to present a brief history of doping in sport and describe creation of WADA in 1999. The components of the World Anti-Doping code (in particular, the Therapeutic Use Exclusion program or TUE) is described. The WADA code defines a TUE as "permission to use, for therapeutic purposes, a drug or drugs which are otherwise prohibited in sporting competition." Experiences of the Canadian Centre for Ethics in Sport Doping Control Review Board are presented because this national TUE committee has been operational for over 12 years. The challenge of developing a rigorous global antidoping program requires acceptance of doping as a problem by sport organizations, athletes, and public authorities. Individual stakeholders must be prepared to preserve the values of sport, which means free from doping. This will require vigilance by all interested parties for the benefit of elite athletes and society overall.

Canada↗