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The Expanded Programme of Immunization in Ondo State, Nigeria, which began in 1978 has been reviewed. Non-availability of constant electrical supply needed to keep vaccine at their original potency, shortage of trained health manpower, administrative shortcomings and lack of proper health education have been identified as some of the factors hindering effective implementation of the programme.
The New York State Perinatal Hepatitis B Prevention Program was implemented in New York State (excluding New York City) as a surveillance and control program in 1988. This report describes and evaluates the program and provides data from 1991 regarding hepatitis B surface antigen (HBsAg)-positive mothers and their infants' subsequent hepatitis B vaccination. The program was created using multiple existing surveillance and data collection systems. Completeness of case-ascertainment was estimated by means of the Chandra Sekar-Deming method (J Am Stat Assoc 1949; 44:101-15). An audit of hospital medical records and follow-up by local health departments were used to validate reporting accuracy. Of 158,273 live births in 1991, 363 (0.2%) were born to confirmed HBsAg-positive mothers. Estimated completeness of case-ascertainment was 96%. Thirty-five percent of HBsAg-positive mothers did not report risk factors for hepatitis B, confirming the need for universal testing. Of the infants, 83% received hepatitis B immune globulin and three doses of vaccine within one year of birth. By using existing data collection systems, the program was established quickly, and start-up funding and training requirements were simplified. Multiple reporting increased case-ascertainment to almost 100%. The program effectively identifies and ensures prompt vaccination of infants born to HBsAg-positive mothers.
Physicians are not immune to psychosocial problems but may face unique impediments to attending to them. Self-care among physicians is not a topic generally included as a part of professional training, nor is it a topic that readily receives consideration in professional practice. The stresses of professional practice can exact a great toll, however, and self-neglect can lead to tragic consequences. In some areas, particularly suicide rates, physicians have increased vulnerability, and in other areas problems may be unrecognized (depression, substance abuse, marital problems, and other stress-related concerns). Female physicians show some particular areas of risk. In this paper, we raise questions about how and why physicians may be particularly vulnerable, review the available literature about the extent and nature of such problems in physicians, discuss possible factors related to the development of these problems in physicians, and suggest a variety of solutions to improve physician self-care.
Prior to 1989, Krabi and Satun, two neighbouring provinces with similar socioeconomic background and health service coverage, had the highest reported incidence rates of neonatal tetanus in Thailand (3 per 1000 livebirths). A control programme was conducted between 1989 and 1991. The objective of this study was to examine changes in prevalence of risk factors among the population and changes in incidence rates of this disease due to this programme. Two 30-cluster surveys to measure prevalence rates of risk factors were conducted in Krabi, before and after the campaign. Information on incidence was obtained from routine surveillance. The intervention in Krabi consisted of mass immunization and intensive education for traditional birth attendants (TBA) whereas only the latter was carried out in Satun. The incidence of neonatal tetanus in both provinces declined dramatically to less than 0.4 per 1000 livebirths in 1990 and 1991. From 1989 to 1991, in Krabi Province, the coverage of at least two doses of tetanus toxoid injections at any time prior to delivery, delivery by trained health personnel, acceptable sterile technique for umbilical cord cutting and correct method of dressing the umbilical stump rose from 70 to 88%, 55-80% cent, 80-94% and 40-74%, respectively. Reduction in the incidence rate of neonatal tetanus was achieved by strengthening of routine health services with or without additional mass immunization. Considering that the coverage of immunization has not yet been completed and the prevalence rates of different risk factors are still high, further attempts to improve the problem of neonatal tetanus are necessary.
Hippocampal lesions in rats produce both a retrograde and an anterograde amnesia of contextual fear conditioning. The present experiments examined the anterograde deficit in context conditioning. The deficit produced by electrolytic hippocampal lesions was apparent when training occurred on 7, 14, or 28 days following surgery, confirming the durability of the amnesia. The role of the hippocampus in context conditioning may be related to an NMDA (N-methyl-D-aspartate) receptor-mediated process. Both NMDA hippocampal lesions and intrahippocampal administration of an NMDA antagonist produced anterograde amnesia. Animals preexposed to the conditioning context 28 days prior to hippocampal lesioning were protected from the deficit normally produced by the lesions. Thus, the hippocampus must form a contextual representation during preexposure that is subsequently stored elsewhere. Once formed this representation of the context can be associated with an unconditional stimulus.
BACKGROUND: Patients with follicular lymphoma may survive for periods of less than 1 year to more than 20 years after diagnosis. We used gene-expression profiles of tumor-biopsy specimens obtained at diagnosis to develop a molecular predictor of the length of survival. METHODS: Gene-expression profiling was performed on 191 biopsy specimens obtained from patients with untreated follicular lymphoma. Supervised methods were used to discover expression patterns associated with the length of survival in a training set of 95 specimens. A molecular predictor of survival was constructed from these genes and validated in an independent test set of 96 specimens. RESULTS: Individual genes that predicted the length of survival were grouped into gene-expression signatures on the basis of their expression in the training set, and two such signatures were used to construct a survival predictor. The two signatures allowed patients with specimens in the test set to be divided into four quartiles with widely disparate median lengths of survival (13.6, 11.1, 10.8, and 3.9 years), independently of clinical prognostic variables. Flow cytometry showed that these signatures reflected gene expression by nonmalignant tumor-infiltrating immune cells. CONCLUSIONS: The length of survival among patients with follicular lymphoma correlates with the molecular features of nonmalignant immune cells present in the tumor at diagnosis.
Preterm infants often receive their diphtheria-tetanus-pertussis (DTP) immunizations on a delayed schedule or in reduced dosage. Since primary care physicians (PCPs) immunize many preterm infants, the purpose of this study was to describe PCPs' knowledge about the use of DTP immunizations in preterm infants. Among the 479 PCPs who completed the questionnaire, 84% of pediatricians and 60% of family physicians correctly identified chronologic age as a criterion for initiating DTP immunizations in preterm infants. However, nearly 45% of PCPs linked this with other criteria such as a minimum weight requirement. Family physicians' answers differed from the recommendations more often than pediatricians' answers. The answers of pediatricians and family physicians who completed residency greater than 20 years ago differed from the recommendations more often than those who completed training less than or equal to 20 years ago. The answers of PCPs with fewer than five preterm infants in their practices differed from the recommendations more frequently than the answers of those with five or more preterm infants in their practices. Educational interventions are needed to bring PCPs' knowledge and practices into compliance with the American Academy of Pediatrics recommendations concerning DTP immunizations for preterm infants.
OBJECTIVE: To evaluate the effectiveness of in-home geriatric assessments as a means of providing preventive health care and improving health and functional status of community-living elderly veterans. DESIGN: Randomized controlled trial with 1-year follow-up. SETTING: Home visits performed in a suburb of Los Angeles. PARTICIPANTS: Community-living veterans 70 years and older not currently receiving health care at the Sepulveda VA Medical Center (n = 131 intervention; 123 controls). INTERVENTION: A home visit by a physician's assistant or nurse, to screen for medical, functional and psychosocial problems, followed by a letter describing findings and recommendations, and follow-up visits by trained volunteers at 4-month intervals for 1 year. Controls received only telephone interviews at 4-month intervals to collect outcome data. MEASUREMENTS: Compliance with recommendations was studied for the intervention group. Outcome comparisons between the two groups included: mortality, medication usage, functional status, immunization rates, and nursing home and hospital utilization. MAIN RESULTS: A mean of four new or suboptimally treated problems was identified for intervention subjects. Subjects complied with 76% of recommendations to see a physician or initiate a specific health practice. At 12-month follow-up, intervention subjects had significantly increased their immunization rates (P < 0.001) and had a significantly increased likelihood of having a primary care physician (P < 0.05). Twelve-month functional status (IADL) scores were significantly higher for intervention subjects than for controls; intervention subjects maintained their functional status, while controls experienced significant decline during the follow-up year (P < 0.05). Non-prescription drug use increased significantly among controls, but not among intervention subjects (P < 0.05). CONCLUSIONS: A brief geriatric screening assessment performed in the home can detect unrecognized and treatable problems, even among relatively healthy older adults. The use of trained volunteers is a feasible strategy for providing health education and follow-up contacts. These results support the concept that preventive gerontological approaches can help maintain important aspects of health and function.
Historically, military recruits have been at high risk of acquiring meningococcal disease. Beginning in the 1940s, the US military relied on mass treatment with sulfadiazine to control outbreaks in training camps. In the 1960s, a vaccine was developed in response to the emergence of sulfadiazine-resistant strains. Since 1971, all new recruits in the US military have been immunized against Neisseria meningitidis during their first days of service. Serogroups represented in vaccines given to service members have changed over time: the quadrivalent (A, C, Y, W135) vaccine has been given since 1982. In the US military, meningococcal disease rates decreased by approximately 94% from 1964 to 1998. After initiating routine immunization in 1971, crude rates decreased sharply and have remained low; in addition, there have been few cases of disease caused by serogroups represented in contemporaneously administered vaccines. In the US military, immunizations have been effective for the prevention of disease caused by vaccine-homologous serogroups of N. meningitidis.
BACKGROUND: Graduating medical students from the class of 1999 from McGill University and the University of Alberta completed a self-administered, anonymous, pilot survey to determine students' perspectives on how their educational experience in common palliative care topics contrasted with their educational experience in the diagnosis and management of hypertension, non palliative aspects of breast cancer, and patients dying of acquired immune deficiency syndrome (AIDS). METHODS: A Likert scale ranging from "excellent," scored 1, "very poor," scored 5, was used. Students also estimated the number of hours they spent, during their training, in operating rooms, on home visits to terminally ill patients, and in interprofessional teaching. RESULTS: Sixty of 114 (53%) students from McGill University, and 53 of 110 (48%) students from the University of Alberta responded to the survey. The mean ratings of education experience in the various topics for both universities combined were as follows: hypertension, 2.03; breast cancer, 2.33; cancer pain, 3.42; communicating with dying patients, 3.32; and caring for patients with AIDS, 4.15. The average number of hours spent in the operating room, on home visits to terminally patients, and in interprofessional teaching for both universities combined were 155 hours, 4.2 hours, and 16 hours, respectively. Of the responding students from both universities 83% favored increased palliative care teaching. CONCLUSION: Despite the disproportionate number of hours spent in operating rooms compared to palliative care community exposure, only two students, one from each university, favored shortening surgical rotations to allow for increased time for palliative care education. Recommendations, including increasing palliative care education during clinical clerkships, are provided to improve medical students' perceptions of their educational experiences in palliative care education.
OBJECTIVES: To assess older urban women's knowledge about sexual transmission of human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS) and to evaluate the relationship between their HIV/AIDS knowledge level and sources of information. DESIGN: Cross-sectional survey conducted between June 2001 and July 2002. Trained research assistants administered a questionnaire in a face-to-face interview. SETTING: General medicine clinic in a large public hospital in a high HIV/AIDS incidence area. PARTICIPANTS: Five hundred fourteen women aged 50 and older. MEASUREMENTS: Nine questions assessing knowledge of risk of HIV sexual transmission with potential scores ranging from 0 to 9 correct answers. Participants identified all sources of HIV information. RESULTS: The mean knowledge score was 3.7 out of a possible 9 correct responses (range 0 (3%) to 8 (1%)). Younger age, employment, and higher educational level were associated with higher knowledge scores, whereas marital status was unrelated. No respondent correctly answered all of the nine questions. The most commonly identified sources of HIV/AIDS information were television (85%), friends (54%), and newspapers (51%). Only 38% of respondents identified health professionals as a source of information about HIV/AIDS. Health professionals, newspapers, and family members were each independently associated with higher knowledge scores (P<.05). CONCLUSION: Older women in a general medicine clinic had limited knowledge of sexual transmission of HIV. HIV/AIDS education specifically targeted to this subpopulation is warranted, and health professionals may have an important role in disseminating such messages.
Idiopathic nephrotic syndrome encompasses two main forms of glomerular diseases, minimal change nephropathy and focal segmental glomerulosclerosis. Minimal change nephropathy is a disease of children which generally responds to corticosteroids. After remission, however, many patients show frequent relapses or steroid dependency. In these patients, cyclosporine may obtain remission of proteinuria in 80% of cases, although relapse usually occurs when the drug is stopped. Focal glomerulosclerosis is generally resistant to corticosteroids. Under cyclosporine some 40% of patients may attain complete or partial remission of the nephrotic syndrome particularly if low-dose prednisone is associated. Relapse of proteinuria usually occurs after stopping the drug. As cyclosporine may expose to chronic nephrotoxicity some guidelines should be followed to prevent this complication: - the doses should not exceed 5 mg/Kg/day - they should be adjusted whenever an increase in plasma creatinine of > or = 30% over the baseline values occurs - treatment should be stopped if there is no response within 3 months - a careful monitoring of patient under the supervision of a clinician trained with the use of cyclosporine is necessary. The term idiopathic nephrotic syndrome (INS) defines the association of a nephrotic syndrome with non specific glomerular lesions, in the absence of immune complex deposition (1). On the basis of renal histology two main types of INS are recognized: minimal change nephropathy (MCN) and focal and segmental glomerular sclerosis (FSGS).
The city of Glasgow has a large population of injecting drug users (IDUs) who are likely to be susceptible to acute hepatitis B infection. We evaluated the effectiveness of a hepatitis B vaccination programme delivered at three existing types of services for IDUs. It was found that while uptake rates were generally low, they were higher at services where throughput of patients was lower, where clients had continuing relationships with services and where staff training and confidence were better.
We conducted a medical records survey of 270 randomly selected patients 20 years of age or older seen by family practice residents in a university-based training program. This study concerned residents' compliance with certain preventive recommendations made by four expert groups: the American Cancer Society, the Canadian Task Force on the Periodic Health Examination, the Immunization Practices Advisory Committee, and the National Institutes of Health Consensus Development Conference on treating elevated cholesterol. The interventions studied were breast examination, mammography, pelvic examination, Pap testing, digital rectal examination, stool guaiac slide testing, serum cholesterol screening, and pneumococcal and influenza vaccinations. We calculated the percentage of eligible patients receiving each of these interventions. The highest rates of resident compliance with health screening recommendations were for Pap testing in women 20-34 and 35-59 years of age (31.7% and 22.6%, respectively), breast examination in women 20-39 years of age (27.3%), and influenza vaccination (23.0%). There were no other rates of compliance that exceeded 20%. Our data thus indicate that residents in this program did not comply well with health maintenance recommendations.
An extensively organized, centrally controlled system, aimed at equalizing and improving the distribution and quality of medical services according to population and geography, characterizes the modern Cuban health care complex. Facilities of increasing sophistication are located in urban areas while an expanding series of ambulatory, multipotential polyclinics attempts to provide most health services in both urban and rural settings. Maternal and child care, immunization programs and other forms of preventive medicine represent major priorities for expenditures. Occupational health is increasingly understood as a valuable resource, and medical professionals on all levels are being trained in significant numbers for Cuba and its allies.
Forty three staff members present on 18 booths for intensive Pulse Polio Immunization were interviewed anonymously during the first round of the programme on 24th October, 1999 to find out their problems likely to affect successful implementation of the programme. The observation revealed some of the problems such as long distance between residence and the booth (46.5%), difficulty in locating the booth (72%), lack of training (90.7%), improper meals (69.7%) and lack of toilet facilities (37.2%). Suitable modifications should be made in light of the observations to secure full support of the staff for success of the programme.
The purpose of this study was to determine the effects of a single bout of resistance exercise on immune cell numbers of moderately active men. Subjects were 16 male volunteers (mean +/- standard deviation [SD] age 30 +/- 7 years, height 180.1 +/- 7.0 cm, mass 83.97 +/- 10.33 kg); 8 were randomly assigned to treatment and 8 to control groups. Treatment was a common resistance training routine (3 sets of 8-10 repetitions at 75% of 1 repetition maximum) of 8 large muscle mass exercises using resistance machines. Blood samples were drawn before exercise and at 0 minutes (P0), 15 minutes (P15), and 30 minutes (P30) postexercise. Control subjects sat quietly in the training facility; blood was drawn at the same intervals as treatment. Leukocyte and lymphocyte (LY) subpopulation numbers were determined. Statistical analysis was analysis of variance (ANOVA) (repeated measures, p < or = 0.050) and multiple comparisons (Dunn method) to isolate variability. All leukocyte subpopulations, except basophils (BA) and eosinophils (EO), increased and counts declined by P15 and P30. Only neutrophils (NE) did not return to preexercise levels by P30. The majority of resistance exercise induced leukocytosis was due to an increase in circulating LY (natural killer cells increased most, CD4+/CD8+ ratio unchanged) and monocytes (MO). The transient, inconsequential immune cell population responses to resistance exercise are similar to those during aerobic activity. The lack of large alterations in and rapid recovery from cell number changes suggests that resistance exercise is not immunosuppressive.
In Wollo region of Ethiopia, various non-governmental officers have been working closely with each other and with the Regional Health Department to implement the policy of daily integrated mother and child health services. The record cards, registers, procedures and training courses of the separate 'vertically' organized services were brought together to enable the development of a model integrated service. There were improvements in accessibility, acceptability and output of the services. The system was evaluated by a joint Ministry of Health and UNICEF team, and was adopted for use in the rest of Ethiopia.