Validation of a Chinese version of the Medical Outcomes Study HIV Health Survey (MOS-HIV) among Chinese people living with HIV/AIDS in Hong Kong

OBJECTIVES

To evaluate the Chinese version of the 35-item Medical Outcomes Study HIV Health Survey (MOS-HIV) in Chinese people living with HIV/AIDS (PLWHA).

METHODS

A cross-sectional survey of 242 ethnic Chinese PLWHA in Hong Kong was conducted.

RESULTS

Cronbach's alphas of the eight multi-item scales of the MOS-HIV ranged from 0.78 to 0.90. Item-total and inter-scale correlation coefficients were acceptable. Factor analysis of the MOS-HIV identified two factors (Mental Health Summary scores and Physical Health Summary scores, or MHS and PHS), accounting for 63% total variance. The PHS and MHS correlated significantly with the WHOQOL-BREF(HK) and the three sub-scales of Profile of Mood States used in this study. Both PHS and MHS were significantly associated with self-perceived change in health status. PHS but not MHS was associated with Karnofsky Performance Status scores. PHS was also associated with disease stage. The MOS-HIV however, did not distinguish between groups of different CD4 cell counts. It is likely that the quality of life of these PLWHA of different disease stages was good in general.

CONCLUSIONS

There is a large demand for evaluating treatments and services programs offered to PLWHA in China. The validated Chinese MOS-HIV would facilitate such research activities.

Design and evaluation of a drama-based intervention to promote voluntary counseling and HIV testing in a South African community

BACKGROUND

Voluntary counseling and testing (VCT) services are a major component of HIV prevention and treatment efforts. We developed a drama-based intervention to promote VCT services in a peri-urban community in South Africa.

METHODS

Young adults from the community received training in HIV/AIDS and drama, and developed sketches to address perceived barriers to VCT. Over 12 months, 80 performances were held in busy community settings. The intervention was evaluated through changes in VCT uptake at the local clinic compared with comparable communities nearby.

RESULTS

After the start of the intervention in August 2003, a 172% increase in the uptake of VCT services was observed in the intervention community. This was significantly greater than demand for VCT in either of the control communities during the same period (P < 0.0001).

CONCLUSION

A structured, community-based education program based on drama can lead to substantial increases in the demand for VCT services in resource-limited settings.

Quality assessment of family planning services in urban health centers of Shahid Beheshti Medical Science University, 2004

PURPOSE

Quality of family planning services is now considered as a global concern and importance. The purpose of the present study is to assess quality of family planning services in the urbanhealth centers of Shahid Beheshti Medical Science University.

DESIGN/METHODOLOGY/APPROACH

This was a descriptive study to assess structure, process and outcome of the family planning care services. A total of 15 health centers of Shahid Beheshti Medical Science University were randomized and the quality of provided care by 65 family planning care providers of these health centers were observed and assessed using checklists. A total of 75 family planning clients were interviewed to assess their knowledge about their selected family planning method all of whom completed the related forms of satisfaction with the services. The tools for data collection were two observational checklists, and two questionnaires with subsequent data analyzed using SPSS 11.5. In total 75 clients with an average age 24 (7 +/- 4) (mean +/- SD) participated in the study. The provision of family planning services by 65 providers was assessed by observation at three intervals. Of the providers, 60 (92.3 per cent) were midwives.

FINDINGS

Mean satisfaction score of clients was 83.3 +/- 9.05 percent meaning clients were highly satisfied with the services. Mean knowledge score of clients about their family planning method of use was 59.1 +/- 18 percent, which shows their moderate knowledge about their method of use.

ORIGINALITY/VALUE

A more advanced tool to assess quality of care of family planning services with more focus on special care for the contraceptives was developed. Quality of care in family planning services of Shahid Beheshti Medical Science University health centers showed adequate facilities and equipment and to have trained personnel however their client's knowledge about the selected method was moderate. Therefore, interventional programs are needed to improve counseling and the educational process of clients, which should be considered in future research and planning of the programs.

Essential tips for measuring levels of consumer satisfaction with rural health service quality

INTRODUCTION

Quality of health services is a matter of increasing importance to health authorities. Monitoring consumer satisfaction of health care is an important input to improving the quality of health services. This article highlights a number of important considerations learned from rural consumer studies relevant to ensuring the valid measurement of consumer satisfaction with rural health services, as a means of contributing to quality improvements.

METHODS

This article compares two methods of analysing rural consumers' satisfaction with healthcare services. In one study of three rural communities in western New South Wales (NSW) and eight communities in north-west Victoria, residents were asked to rate their satisfaction with five key aspects of local health services (availability, geographical accessibility, choice, continuity, economic accessibility as measured by affordability) using a 5 point Likert scale from: one = very satisfied to five = very dissatisfied. An alternative method of assessing levels of consumer satisfaction was undertaken in the survey of eight rural communities in north-west Victoria by investigating consumers' experiences with actual and potential complaints in relation to health services.

RESULTS

Both the NSW and Victorian respondents reported generally high levels of satisfaction with the five indicators of quality of health care. At the same time, 11% of Victorian study respondents reported having made a complaint about a health service in the previous 12 months, and one-third of the Victorian respondents reported experiences with their health services about which they wanted to complain but did not, over the same period.

CONCLUSIONS

Interpretation of apparent consumer satisfaction with their health services must take particular account of the measures and research methods used. In assessing consumer satisfaction with health services in rural areas, specific attention should be given to maximising the engagement of rural consumers in order to ensure representativeness of findings, and to minimise possible biases in satisfaction ratings associated with the use of particular tools.

Australasian dialectical behaviour therapy pilot outcome study: effectiveness, utility and feasibility

OBJECTIVES

This paper aims to describe the outcome of 10 patients treated in a New Zealand pilot study of dialectical behaviour therapy (DBT) for people with borderline personality disorder (BPD), and to ascertain the clinical utility and feasibility of implementing DBT into a standard New Zealand public mental health service.

METHOD

Patients had a clinical and an International Personality Disorder Examination diagnosis of BPD and received 6 months of standard DBT treatment. Rating scales used were the Millon Clinical Muliaxial Inventory, 3rd edition (MCMI-III) and the Symptom Checklist 90-Revised (SCL-90-R), which were completed pre treatment and post treatment. Pre-post treatment data were completed on inpatient resource usage. Qualitative patient interviews were conducted post treatment.

RESULTS

There were statistically significant improvements in functioning on 10 of the 24 MCMI-III subscales (p < 0.03 to p < 0.0008), including notably the borderline personality subscale (p < 0.01) and the anxiety (p < 0.05) and depression (p < 0.001) subscales. There was a statistically significant improvement on the Global Severity Index of the SCL-90-R (p < 0.001) and on 10 of the 12 SCL-90-R scales (p < 0.05 to p < 0.001). The hospital bed days used decreased from 0.57 days per patient per month to 0.2 days per patient per month.

CONCLUSIONS

These preliminary results document the clinical effectiveness of DBT. Dialectical behaviour therapy has practical and clinical utility of relevance to Australasian public mental health services. A DBT service can be successfully implemented within existing public mental health services.

Triage Accuracy at a Multiple Casualty Incident Disaster Drill: The Emergency Medical Service, Fire Department of New York City Experience

We sought to evaluate the accuracy and speed for the triage of multiple patients during a disaster drill by Emergency Medical Service (EMS) personnel. During a disaster drill (train collision with blast injury and chemical release), the accuracy and speed of triage of 130 patient-actors by the Fire Department of New York City (FDNY) EMS personnel was evaluated using the Simple Triage and Rapid Treatment (START) triage system. All EMS personnel had been previously trained in START, but refresher training was not administered before the drill. Overall triage accuracy was 78%. In patients that had additional changes in their status during the triage process (injects), 62% were retriaged appropriately. Because of security and decontamination procedures, triage at the triage/treatment area began 40 minutes after the drill commenced. It took 2 hours and 38 minutes to completely clear the scene of all patients. On average, the time from the start of triage to transport was 1 hour and 2 minutes. Despite the fact that triage is a skill practiced by every EMS system in the country on a daily basis, few studies regarding triage accuracy are available. Limited data suggest that the triage accuracy rates using different triage strategy algorithms are approximately 45% to 55%. During this drill, FDNY-EMS triage accuracy using the START system exceeded these expectations. This study provides insight as to the triage experience of a large urban EMS system operating at a disaster drill.

“You Need to Know Where We’re Coming From”: Canadian Aboriginal Women's Perspectives on Culturally Appropriate HIV Counseling and Testing

The purpose of this qualitative descriptive study was to determine Canadian Aboriginal women's perspectives on culturally appropriate HIV counseling and testing. Data were collected through semistructured individual interviews with 7 Aboriginal women, and one focus group, in a western Canadian city. Four major categories were elucidated through thematic content analysis: Aboriginal women's life experiences that may influence their risk of HIV infection and their response to testing; barriers to HIV testing; guiding principles of the ideal HIV testing situation; and characteristics of culturally appropriate HIV testing. The fear of being judged by both the Aboriginal and non-Aboriginal communities and the need for sensitivity to the historical and current context of Aboriginal women's life experiences were pervasive themes throughout the findings.

Surgical service centralisation in Australia versus choice and quality of life for rural patients

High patient volume for both hospitals and surgeons is an important determinant of operative mortality and outcome for complex and infrequently performed operations. The 13% of Australia's population who live in rural and remote areas often choose to have surgery close to home and support networks despite the potentially higher operative mortality and morbidity. Rural patients should be able to make an informed choice about having their surgery locally. Rural and metropolitan surgeons should discuss and reach mutual agreement on where each patient is best treated. A balance must be struck between quality of services that can be provided locally and geographic convenience.

Emergency medical service providers’ experience with family presence during cardiopulmonary resuscitation

OBJECTIVE

To describe emergency medical service providers' experiences with family member presence during resuscitation, and to determine whether those experiences are similar within urban and suburban settings.

METHODS

We conducted a personally distributed survey of a convenience sample of urban and suburban emergency medical service (EMS) providers presenting to two Midwestern Emergency Departments. Providers were questioned as to their experiences with resuscitating patients in the presence of family members.

RESULTS

There were 128 respondents to the survey (59 urban and 69 suburban), of which 70.1% were EMT-Paramedics. No provider who was approached refused participation. Nearly all (122) had performed CPR in the presence of family members, with most (77%) performing greater than 20. Subjects averaged 12.3 years of experience. The majority of urban and suburban providers felt it was inappropriate for family to witness resuscitations (75.9% versus 60.3%, respectively; p=0.068). Many providers reported feeling uncomfortable with family presence (31.5% urban versus 44.8% suburban; p=0.136), and few preferred that family witness the resuscitation (13.2% urban versus 15.4 suburban; p=0.738). A minority of providers believed that family were better prepared to accept the death of the patient (37.0% urban versus 37.6% suburban; p=0.939). Approximately half felt comfortable providing emotional support (66.0% urban versus 53.7% suburban; p=0.173). Many felt that family caused a negative impact during resuscitation (53.7% urban and 36.8% suburban; p=0.061). Urban providers more often reported feeling threatened by family members during resuscitation (66.7% versus 39.7%; p=0.003), and felt that family often interfered with their ability to perform resuscitations (35.6% versus 16.4%, p=0.014).

CONCLUSIONS

EMS providers have substantial experience with family witnessed resuscitations, are uncomfortable about their presence, and often must provide support for families. While urban providers tended to report more negative experiences and perceptions, there were minimal differences between the two groups.

A model of dental public health teaching at the undergraduate level in Peru

There has been a growing interest among dental educators regarding the opportunities offered by community-based dental education as a means to allow dental students to assume their role as health professionals in the real world. Although several dental schools have integrated community-based education into their curricula, most have not engaged their students in the development of competencies to address dental health needs at the community level. The purpose of this article is to discuss the teaching-learning experiences in dental public health at the undergraduate level in the Faculty of Stomatology at the Universidad Peruana Cayetano Heredia (FS-UPCH) in Lima, Peru. The teaching-learning activities in dental public health at the FS-UPCH consist of two well-defined stages: experiences in low-income urban communities and experiences in low-income rural communities. Both stages have been designed to make it possible for students to acquire competency in addressing oral health needs at the community level as well as to enlarge and deepen their knowledge about the social and health situation in Peru. In community-based dental education, students are not only placed in community settings to treat individual patients, but also challenged to consider dental public health issues, including the administrative aspects of dental services.

Rural–Urban Differences in Medical Care for Nursing Home Residents with Severe Dementia at the End of Life

OBJECTIVES

To identify factors associated with the use of selected medical services near the end of life in cognitively impaired residents of rural and urban nursing homes.

DESIGN

Retrospective cohort study using Centers for Medicare and Medicaid Services administrative data for 1998 through 2002.

SETTING

Minnesota and Texas nursing homes.

PARTICIPANTS

Nursing home residents aged 65 and older with severe cognitive impairment who subsequently died during 2000/01.

MEASUREMENTS

Minimum Data Set and Medicare Provider Analysis and Review, Hospice, and Denominator files were used to identify subjects and to assess medical service use. U.S. Department of Agriculture metro-nonmetro continuum county codes defined rural (codes 6-9) and urban (codes 0-2) nursing homes. Nursing home residents with hospice or health maintenance organization benefits were excluded. Use of hospital services at the end of life was adjusted for use of corresponding services before the last year of life. Outcome variables were feeding tube use, any hospitalization, more than 10 days of hospitalization, and intensive care unit (ICU) admission.

RESULTS

The population included 3,710 subjects (1,886 rural, 1,824 urban). In multivariable logistic regression analyses (all P<.05), feeding tube use was more common in urban nursing home residents, whereas rural nursing home residents were at greater risk for hospitalization.

CONCLUSION

Rural residence was also associated with lower risk of more than 10 days of hospitalization and ICU admission. Nonwhite race and stroke were associated with higher use of all services. Rural nursing home residence is associated with lower likelihood of use of the most-intensive medical services at the end of life.

Feasibility and benefits of implementing a Slimming on Referral service in primary care using a commercial weight management partner

OBJECTIVES

To assess participation in a costed Slimming on Referral service and identify factors associated with success.

STUDY DESIGN

Simple intervention offering participation in a new service to 100 eligible patients. The setting was two Derby general practices, one inner city and one suburban.

PARTICIPANTS

One hundred and seven patients (mean age 50 years) attending general practice for non-obesity reasons.

INCLUSION CRITERIA

BMI > or = 30, age > or = 18 years, not pregnant, no recent commercial weight management group membership, willingness to attempt weight loss.

METHODS

Patients were offered free attendance at a local Slimming World group for 12 consecutive weeks. Body weight and height were measured at baseline, and questionnaires established perceived health, motivation to lose weight, employment, concerns, responsibilities and well-being. Weight was measured at each group visit. The main outcome measures were: (1) changes in body weight at 12 and 24 weeks, (2) social and demographic factors associated with barriers to enrolment, continued attendance and successful weight loss.

RESULTS

Ninety-one (85%) patients attended a group, with 62 completing 12 weeks. Average weight loss in participants was 5.4 kg (6.4% baseline weight). Forty-seven then chose to self-fund, with 34 (37% original group) completing a further 12 weeks. Average weight loss over the total 24 weeks was 11.1 kg (11.3% baseline weight). Regular attendance was affected by income, financial concerns (independent of actual income), age, perceived importance of weight loss and initial weight loss success. Well-being of patients significantly improved between baseline and both 12 and 24 weeks.

CONCLUSIONS

Collaboration with an appropriate commercial weight management organization offers a feasible weight management option that is either similar to, or better than, other options in terms of attrition, efficacy and cost.

The Threats to Australian Patient Safety (TAPS) study: incidence of reported errors in general practice

OBJECTIVE

To determine the incidence of errors anonymously reported by general practitioners in NSW.

DESIGN

The Threats to Australian Patient Safety (TAPS) study used anonymous reporting of errors by GPs via a secure web-based questionnaire for 12 months from October 2003.

SETTING

General practices in NSW from three groupings: major urban centres (RRMA 1), large regional areas (RRMA 2-3), and rural and remote areas (RRMA 4-7).

PARTICIPANTS

84 GPs from a stratified random sample of the population of 4666 NSW GPs - 41 (49%) from RRMA 1, 22 (26%) from RRMA 2-3, and 21 (25%) from RRMA 4-7. Participants were representative of the GP source population of 4666 doctors in NSW (Medicare items billed, participant age and sex).

MAIN OUTCOME MEASURES

Total number of error reports and incidence of reported errors per Medicare patient encounter item and per patient seen per year.

RESULTS

84 GPs submitted 418 error reports, claimed 490 864 Medicare patient encounter items, and saw 166 569 individual patients over 12 months. The incidence of reported error per Medicare patient encounter item per year was 0.078% (95% CI, 0.076%-0.080%). The incidence of reported errors per patient seen per year was 0.240% (95% CI, 0.235%-0.245%). No significant difference was seen in error reporting frequency between RRMA groupings.

CONCLUSIONS

This is the first study describing the incidence of GP-reported errors in a representative sample. When an anonymous reporting system is provided, about one error is reported for every 1000 Medicare items related to patient encounters billed, and about two errors are reported for every 1000 individual patients seen by a GP.

Prevalência de sinais e sintomas, fatores sociodemográficos associados e atitude frente aos sintomas em um centro urbano no Sul do Brasil

OBJECTIVE

To determine the prevalence of signs and symptoms in the adult population, the sociodemographic factors associated with them, and the actions taken as a result of these symptoms, according to sex.

METHODS

A population-based cross-sectional study was carried out in the city of Rio Grande (state of Rio Grande do Sul), Brazil, in 2000. We interviewed 1 259 people > or = 15 years of age. Data were collected using a structured questionnaire containing 18 symptoms in addition to sociodemographic questions. The prevalence of symptoms and prevalence ratios for sex, age, and socioeconomic status were estimated after alternately adjusting for these variables. The actions resulting from the presence of symptoms were also analyzed for each sex.

RESULTS

Mean age was 40.33 years (53.9% were women). The most prevalent symptom was headache (55.4%). Joint pain, insomnia, constipation, high blood pressure, and shortness of breath increased with age. The following were more prevalent among the lower social classes: headache, nervousness, joint and back pain, insomnia and depression, high blood pressure, chest pain, and shortness of breath. A total of 4 424 health problems were reported (an average of 3.25 per person); 60.2% did not generate any action, 31.6% resulted in self-medication, and 8.2% resulted in a visit to a medical facility. Headache, nervousness, joint and back pain, insomnia, depression, constipation, high blood pressure, chest pain, and shortness of breath were significantly higher in women, whereas cough was significantly more prevalent in men. Women and men took similar actions in the presence of signs and symptoms.

CONCLUSION

It is necessary to establish health policies that lay an emphasis on mental health and education for self care and on those symptoms that signal the need to go to a health facility. It is also necessary to study the role of social class in determining health behavior and the choice to seek care.

Differences and similarities in poisoning admissions between urban and rural health centers in Zimbabwe

BACKGROUND

Toxicoepidemiological data from rural areas of developing countries is scarce. Most studies examine admissions to urban referral hospitals and extrapolate to lower level health facilities. The validity of this approach was examined in this work.

METHODS

A retrospective review of all poisoning admissions was conducted at the provincial hospital (PH) and six district hospitals (DH) in Mashonaland Central province, Zimbabwe for the period January 1998 to December 1999 (inclusive). Patient records were traced by hand from medical ward registers. Relevant information was collected using a standard data collection tool.

RESULTS

There were 711 poisoning admissions to the DH and 341 to the PH. Case demographic details were similar at both the PH and DH, with a male to female ratio of 1:1 and most cases in the 0-5, 16-20 and 21-25 year age groups. Most admissions resulted from accidental poisoning (>60%) at both levels of care. However, the important causes of admission differed with animal envenomation (especially snakebite) predominating at DH (43.6% of admissions; 99% CI 38.9%-46.5%), whilst pesticide poisoning (26.1%; CI 20.0%-32.2%) predominated at the PH. Pharmaceutical exposures were common at the PH (15.2%; CI 10.2%-20.3%), but not at the DH (3.7%; CI 2.1%-5.1%). Despite this, patient demographics and reasons leading to poisoning were similar for animal, pesticide and pharmaceutical exposures.

CONCLUSION

Important differences existed between provincial and district poisoning data in Zimbabwe. Caution must be used when using urban referral hospital data to describe prevalence of poisoning in rural areas.

The response of general practitioners to the threat of violence in their practices: results from a qualitative study

BACKGROUND

Violence directed towards GPs has been recognized as a significant problem in the UK. In Australian urban general practice, no study has previously examined this topic.

OBJECTIVE

The objective of this study was to investigate the responses of Australian urban GPs to experiences of violence and to perceptions of risk of violence.

DESIGN

A qualitative study of data collected from two sources-focus group discussions and qualitative questionnaire responses. Focus group discussions were audiotaped and transcribed. Questionnaires offered the opportunity for respondents to make qualitative comments. The focus group transcripts and qualitative questionnaire responses were coded independently by members of the research team and subjected to thematic analysis.

SETTING

Three urban Divisions of General Practice in New South Wales, Australia.

SUBJECTS

Focus groups were conducted with male and female GPs comprising a range of ages, socio-economic practice catchments and practice structures. Questionnaires were distributed to all GPs in the three divisions.

RESULTS

The GPs in this study perceived themselves as being at significant risk of occupational violence. Despite responses to violence being largely ad hoc and uncoordinated, a coherent schema of GPs' responses to the threat of violence is apparent in the data. This has been characterized as encompassing primary, secondary and tertiary responses, and reflects a continuum of proactive to reactive responses.

CONCLUSION

The findings will have implications for further research and for policy in the area.

Stepped care vs. matched care for mood and anxiety disorders: a randomized trial in routine practice

OBJECTIVE

The effectiveness of two versions of stepped care [with either brief therapy (BT) or cognitive behavioural therapy (CBT) as a first step] is studied in comparison with the traditional matched care approach (CAU) for patients with mood and anxiety disorders.

METHOD

A randomized trial was performed in routine mental health care in 12 settings, including 702 patients. Patients were interviewed once in 3 months for 18-24 months (response rate 69%).

RESULTS

Overall, patients' health improved significantly over time: 51% had achieved recovery from the DSM-IV disorder(s) after 1 year and 66% at the end of the study. Respectively, 50% and 60% had 'normal' SCL90 and SF36 scores. Cognitive behavioural therapy and BT patients achieved recovery more often than CAU patients (ORs between 1.26 and 1.48), although these results were not statistically significant.

CONCLUSION

Stepped care, with BT or CBT as a first step, is at least as effective as matched care.

Access to oral health care - an Australian perspective*

The objectives of this paper are to give a brief description of the Australian context for its dental care services and to discuss some of the nationally recognized issues in access to dental care with special reference to the situation in the most populous state, New South Wales. Australia is the size of continental USA but with only around 21 million people, 85% of whom reside within 50 km of the coastline. Thus, access to health care has a strong urban-rural dimension. The universal healthcare coverage excludes dental care, 80-90% of which is delivered through traditional fee-for-service private dental care. A public dental care system exists with varying eligibility criteria from state to state, mostly directed at children, low-income individuals, pensioners, and defined disadvantaged groups. Thus, access to dental care also has a strong socioeconomic dimension with disadvantaged people having serious access problems and extensive waiting times. Government and other reports have documented considerable polarization issues both in oral health and in access to dental care. Suggested change strategies have ranged from broad political changes in the dental care system to local oral health promotion initiatives, but overall, dental care remains a pawn in state-commonwealth political squabbles. In response to strong public reactions documented shortcomings of the public dental care system the government of New South Wales has recently initiated a political inquiry into dental care. Unless new resources are injected and policy adjustments made, serious changes are unlikely.

The impact of an urban outreach teaching project: developing cultural competence

The purpose of this study was to explore the development of cultural competence in a group of university nursing students in the context of an interactive substance abuse prevention project attached to a health promotion course with 414 racially diverse high school students. The project provided opportunities for contact, interaction, and reflection. A descriptive approach was utilized to elicit the meaning attached to the experience. Data included written content from an exit survey, field notes from onsite debriefings, transcriptions of a focus group interview, and an analysis of theoretical papers. Findings indicate that when university students participate in an urban teaching project under conditions of diminishing anxiety and are given opportunities for reflection, they not only increase cultural competence but they also develop a sense of advocacy. Recommendations are made for building community partnerships to enhance cultural competence.

Straight to test: introduction of a city-wide protocol driven investigation of suspected colorectal cancer

OBJECTIVE

To decrease waiting times for colorectal cancer diagnosis.

METHODS

Following extensive negotiations on three sites, we replaced the standard referral route of GP to outpatient clinic with city-wide implementation of a protocol driven sequence based on the patient's declared symptoms, the initial consultation being replaced by the first test taking place within 31 days. No choice in test allocation was granted; difficult cases were adjudicated by named consultants. We used a 'dry run' to make sure that our planned changes would not overload our local capacity, leading to a pilot run involving 1/3 clinicians, followed by a full cross-city implementation over two months.

RESULTS

In 2001, before the pilot only 116/188 (62%) of our colorectal cancers who were referred either under the 2-week-wait arrangements or on a 'soon' basis were diagnosed within 31 days of referral. Our 'dry run' established that we did have the capacity to service our planned sequence of tests. In the pilot, all colorectal cancers were diagnosed within 31 days of referral, and 95% of all diagnoses (no abnormality or benign disease) were reached within 31 days of referral. After full implementation 19/19 (100%) of our cancers coming through our protocol system were diagnosed within 31 days and 95% of patients with benign disease.

CONCLUSION

Follow-up audit of our system one and two years later shows that we now diagnose approximately 80% of our colorectal cancers who are referred under the 2 week wait or as 'soon' referrals within 31 days. We have successfully redesigned our service, at minimal expense, in a way, which should enable us to meet the government targets in the National Cancer Plan.

Provision of general and HIV-specific health maintenance in middle aged and older patients in an urban HIV clinic

Given the increased prevalence of HIV infection in older individuals, we evaluated the adequacy of HIV-specific health maintenance, age-appropriate cancer screening, and diabetes management in an urban HIV clinic. We randomly selected 222 HIV-positive patients 40 years or older followed at the Johns Hopkins University Moore Clinic between 1999 and 2002. Demographic, clinical, and pharmaceutical data were abstracted from clinic charts. Outcomes of interest were vaccinations, annual rapid plasmin reagin (RPR) testing, and Papanicoloau smears and mammography in women. Logistic regression analyses were performed to identify variables significantly associated with being up to date on vaccinations. The sample was 56% female and 82% African American with a mean age of 50.9 years. Sixty-five percent used tobacco, 10% used alcohol, and 13% used illicit drugs daily. At the time of evaluation, 87% had received the pneumococcal vaccine. Of nonimmune patients, 66% were vaccinated for hepatitis B and 28% for hepatitis A. Eighty-two percent of women were referred for Papanicoloau smears and 56% for mammography. Only 59% completed the Papanicoloau smear, and 31% had mammography. Forty-two percent of patients with diabetes underwent quarterly foot examinations, and 33% had microalbuminuria screening. Risk factors for missed vaccinations include prior AIDS diagnosis (odds ratio [OR] 1.82, 95% confidence interval [CI] 1.55, 3.13), CD4+ cell count less than 50 cells/mm(3) at the time of visit (OR 6.31, 95% CI 1.74, 22.9), and a history of chronic obstructive pulmonary disease (COPD) or asthma (OR 2.54, 95% CI 1.03, 6.28). In summary, HIV-positive patients are more likely to receive HIV-specific primary care interventions, especially vaccinations that can be given in clinic, than routine health maintenance screening that required referral and evaluation elsewhere. This suggests that if health maintenance screening can be delivered in the same clinic, usage rates are likely to increase.

Matching community need with physician training: the OSU Urban Family Medicine Program

There continues to be a shortage of primary care physicians practicing within urban, Iower-socioeconomic and minority communities despite the fact that many of the 125 allopathic and 19 osteopathic medical schools are located within the affected urban cities. Recognizing a need to better train and recruit primary care physicians to serve in urban settings and provide care to those underserved. The Ohio State Department of Family Medicine established an Urban Family Medicine Residency Program headquartered in Near East Columbus, OH. Starting in 2003, the Urban Family Medicine Residency Program began training up to two residents each academic year. The mission, vision and (curriculum have attracted residency applicants and faculty who have displayed sincere interest and commitment to practicing in urban lower socioeconomic communities.

National survey of diabetes care in general practice

This survey was mounted to assess the extent and organisation of diabetes care in general practice in Ireland. It was a postal questionnaire surveying 25% of general practitioners, The response being 396 (70%). 355 (92%) report providing most care to a mean 65% of their type 2 patients, and 243 (64%) provide most care to 38% of their type 1 patients. The extent of structured care is less frequent with 43% maintaining a diabetes register, and 51% using a recall system. Access to multidisciplinary diabetes expertise in the community is low, particularly for dietetics (50%) and diabetes specialist nursing (7%). Rural doctors are significantly more likely to report providing care to patients with type 1 and 2 diabetes. Irish general practitioners report providing a substantial amount of care, particularly for patients with type 2 diabetes, but this is largely unstructured. Significant investment is needed to ensure uniformly structured care in this setting.

Syphilis Management in St. Petersburg, Russia: 1995–2001

OBJECTIVES

The objectives of this study were to describe the recent syphilis epidemic in St. Petersburg, Russia; and to document the syphilis management practices in Russia to help inform the best way forward for a system in transition.

DESIGN

This study was a retrospective cohort study of syphilis diagnosed and followed in St. Petersburg, 1995-2001.

RESULTS

A total of 1,024 persons were identified with syphilis. Persons treated for secondary syphilis with 400,000 IU aqueous penicillin intramuscularly every 3 hours for 28 days or 2.4 micro benzathine penicillin intramuscularly weekly for 2 weeks responded most rapidly. Persons treated with 1.5 micro bicillin-5 intramuscularly at diagnosis and then two times per week for 3 weeks or 2.4 micro bicillin-1 intramuscularly weekly for 3 weeks displayed sluggish responses (P<0.0001). Regimens for treating later stages revealed similar responses (P=0.21). Benzathine penicillin at a dosage of 2.4 micro intramuscularly weekly for 3 weeks was not a used regimen.

CONCLUSION

Benzathine penicillin at a dosage of 2.4 mu intramuscularly weekly for 1 to 2 weeks is in moderate use but its use should increase; 2.4 mu benzathine penicillin intramuscularly weekly for 3 weeks should be introduced as the standard of care for late syphilis. The efficacy of the locally manufactured bicillin-1 and bicillin-5 is in question.