Key informants perspectives on creating a high impact research department in family and community medicine: a qualitative project

BACKGROUND

Primary care is integral to the health system and population health. Primary care research is still in development and most academic departments lack effective research investments. High impact primary care research programs are needed to advance the field to ensure a robust primary care system for the future. The project objective was to understand key informants' views of structures, functions, and processes required to create a high impact research program in an academic primary care department.

METHODS

A descriptive qualitative project with key informants from research programs in primary care. Participants included international research leaders in primary care (n = 10), department of family and community researchers (n = 37) and staff (n = 9) in an academic primary care department, other university leaders (n = 3) and members of the departmental executive leadership team (1 department; 25 members). Semi-structured interviews (n = 27), and focus groups (n = 6) were audio recorded, transcribed, and analyzed using thematic analysis. We used a socioecological framework which described micro, meso, macro levels of influence.

RESULTS

At the micro level despite barriers with respect to funding, protected time and lack of formal mentorship, personal motivation was a key factor. At the meso level, the organizational structure that promoted collaboration and a sense of connection emerged as a key factor. Specifically research leaders identified a research faculty development pipeline based on equity, diversity, inclusion, indigeneity, and accessibility principles with thematic areas of focus as key enablers. Lastly, at the macro level, an overarching culture and policies that promoted funding and primary care research was associated with high impact programs.

CONCLUSION

The alignment/complementarity of micro, meso, and macro level factors influenced the creation of a high impact research department in primary care. High impact research in primary care is facilitated by the development of researchers through formalized and structured mentorship/sponsorship and a department culture that promote primary care research.

In Support of Community Drug Checking Programs: Position Statement of AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction)

BACKGROUND

Position statements clarify key issues that are in alignment with the vision, mission, and values of the AMERSA, Inc. (Association for Multidisciplinary Education and Research in Substance use and Addiction). This Position Statement, endorsed by the AMERSA Board of Directors on October 3, 2023, amplifies the position of the organization, guides their activities, and informs the public and policymakers on the organization's stance on this issue.

ISSUE

The unregulated drug supply in the United States evolves constantly, leaving those who use drugs potentially unaware of new adulterants in their drugs. Not knowing that information can leave people vulnerable to serious adverse events such as fatal overdoses, wounds, and other health consequences. Without real-time data on the composition of drugs available in a community, healthcare providers and public health practitioners are left with insufficient data, making it increasingly difficult to know how to best serve people who use drugs. In this context, community-based drug checking has become recognized as an important harm reduction strategy with the potential to provide those who use drugs with more information about their supply.

RECOMMENDATIONS

It is imperative to expand funding and increase access to drug checking programs in communities across the United States. Key policy changes, such as those related to decriminalizing drug and drug paraphernalia possession, are needed to increase the utilization of drug checking programs. Protection of persons who use drugs through harm reduction strategies, including drug checking programs needs to be widely available and accessible.

[Issues and challenges of primary care medicine: The Northern Vaud Project]

On the face of challenges, particularly related to population aging, increasing complexity of medicine, demographic changes, and uneven geographical distribution of general practitioners (GPs), the healthcare system needs to be reimagined to ensure and maintain efficient care and address the chronic burden on emergency services. A concept of integrated community-based continuity of care, aimed at training future GPs, is one of the solutions proposed by the Northern Vaud Hospital Institutions. This project contributes to strengthening the interface and transition between the hospital and community medicine. Through numerous external mandates, it creates synergies with various socio-healthcare stakeholders in the Northern Vaud region.

Improving the Quality of Residency Programs in Family and Community Medicine

OBJECTIVE

To develop and present an instrument to evaluate and monitor the quality of medical residency programs in residencies in family and community medicine (FCM) based on preceptors and residents, considering the insertion of the health network program.

METHOD

The instrument was developed in three stages: 1) interview with the preceptors of FCM; 2) literature review; and 3) production, adequacy, and approval of the evaluation instrument by renowned professionals of the Brazilian FCM. The third stage included 9 people and used the Delphi technique with 80% agreement. For the qualitative results, Bardin's Content Analysis was used.

RESULTS

In all, there were five evaluation cycles to adapt the proposed recommendations, with the elimination of one item and weighting, with a results analysis methodology of 10 resulting items, reaching an expected matrix for organizing residency programs in the health network, divided into 3 domains: Organization of the Unit, Human Resources, and Preceptor-resident relationship.

CONCLUSION

An instrument for evaluating and monitoring residency programs in family and community medicine can be a tool to facilitate program managers and allow evaluation and monitoring, continuously qualifying them.

Assessment of dynapenia and undernutrition in primary care, a systematic screening study in community medicine

Screening for sarcopenia is a growing public health issue since associated with functional alterations and an increase in morbidity and mortality.

OBJECTIVE

To analyze the prevalence of decreased muscle strength (dynapenia) in patients aged 18 to 74 in community medicine, as measured in the general practitioner's office, and to assess the prevalence of undernutrition in this population.

METHOD

Muscle strength was measured with a Hand Grip (HG) dynamometer according to European recommended thresholds and French guidelines. Malnutrition was defined according to the GLIM criteria.

RESULTS

Of 341 patients, 303 were evaluated (89%): mean age was 47.8 ± 17.4 years, including 51.2% women, 103 with an acute disease (AD) and 200 with a chronic disease (CD). 23.5% were below the 10th percentile threshold in the CD group and 19.4% in the AD group. For these patients, muscle age, evaluated on the median values for age, was higher by 39.3 ± 15.2 years for men and by 41.5 ± 13.6 years for women. Maximum HG values were significantly correlated with changes in International Physical Activity Questionnaire (IPAQ) score (F = 10.22; p = 0.0017) and weight changes (%) (F = 5.30; p = 0.0227) in women only, regardless of age, BMI, disease, professional status or type of work (manual or not); 19.1% suffered from malnutrition (10.9% Stage 1 and 8.3% Stage 2), with 20.0% in the CD group and 17.4% in the AD group.

CONCLUSION

This study highlights the feasibility of screening for sarcopenia in primary care community medicine. The prevalence of dynapenia in the studied population (nearly one in 5 patients) and the observed higher-than-expected undernutrition (17.5%) justify their screening for appropriate management care.

CLINICAL TRIAL REGISTRATION

NCT04451694; referred to as "observational research", "non-interventional", or « non-RIPH ».

The framework for modern community medicine in Japan

Along with the transition to depopulation and an aging society in Japan, the modification of community medicine and its related systems is required. With this in mind, the Japanese government has recently advocated two major plans: 'Community Healthcare Vision' and 'Community-based Integrated Care System'. This paper proposes a theoretical framework to understand modern community medicine based on the ongoing government plans. The key viewpoints consisting of the framework are 'community and/or region', 'care systematization,' and 'coworking with residents (citizens)'. This is expected to be useful for capturing and monitoring the whole picture of modern community medicine in Japan. Such modeling might aid in the future development of medicine and medical science, as in other developed countries.

Factors associated with the attraction and retention of family and community medicine and nursing residents in rural settings: a qualitative study

BACKGROUND

The current shortage of primary care doctors and nurses is causing difficulties in replacement, and this shortage is expected to increase. This situation is more pronounced in rural environments than in urban ones. Family and community care specialty training is a key component of both the transition to clinical practice and the retention of new professionals. The aim of this study is to explore the attitudes and perceptions of internal medicine residents and internal nurse residents trained in a rural teaching unit on factors associated with recruitment and retention, including the role of the specialty training programme.

METHODS

A qualitative study was conducted. Purposive sampling was used, and thirteen residents from the central Catalonia teaching unit who were in their final year of training participated in semistructured interviews. The data were collected during 2022 and were subsequently analysed with thematic analysis. The study is reported using the COREQ checklist.

RESULTS

Six themes emerged from data related to perceptions and attitudes about the factors associated with recruitment and retention: training programme, characteristics of the family and community specialty, concept of rural life, family and relational factors, economic and resource factors, and recruitment and job opportunities.

CONCLUSIONS

Family and community medicine and nursing residents trained in rural settings expressed satisfaction with the specialty programme and most features of primary care, but they experienced a wide range of uncertainties in deciding on their professional future in terms of living in rural areas, family support, financial support and recruitment. This study identifies individual and structural factors that could be of great use to retain doctors and nurses in rural areas.

Understanding the need for developing a structured competency-based curriculum for health policy and programs among community medicine postgraduates: A grounded theory approach

Introduction

Many plans and policy changes about health outcomes have evolved, but none of them have ever given a definite shape to the postgraduate (PG) curriculum so as to make it more intensive and integrative, which needs to be so structured and tailored that it is more patient, community centric, and less knowledge based.

Objectives

The objective of this study was to identify the gap in existing curriculum in learning of health policy and program among PGs of community medicine and recommend a structured model for the same.

Materials and Methods

A qualitative study (grounded theory approach) with all PGs of community medicine in one teaching institute in South India (8 PG students) was taken up.

Results

PGs felt that they never had any day-to-day update. They wanted to understand the working pattern and ground reality of policy and program which was unavailable to them. People who came to postgraduation after being medical officers felt that the monitoring and evaluation done by inexperienced MD Community Medicine students was never accepted by state public health because they did not understand the implementation problems and so could not rightly critically evaluate the programmatic challenges.

Conclusion

With the shift in medical education patterns and expectations of residents, it becomes important to justify the need of developing a structured based curriculum, more so for policy and programs, which will make them capable enough by polishing their managerial and financial skill set. The evaluation technique should focus more on practical aspects on field instead of their theory examination.

Knowledge about Chagas Disease among Family and Community Medicine Residents in a Non-Endemic Region: A Cross-Sectional Study

Chagas disease (CD) is a parasitic disease endemic to continental Latin America that has globalized in recent years. The most relevant mechanisms of transmission of CD in non-endemic countries are transfusion with infected blood and mother-to-child transmission. There is limited information regarding practicing physicians' knowledge of CD transmission, clinical presentation, and treatment in non-endemic countries, including Spain. Our objective was to analyze the level of knowledge about CD in family and community medicine residents and how it has evolved over the last 5 years. A cross-sectional study was performed in the framework of the training program for family and community medicine specialists in Alicante, Spain. Convenience sampling was used to enroll 214 fourth-year family and community medicine residents from 2016 to 2020. Participants completed the validated Chagas Level of Knowledge Scale questionnaire prior to attending the seminar "Health Care for the Immigrant Population." The mean score on the scale was 7.1/10 points. Only 12 participants (5.6%) answered all questions correctly. Resident physicians who reported having received prior information on CD scored better than those who were not informed (mean, 7.2 versus 6.1 points). Participants from Latin America had scores similar to those of the rest of the participants. Over the 5-year study period, questionnaire scores tended to increase. Knowledge about CD among family and community medicine residents has improved in recent years, although it is still not optimal. Specific training on CD during specialized health care training is warranted.

Executive summary - Diagnosis, treatment and prophylaxis of influenza virus infection - Consensus statement of the Spanish Society of Infectious Diseases and Clinical Microbiology (SEIMC), the Spanish Society of Pediatric Infectious Diseases (SEIP), the Spanish Association of Vaccinology (AEV), the Spanish Society of Family and Community Medicine (SEMFYC) and the Spanish Society of Preventive Medicine, Public Health and Health Management (SEMPSPGS)

The influenza virus has accompanied humans since time immemorial, in the form of annual epidemics and occasional pandemics. It is a respiratory infection with multiple repercussions on people's lives at an individual and social level, as well as representing a significant burden on the health system. This Consensus Document arises from the collaboration of various Spanish scientific societies involved in influenza virus infection. The conclusions drawn are based on the highest quality evidence available in the scientific literature and, failing that, on the opinion of the experts convened. The Consensus Document addresses the clinical, microbiological, therapeutic, and preventive aspects (with respect to the prevention of transmission and in relation to vaccination) of influenza, for both adult and pediatric populations. This Consensus Document aims to help facilitate the clinical, microbiological, and preventive approach to influenza virus infection and, consequently, to reduce its important consequences on the morbidity and mortality of the population.

Is it possible for drug shops to abide by the formal rules? The structural determinants of community medicine sales in Uganda

The medicines retail sector is an essential element of many health systems in Africa and Asia, but it is also well known for poor practice. In the literature, it is recognised that improvements in the sector can only be made if more effective forms of governance and regulation can be identified. Recent debate suggests that interventions responsive to structural constraints that shape and underpin poor practice is a useful way forward. This paper presents data from a mixed-methods study conducted to explore regulation and the professional, economic and social constraints that shape rule breaking among drug shops in one district in Uganda. Our findings show that regulatory systems are undermined by frequent informal payments, and that although drug shops are often run by qualified staff, many are unlicensed and sell medicines beyond their legal permits. Most shops have either a small profit or a loss and rely on family and friends for additional resources as they compete in a highly saturated market. We argue that in the current context, drug shop vendors are survivalist entrepreneurs operating in a market in which it is extremely difficult to abide by policy, remain profitable and provide a service to the community. Structural changes in the medicines market, including removing unqualified sellers and making adjustments to policy are likely prerequisite if drug shops are to become places where individuals can earn a living, abide by the rules and facilitate access to medicines for people living in some of the world's poorest countries.

Initier la PrEP en médecine de ville et envisager la santé sexuelle des personnes en situation de migration

In June 2020, 32,000 people began HIV Pre-exposure prohylaxis (PrEP) in France. The objective of this work is to propose PrEP for migrants in city medical offices in collaboration with hospitals. This is happening in the Goutte d’Or neighborhood of Paris where one-third of the inhabitants were born abroad [1]. The Goutte d’Or multidisciplinary and multi-site health center (MSP), composed of independent health professionals, hosted this study.The obstacles to overcome are multifold, notably talking about sexuality and presenting a prevention method that is little known to people in migratory situations. In addition, the first prescription of ARVs in this period had to be given by a hospital doctor (until June 1st 2021) [2].The working hypothesis is that general practitioners can overcome these obstacles within the framework of a protocol defining the discussions on sexuality and the organization of a PrEP consultation along with the GP and a hospital doctor within the city doctor’s office.The study took place between March 1st 2018 and October 31st 2020. 180 questionnaires concerning opportunities for PrEP were distributed by general practitioners (GP) and a midwife from the MSP. 43 people were identified as qualifying for the PrEP. 24 PrEP were prescribed, 23 continuously, and one on demand. A semi-directive interview on sexual health was proposed to the 43 people identified for PrEP consultations.The in-depth interviews confirmed that although sexual health may not be the primary interest of the consultants, there are nevertheless real needs that are not often taken into account.

[Referral criteria to clinical genetics from primary care: Consensus document]

INTRODUCTION

Primary care (PC) is the first contact between the patient and the doctor, so it is essential to be clear about the criteria for suspecting a genetic disease and where it should be referred for study.

MATERIAL AND METHODS

Four scientific societies: the Spanish Society of Family and Community Medicine (semFYC), the Spanish Association of Human Genetics (AEGH), the Spanish Association of Pediatrics (AEP) and the Spanish Society of Medical Oncology (SEOM), have reviewed the criteria for referral to the clinical genetics services of the different published guidelines with the purpose of define the recommendations for PC.

CONCLUSIONS

With this consensus document, the PC doctor and pediatrician will know when, how and where to refer their patients with hereditary and/or genetic pathology to clinical genetics services.

Entrustable professional activities for Junior Brazilian Medical Students in community medicine

BACKGROUND

Entrustable professional activities (EPAs) have been defined to promote the workplace participation of undergraduate medical students, generally in the context of high-income countries with a focus on the secondary and tertiary health care sectors. These EPAs have limited applicability to training and health care contexts in low- to middle-income countries that have a focus on primary health care, for instance, the context of community medicine. The purpose of this article is to report the process and results of defining EPAs for undergraduate medical training in a community health care setting.

METHODS

A modified Delphi study was performed to develop EPAs for the training of medical students in community medicine during their first and second years of education at the Marília Medical School (FAMEMA), Brazil. The supervision level was operationalized in terms of a student's ability to perform the EPA autonomously in an effective and safe manner with supervision readily available on request. Panellists (9 physicians and 6 nurses) rated the completeness of the proposed list of EPAs and EPA categories on four-point Likert scales. The threshold for consensus among panellists was a mean content validity index of at least 80%.

RESULTS

Consensus was reached after two Delphi rounds, resulting in 11 EPAs for undergraduate medical education and training in community medicine. These EPAs were organized into three overarching EPA domains: integrality of care for individual health needs in all phases of the life cycle (5 EPAs), integrality of care for family health needs (3 EPAs), and integrality of care for community health needs (3 EPAs). For each EPA, descriptions of the following categories were created: title; specifications and limitations; conditions and implications of the entrustment decision; knowledge, skills, and attitudes; links to competencies; and assessment sources.

CONCLUSION

The resulting 11 EPAs for training medical students in community medicine expand the application of the EPA framework to both early undergraduate medical education and the context of primary health care. This report can support and guide other medical schools in their attempts to train students in primary health care contexts and to incorporate EPAs into their curricula.

Perceptions on COVID-19 Vaccination among People Aged more than 50 years in Urban Field Practice Area of Department of Community Medicine in a Tertiary Care Teaching Hospital, Hyderabad: A Reflection from Focus Group Discussions

BACKGROUND

Despite several efforts to limit the viral transmission, the COVID-19 vaccine has been the only "the ray of hope" to end the pandemic. However, vaccine hesitancy could reduce coverage and hinder herd immunity. People's intention to get vaccinated can be shaped by several factors, including risk perception which, in turn, is influenced by effect. The need to acquaint oneself to the beliefs, concerns, and circumstances of one's own population in the community becomes important for successful implementation of the program. Therefore, the present study was conducted to gain insights into perceptions of vaccination.

OBJECTIVES

The objective is to understand the felicitating factors and hindering factors for acceptance of vaccines by the population among people aged 50 years in urban field practice area of the Department of Community Medicine in a Tertiary care teaching hospital, Hyderabad.

SUBJECTS AND METHODS

Data were extracted from audio recording of five focus group discussions that were conducted in the urban field practice care of a tertiary care teaching hospital in Hyderabad through open-ended questions. Categories, subcategories, and themes were created by deductive approach.

RESULTS

The motivating factors for vaccine acceptance were found to be fear of getting disease, wanting to return normalcy, and trust in treating doctors, whereas, barriers were fear of death due to vaccine, opacity in vaccine details, anxiety, and misinterpretation of adverse events.

CONCLUSION

Having a clear understanding about the belief system of the target population could help in designing the guidelines for vaccination program to escalate the immunization and increase the acceptance.

A retrospective review of the community medicine needs from osteoporosis services in Canada

BACKGROUND

Comprehensive, real-world osteoporosis care has many facets not explicitly addressed in practice guidelines. We sought to determine the areas of knowledge and practice needs in osteoporosis medicine for the purpose of developing an osteoporosis curriculum for specialist trainees and knowledge translation tools for primary care.

METHODS

This was a retrospective review of referral questions received from primary care and specialists to an academic, multi-disciplinary tertiary osteoporosis and metabolic bone clinic. There were 400 referrals in each of 5 years (2015-2019) selected randomly for review. The primary referral question was elucidated and assigned to one of 16 pre-determined referral topics reflecting questions in the care of osteoporosis and metabolic bone patients. The top 7 referral topics by frequency were determined while recording the referral source.

RESULTS

The majority of referrals (71%) came from urban primary care. The most common specialists to request care included rheumatology, oncology, gastroenterology and orthopedic surgery (fracture liaison services). Primary care referrals predominantly requested assistance with routine osteoporosis assessments, bisphosphonate holidays, bisphosphonate adverse effects/alternatives, fractures occurring despite therapy and adverse changes on bone densitometry despite treatment. Specialists most often referred patients with complex secondary bone diseases or cancer. The main study limitation was that knowledge needs of referring physicians were inferred from the referral question rather than tested directly.

CONCLUSION

By assessing actual community demand for services, this study identified several such topics that may be useful targets to develop high quality knowledge translation tools and curriculum design in programs training specialists in osteoporosis care.

Medical training programs: comparisons between family and community medicine, internal medicine, intensive care medicine, anesthesiology and critical care, and emergency medicine

OBJECTIVES

To analyze whether current medical residency training programs in Spain foster the acquisition of knowledge and skills that enable specialists to provide emergency and urgent medical care.

MATERIAL AND METHODS

We studied documents related to the content of residency programs for the following 4 specialties in effect in June 2021: internal medicine, intensive care medicine, anesthesiology and critical care, and family and community medicine. Program descriptions were obtained from the website of the Spanish Ministry of Health and the professional associations for each specialty. The associations' unofficial drafts and proposed updates were also studied. For emergency and urgent medicine, we studied drafts and updates of proposals presented to the Ministry of Health by the Spanish Society of Emergency Medicine (SEMES) in 2010 and an updated version presented in 2021. The proposals were drafted by the SEMES committee to promote specialization in emergency medicine.

RESULTS

Existing residency programs treat the management of urgent events from diverse points of view related to hospital settings (internal medicine focusing on admitted patients, anesthesiology on patients in perioperative settings, and intensive care on those in their specialized units) or to primary care centers (family medicine), where they are an extension of routine care. The residents' rotations in emergency medicine vary. In anesthesiology, intensive care medicine, and family medicine, training occurs while residents are on call - in the first year for trainees in anesthesiology and intensive care medicine but throughout the 4-year residency (with time decreasing each year) for trainees in family medicine. Internal medicine offers an initial 3-month rotation in emergency medicine in the early phase and then assigns on-call shifts, without specifying a number. The proposed program submitted by SEMES includes wide-ranging contact with emergencies in various hospital settings (observation ward, trauma care, and pediatric care). Training in out-of-hospital emergencies and emergency and urgent care resource coordination centers are also included.

CONCLUSION

Currently available residency training in Spain does not provide appropriate preparation for practicing emergency medicine. Emergency medicine has its own body of theory and settings for practice that differ from those of other specialties. Therefore, at present there is a training gap in Spain that should be filled by creating a specialization in emergency medicine.

[Elements influencing the election of Family and Community Medicine]

AIM

To analyze the perceptions, motives and reasons that influence the election of Family and Community Medicine (FCM) speciality, thus exploring possible proposals for change in the health system model and university training.

DESIGN

Descriptive-interpretative qualitative research from a socio-constructivist perspective.

EMPLACEMENT

Medical speciality training departments in the Metropolitan Area of Barcelona.

PARTICIPANTS AND CONTEXT

55 first year junior doctors belonging to the FCM Barcelona Ciutat ICS training department were contacted; 25 agreed to participate. They were segmented into two groups depending on if the choice of FCM had been their first option or not. Through snowball sampling 11 more junior doctors from other specialities were recruited.

METHOD

Three focus groups were formed: (a) first choice FCM, (b) not first choice FCM and (c) other specialities. Semi-structured 2-h long interviews took place with each of the groups. Literal transcription and inductive codification with a first triangulation within each group and a second one between the three of them and thematic content analyses.

RESULTS

The choice of speciality is lived as an academic milestone and is thought determining professional and personally. It is a complex weave of influencing elements but some of main factors were university training, health system model, professional prospects and the social appreciation of the speciality. Analyzing the relation between these elements puts light on a phenomena we have called "the discredit of Primary Care (PC)".

CONCLUSION

The FCM specialty will not be attractive in a hospital-centric health and training system that does not bet on PC organizationally or economically.

Community Medicine (revised and corrected)]

A "la Scienza e l'Arte di prevenire le malattie, di prolungare la vita e di promuovere la salute attraverso gli sforzi organizzati della società" sono stati attribuiti molti nomi, variamente associati tra loro: Sanità pubblica, termine onnicomprensivo della multidisciplinarietà della materia, ma anche Igiene, Medicina preventiva, Medicina sociale, Medicina di comunità a seconda del prevalente campo di attività messo in atto. L'inserimento della dimensione comunitaria nella teoria e nella pratica della Medicina richiede però la definizione di comunità, il coinvolgimento nell'azione di tutela della salute (promozione, conservazione e recupero), la localizzazione territoriale (dove la gente vive e lavora), la disponibilità di risorse finalizzate e così via. Una esigenza quanto mai necessaria specialmente ora che l'ormai "mitico" Recovery Plan - ovvero Piano Nazionale di Ripresa e Resilienza (PNRR) - cita ripetutamente la"Comunità" facendone un elemento di rilievo dell'azione progettuale. Uno degli interventi previsti è infatti la realizzazione entro il 2026 di 1.288 Case della Comunità. Queste sono ideate come strutture sanitarie, promotrici di un modello di intervento multidisciplinare, nonché luoghi privilegiati per la progettazione di interventi di carattere sociale e di integrazione sociosanitaria esprimendo una nuova modalità di presa in carico delle persone e delle comunità per prevenire le malattie, prolungare la vita e promuovere la salute. Ne consegue che la sede della Casa della Comunità deve essere visibile e facilmente accessibile per la comunità di riferimento (struttura di prossimità) perché è il luogo dove il cittadino può trovare una risposta adeguata alle più diverse esigenze sanitarie o sociosanitarie. La soluzione organizzativa raccomandata (in informatica "hub & spoke") prevede un elemento centrale di una rete per le cure primarie e per i supporti sociali e assistenziali, proponendosi come luogo di offerta, ma contestualmente come luogo di relazione e di attenzione a tutte le dimensioni di vita della persona e della comunità.

Comparison of the Effectiveness of an Abbreviated Program versus a Standard Program in Mindfulness, Self-Compassion and Self-Perceived Empathy in Tutors and Resident Intern Specialists of Family and Community Medicine and Nursing in Spain

Health professionals are among the most vulnerable to work stress and emotional exhaustion problems. These health professionals include tutors and resident intern specialists, due to the growing demand for the former and the high work overload of the latter. Mindfulness training programs can support these professionals during times of crisis, such as the current global pandemic caused by the coronavirus-19 disease. The objective of this study was to compare the effectiveness of an abbreviated Mindfulness-Based Stress Reduction (MBSR) and Mindful Self-Compassion (MSC) training program in relation to a standard training program on the levels of mindfulness, self-compassion, and self-perceived empathy in tutors and resident intern specialists of Family and Community Medicine and Nursing. A total of 112 professionals attached to six Spanish National Health System teaching units (TUs) participated in this randomized and controlled clinical trial. Experimental Group (GE) participants were included in the standard or abbreviated MBSR programs. The Five Facet Mindfulness Questionnaire (FFMQ), the Self-Compassion Scale short form (SCS-SF), and the Jefferson Scale of Physician Empathy (JSPE) were administered three times during the study: before, immediately after, and 3 months after the intervention. Adjusted covariance analysis (ANCOVA), using pretest scores as the covariate, showed a significant increase in mindfulness (F(2,91) = 3.271; p = 0.042; η2 = 0.067) and self-compassion (F(2,91) = 6.046; p = 0.003; η2 = 0.117) in the post-test visit, and in self-compassion (F(2,79) = 3.880; p = 0.025; η2 = 0.089) in the follow-up visit, attributable to the implementation of the standard training program. The standard MBSR and MSC training program improves levels of mindfulness and self-compassion, and promotes long-lasting effects in tutors and resident intern specialists. New studies are needed to demonstrate the effectiveness of abbreviated training programs.

Professor Mohamed Soussi Soltani: Leader, Innovator and Researcher in Public Health

Mohamed Soussi SOLTANI (June 27, 1953 - March 2, 2016) is Professor of Preventive and Community Medicine at the Faculty of Medicine of Monastir (Tunisia). The objective of this paper is to present, to new generations of the specialty in the Greater Maghreb, this leading teacher from the Center-East of Tunisia (Monastir), through the testimonies of his companions, and his indexed publications. All the colleagues of the late SOLTANI testified to his high human and professional qualities, particularly perseverance, commitment, forward thinking, integrity and professionalism. The scientific life of the late Professor Soltani was oriented towards two major themes: Public Health and Family Medicine. Indeed, the deceased has developed several new preventive activities in first-line structures such as anonymous and free HIV screening, family planning, rational use of drugs, breast cancer screening, smoking cessation, prevention of rheumatic heart disease. Pr SOLTANI welcomed general practitioners from the Monastir region to the Faculty's Community Medicine Department, creating with them a movement to advocate for the academic and professional development of general medicine into an authentic specialty of family medicine. Out of the 34 publications of Professor SOLTANI, indexed on PubMed, 11 were signed by himself in first position, mainly relating to maternal health (prenatal surveillance, education for maternal health, pregnancy referral system) and infant (low birth weight, vaccination, mother-to-child transmission of hepatitis B, meningitis due to Haemophilus influenzae). Thus, with a life prospering by innovations and research in public health, Professor SOLTANI will always remain a model for young people in the specialty of Preventive and Community Medicine. His followers have an obligation to write his complete biography, to safeguard it and pass it on to new generations of public health.

The linkage between medical student readiness for interprofessional learning and interest in community medicine

OBJECTIVES

The purpose of this study is to investigate the relationship between medical student readiness for interprofessional learning and interest in community medicine prior to incorporating community-oriented interprofessional education into the curriculum.

METHODS

A questionnaire was administered to students at Nagasaki University School of Medicine in Japan during each of three consecutive years (N=2244). The Readiness for Interprofessional Learning Scale (RIPLS) was administered in addition to a questionnaire to evaluate interest in community medicine. The Kruskal-Wallis and Steel-Dwass tests were used to determine differences between school years. Correlation between the RIPLS score and interest in community medicine was evaluated with Spearman's rank correlation coefficient. Relationships between RIPLS score and demographic parameters, and interest in community medicine were evaluated with multiple linear regression analysis.

RESULTS

Eighty-four percent (1891/2244) of students responded. The RIPLS score was highest in school year 1, followed by year 6, year 5, year 3, and years 4 and 2. Interest in community medicine correlated with the RIPLS score (rs = 0.332, p < 0.001), but less in year 1 (rs = 0.125, p = 0.002) than in other years. RIPLS score was significantly associated with gender, age, school year, interest in community medicine, but not the year that the survey was conducted.

CONCLUSIONS

Community-oriented interprofessional education has the potential to improve attitudes towards interprofessional learning. When introducing this promising education into the curriculum from year 1, attracting students' interest in community medicine should be considered.

Acceptance of a homestay program and attitude toward community medicine among medical students

Background

In community-based medical education, opportunities for medical students to interact with local residents are important. To facilitate such interaction, we aimed to evaluate acceptance of a homestay program and attitude toward community medicine among medical students.

Methods

The participants (n = 39) were allowed to stay in the local homes of residents for one night in August 2016, 2017, and 2018. Before and after the homestays, the students responded to a self-reported questionnaire using the visual analog scale (VAS; 0–100 mm). The questionnaire included four questions on homestay/community medical training and community medicine and four questions about attitude toward community medicine in the local areas of medical students. Then, we compared the VAS scores before and after training.

Results

The VAS scores for all questions about homestay/community medical training and community medicine significantly increased: “Is it worthwhile for you to have experience in the field of community medicine,” “Did you find the homestay enjoyable,” “Does the homestay add educational significance to the program,” and “Is direct interaction with residents meaningful?” For the two questions about attitude toward community medicine, the VAS scores significantly increased: “Is there a challenge to practicing community medicine” and “In the future, do you want to work in Tamba area where you stayed?”

Conclusions

The medical students were extremely enthusiastic about the educational program for community medicine involving residential homestays, which improved their attitudes toward practicing community medicine. Moreover, the students appreciated that their training sites could become their future workplaces.

Comparative evaluation of community interventions for the immigrant population of Latin American origin at risk for Chagas disease in the city of Barcelona

Introduction

Chagas disease presents bio-psycho-social and cultural determinants for infected patients, their family members, close friends, and society. For this reason, diagnosis and treatment require an active approach and an integral focus, so that we can prevent the disease from creating stigma and exclusion, as is actively promoting access to diagnosis, medical attention and social integration

Methodology

The study was conducted in the Metropolitan Area of Barcelona (Catalonia, Spain) from 2004 to 2017. After an increased detection rates of CHD in our region, the process of construction of community strategies started (2004–2013). Different community interventions with informational, educational, and communication components were designed, developed, implemented, and evaluated. The results of the evaluation helped to determine which intervention should be prioritized: 1) workshop; 2) community event; 3) in situ screening. Afterwards, those strategies were implemented (2014–2017).

Results

Each of the three strategies resulted in a different level of coverage, or number of people reached. The in situ screening interventions reached the highest coverage (956 persons, 58.98%).Clear differences exist (p-value<0.001) between the three strategies regarding the percentage of screenings and diagnoses carried out. The largest number was in the in situ screening intervention, with a total of 830 persons screened despite the greatest number of diagnoses was among the workshop participants (33 persons, 20.75% of those screened). The prevalence of infection found is similar among the three strategies, ranging from 16.63% to 22.32% of the screened patients (p-value = 0.325).

Conclusions

The results of the study show that community interventions seem to be necessary to improve access to diagnosis and treatment of CHD in the area of Barcelona. They also show which strategy is the most appropriate based on the detected needs of the community, the proposed objectives of the intervention, and the given socio-temporal context.

Right-Site Care Programme with a community-based family medicine clinic in Singapore: secondary data analysis of its impact on mortality and healthcare utilisation

OBJECTIVE

Stable patients with chronic conditions could be appropriately cared for at family medicine clinics (FMC) and discharged from hospital specialist outpatient clinics (SOCs). The Right-Site Care Programme with Frontier FMC emphasised care organised around patients in community rather than hospital-based providers, with one identifiable primary provider. This study evaluated impact of this programme on mortality and healthcare utilisation.

DESIGN

A retrospective study without randomisation using secondary data analysis of patients enrolled in the intervention matched 1:1 with unenrolled patients as controls.

SETTING

Programme was supported by the Ministry of Health in Singapore, a city-state nation in Southeast Asia with 5.6 million population.

PARTICIPANTS

Intervention group comprises patients enrolled from January to December 2014 (n=684) and control patients (n=684) with at least one SOC and no FMC attendance during same period.

INTERVENTIONS

Family physician in Frontier FMC managed patients in consultation with relevant specialist physicians or fully managed patients independently. Care teams in SOCs and FMC used a common electronic medical records system to facilitate care coordination and conducted regular multidisciplinary case conferences.

PRIMARY OUTCOME MEASURES

Deidentified linked healthcare administrative data for time period of January 2011 to December 2017 were extracted. Three-year postenrolment mortality rates and utilisation frequencies and charges for SOC, public primary care centres (polyclinic), emergency department attendances and emergency, non-day surgery inpatient and all-cause admissions were compared.

RESULTS

Intervention patients had lower mortality rate (HR=0.37, p<0.01). Among those with potential of postenrolment polyclinic attendance, intervention patients had lower frequencies (incidence rate ratio (IRR)=0.60, p<0.01) and charges (mean ratio (MR)=0.51, p<0.01). Among those with potential of postenrolment SOC attendance, intervention patients had higher frequencies (IRR=2.06, p<0.01) and charges (MR=1.86, p<0.01).

CONCLUSIONS

Intervention patients had better survival, probably because their chronic conditions were better managed with close monitoring, contributing to higher total outpatient attendance frequencies and charges.

Internal Medicine Residency Program Responses to the Increase of Residency Applications: Differences by Program Type and Characteristics

BACKGROUND

Over the past decade, the number of residency applications has increased substantially, causing many residency programs to change their recruitment practices.

OBJECTIVE

We determined how internal medicine (IM) residency programs have responded to increased applications by program type (community-based, community-based/university-affiliated, and university-based) and characteristics (percentage of international medical graduates, program size, and program director [PD] tenure).

METHODS

The Association of Program Directors in Internal Medicine conducted a national survey of 363 IM PDs in 2017. Five questions assessed IM program responses to the increased number of residency applications in 3 areas: changes in recruitment strategies, impact on ability to perform holistic review, and interest in 5 potential solutions. We performed a subgroup analysis to measure differences by program type and characteristics.

RESULTS

The response rate was 64% (233 of 363). There were no differences by program type or characteristics for experiencing an increase in the number of applicants, altering recruitment practices, or conducting holistic reviews. There were moderate differences in alterations of recruitment practices by program characteristics and moderate differences in interest in proposed solutions by program type. Community-based programs had the greatest interest in a program-specific statement (59%, P = .032) and the lowest percentage in a national database of matched applicants (44%, P = .034).

CONCLUSIONS

IM residency programs are experiencing an increasing number of applications and are accommodating by adjusting recruitment practices in a variety of ways. A majority of IM PDs supported 4 of the 5 solutions, although the level of interest differed by program type.

Analysis of severe adverse effects following community-based ivermectin treatment in the Democratic Republic of Congo

BACKGROUND

The progress of mass, community-directed, treatment with ivermectin (CDTI) for onchocerciasis control was disrupted by severe adverse effects (SAE) in the Democratic Republic of Congo (DRC). The study aimed at determining the frequency of post-CDTI SAE as well as factors associated with the occurrence of SAE.

METHODS

Our retrospective study relied on SAE collection cards, as archived by the DRC Ministry of Health, and compiled for people who benefited from ivermectin treatment then further developed SAE. The study included 945 post-CDTI SAE recorded in DRC between 2003 and 2017. These cases occurred in 15 projects out of 22 projects implemented in the country. All cards were reviewed and analysed.

RESULTS

Between the years 2003 and 2017, the total average population treated was around 15,552,588 among which 945 cases of SAE were registered in DR Congo, i.e. 6 cases of SAE for 100,000 persons treated per year. 55 deaths related to post-CDTI SAE were recorded, which represents 5.8% of all cases of SAE. Non-neurological SAE were dominated by severe headaches (74.8%), myalgia (64.0%) and arthralgia (62.7%). Neurological SAE were mainly coma (94.1%), motor deficit (75.4%) and palpebral subconjunctival haemorrhages (38.8%). Factors associated with the occurrence of SAE were: male, age over 18 years old, alcohol consumption, hemp intake and the presence of loiasis. The study also highlighted weaknesses of the National Program for Onchocerciasis Control (NPOC)  in terms of awareness campaigns among the population.

CONCLUSION

Co-endemicity of loiasis and onchocerciasis is one of the key factors responsible for the occurrence of SAE following ivermectin treatment. Mobilization of resources necessary to the appropriate management of SAE and awareness of populations are essential to achieve onchocerciasis control in DRC.

Community Interventions to Promote Mental Health and Social Equity

PURPOSE OF REVIEW

We review recent community interventions to promote mental health and social equity. We define community interventions as those that involve multi-sector partnerships, emphasize community members as integral to the intervention, and/or deliver services in community settings. We examine literature in seven topic areas: collaborative care, early psychosis, school-based interventions, homelessness, criminal justice, global mental health, and mental health promotion/prevention. We adapt the social-ecological model for health promotion and provide a framework for understanding the actions of community interventions.

RECENT FINDINGS

There are recent examples of effective interventions in each topic area. The majority of interventions focus on individual, family/interpersonal, and program/institutional social-ecological levels, with few intervening on whole communities or involving multiple non-healthcare sectors. Findings from many studies reinforce the interplay among mental health, interpersonal relationships, and social determinants of health. There is evidence for the effectiveness of community interventions for improving mental health and some social outcomes across social-ecological levels. Studies indicate the importance of ongoing resources and training to maintain long-term outcomes, explicit attention to ethics and processes to foster equitable partnerships, and policy reform to support sustainable healthcare-community collaborations.

Controlled clinical trial comparing the effectiveness of a mindfulness and self-compassion 4-session programme versus an 8-session programme to reduce work stress and burnout in family and community medicine physicians and nurses: MINDUUDD study protocol

BACKGROUND

Health personnel are susceptible to high levels of work stress and burnout due to the psychological and emotional demands of their work, as well as to other aspects related to the organisation of that work. This paper describes the rationale and design of the MINDUUDD study, the aim of which is to evaluate the effectiveness of a mindfulness and self-compassion 4-session programme versus the standard 8-session programme to reduce work stress and burnout in Family and Community Medicine and Nursing tutors and residents.

METHODS

The MINDUDD study is a multicentre cluster randomised controlled trial with three parallel arms. Six Teaching Units will be randomised to one of the three study groups: 1) Experimental Group-8 (EG8); 2) Experimental Group-4 (EG4) Control group (CG). At least 132 subjects will participate (66 tutors/66 residents), 44 in the EG8, 44 in the EG4, and 44 in the CG. Interventions will be based on the Mindfulness-Based Stress Reduction (MBSR) program, including some self-compassion practices of the Mindful Self-Compassion (MSC) programme. The EG8 intervention will be implemented during 8 weekly face-to-face sessions of 2.5 h each, while the EG4 intervention will consist of 4 sessions of 2.5 h each. The participants will have to practice at home for 30 min/day in the EG8 and 15 min/day in the EG4. The Five Facet Mindfulness Questionnaire (FFMQ), Self-Compassion Scale (SCS), Perceived Stress Questionnaire (PSQ), Maslach Burnout Inventory (MBI), Jefferson Scale of Physician Empathy (JSPE), and Goldberg Anxiety-Depression Scale (GADS) will be administered. Measurements will be taken at baseline, at the end of the programs, and at three months after completion. The effect of the interventions will be evaluated by bivariate and multivariate analyses (Multiple Linear Regression).

DISCUSSION

If the abbreviated mindfulness programme is at least as effective as the standard program, its incorporation into the curriculum and training plans will be easier and more appropriate. It will also be more easily applied and accepted by primary care professionals because of the reduced resources and means required for its implementation, and it may also extend beyond care settings to academic and teaching environments as well.

TRIAL REGISTRATION

The study has been registered at ClinicalTrials.gov ( NCT03629457 ; date of registration: 13.08.2018).

[ESTABLISHING A REGISTRY FOR INFLAMMATORY BOWEL DISEASE PATIENTS IN MACCABI HEALTHCARE SERVICES - JOINT PROJECT BETWEEN HOSPITALS, EPI-IIRN GROUP AND COMMUNITY MEDICINE]

INTRODUCTION

Inflammatory bowel diseases (IBD) are becoming a significant cause for chronic long term complex morbidity, particularly among adolescents and young adults. IBD patients require multidisciplinary management and considerable health resources. Recent advances and developments in the diagnostics and therapeutic options require identification and tight monitoring of these patients at both hospital and community level for better management and care.

AIMS

To establish at Maccabi Healthcare Services (MHS) a dedicated registry for inflammatory bowel disease patients for long term monitoring in order to optimize care, better use of health resources and to promote high quality research.

METHODS

A national project, initiated and headed by a team from Shaare Zedek Medical Center aimed to resolve the complexity in identifying IBD patients at the community setting. The project included data from all Israeli HMOs and major hospitals, that was incorporated into various algorithms to determine prevalence and incidence and to distinguish between Crohn's disease and ulcerative colitis diagnoses. Eventually, an algorithm that includes the number of diagnoses, number of purchases and duration of IBD-related medications showed the best results for separating those that suffer from IBD and those that do not. This algorithm was further validated by chart review.

RESULTS

According to the established registry criteria there were 14488 IBD patients in MHS, 13000 active. Additionally we have established an ongoing platform for ongoing monitoring of clinical, therapeutic, laboratory and imaging information.

DISCUSSION

Establishing an IBD registry in MHS was enabled by a national project that combined deep professional knowledge of the disease by leading academic centers together with advanced informatics and community large data. We now move on to operate the registry in real life, together with live monitoring of various parameters in order to promote excellent care, communication with patients, management and control and to enable prospective high quality research.

[HADASSAH MEDICAL ORGANIZATION - A PIONEER IN POPULATION HEALTH]

Population health is a term encompassing "the health outcomes of a group of individuals, including the distribution of such outcomes within the group." Only recently have hospitals viewed themselves as focal points for promoting health in a community, involving themselves with population health. Hadassah Medical Organization (HMO), however, has been in the business of population health since its founding. Its early programs, promoting and delivering nutritional support, maternal-child health and other services to the Yishuv's inhabitants, showed that the HMO defined its community broadly. Hospital care came later. The HMO was established together with the Hebrew University Israel's first School of Public Health and Community Medicine in the 1960's, contributing >1200 Israeli alumni, and exposing thousands of medical students to population health. The School's founders developed Community-Oriented Primary Care, aimed at assessing and addressing health determinants and outcomes at the community level implemented in many centers worldwide. Reaching beyond Israel's borders, the School has trained a global public health workforce through its International Masters in Public Health with >820 graduates from 92 countries. HMO's researchers have made important contributions in the fields of epidemiology, health economics and policy and population health methodology as well as hospital and community quality of care. This article reviews HMO's contribution to population health at local, municipal, national and international levels. We will demonstrate the unique circumstances in Hadassah, Jerusalem and Israel which have enabled world-class research and training in population health, identifying important contributions to policy and service provision, as well as addressing future population health challenges.

Community-deliverable exercise and depression in adults with arthritis: Confirmatory evidence of a meta-analysis using the IVhet model

OBJECTIVE

Using the traditional random-effects model, a recently reported standardized effect size (g) reduction of -0.42 (95% CI, -0.58 to -0.27) was observed in depressive symptoms as a result of community-deliverable exercise in adults with arthritis and other rheumatic diseases. However, a recently proposed alternative model (IVhet) has been shown to have superior coverage probability to the random-effects model. The purpose of this brief report was to compare these previous random-effects results with the IVhet model.

METHODS

Based on a previous meta-analysis of 35 g's representing 2449 participants, results for depressive symptoms were pooled using the IVhet model. Influence analysis, number needed-to-treat, percentile improvement, and gross estimates of the number of inactive adults with arthritis who could benefit from exercise were also calculated.

RESULTS

The IVhet model yielded statistically significant reductions in depressive symptoms (g = -0.30, 95% CI, -0.49 to -0.11), a difference that was -0.12 (28.7%) smaller than the random-effects model. With each study deleted from the model once, results remained statistically significant, ranging from -0.28 to -0.34. The percentile improvement, number needed-to-treat, and estimated number of people with arthritis in the United States who could improve their depressive symptoms by participating in a regular exercise program were, respectively, 11.8% (95% CI, 4.5% to 18.8%), 8 (95% CI, 5 to 23), and 2.7 million (95% CI, 1.0 to 4.4 million).

CONCLUSIONS

These findings provide more conservative and accurate evidence that community-deliverable exercise improves depressive symptoms in adults with arthritis and other rheumatic diseases. Future meta-analyses may want to consider using the IVhet versus traditional random-effects model.

The factors influencing long-term outcomes of stenting for malignant colorectal obstruction in elderly group in community medicine

PURPOSE

Malignant bowel obstruction is a complication of colorectal carcinoma or metastasis from other carcinoma, and it causes significant damage on the condition of elderly patients; however, the self-expandable metallic stents (SEMSs) have been effectively used either for palliation or for bridging to the surgical procedure for this condition. The aim of this study was to investigate the factors influencing long-term outcomes of old-aged patients with SEMS for large bowel obstruction to develop the strategy for those patients in the community medicine.

METHODS

We performed a retrospective review of 42 patients with a median age of 83.0 years (range, 65-99 years), who underwent SEMS placement for malignant colorectal obstruction between 2006 and 2015 in our hospital. Univariate and multivariate logistic regressions were performed on data from the patients to assess the factors affecting 6-month survival without stent dysfunction.

RESULTS

The study population comprised 24 females (57.1%) and 18 males (42.9%). Of these, 38 patients (90.5%) received SEMS as palliation, whereas 4 patients (9.5%) underwent subsequent surgery. SEMSs were successfully inserted in 97.6% of patients. The median duration of follow-up was 205.0 days (range, 20-1377 days). On multivariate analysis, shorter stents (< 10 cm) yielded better outcomes than longer stents (≥ 10 cm) (P = 0.041), and the Cox proportional hazard model also indicated that shorter stents (P = 0.036) predicted longer event-free survival.

CONCLUSIONS

Elderly patients with malignant bowel obstruction receiving shorter stents had longer event-free survival after stenting with better general condition.

Expanding HIV testing and linkage to care in southwestern Uganda with community health extension workers

INTRODUCTION

Achieving the UNAIDS goals of 90-90-90 will require more than doubling the number of people accessing HIV care in Uganda. Community-based programmes for entry into HIV care are effective strategies to expand access to HIV care, but few programmes have been evaluated with a particular focus on scale-up.

METHODS

Integrated Community Based Initiatives, a Uganda-based non-governmental organization, designed and implemented a programme of community-based HIV counselling and testing and facilitated linkage to care utilizing community health extension workers (CHEWs) in rural Sheema District, Uganda. CHEWs performed programme activities during 1 October 2015 through 31 March 2016. Outcomes for this evaluation were (1) the number of people tested for HIV, and (2) the proportion of those testing positive who were seen at an ART clinic within three months of their positive test, and (3) the cost of the programme per person newly diagnosed with HIV. Microcosting methods were used to calculate the programme costs. Program scalability factors were evaluated using a published framework.

RESULTS

Sixty-two CHEWs attended a five-day training that introduced the biology of HIV, the conduct of confidential HIV testing, HIV prevention messages, and linkage, referral, and reporting requirements. CHEWs received a $30 monthly stipend and a field testing kit that included a bicycle, field bag, umbrella, gumboots, reporting booklet, pens, and HIV testing materials. Trained CHEWs tested 43,696 persons for HIV infection during the six-month programme period. Nine-hundred seventy-four participants (2.2%) were identified as HIV positive, and 623 participants (64%) were linked to HIV care. An estimated 69% of adult residents received testing as part of this campaign. The programme cost $3.02 per person test, $135.70 per positive person identified, and $212.15 per HIV-positive person linked to care.

CONCLUSIONS

Lay community health extension workers (CHEWs) can be rapidly trained to scale-up home-based HIV testing and counselling (HTC) and linkage to care in a high-quality and low-cost manner to large numbers of people in a rural, high burden setting. A combination HIV testing approach, such as adding partner testing to community-based testing, could increase the proportion of HIV-positive persons identified.

Association between Weight Change and Mortality in Community Living Older People Followed for Up to 14 Years. The Hordaland Health Study (HUSK)

OBJECTIVES

To study the importance of weight change with regard to mortality in older people.

DESIGN

Prospective cohort study.

PARTICIPANTS

The cohort includes participants in the Hordaland Health Study, Norway, 1997-99 (N=2935, age 71-74 years) who had previously participated in a survey in 1992-93.

MEASUREMENTS

Participants with weight measured at both surveys were followed for mortality through 2012. Cox proportional hazards models were used to calculate risk of death according to changes in weight. Hazard ratios (HR) with 95% confidence intervals (CIs) for people with stable weight (± <5% weight change) were compared to people who lost (≥5%) or gained (≥5%) weight. Cox regression with penalized spline was used to evaluate the association between weight change (in kg) and mortality. Analyses were adjusted for age, sex, physical activity, smoking, diabetes, hypertension, and previous myocardial infarction or stroke. Participants with cancer were excluded.

RESULTS

Compared to those with stable weight, participants who lost ≥5% weight had an increased mortality risk (HR 1.59 [95% CI: 1.35-1.89]) while the group with weight gain ≥5% did not (HR 1.07 [95% CI 0.90-1.28]). Penalized spline identified those who lost more than about three kg or gained more than about 12 kg as having increased risk of death.

CONCLUSION

Even a minor weight loss of ≥5% or >3 kg were significantly associated with increased risk of mortality. Thus, weight should be routinely measured in older adults.

Carotid Atherosclerosis, Cerebrospinal Fluid Pressure, and Retinal Vessel Diameters: The Asymptomatic Polyvascular Abnormalities in Community Study

Purpose

To assess relationships between carotid artery atherosclerosis and retinal arteriolar and venular diameters.

Methods

The community-based longitudinal Asymptomatic Polyvascular Abnormalities Community Study (APAC) included a sub-population of the Kailuan study which consisted of 101,510 employees and retirees of a coal mining industry. Based on the Chinese National Census 2010 and excluding individuals with history of cerebrovascular ischemic events, 4004 individuals were included into the APAC. All participants underwent a detailed clinical examination including blood laboratory tests and carotid artery duplex ultrasound examination. The cerebrospinal fluid pressure (CSFP) was estimated using the formula: CSFP[mmHg] = 0.44xBody Mass Index[kg/m²]+0.16xDiastolic Blood Pressure[mmHg]–0.18 x Age[Years]–1.91.

Results

In multivariable analysis (goodness of fit r²:0.12), thicker retinal arteries were associated with a thinner common carotid artery intima-media thickness (IMT) (P = 0.002; standardized regression coefficient beta:-0.06; non-standardized regression coefficient B:-6.92;95% confidence interval (CI):-11.2,-2.61) after adjusting for thicker retinal nerve fiber layer (P<0.001;beta:0.18;B:0.35;95%CI:0.28,0.42), lower diastolic blood pressure (P<0.001;beta:-0.16;B:-0.17;95%CI:-0.21,-0.3), younger age (P<0.001;beta:-0.08; B:-0.16;95%;CI:-0.25,-0.08), and less abdominal circumference (P = 0.003;beta:-0.06;B:-0.11;95%CI:-0.18,-0.03). Thicker retinal vein diameter was associated (r = 0.40) with higher estimated CSFP (P<0.001;beta:0.09;B:0.78;95%CI:0.47,1.08) after adjusting for wider retinal arteries (P<0.001;beta:0.27;B:0.36;95%CI:0.31,0.41), thicker retinal nerve fiber layer thickness (P = 0.03;beta:0.22;B:0.56;95%CI:0.46,0.65) and male gender (P<0.001;beta:-0.08;B:-3.98;95%CI:-5.88,2.09).

Conclusions

Thinner retinal artery diameter was significantly, however weakly, associated with increased common carotid artery IMT. It suggests that retinal microvascular changes were only week indicators for an atherosclerotic carotid artery pathology. Thicker retinal vein diameter was associated with higher estimated CSFP, confirming associations between higher estimated CSFP and higher incidence of retinal vein occlusion.

Much needs to be done to forge alliances at grass roots

Kevin Corbett and Jenny Finch (reflections, April 13) are right to call for stronger nursing alliances between primary care and community nurses.

Changing the culture of a medical school by orienting students and faculty toward community medicine

Oklahoma's health status has been ranked among the worst in the country. In 1972, the University of Oklahoma established the Tulsa branch of its College of Medicine (COM) to expand the physician workforce for northeastern Oklahoma and to provide care for the uninsured patients of the area. In 2008, the Tulsa branch launched a distinct educational track, the University of Oklahoma COM's School of Community Medicine (SCM), to prepare providers equipped and committed to addressing prevalent health disparities.The authors describe the Tulsa branch's Summer Institute (SI), a signature program of the SCM, and how it is part of SCM's process of institutional transformation to align its education, service, and research missions toward improving the health status of the entire region. The SI is a weeklong, prematriculation immersion experience in community medicine. It brings entering medical and physician assistant students together with students and faculty from other disciplines to develop a shared culture of community medicine. The SI uses an unconventional curriculum, based on Scharmer's Theory U, which emphasizes appreciative inquiry, critical thinking, and collaborative problem solving. Also, the curriculum includes Professional Meaning conversations, small-group sessions to facilitate the integration of students' observations into their professional identities and commitments. Development of prototypes of a better health care system enables participants to learn by doing and to bring community medicine to life.The authors describe these and other curricular elements of the SI, present early evaluation data, and discuss the curriculum's incremental evolution. A longitudinal outcomes evaluation is under way.