Travelers' Diarrhea

On the average, one-fourth of North Americans visiting developing countries experience a self-limited diarrheal illness that interferes with holiday or business activities. Recent work suggests that these episodes are caused by a small inoculum of enteropathogenic Escherichia coli which are common in the country visited and rare in the country of origin. Neither antimicrobial treatment nor anti-diarrheal agents have proven benefit once the illness has begun. Despite its frequent use, iodochlorhydroxyquin has not been shown in double blind studies to be effective as a preventive agent, and may be dangerous. The status of furazolidone for prevention of tourist diarrhea is questionable. Both neomycin sulfate and phythalylsulfathiazole have demonstrated efficacy as chemoprophylactics in Mexico. However, their use should be restricted to limited types of travel and travelers.General admonitions concerning avoidance of certain ingestibles are recommended; despite questionable value in preventing travelers'' diarrhea such precautions may prevent more serious gastrointestinal illness.     

American travel deaths in Mexico. Causes and prevention strategies.

About 3 to 4 million Americans travel to Mexico every year, yet their mortality experience has never been analyzed. Fatalities among US travelers to Mexico during the years 1975 and 1984 were examined using a previously unanalyzed data source. The leading cause of death to all US travelers to Mexico was injuries (51%), with 18% of deaths resulting from motor vehicle crashes. Of all travelers'' deaths, 37% were due to circulatory diseases and less than 1% were due to infectious diseases. While the proportion of all deaths from motor vehicle crashes was similar for US citizens traveling in Mexico and US residents, travelers had significantly higher proportions of injury deaths due to aircraft crashes and drowning. Injury, rather than infectious diseases, appears to pose the greatest risk of death to travelers to Mexico. Physicians and travel clinics need to place greater emphasis on injury prevention when giving advice to clients traveling to Mexico.     

Cytokines,neuropeptides, and other factors in cutaneous immune responses.

A routine visit to a physician''s office generally is composed of the reason for the visit; attention to ongoing medical problems; and preventive medicine considerations. A separate visit for preventive medicine activities can be helpful. A computer-generated annual birthday greeting to patients that suggests specific preventive medicine studies would result in a more problem-focused office visit and greater precision in the execution of preventive medicine activities.     

The role of computers in preventive medicine in a rural family practice.

Five family physicians in a group practice in rural Quebec have introduced a computer system to improve the delivery of preventive medicine. In addition to billing, the computer is used mainly to recall specific groups of patients for preventive measures, to prompt the physicians to carry out certain procedures at the patient''s next visit, to indicate which procedures are required for the family members and to generate reminder letters. The physicians are conducting a randomized controlled trial to evaluate the impact of computer-generated reminder letters on patient compliance and disease prevention among families in their practice.     

The Influences of Group and Independent General Practice on Patient Care: A Comparative Study in Ontario

When the practices of four general practitioners, members of multispecialist-general practitioner salaried groups (clinic doctors) were compared with those of four independent general practitioners (solo practitioners), it was noted that: group practice patients had more office laboratory investigation and greater in-hospital consultation and referral. On the other hand, independent practitioners'' patients seemed to receive more personal attention from the doctor, a fuller explanation of diagnosis and treatment during office hours, more drug samples and more laboratory investigation in hospital.Group and independent practices are similar with respect to the rate of follow-up visits, the volume of preventive medicine, the number of radiographs and special procedures, the total number of drugs ordered, and the in-hospital formal written consultation rate and office consultation rate.The similarities between two types of practice may be a result of the interaction of group and independent practice in the same community.It is concluded that the team approach to medical care is not incompatible with independent practice.     

Colposcopy in a family planning clinic: a future model?

The first year''s experience of a satellite colposcopy clinic in the Glasgow Family Planning Centre was analysed. Establishment of the clinic was supervised by an experienced member of the colposcopy team at the department of gynaecology, Western Infirmary, Glasgow, who trained one of the family planning centre''s staff. Close links were thus maintained with the hospital clinic to which patients were referred for treatment. The policy at the new colposcopy clinic was to study prospectively all women in the hospital catchment area whose cervical smears were reported as abnormal. In 58 of 162 such patients there was at least moderate dyskaryosis and the cytologist''s recommendation had been referral for colposcopy. In 104 cases the changes were either atypia alone or mild dyskaryosis and a repeat smear was recommended within three to 12 months; 18 of these patients had grade II or III cervical intraepithelial neoplasia on biopsy, and relying on repeat smears would have resulted in an 11.7% false negative rate. If an atypical cytological picture is to be an indication for colposcopy clinics attached to family planning centres may have an important role, given satisfactory training and close links with central specialist colposcopy clinics.     

Acupuncture or Low Frequency Infrared Treatment for Low Back Pain in Chinese Patients: A Discrete Choice Experiment

Acupuncture is a popular but controversial treatment option for low back pain. In China, it is practised as traditional Chinese medicine; other treatment strategies for low back pain are commonly practised as Western medicine. Research on patient preference for low back-pain treatment options has been mainly conducted in Western countries and is limited to a willingness-to-pay approach. A stated-preference, discrete choice experiment was conducted to determine Chinese patient preferences and trade-offs for acupuncture and low frequency infrared treatment in low back pain from September 2011 to August 2012 after approval from the Department of Scientific Research in the study settings. Eight-six adult outpatients who visited the ‘traditional medicine department’ at a traditional Chinese medicine hospital and the ‘rehabilitation department’ at a Western medicine hospital in Guangdong Province of China for chronic low back pain during study period participated in an interview survey. A questionnaire containing 10 scenarios (5 attributes in each scenario) was used to ask participants'' preference for acupuncture, low frequency infrared treatment or neither option. Validated responses were analysed using a nested-logit model. The decision on whether to receive a therapy was not associated with the expected utility of receiving therapy, female gender and higher out-of-pocket payment significantly decreased chance to receive treatments. Of the utility of receiving either acupuncture or low frequency infrared treatment, the treatment sensation was the most important attribute as an indicator of treatment efficacy, followed by the maximum efficacy, maintenance duration and onset of efficacy, and the out-of-pocket payment. The willingness-to-pay for acupuncture and low frequency infrared treatment were about $618.6 and $592.4 USD per course respectively, demonstrated patients'' demand of pain management. The treatment sensation was regarded as an indicator of treatment efficacy and the most important attribute for choosing acupuncture or low frequency infrared treatment. The high willingness-to-pay demonstrated patients'' demand of pain management. However, there may be other factors influencing patients'' preference to receive treatments.     

Lessons my $3101 cat taught me about universal health care

Dr. Brian Goldman describes how his cat''s experience with veterinary medicine has helped shape his views about Canada''s health care system.     

Adherence to Chemoprophylaxis and Plasmodium falciparum Anti-Circumsporozoite Seroconversion in a Prospective Cohort Study of Dutch Short-Term Travelers

Background

We conducted a prospective study in a cohort of short-term travelers assessing the incidence rate of anti-circumsporozoite seroconversion, adherence to chemoprophylaxis, symptoms of malaria during travel, and malaria treatment abroad.

Methods

Adults were recruited from the travel clinic of the Public Health Service Amsterdam. They kept a structured daily travel diary and donated blood samples before and after travel. Blood samples were serologically tested for the presence of Plasmodium falciparum anti-circumsporozoite antibodies.

Results

Overall, the incidence rate (IR) of anti-circumsporozoite seroconversion was 0.8 per 100 person-months. Of 945 travelers, 620 (66%) visited high-endemic areas and were advised about both chemoprophylaxis and preventive measures against mosquito bites. Most subjects (520/620 = 84%) took at least 75% of recommended prophylaxis during travel. Travel to Africa, use of mefloquine, travel duration of 14–29 days in endemic areas, and concurrent use of DEET (N,N-diethyl-meta-toluamide) were associated with good adherence practices. Four travelers without fever seroconverted, becoming anti-circumsporozoite antibody-positive. All four had been adherent to chemoprophylaxis; two visited Africa, one Suriname, one India. Ten subjects with fever were tested for malaria while abroad and of these, three received treatment. All three were adherent to chemoprophylaxis and tested negative for anti-circumsporozoite antibodies.

Conclusion

Travel to Africa, using mefloquine, travel duration of 14–29 days in endemic areas, and use of DEET were associated with good adherence to chemoprophylaxis. The combination of chemoprophylaxis and other preventive measures were sufficient to protect seroconverting travelers from clinical malaria. Travelers who were treated for malaria abroad did not seroconvert.     

The battered child syndrome

The experience of the Children''s Hospital of Winnipeg from 1957 to 1971 with abused infants and children is presented with statistical data on 132 children. Details as to incidence, source and types of abuse are presented along with a discussion of the management of the problem. A follow-up study on a group of the abused children is also presented with comments directed towards some preventive measures.     

Evaluation of the returned traveler.

Recognition of clinical syndromes in returned travelers is an important part of providing care to international travelers. The first step is to take a history with attention to pre-travel preventive measures, the patient's itinerary, and potential exposure to infectious agents. The patient should then be examined to document physical signs, such as fever, rash, or hepatosplenomegaly, and to have basic laboratory data obtained. This evaluation will provide most physicians with the necessary information to generate a differential diagnosis. Each diagnosis should be matched against the incubation period of the disease, the geographic location of illness, the frequency of illness in returned travelers, and the pre-travel preventive measures. Careful attention to these aspects of patient care should result in the appropriate diagnosis and therapeutic intervention for the ill returned traveler.     

Cervical Cancer—Use of a Non-Physician Health Team for Screening Procedures

A team of non-physician personnel has been trained in cytologic screening for cervical cancer. In a county hospital clinic setting among low income women whose annual pelvic examinations were being by-passed by physicians, this three-person team has performed pelvic examinations and screening under physician supervision for one year.Results of the first year''s experience, measured in cancer detection and in recognition and referral of benign gynecological disease as well, would suggest that a non-physician team, with a registered nurse doing a pelvic examination of screening type, can screen for cervical cancer and other pelvic disease efficiently and without a significant lowering of the quality of medical care.The training and use of teams of allied health care personnel directed by physicians is suggested as a practical means of overcoming the increasing shortage of physician services in annual screening for cervical cancer among low income women.     

Are combined orthopaedic and rheumatology clinics worth while?

The practice of holding combined orthopaedic and rheumatology clinics is widespread, but no attempt has been made to assess their usefulness. In a one year prospective study patients were randomised either to a combined clinic with a rheumatologist and an orthopaedic surgeon or to a clinic with an orthopaedic surgeon alone. The details of the patients'' disease, the interview, the surgeons'' and rheumatologists'' responses, and the patients'' opinions were recorded on questionnaires. Interviews were appreciably longer in the combined clinic, and more referrals for surgery were made. The rheumatologist correctly predicted the need for surgery in 95% of cases, and his presence in the clinic was considered desirable by the surgeon, principally when the referral letter was inadequate. It is concluded that most patients with rheumatic diseases can be seen more efficiently in routine orthopaedic clinics provided a good quality letter of referral is sent.     

Some experience in an area health authority child health clinic.

Three years'' experience as a doctor taking two clinics a week in an area health authority child health clinic was reviewed. A wide range of clinical conditions was seen, including: problems associated with feeding in breast- and bottle-fed infants; minor developmental abnormalities (mental, behavioural, and physical); surgical and orthopaedic conditions requiring treatment; medical conditions, mainly respiratory and alimentary infections, skin conditions, and problems of over-treatment for minor ailments; and minor genetic abnormalities. Mothers asked for advice on a wide range of topics, risks and benefits of immunisation being the most common. The clinic doctor needs a wide experience in paediatrics to deal with such problems. It is suggested that all lecturers in child health and paediatric and senior registrars should take one clinic a week for six months, and all medical students should attend some clinics as part of their paediatric training. Health visitors have an important role in helping the clinic doctor, but their training should be more realistic and appropriate facilities should be provided to keep them up to date in their work.     

军校预防医学专业本科学员临床课程教学现状及建议

随着医学模式的转变,预防医学已经成为现代医疗体系的重要组成部分,在提高公共卫生健康水平方面发挥着越来越重要的作用。为了更好地开展预防医学工作,预防医学专业学员不仅要掌握牢固的预防医学专业知识,更要具备丰富的临床医学知识。针对预防医学专业本科学员的临床课程教学,我校经过多年的探索与改革,已经积累了丰富经验,教学质量较高;但现阶段仍然存在着一些问题。本文分析我校预防医学专业本科学员临床课程的教学现状及存在的主要问题,并提出建议;从而为进一步提高预防医学专业本科学员的临床课程教学质量提供依据。     

Preventive practice among primary care physicians in British Columbia: relation to recommendations of the Canadian Task Force on the Periodic Health Examination.

OBJECTIVES: To compare the current practice of preventive medicine in British Columbia with the recommendations of the Canadian Task Force on the Periodic Health Examination. Four common, preventable forms of cancer (cervical, breast, lung and colorectal) were used as sentinel conditions. DESIGN: Random sample mailed survey. SETTING: Private primary care practices in British Columbia. PARTICIPANTS: A sample of 300 primary care physicians in 1991; of 285 eligible physicians 185 (65%) responded. OUTCOME MEASURE: Compliance with preventive practices recommended by the task force. RESULTS: Preventive practice complied with the task force''s recommendations for breast examinations, mammography, cervical smears and initial counselling against smoking; over 90% of the physicians performed these manoeuvres in all or most cases. However, less than half performed two recommended manoeuvres for all or most patients who smoke: advice to follow a diet high in beta-carotene (reported by 10%) and scheduling of follow-up visits to reinforce antismoking counselling (by 46%). Most of the physicians stated that they perform preventive manoeuvres in the context of an annual general physical examination rather than integrating them into routine patient care. CONCLUSIONS: The task force''s carefully constructed recommendations are incompletely followed. Overall, there appears to be a high level of compliance with traditional and recommended manoeuvres but also widespread persistence in performing traditional manoeuvres no longer recommended and failure to adopt new recommendations.     

医患沟通技能培养在生殖医学教育中的实践及体会

目的：探讨医患沟通技能培养对生殖医学教育的作用及效果。方法：选择2010 级临床本科专业两个班级共30 人作为观察 组,进行医患沟通技能培养;另选取同年级的两个班级共28 人作为对照组,进行传统生殖医学教学模式培养。运用自行编制的教 学效果调查问卷及SEGUE 量表对两组学生的教学效果及医患沟通技能进行评价及比较。结果：与对照组相比,观察组的教学效 果有明显优势,学生对生殖医学更感兴趣,使生殖医学的教学更富有启发性,学生处理问题的能力显著增强,学生对生殖医学的 知识掌握程度及综合应用能力显著提高,差异具有统计学意义（P<0.05）;与对照组相比,观察组学生在信息收集、信息给予、理解 病人及沟通结束等四个维度的医患沟通能力显著增强,差异具有统计学意义（P<0.05）。结论：在生殖医学教育中加强医患沟通技 能的培养是一种行之有效的教学方法,值得推广。     

Ionizing Radiation as an Industrial Health Problem

Ionizing radiation, first as x-rays, later in natural form, was discovered in Europe in the late 1890''s. Immediate practical uses were found for these discoveries, particularly in medicine. Unfortunately, because of the crude early equipment and ignorance of the harmful effects of radiation, many people were injured, some fatally. Because of these experiences, committees and regulatory bodies were set up to study the problem. These have built up an impressive fund of knowledge useful in radiation protection.With the recent development of the peaceful uses of atomic energy, sources of radioactivity have appeared cheaply and in abundance. A rapidly growing number are finding industrial application. Because of their potential risk to humans, the industrial physician must acquire new knowledge and skills so that he may give proper guidance in this new realm of preventive medicine.The Radiation Protection Program of one such industry, the Hydro-Electric Power Commission of Ontario, is summarized.     

Guardians' Perceptions of Cats' Welfare and Behavior Regarding Visiting Veterinary Clinics

To assess the welfare of cats at the veterinary clinic and how caregivers and veterinarians affect it, a survey of Italian cat guardians (n = 1,111) was conducted using a 28-item multichoice questionnaire. Most cats showed impaired welfare during all stages of a clinic visit: before entering, in the waiting room, moving to the examination room, on the examination table, and after returning home. A relationship was found between welfare states in each stage. Stress worsened with further experience and had negative effects on traveling and handling in other situations. Restraint, pain, and anxiety led to aggression toward vets and guardians. Guardians showed a positive attitude toward their cats' health and welfare, and the veterinarians' behavior toward the cats was a reason for changing the veterinarian. One in 10 veterinarians examined the cat immediately, without stroking, talking, or offering food. However, the use of food was effective only if cats were not already stressed. Educating guardians and veterinarians to minimize stress during every stage of a clinic visit is the best approach to improving welfare for cats visiting the clinic.     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country''s health care system prompted experimental changes in the operation and training procedures at St. Mary''s of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country''s dismal rate of institutionalization.