Multiculturalism and AIDS: different communities mean different educational messages required

Having a multitude of different ethnic communities forces Canada''s AIDS educators to use many different methods to deliver their messages. These range from an AIDS bingo game that has been used to educate natives in northern Manitoba to attempts to take AIDS education to the streets of Toronto. With AIDS education, reports Olga Lechky, one message definitely does not fit all.     

TAX-SUPPORTED MEDICAL CARE FOR CALIFORNIA'S CHILDREN—Where Should It Be Going?

The multiplication of separate governmental agencies providing health services to California''s children, the increasing difficulties in staffing tax-supported health agencies and the recent studies of the quality of care under these programs, have all pointed to an urgent need for prompt decisions on certain basic questions about the function of tax-supported medical care for children of dependent families.Fourteen separate kinds of health services are currently provided through public funds at an annual cost to California taxpayers of $52,000,000. These funds underwrite an uncoordinated, fragmented, patchwork quilt of medical care for some 500,000 children. Coordination and integration of these services through “one door” with uniform eligibility requirements and maximum utilization of private physicians'' services that meet appropriate standards is needed now. California physicians have an urgent responsibility to provide leadership in the development of more effective and more economical organization and distribution of higher quality medical care services for California''s children dependent on public support.     

Manitoba crash a wake-up call for "fly-in" physicians

A December plane crash in northern Manitoba served to remind the province''s "fly-in" physicians of the perils their work may entail. Four people were killed and 13 injured in the crash, which left Dr. Gerry Huot in serious condition in a Winnipeg hospital. The accident caused a serious head injury, and 4 months later he remains in hospital. It is causing some physicians to rethink their travel plans.     

Vitamin-D-deficient rickets in Manitoba, 1972-84.

Vitamin-D-deficient rickets still exists in children in Manitoba and adjacent areas. Between 1972 and 1984, 48 cases were documented at Winnipeg Children''s Hospital. The patients ranged in age from 1 to 49 months; 40 were Canadian natives (38 Indians and 2 Inuit), most of whom lived in the Island Lake area of northern Manitoba. Of the 48, 16 had clinical signs of rickets, 12 had tetany due to hypocalcemia and 38 had radiologic evidence of rickets. Hypocalcemia was found in 27, and hypophosphatemia in 19; hyperaminoaciduria was found in 7 of 20. All 48 had elevated serum alkaline phosphatase levels. In addition to rickets, 16 patients aged 12 months or more had evidence of malnutrition. Climate and lifestyle in northern areas of the Canadian midwest result in little or no biosynthesis of vitamin D by solar radiation; therefore, adequate dietary vitamin D intake is essential to prevent deficiency. The diets of pregnant women and infants in these areas are deficient in vitamin D. The authors recommend vitamin D supplements for all pregnant women and infants in areas of risk to eradicate this preventable disease.     

我国省级层面分级诊疗文件比较分析

通过访问各省（区、市）卫生计生委的官方网站,获取有关分级诊疗政策的文件,在获取国家卫计委和万方、知网的相关分级诊疗文献的基础上,对各省（区、市）2016年2月28日以前的分级诊疗文件进行分析研究,通过对比各省分级诊疗文件的基本情况和实施措施等具体内容,分析不同省份在分级诊疗文件内容设定中存在的问题,从而为未来的分级诊疗决策和实践提供经验。     

Hospital visiting hours: time for improvement

In a survey of hospital visiting hours in general medical and surgical wards throughout the United Kingdom a pattern of visiting emerged showing that many hospitals still have very restricted visiting. A quarter of the 404 hospitals that responded permitted visiting for an average of two hours a day or less. In contrast, just over a third of hospitals allowed visiting for more than five hours a day. There was no relation between visiting times and type of hospital, but a striking regional variation in visiting hours was found, with more liberal visiting in south east England and restricted visiting in northern England, Scotland, Wales, and Northern Ireland.     

Variation in the structure of bird nests between northern Manitoba and southeastern Ontario

Traits that converge in appearance under similar environmental conditions among phylogenetically independent lineages are thought to represent adaptations to local environments. We tested for convergence in nest morphology and composition of birds breeding in two ecologically different locations in Canada: Churchill in northern Manitoba and Elgin in southeastern Ontario. We examined nests from four families of passerine birds (Turdidae: Turdus, Parulidae: Dendroica, Emberizidae: Passerculus and Fringillidae: Carduelis) where closely related populations or species breed in both locations. Nests of American Robins, Yellow Warblers, and Carduelis finches had heavier nest masses, and tended to have thicker nest-walls, in northern Manitoba compared with conspecifics or congenerics breeding in southeastern Ontario. Together, all species showed evidence for wider internal and external nest-cup diameters in northern Manitoba, while individual species showed varying patterns for internal nest-cup and external nest depths. American Robins, Yellow Warblers, and Carduelis finches in northern Manitoba achieved heavier nest masses in different ways. American Robins increased all materials in similar proportions, and Yellow Warblers and Common Redpolls used greater amounts of select materials. While changes in nest composition vary uniquely for each species, the pattern of larger nests in northern Manitoba compared to southeastern Ontario in three of our four phylogenetically-independent comparisons suggests that birds are adapting to similar selective pressures between locations.     

Manitoba municipalities want foreign-trained physicians to fill medical-care gap

For the third year in a row, Manitoba municipalities have passed a resolution asking that physicians trained outside the Commonwealth be permitted to work as medical residents in rural communities. The resolution noted that most graduates of the University of Manitoba''s Class of ''96 had already accepted positions outside the province. Although the provincial government has sweetened the pot for Canadian-trained physicians, a long-term solution to Manitoba''s critical shortage of rural physicians seems elusive.     

Meningitis in the central Arctic: a 4-year experience.

There were 37 cases of meningitis during a 4-year period among the native and white populations served by the Churchill Health Centre in northern Manitoba, an annual incidence of 128 per 100 000 in the overall population and of 202 per 100 000 among the Inuit. Bacterial meningitis predominated; Neisseria meningitidis and Haemophilus influenzae each accounted for one third of the cases. There were five deaths, and 14 of the survivors had severe sequelae. Therefore, although the doctors and nurses involved in the study had improved access to telecommunication and air transportation services in caring for patients in isolated northern settlements, and despite their efforts to be vigilant for possible cases of meningitis and to begin vigorous treatment early, the incidence, morbidity and mortality of this disease remained relatively high, particularly among the Inuit.     

The practitioner,the patient and resistance to change: recent ideas on compliance.

Despite the explosion of research into the effect of medical advice on patient behaviour, only about 50% of patients comply with long-term drug regimens. And when it comes to changes in lifestyle, the percentage of patients who comply with medical advice often falls to single figures. Review articles on compliance have traditionally concentrated on factors that make it easier for patients to adhere to medical advice. However, recent articles urge clinicians to be more understanding of the wider implications of compliance in their patients'' lives. This article focuses on how clinicians'' consulting methods can affect patients'' behaviour. Specifically, the authors consider the patient-centred clinical method as well as insights from and consulting techniques pioneered in the addictions field that can help to bring ambivalent patients closer to decisions about change. Instead of seeing resistance to change as rooted entirely in the patient, the authors view it as stemming partly from the way clinicians talk to patients. An advice-giving approach is usually inadequate to motivate people to embark on major lifestyle changes. Instead, the authors propose a negotiation-based framework that harnesses patients'' intrinsic motivation to make their own decisions. This approach also promotes clinicians'' acceptance of patients'' decisions, even if these decisions run counter to current medical wisdom.     

Effect of preventive home visits by a nurse on the outcomes of frail elderly people in the community: a randomized controlled trial

BACKGROUND: Timely recognition and prevention of health problems among elderly people have been shown to improve their health. In this randomized controlled trial the authors examined the impact of preventive home visits by a nurse compared with usual care on the outcomes of frail elderly people living in the community. METHODS: A screening questionnaire identified eligible participants (those aged 70 years or more at risk of sudden deterioration in health). Those randomly assigned to the visiting nurse group were assessed and followed up in their homes for 14 months. The primary outcome measure was the combined rate of deaths and admissions to an institution, and the secondary outcome measure the rate of health services utilization, during the 14 months; these rates were determined through a medical chart audit by a research nurse who was blind to group allocation. RESULTS: The questionnaire was mailed to 415 elderly people, of whom 369 (88.9%) responded. Of these, 198 (53.7%) were eligible, and 142 consented to participate and were randomly assigned to either the visiting nurse group (73) or the usual care group (69). The combined rate of deaths and admissions to an institution was 10.0% in the visiting nurse group and 5.8% in the usual care group (p = 0.52). The rate of health services utilization did not differ significantly between the 2 groups. Influenza and pneumonia vaccination rates were significantly higher in the visiting nurse group (90.1% and 81.9%) than in the usual care group (53.0% and 0%) (p < 0.001). INTERPRETATION: The trial failed to show any effect of a visiting nurse other than vastly improved vaccination coverage.     

Inappropriate hospital use by patients receiving care for medical conditions: targeting utilization review

OBJECTIVE: To describe characteristics associated with inappropriate hospital use by patients in Manitoba in order to help target concurrent utilization review. Utilization review was developed to reduce inappropriate hospital use but can be a very resource-intensive process. DESIGN: Retrospective chart review of a sample of adult patients who received care for medical conditions in a sample of Manitoba hospitals during the fiscal year 1993-94; assessment of patients at admission and for each day of stay with the use of a standardized set of objective, nondiagnosis-based criteria (InterQual). PATIENTS: A total of 3904 patients receiving care at 26 hospitals. OUTCOME MEASURES: Acute (appropriate) and nonacute (inappropriate) admissions and days of stay for adult patients receiving care for medical conditions. RESULTS: After 1 week, 53.2% of patients assessed as needing acute care at admission no longer required acute care. Patients 75 years of age or older consumed more than 50% of the days of stay, and 74.8% of these days of stay were inappropriate. Four diagnostic categories accounted for almost 60% of admissions and days, and more than 50% of those days of stay were inappropriate. Patients admitted through the emergency department were more likely to require acute care (60.9%) than others (41.7%). Patients who were Treaty Indians had a higher proportion of days of stay requiring acute care than others (45.9% v. 32.8%). Patients'' income and day of the week on admission (weekday v. weekend) were not predictive factors of inappropriate use. CONCLUSION: Rather than conducting a utilization review for every patient, hospitals might garner more information by targeting patients receiving care for medical conditions with stays longer than 1 week, patients with nervous system, circulatory, respiratory or digestive diagnoses, elderly patients and patients not admitted through the emergency department.     

Does closing branch surgeries affect home visiting?

Home visiting rates in a rural general practice were compared for 12 months before and 12 months after five branch surgeries were closed. In villages whose surgeries were closed no statistically significant change occurred in the new or repeat visiting rates. The consulting rate at the main surgery remained constant over the two years. Although visiting rates to villages that had had a branch surgery did not change after the closures, the pattern of visiting to these villages became more rational.     

The Winnipeg Children's Hospital child protection centre: a provincial medical initiative.

The Winnipeg Children''s Hospital child protection centre is a hospital-based provincial protection program that focuses on the diagnosis, treatment and prevention of child abuse and neglect in Manitoba. The multidisciplinary group of professionals working in the centre differs from most hospital-based teams in that it has a strong government liaison both functionally and financially, has strong ties to the welfare system and has legal counsel relating to the court system. The centre represents the philosophy that medical participation in welfare matters relating to children need not be relegated to the sidelines. This paper describes the centre''s history and structure, and it outlines some of its research projects.     

Ward meetings: a forum for patients' concerns.

A series of meetings between patients and staff were held on two general medical wards to discuss the concerns of patients. Issues ranged from the quality of hospital food, ward facilities, and visiting arrangements to the medical and nursing care provided and patients'' views on medical students. Most issues were raised by the patients themselves and the outcome was either acceptance or rejection of a suggestion, an explanation by the staff, or a general discussion if a specific decision was inappropriate. Most staff and patients considered the meetings to be valuable. Ward meetings thus seem to provide a way of making hospitals more responsive to patients'' concerns.     

CONTROL OF INSECTICIDE EXPOSURE IN EMPLOYMENT—A Guide to Physicians for Dealing with Organic Phosphates

Increasingly larger amounts of the highly efficient and highly toxic organic phosphate insecticides, particularly parathion, tetraethyl pyrophosphate, and Systox (demeton), are being applied on California''s farms. These insecticides have become an economic necessity to agriculture. They can be used safely when rigid precautions are utilized and when medical supervision is provided for employees regularly working with these chemicals.The demand for the services of physicians prepared to supply this kind of industrial medical supervision is expected to increase in California.The basic procedures through which effective medical supervision can be provided are outlined.     

Getting by at home. Community-based long-term care of Latino elders.

Although evidence suggests that the morbidity and mortality of Latino elders (of any Hispanic ancestry) are similar to those of non-Latino whites, Latinos have higher rates of disability. Little is known about influences on the use of in-home health services designed to assist disabled Latino elders. We examine the effects of various cultural and structural factors on the use of visiting nurse, home health aide, and homemaker services. Data are from the Commonwealth Fund Commission''s 1988 national survey of 2,299 Latinos aged 65 and older. Mexican-American elders are less likely than the average Latino to use in-home health services despite similar levels of need. Structural factors including insurance status are important reasons, but acculturation is not pertinent. Physicians should not assume that Latino families are taking care of their disabled elders simply because of a cultural preference. They should provide information and advice on the use of in-home health services when an older Latino patient is physically disabled.     

The Inability of the Consumer Price Index to Measure “Cost of Quality” of Medical Care,Report of the Bureau of Research and Planning

The Consumer Price Index (CPI) of the Bureau of Labor Statistics is an index which measures the price changes of 300 goods and services. Among these 300 items are several which reflect price changes for selected health care and medical care services. These comprise the medical care index and physician fee index, depending on what services are being measured.The Physician Fee Index is based upon charges for five procedures rendered by physicians: Appendectomy, tonsillectomy, obstetrical delivery, home visits and office visits.Although the CPI takes into account quality changes in the prices for various goods, it is unable to do so for services, particularly physicians'' services.The difficulty in measuring the “cost” of quality of medical care overstates price increases in the physician fee and medical care indexes.     

电子病历系统在医院信息管理系统中应用初探

电子病历系统是通过计算机等电子设备为载体,对医院患者的诊疗活动进行数字化记录的软件。电子病历中详细记录了医嘱、病程、过敏史、影像检查结果、出院记录等多项医疗数据。电子病历完整、系统、科学地记录了患者身体健康情况以及历次就诊记录,通过一个维度将患者内部不同层次的信息有机的联系在一起。与传统的纸张病历相比,电子病历可以迅速实现不同时间、不同医院医疗信息的高效整合以及信息共享,为临床诊疗提供大量科学准确的信息,大大提高医院的服务效率。本文通过电子病历系统在医院信息管理系统中的应用情况进行简要分析,以期提高电子病历系统在临床中解决实际医疗问题的能力。     

The effects of population and thermal acclimation on the growth,condition and cold responsive mRNA expression of age-0 lake sturgeon (Acipenser fulvescens)

In Manitoba, Canada, wild lake sturgeon (Acipenser fulvescens) populations exist along a latitudinal gradient and are reared in hatcheries to bolster threatened populations. We reared two populations of lake sturgeon, one from each of the northern and southern ends of Manitoba and examined the effects of typical hatchery temperatures (16°C) as well as 60-day acclimation to elevated rearing temperatures (20°C) on mortality, growth and condition throughout early development. Additionally, we examined the cold shock response, which may be induced during stocking, through the hepatic mRNA expression of genes involved in the response to cold stress and homeoviscous adaptation (HSP70, HSP90a, HSP90b, CIRP and SCD). Sturgeon were sampled after 1 day and 1 week following stocking into temperatures of 8, 6 and 4°C in a controlled laboratory environment. The southern population showed lower condition and higher mortality during early life than the northern population while increased rearing temperature impacted the growth and condition of developing northern sturgeon. During the cold shock, HSP70 and HSP90a mRNA expression increased in all sturgeon treatments as stocking temperature decreased, with higher expression observed in the southern population. Expression of HSP90b, CIRP and SCD increased as stocking temperature decreased in northern sturgeon with early acclimation to 20°C. Correlation analyses indicated the strongest molecular relationships were in the expression of HSP90b, CIRP and SCD, across all treatments, with a correlation between HSP90b and body condition in northern sturgeon with early acclimation to 20°C. Together, these observations highlight the importance of population and rearing environment throughout early development and on later cellular responses induced by cold stocking temperatures.