A multivariate examination of 'artificial mussels' in conjunction with spot water tests in freshwater ecosystems.

Metal pollution in aquatic systems is considered a serious environmental issue globally due to their ability to accumulate in aquatic environments. Wetlands are vulnerable to this pollution as they are known to trap toxins, removing them from the water. Artificial mussel technology, originally developed for marine environments, was applied to this freshwater system and spot water samples were collected. The Nyl River floodplain (Ramsar classified) is one of the largest and most ecologically significant wetlands in South Africa. The aims of this study were to determine metal contamination along the Nyl River system by means of artificial mussels (AM) and water ICP-MS analysis and to determine whether the use of AMs in conjunction with spot water testing could give more insight into the pollution in freshwater wetlands. The concentrations of Al, Cd, Cr, Co, Cu, Fe, Mn, Ni, Pb and Zn were determined at seven sites. It was determined that the levels accumulated by the AMs differed in spatial and temporal trends when compared to spot water samples. It was determined that there were high levels of some metals found in the spot water tests that were not corroborated by the AMs results, which could indicate isolated pollution events. The use of AMs in conjunction with spot water testing was determined to be beneficial in gaining deeper insight into water metal conditions in dynamic freshwater systems.

Ecological risk assessment of trace elements in sediment: A case study from Limpopo, South Africa.

This study aimed to determine the ecological risk posed by metals, in sediments from the Nyl River system in Limpopo, South Africa. Metals were extracted from sediment samples by aqua regia microwave digestion and were analysed using standard ICP-OES techniques. The ecological risk indices applied to the data included Contamination Factor, Pollution Load Index, Geo-accumulation Index and Enrichment Factor. The results showed that the levels of Ni at STW and NYL in the HF period exceeded the Canadian Sediment Quality Guidelines by a factor of 1.36 and 1.83 respectively whereas NYL and MDD had 2.57 and 1.32 times the allowed limit of Ni in the LF period. During the HF period, the GC site exceeded the allowed limit of Zn by a factor of 1.04 and NYL had 1.21 times the allowed Zn in the LF period. The levels of metals are generally low near the origin of the river and increase moving downstream. The levels of metals in the Nyl River floodplain, a Ramsar accredited wetland, were high with CF scores ranging between 0.905 and 5.82, Igeo values with a range of -0.541 to 2.441 and EF scores ranging from 0.959 to 6.171. and posed a greater risk than the other sites. This indicated that the wetland is performing its ecological function by trapping and removing toxins from the water body. The Pollution Load Index determined that the Golf Course (PLI=4.586) and STW (PLI=2.617) sites were polluted only in the low flow period whereas the Nyl River floodplain (HF PLI=79.845; LF PLI=30378.768) and Moorddrift Dam (HF PLI=1.903; LF PLI=9.256) sites were polluted in high flow and low flow periods.

Modification of the skin incision to allow versatility in placement of the skin paddle when raising a fibular osteocutaneous flap.

A simple modification to the skin incision in raising the fibular osteocutaneous flap allows the skin paddle to be centred on the best available peroraters running through the posterior intercrural septum into the flap. This maximises the success rate for reperfusion of the skin paddle following vascular anastamosis at the recipient site.

Surgical management of cutaneous squamous cell carcinoma of the head and neck.

A retrospective audit was made of histological records and hospital case notes of patients who had cutaneous squamous cell carcinomas excised from the head and neck region at the Maxillofacial Units at St Richard's Hospital, Chichester and Southlands Hospital, Shoreham-By-Sea, UK. A total of 227 lesions were excised from 183 patients over a 5-year period between 1990 and 1995. The local recurrence rate was 4% (9/227) and 12 (7%) of the patients presented with or developed regional nodal metastases. Of the 183 patients, 177 (97%) were cured. These rates compare favourably with those of other published series of cutaneous squamous cell carcinoma managed by surgical techniques that did not follow the micrographical technique of Mohs. Certain characteristics may aid in the prediction of those cancers that may be more aggressive. It is important to evaluate each case in terms of histological grade and site and to design management plans to deal with each lesion in the most appropriate way.

Implementing community-oriented primary care projects in an urban family practice residency program.

BACKGROUND: Clinics interested in pursuing community-oriented primary care (COPC) have struggled with the implementation of its theory. Although we are still early in the COPC transformation process, the HealthPartners Family Practice Residency Program has had several successful COPC projects during our 10 years of experience. This article describes these projects and the 8 lessons learned, including some that differ from traditional COPC teaching and practice. In our experience, clinics should select a topic or problem that creates a passion within their clinic. Projects can start small within the clinic and expand outward into larger portions of the urban community. Partnerships begin the process of extending into the community and increasing the project's impact. The evaluation of projects should begin with clinic-based data. A physician champion and a nonphysician staff person increase the success of the project. Resident involvement is enhanced with concrete tasks and community connections. Ultimately, the project needs to be institutionalized within the clinic to survive. The whole COPC endeavor is a long, slow process that requires time, energy, and committed individuals. In our experience, COPC is a journey, not an end, and there are many rich rewards to be found along the way.

Occlusal outcome in patients undergoing orthognathic surgery with internal fixation.

Fifty consecutive patients undergoing orthognathic surgery with internal fixation (IF) were studied retrospectively with a weighted Peer Assessment Rating (PAR) Index to assess occlusal outcome at the end of all active treatment, and compared with 50 patients who had undergone treatment for malocclusion by orthodontic means alone. In the surgically treated patients, the mean percentage reduction in the weighted PAR Index was 83% and 31 out of 38 patients (82%) were 'greatly improved'. This implies a high standard of treatment in terms of the occlusal outcome. There was no difference in the proportion of patients having a final weighted PAR Index of less than 10 and no significant difference in the final weighted PAR Index between the two groups. This suggests that the occlusal outcome is no different whether patients undergo orthognathic surgery or orthodontic treatment alone, and that excellent occlusal results can be achieved in patients undergoing orthognathic surgery with internal fixation.

A curriculum for multicultural education in family medicine.

BACKGROUND AND OBJECTIVES: To deliver effective medical care to patients from all cultural backgrounds, family physicians need to be culturally sensitive and culturally competent. Our department implemented and evaluated a 3-year curriculum to increase residents' knowledge, skills, and attitudes in multicultural medicine. Our three curricular goals were to increase self-awareness about cultural influences on physicians, increase awareness about cultural influences on patients, and improve multicultural communication in clinical settings. Curricular objectives were arranged into five levels of cultural competence. Content was presented in didactic sessions, clinical settings, and community medicine projects. METHODS AND RESULTS: Residents did self-assessments at the beginning of the second year and at the end of the third year of the curriculum about their achievement and their level of cultural competence. Faculty's evaluations of residents' levels of cultural competence correlated significantly with the residents' final self-evaluations. Residents and faculty rated the overall curriculum as 4.26 on a 5-point scale (with 5 as the highest rating). CONCLUSIONS: Family practice residents' cultural knowledge, cross-cultural communication skills, and level of cultural competence increased significantly after participating in a multicultural curriculum.

Strategic footholds for medical education about domestic violence.

The author describes in detail the successful education initiatives on domestic violence, especially violence against adult women, that have been implemented for family medicine residents at the St. Paul-Ramsey Medical Center in St. Paul, Minnesota, and for medical students at each of the three Minnesota medical schools. For example, in 1990 the residency program adopted a community-oriented primary care approach to teaching and clinical activities, including the area of domestic violence. This approach stresses partnerships with community organizations that deal with domestic abuse. Also developed was a curriculum to help residents deal with their apprehension about domestic violence and acquire the knowledge, attitudes, and skills they need to confront this problem effectively. At the three medical schools, teaching about domestic violence takes place in preclinical courses, during clinical rotations (where students work with abuse victims), and through extracurricular activities. The author describes some important types of resistance to having instruction about domestic violence in the medical curriculum. To move forward, faculty must overcome their discomfort with the topic yet acknowledge that teaching about it is difficult and requires personal stamina and empathy with colleagues. Faculty must also agree to collaborate with those who have sensitivity and expertise in the area, and must make a long-term commitment to prepare physicians to recognize problems of domestic violence and work effectively with its victims and perpetrators.

PIP: In Minnesota, training about interpersonal violence against women has been successfully incorporated into the curriculum of a family medicine residency program and the three medical schools. Residents in the community-oriented program learn to focus on domestic violence during patient examinations, as part of clinical activity, through provider networks, by working with other community groups, and as members of state or national organizations. This hierarchy was incorporated into a "matrix of community medicine" that describes appropriate activities at each level for each activity involved in providing community-oriented primary care (defining the population, assessing problems, intervening, monitoring, and building community partnerships). The resulting framework was used to describe the scope of potential involvement in domestic violence by the residency program. The matrix was also used to display the issues, resources, and programs available to train residents about domestic violence. The medical schools incorporate discussions of domestic violence in preclinical courses at all sites, allow students to work with abuse victims during clinical rotations, and offer a variety of extracurricular activities. This training is enhanced by using the community agencies and resources that represent years of experience in the field. The training is challenging because responding to cases of domestic violence is difficult and time consuming. Teachers must be able to move past their personal discomfort with the subject and approach the issue with stamina.

A 13 year review of childhood lead poisoning in Christchurch and Nelson.

AIMS: To find the sources of lead currently poisoning people in Christchurch and Nelson and to review the presentation, epidemiology and symptoms of children with lead poisoning. METHODS: Forty seven people were admitted to hospital in Christchurch and Nelson during the 13 year period January 1981-March 1994 a retrospective case note review was performed. RESULTS: Thirty four children and 13 adults had elevated lead levels. Lead based paint was the main source of lead for children requiring treatment. Most children were asymptomatic or had no specific signs and symptoms. In most cases the diagnosis was not made on clinical grounds. CONCLUSIONS: Excessive lead absorption requiring hospital treatment is now most commonly seen in children. It is likely that many cases of significant lead poisoning are currently being overlooked. Medical practitioners and parents need to be made more aware of the problem. Targeted screening or population screening may be needed. Governmental efforts need to be focused on protecting children from lead exposure in the home.

Reorganization of a private psychiatric unit to promote collaboration with managed care.

Managed care organizations have become significantly involved in health care in the Denver metropolitan area. Their presence has challenged psychiatric hospitals to reduce costs and length of stay. In 1990, a locked private psychiatric unit was reorganized into locked, open, and partial care services through which patients progress at individualized rates. One treatment team manages patients in all settings, allowing a reduction in staffing costs and flexibility in treatment design. The hospital administration takes an active role in facilitating collaborative decision making between hospital clinicians and managed care representatives. In the first year after reorganization, length of stay was significantly reduced; 90 percent of patients were discharged from 24-hour care within ten days or less, whereas only 40 percent were discharged within that time in the original program. Staffing costs were reduced by 15 percent. No increase in recidivism was noted.

Maternity leave for practicing family physicians.

BACKGROUND: Approximately 37% of all medical students and 36% of family medicine residents in training in the United States are women. The American Academy of Family Physicians (AAFP) has developed a recommended parental leave policy for residents in training but has not established a similar policy for physicians in practice. The purpose of this study was to assess the prevalence of maternity leave policies for practicing family physicians. METHODS: A 14-item self-administered survey questionnaire was designed and mailed to 940 AAFP members randomly selected from the total active female membership. RESULTS: A 52% response rate was obtained. The mean age of respondents was 35 years. Only one third of the physicians not in solo practice reported having a stated maternity leave policy in their current place of practice. Academic programs, when compared with single specialty family practice groups, multispecialty groups and health maintenance organization (HMO) or preferred provider organization (PPO) groups, were more likely to have maternity leave policies and to provide salary on leave. Practice groups with eight or more partners were more likely to have policies that provided salary and benefits while on leave. Ninety percent of respondents requested maternity leave guidelines for practicing family physicians. CONCLUSIONS: Women family physicians expressed strong interest in the development of maternity leave guidelines for their specialty. Guideline components are outlined.

Sensory gating deficits in psychiatric inpatients: relation to catecholamine metabolites in different diagnostic groups.

Acutely ill psychiatric inpatients were examined for a deficit in sensory gating, measured as failure to suppress the P50 wave of the auditory-evoked response to the second of paired stimuli. Previously, we had found that in mania, this sensory gating deficit is correlated with increased plasma-free levels of the noradrenergic metabolite 3-methoxy, 4-hydroxyphenylglycol (pMHPG), whereas in schizophrenia, there is no correlation with catecholamine metabolism. To assess the generalizability of these findings, we examined inpatients with a broader range of diagnoses, including those with multiple DSM III-R Axis I, II, and III diagnoses. The patients were grouped into three diagnostic spectra for analysis: schizophrenic, manic, and depressive. In the schizophrenic patients, there was no relationship between pMHPG or other catecholamine metabolites and the sensory gating deficit. In manic patients, however, a positive correlation between pMHPG level and the sensory gating deficit was again observed. This relationship did not extend to the depressive patients, who uniquely showed sensory gating deficits that correlated negatively with the severity of their illness. The data suggest that sensory gating deficits are common to these three diagnostic spectra, but the deficits in each group have different relationships to catecholamine metabolism and symptom severity that may reflect differences in the underlying neuronal pathophysiology of these illnesses.