[Nutritional management of patients with head and neck cancer treated with radiation]. / Prise en charge nutritionnelle des patients atteints de cancer de la tête et du cou traité par irradiation.

Radiotherapy and chemotherapy are standard treatment of head and neck cancer alone or associated to surgical treatment. Early (during treatment or the following weeks) and late side effects contribute to malnutrition in this population at risk. In this context, nutritional support adapted by dietary monitoring and enteral nutrition (nasogastric tube or gastrostomy) are often necessary. The early identification of the patients with high malnutrition risk and requiring enteral nutrition is necessary to improve the tolerance and efficacy of treatment.

Teaching prevention through electives.

The Liaison Committee on Medical Education (LCME) accreditation standards affirm that the medical school curriculum should include elective courses to supplement the required courses and provide opportunities for students to pursue individual academic interests. The breadth of opportunities in preventive medicine and population health is extensive as students seek rotations at health departments, rural and urban community health centers, community agencies, occupational health sites, schools, and abroad. A growing number of students choose to participate in MD/MPH dual-degree programs. This article describes four prototypes that foster student learning in preventive medicine: population health, international health, American Medical Student Association opportunities, and public health degree programs. These four types of electives enable students to participate in the front lines of preventive services through experiential learning in: community and population health both at home and abroad, continuous quality improvement, organization and behavioral change, interprofessional teamwork, and health care policy. For those with particular interests in population health and preventive medicine, an increasing number of medical schools offer dual MD/MPH programs, either in conjunction with schools of public health or in graduate programs in public health.

Filling the gaps: the role of public health departments under health care reform.

The nation's public health system can take credit for many of this century's improvements in life expectancy. But public health has been forced to take a back seat to high-technology medicine, reducing its funding and clout among local, state, and federal policymakers. For health reform to achieve the goals of cost containment and universal access, the nation's public health system must be strengthened and work in partnership with the medical care system.

A priority rating system for public health programs.

When resources are limited, decisions must be made regarding which public health activities to undertake. A priority rating system, which incorporates various data sources, can be used to quantify disease problems or risk factors, or both. The model described in this paper ranks public health issues according to size, urgency, severity of the problem, economic loss, impact on others, effectiveness, propriety, economics, acceptability, legality of solutions, and availability of resources. As examples of how one State can use the model, rankings have been applied to the following health issues: acquired immunodeficiency syndrome, coronary heart disease, injuries from motor vehicle accidents, and cigarette smoking as a risk factor. In this exercise, smoking is the issue with the highest overall priority rating. The model is sensitive to the precision of the data used to develop the rankings and works best for health issues that are not undergoing rapid change. Cost-benefit and cost-effectiveness analyses can be incorporated into the model or used independently in the priority-setting process. Ideally, the model is used in a group setting with six to eight decision makers who represent the primary agency as well as external organizations. Using this method, health agencies, program directors, or community groups can identify the most critical issues or problems requiring intervention programs.

Status of hepatitis B screening and vaccine use in facilities for mentally retarded persons.

State mental retardation program directors in all 50 states were questioned on the status of hepatitis B screening and immunization programs in facilities for mentally retarded persons. Results from 43 states indicated serologic screening of selected residents and staff in 37 states and limited use of the new hepatitis B vaccine in 36 states, primarily in institutions and group homes. Not all states were sharing results of screening tests with school systems in which residents were enrolled. Attention should be addressed to the need for vaccination in community settings and the development of guidelines for schools in preventing the transmission of hepatitis B.

Smokeless tobacco--an overview for physicians.

This is one of a series of articles from western state public health departments.

Cost of hepatitis B prevention in hospital employees: pre-exposure immunization.

A cost-effectiveness analysis of alternative strategies to prevent hepatitis B in hospital workers was developed to compare pre-exposure immunization with post-exposure prophylaxis. The analysis included the impacts of hepatitis B incidence, employee turnover, strategy efficacy, and medical care expenses to determine the economic effectiveness of immunization and prophylaxis for employees at different risks for hepatitis B exposure. The prophylaxis strategy was found to cost $322 per high-risk employee for a five-year period, while the immunization strategy was found to cost $263 per high-risk employee for a five-year period, for a saving of $59 per employee. Sensitivity analysis demonstrated that pre-exposure immunization remained a cost-effective alternative to post-exposure prophylaxis over a wide range of different model assumptions.

The hepatitis B vaccine: utilization decision process and outcomes in community hospitals.

The process by which administrators, physicians, and other health professionals develop decisions on the adoption of innovations was examined through a study of the decision process relating to the institutional use of a vaccine to prevent hepatitis B. Mail questionnaires and telephone follow-up interviews were used to collect data on the decision process in 56 Arizona hospitals in 1983 and 1984. A five-stage decision process was employed by the institutions. Critical stages in the process involved defining who would make the adoption decision and the collection of information related to the innovation. The institutional plans for vaccine distribution did not exhibit a clear consensus regarding the identification of high-risk employee groups. Employee acceptance of the vaccine, even with the cost paid by the hospital, was limited.

Hepatitis B prevention in small rural hospitals.

A retrospective study of 246 potential hepatitis B exposure incidents in 12 rural hospitals in Arizona over a two-year period revealed a rate of 6.3 incidents per 100 employees per year. Needle punctures accounted for 68% of the incidents; 17% were cuts from instruments or broken glassware. Although 51% occurred in nursing personnel, housekeepers accounted for a surprising 19.5% of the reports. Only 50% of the employees received any medical attention following incidents. None received hepatitis B immune globulin (HBIG); seven received immune globulin (IG). The mean cost to the hospitals for the 122 incidents where treatment was given was $64.50 per incident. In all, 10 hospitals had no written policy for hepatitis B prevention, 3 did not stock IG and 11 did not stock HBIG. There was little awareness of hepatitis B as a nosocomial problem within these institutions, perhaps because no reported cases of clinical hepatitis B occurred in employees of the 12 hospitals in the two years.

Should your hospital's employees receive hepatitis B vaccine?

The hepatitis B risk for hospital employees is a function of their own prior experience with this disease and their frequency of exposure to patient blood, plus characteristics of the hospital's patient population, services, and prevention policies. Assessment of the hospital's risk includes consideration of costs associated with employee cases of hepatitis B, employee turnover rates, frequency of exposure incidents, and costs for preexposure and postexposure hepatitis B prevention policies. Benefits occur for both employee and hospital when the risk of hepatitis B transmission is minimized. Each institution must remember that it does not operate in isolation; its policies will be compared to those of other health care organizations. Participation in community efforts to develop local standards is advisable, but administrators should also recognize the possibility of having unique groups of high-risk employees in their own hospital. Analysis of each of the twelve issues will provide hospital decision-makers with information needed to select appropriate hepatitis B prevention strategies for their institution. This information should help in the development of a plan that will balance the costs and benefits of hepatitis B vaccine and, at the same time, protect employees from this occupational health problem.