Improving colon cancer screening rates in primary care: a pilot study emphasising the role of the medical assistant.

BACKGROUND: Colorectal cancer (CRC) is the third-leading cause of cancer death for both men and women in the USA. Despite consensus recommendations for screening, just over half of eligible adults nationally have undergone screening. We therefore implemented a programme to improve the rate of CRC screening. METHODS: This study was conducted in the Utah Health Research Network and the University of Utah Community Clinics, a 100 000 patient, seven-practice, university-owned system offering primary and secondary care and ancillary services including endoscopy. We focused on patients aged >or=50 who were seen between 1 January 2003 and 31 October 2006, and who were not current for CRC screening at the time of the visit. The study included a three-phase INTERVENTION: electronic medical record (EMR) reminders, physician and medical assistant (MA) education about CRC screening guidelines, and redesign of patient visit workflow with an expanded role for MAs to review patients' CRC screening status and recommend testing when appropriate. With patient agreement, the MA entered a preliminary order in the EMR, and the physician confirmed or rejected the order. The primary outcome measure was the rate of screening colonoscopy ordered for eligible patients. RESULTS: The baseline colonoscopy referral rate was 6.0%. Provider education and electronic reminders had minimal immediate impact on screening rates. Addition of the expanded MA role was associated with a sustained increase in colonoscopy referral order rate to 13.4%, a relative improvement of 123%. CONCLUSIONS: The MA can play a key role in improving CRC screening rates as part of a redesigned system of primary care.

High rates of multiple antibiotic resistance in Streptococcus pneumoniae from healthy children living in isolated rural communities: association with cephalosporin use and intrafamilial transmission.

OBJECTIVE: Streptococcus pneumoniae is one of the most clinically significant pathogens with emerging antibiotic resistance. We performed a surveillance study in isolated rural populations of healthy children to estimate the prevalence of pneumococcal resistance and to contrast factors that predict pneumococcal carriage with those that specifically predict resistant pneumococcal carriage. METHODS: The study was conducted in 1998 in 2 rural communities in Utah. Families were recruited directly for participation through community canvassing. Surveillance nasopharyngeal cultures were obtained from children who were younger than 8 years. Antibiotic usage and information on other potential risk factors were obtained from questionnaires and local pharmacy records. Resistance was determined by testing isolates for susceptibility to penicillin, cefaclor, trimethoprim-sulfamethoxazole, erythromycin, ceftriaxone, and trovafloxacin. Selected resistant isolates were characterized further by serotyping, pulsed field gel electrophoresis, and Southern blot with DNA probes specific for the pneumococcal lytA gene and for antibiotic resistance genes. RESULTS: In April 1998, surveillance nasopharyngeal cultures were obtained from 368 children aged

Integrating public health into medical education: community health projects in a Primary Care Preceptorship.

Physicians must integrate care of populations with the care of individual patients to function optimally in today's health care environment. With this understanding, medical school curricula are increasingly addressing the skills and knowledge of public health along with those of clinical medicine. The University of Utah School of Medicine in 1997 revised its four-year curriculum to increase the teaching of topics needed by future physicians, including public health. This report describes one course in the curriculum, the Primary Care Preceptorship (PCP), a fourth-year, six-week required rotation that assists students in learning about the health needs of a community along with providing primary care for its individual residents. Students in the PCP spend approximately 60% of their time in clinical primary care and 40% completing a community health project. In the first year of the PCP, 32 students completed projects on clinical problems, 27 on community health needs assessment, 26 on patient education, and 15 on epidemiology.

What opportunities have we missed, and what bad deals have we made?

In addition to its many accomplishments, family medicine has inevitably made some choices that have not worked out as well. Respectful consideration of where we may have done so can help inform future decision making. This paper suggests some decisions that in retrospect appear to be bad deals, good deals gone bad, or missed opportunities. Bad deals include the limiting effects of our specialty's name and of our go-it-alone philosophy. Good deals gone bad include our affinity for a permanent counterculture role, our persistent belief that big is better, and limited evolution of our residency family practice centers. We have missed opportunities to lead development of a new model of patient-responsive health care, to change the system of payment for care, to maximize the strength of our discipline by links between university and community family physicians, and to build a powerful program of family medicine research.

Medicine and public health. Whose agenda?

My grandfather was a general practitioner in a rural midwestern town during the first half of this century. His office consisted of a single examining room in the family home, a tiny waiting area, and little envelopes in which he dispensed medications. Patient hours were in the evening, no appointment necessary. Mostly, folks chatted in the living room with my grandmother while waiting to see "Grandpa Doc." My grandfather's nights often included trips to neighbors' kitchens to deliver babies. Days were time to serve as the county health officer, student health director for the local college, and organizer of the town's free clinic for indigent patients, based in the Presbyterian church.

Multiple chemical sensitivity syndrome.

Multiple chemical sensitivity (MCS) is a syndrome in which multiple symptoms reportedly occur with low-level chemical exposure. Several theories have been advanced to explain the cause of MCS, including allergy, toxic effects and neurobiologic sensitization. There is insufficient scientific evidence to confirm a relationship between any of these possible causes and symptoms. Patients with MCS have high rates of depression, anxiety and somatoform disorders, but it is unclear if a causal relationship or merely an association exists between MCS and psychiatric problems. Physicians should compassionately evaluate and care for patients who have this distressing condition, while avoiding the use of unproven, expensive or potentially harmful tests and treatments. The first goal of management is to establish an effective physician-patient relationship. The patient's efforts to return to work and to a normal social life should be encouraged and supported.

Cultures in conflict: a challenge to faculty of academic health centers.

Academic health centers (AHCs) are experiencing turmoil in all three of their traditional missions of teaching, research, and patient care. The authors examine origins of universities and medical education to place in historical context the stresses affecting AHCs at the end of the 20th century. They describe the cultures of the university to suggest strategies for successful adaptation to these stresses. Clashes of values and norms of the cultures within universities and AHCs can hinder effective adaptation to external change. Administrators, researchers, teachers, and clinicians can have strongly conflicting perspectives. For example, business skill is of increasing importance to the survival of the clinical enterprise, but not typically valued by faculty members. University faculty have often considered accountability as antithetical to academic freedom, and, until recently, accountability was not strongly demanded of AHCs. The authors conclude that AHC faculty must transcend the outdated view that the roles of the scholar, scientist, and healer are in opposition to those of the leader and manager. If AHCs are to survive and prosper through their current cultural transition, their faculty must understand all these roles as part of their intellectual and organizational responsibility.

Long-term bone marrow culture profiles in patients with myelodysplastic syndromes are not explicable by defective apoptosis.

It has been suggested that increased intramedullary apoptosis may explain the paradox between peripheral blood cytopenias and the hyper- or normo-cellular bone marrow observed in the myelodysplastic syndromes (MDS). We wished to see if culture performance could be related to the presence of apoptotic cells in a group of patients with MDS (12 patients) and other patients with peripheral blood cytopenias (six patients) which caused diagnostic difficulty. There was no correlation between LTBMC or adherent cell growth and the presence of apoptotic cells in the original marrow sample. A variable degree of apoptosis was observed in both groups of patients. LTBMC profiles correlated well with diagnosis but were unrelated to the extent of intramedullary apoptosis. This suggests that apoptosis is a much more ubiquitous process in disease than previously thought.

Spontaneous intramedullary apoptosis is present in disorders other than myelodysplasia.

Myelodysplastic syndrome (MDS) is a group of hematopoietic disorders characterized by peripheral cytopenias in the presence of normo- or hypercellular dysplastic marrow. It has been suggested that premature intramedullary apoptosis may contribute to this phenomenon. We used terminal dUTP nick-end labeling (TUNEL) of bone marrow biopsy specimens and cytocentrifuge preparations from patients with MDS and a variety of other hematopoietic disorders to determine whether there is increased intramedullary apoptosis in MDS and whether any such effect is specific to MDS. TUNEL labeling of bone marrow from 24 patients with MDS revealed significant positivity in 10 of 11 patients with refractory anemia (RA), five of seven with RA and excess of blasts (RAEB), all three patients with RAEB in transformation (RAEB-t), and all three patients with RA with ring sideroblasts (RARS). The percent of positive cells ranged from 5 to 50% but showed no apparent correlation with morphological subtype. In a series of 29 patients with acute leukemia, 17 showed significant positivity (13 of 13 with myeloid disease: three M1, seven M2, one M3, two M4; four of 16 patients with lymphoid disease: one Burkitt-type lymphoma, two null acute leukemia, and one common acute lymphoid leukemia). Intramedullary apoptosis was associated with myeloid or early committed progenitor cells and was highest in secondary acute myeloid leukemia (AML). Normal bone marrow samples from 12 individuals showed no evidence of apoptosis. Our results suggest that an increased level of intramedullary apoptosis is apparent in both patients with MDS and those with AML; those with secondary AML have the highest levels. The relative absence of such findings in lymphoid malignancy suggests that the apoptotic pathways are different in this lineage.