Training physicians for the future US Health Care System.

Changes in US medical education have not yet paralleled the extraordinary recent advances in biomedical science. This is about to change with recent innovations in undergraduate medical education (UME) pedagogy. These changes include the 'flipped classroom,' new Liaison Committee on Medical Education requirements for learners to function collaboratively on health care teams that include other health professionals, the comprehensive development of professional identity in learning communities and adoption of measurable outcomes, termed 'entrustable professional activities'. These innovations offer the opportunity for a consistent longitudinal educational continuum in the US from UME to Graduate Medical Education (GME) and continuing medical education (CME). Such innovation addresses both individual patient and population health, with the potential for increasing shared decision-making and patient satisfaction. These innovations in US medical education have the potential to address the Institute for Healthcare Improvement's triple aim of improving patient care, improving the health of populations and reducing the per capita cost of health care.

Educational agendas for interdisciplinary end-of-life curricula.

The importance of an interdisciplinary end-of-life curricula for the intensive care unit is now recognized. Educational agendas for interdisciplinary end-of-life curricula are being developed across the United States. However, the limited database on palliative care education precludes evidence-based recommendations. Through a case-based approach, the need for an interdisciplinary team is explored, including the definition of an interdisciplinary team and the step-wise incorporation of specific members, such as physicians, nurses, social workers, and the chaplain, as patient care evolves. Core competencies for end-of-life care are enumerated including the approaches to end-of-life care, ethical and legal constraints, symptom management, specific end-of-life syndromes/palliative crises, and development of communication skills for trusting relationships. Finally, four phases of ICU management of curative and comfort care are proposed: phase I, focus on checklist for transfer; phase II, focus on life-saving treatments; phase III, focus on the "whole" patient; and phase IV, focus on palliative care.

Exhaled nitric oxide levels correlate with measures of disease control in asthma.

BACKGROUND: Asthma guidelines emphasize maintaining disease control. However, objective measures of asthma disease control are lacking. OBJECTIVE: We sought to examine the relationship between exhaled nitric oxide (NO) levels and measures of asthma disease control versus asthma disease severity. METHODS: We performed a cross-sectional study of 100 patients (age range, 7-80 years) with asthma. We administered a questionnaire to identify characteristics of asthma, performed spirometric testing before and after administration of a bronchodilator, and measured exhaled NO levels in all participants. RESULTS: Exhaled NO was significantly correlated with the following markers of asthma disease control: asthma symptoms within the past 2 weeks (P =.02), dyspnea score (P =. 02), daily use of rescue medications (P =.01), and reversibility of airflow obstruction (P =.02). Exhaled NO levels were not correlated with the following markers of asthma disease severity: history of respiratory failure (P =.20), health care use (P =.08), fixed airflow obstruction (P =.91), or a validated asthma severity score (P =.19). Markers with relevance to both disease control and severity showed either a weak correlation (FEV(1) and FEV(1) percent predicted) or no correlation (controller drug use) with exhaled NO. CONCLUSION: We conclude that exhaled NO levels are correlated predominantly with markers of asthma control rather than asthma severity. Monitoring of exhaled NO may be useful in outpatient asthma management.

Pneumoperitoneum: a review of nonsurgical causes.

OBJECTIVE: To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate. DATA SOURCE: We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications. STUDY SELECTION: We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy. DATA SYNTHESIS: Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic. CONCLUSIONS: Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Increased exhaled nitric oxide in chronic bronchitis: comparison with asthma and COPD.

STUDY OBJECTIVES: To test the hypothesis that exhaled nitric oxide (NO) is increased in patients with chronic bronchitis, and to compare the results with exhaled NO in patients with asthma and COPD. STUDY DESIGN: Cross-sectional survey. SETTING AND PATIENTS: Veterans Administration pulmonary function laboratory. Patients (n = 179) were recruited from 234 consecutive patients. Two nonsmoking control groups of similar age, with normal spirometry measurements and no lung disease, were used (18 patient control subjects and 20 volunteers). MEASUREMENTS: Participants completed questionnaires and spirometry testing. Exhaled NO was measured by chemiluminescence using a single-breath exhalation technique. RESULTS: Current smoking status was associated with reduced levels of exhaled NO (smokers, 9. 2 +/- 0.9 parts per billion [ppb]; never and ex-smokers, 14.3 +/- 0. 6 ppb; p < 0.0001). Current smokers (n = 57) were excluded from further analysis. Among nonsmokers, the levels of exhaled NO were significantly higher in patients with chronic bronchitis (17.0 +/- 1. 1 ppb; p = 0.035) and asthma (16.4 +/- 1.3 ppb; p = 0.05) but not in those with COPD (14.7 +/- 1.0 ppb; p = 0.17) when compared with either control group (patient control subjects, 11.1 +/- 1.6 ppb; outside control subjects, 11.5 +/- 1.5 ppb). The highest mean exhaled NO concentration occurred in patients with both chronic bronchitis and asthma (20.2 +/- 1.6 ppb; p = 0.005 vs control subjects). CONCLUSIONS: Exhaled NO is increased in patients with chronic bronchitis. The increase of exhaled NO in patients with chronic bronchitis was similar to that seen in patients with asthma. The highest mean exhaled NO occurred in patients with both chronic bronchitis and asthma. Exhaled NO was not increased in patients with COPD. Although chronic bronchitis and asthma have distinct histopathologic features, increased exhaled NO in patients with both diseases suggests common features of inflammation.

Smoking cessation in primary care clinics.

OBJECTIVES: To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements. DESIGN: Randomized clinical trial. SETTING: Two university-affiliated community primary care clinics. PATIENTS: Two hundred five smokers with routinely scheduled appointments. INTERVENTION: All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements. MEASUREMENTS AND MAIN RESULTS: Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95% [CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy ( p =.05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%. CONCLUSIONS: The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.

Associations of smoking with hospital-based care and quality of life in patients with obstructive airway disease.

STUDY OBJECTIVES: To investigate the relationship between direct or environmental tobacco smoke (ETS) exposure and both hospital-based care (HBC) and quality of life (QOL) among subjects with asthma. STUDY DESIGN: We report baseline cross-sectional data on 619 subjects with asthma, including direct or ETS exposure and QOL, and prospective longitudinal data on HBC using administrative databases for 30 months following baseline evaluation. SETTING AND PATIENTS: Participants were health maintenance organization members with physician-diagnosed asthma involved in a longitudinal study of risk factors for hospital-based asthma care. MEASUREMENTS: Demographic characteristics and QOL were assessed with administered questionnaires, including the Marks Asthma Quality-of-Life (AQLQ) and SF-36 questionnaires. HBC was defined as episodes per person-year of hospital-based asthma care, which included emergency department and urgency care visits, and hospitalizations for asthma. RESULTS: Current smokers reported significantly worse QOL than never-smokers in two of five domains of the AQLQ (p < 0.05). Subjects with ETS exposure also reported significantly worse QOL than those without ETS exposure in two domains (p < 0.05). On the SF-36, current smokers reported significantly worse QOL than never-smokers in five of nine domains (p < 0.05). Subjects with ETS exposure reported significantly worse QOL than those without ETS exposure in three domains (p < 0.05). Current smokers used significantly more hospital-based asthma care than never-smokers (adjusted relative risk [RR], 1.40; 95% confidence interval [CI], 1.01 to 1.95) while ex-smokers did not exhibit increased risk compared with nonsmokers (adjusted RR, 0.94; 95% CI, 0.7 to 1.3). Also, subjects with ETS exposure used significantly more hospital-based asthma care than those without ETS exposure (RR, 2.34; 95% CI, 1.80 to 3.05). CONCLUSIONS: Direct or environmental tobacco exposure prospectively predicted increased health-care utilization for asthma and reduced QOL in patients with asthma. These findings add to our existing knowledge of the detrimental effects of tobacco smoke and are of relevance specifically to patients with asthma.

Lack of correlation of symptoms with specialist-assessed long-term asthma severity.

STUDY OBJECTIVES: To validate three indicators of asthma severity as defined in the National Asthma Education Program (NAEP) guidelines (ie, frequency of symptoms, degree of airflow obstruction, and frequency of use of oral glucocorticoids), alone and in combination, against severity as assessed by pulmonary specialists provided with 24-month medical chart data. DESIGN: Cross-sectional comparison of questionnaire and clinical-based markers of asthma severity with physician-assessed severity based on chart review. The pulmonologists did not have access to the results of the baseline evaluations when making their severity assessments. SETTING AND PARTICIPANTS: Study participants were 193 asthmatic members (age range, 6 to 55 years) of a large health maintenance organization who underwent a baseline evaluation as part of a separate longitudinal study. This evaluation consisted of spirometry, skin prick testing, and a survey that included questions on symptoms and medication use. The participants in the ancillary study were selected, based on their baseline evaluation, to reflect a broad range of asthma severity. RESULTS: Based on the chart review, 86 of the study subjects (45%) had mild disease, 90 (45%) had moderate disease, and 17 (9%) had severe disease. This physician-assessed severity correlated highly (p < or = 0.013) with NAEP-based indices of severity based on oral glucocorticoid use (never, infrequently for attacks, frequently for attacks, and daily use) and on spirometry (FEV1 > 80% predicted, 60 to 80% predicted, and <60% predicted). It did not, however, correlate with current asthma symptoms (< or = once/week, 2 to 6 times/week, daily) (p=0.87). A composite severity score based on spirometry and the glucocorticoid use data still provided an overall agreement of 63%, with a weighted kappa of 0.40. CONCLUSIONS: While current symptoms are the most important concern of patients with asthma, they reflect the current level of asthma control more than underlying disease severity. Investigators must therefore use caution when comparing groups of patients for whom severity categorization is based largely on symptomatology. This observation, that symptoms alone do not reflect disease severity, becomes even more important as health-care delivery moves closer to protocols/practice guidelines and "best treatment" programs that rely heavily on symptoms to guide subsequent treatment decisions.

20-year trends in the prevalence of asthma and chronic airflow obstruction in an HMO.

Although asthma is on the rise in the United States and elsewhere, data on age-sex-specific patterns of change in various types of health care utilization are scarce. We report on 20-yr trends in the treated prevalence of asthma among members of a large health maintenance organization. Data are presented separately for each of six age-sex categories, and include both the treated prevalence of asthma as well as the treated prevalence of the broader category of chronic airflow obstruction (CAO), defined as asthma, chronic bronchitis, or emphysema. During the period 1967-1987 the treated prevalence of asthma and CAO increased significantly in all age-sex categories except males aged 65 and older. These patterns are in contrast to previous studies of this population that showed that increases in asthma hospitalizations and hospital-based episodes of care were limited primarily to young boys. Not only do these findings support other evidence of a real increase in asthma prevalence, but they also highlight the risks associated with drawing inferences about changing disease epidemiology based on a single type of health care utilization.

Case study: audio feedforward treatment of selective mutism.

Selective mutism is a relatively rare and difficult-to-treat disorder. Audio feedforward is a potential intervention that involves having the individual with selective mutism listen to audiotapes edited to depict him or her speaking in situations in which he or she is not currently speaking. The successful use of this intervention for three children with selective mutism is reported. The intervention was used in both school and community settings. This intervention has not always proved successful, sometimes because children refused to make the audiotapes.

Characteristics of patients with asthma within a large HMO: a comparison by age and gender.

Adequate information about characteristics of asthmatic patients in large health maintenance organizations (HMOs) is still lacking. As part of an ongoing longitudinal study, baseline data were collected on 914 individuals aged 3 to 55 yr with physician-diagnosed asthma within a large HMO, Kaiser Permanente, NW Region. There were no significant differences between men and women in post-bronchodilator FEV1 when expressed as percent (%) predicted yet women with asthma reported more daytime and nocturnal symptoms than men (p = 0.002), and worse quality of life in all but three of 14 subscales in two asthma quality of life instruments. Specifically, women in the 35-55 yr age group uniformly reported worse physical functioning on the SF-36 quality of life scale (71 +/- 23 versus 85 +/- 18; p = 0.001), social functioning (73 +/- 21 versus 77 +/- 20; p = 0.016), and bodily pain (63 +/- 27 versus 72 +/- 24; p < 0.001). Also these women reported use of more health care (p = 0.002) and more medications for asthma than men (p < 0.01). Our data suggest that men and women respond differently to their asthma, and observed gender differences in various measures of asthma such as hospital admissions, quality of life, and use of metered dose inhalers (MDIs), may be related to this difference in response to disease, rather than to real differences in the disease between men and women. Understanding gender related differences in response to a chronic disease such as asthma is important in tailoring an education and management plan to each individual patient.

Specialty differences in the management of asthma. A cross-sectional assessment of allergists' patients and generalists' patients in a large HMO.

OBJECTIVE: To examine the differences in medical management and quality of life between patients with asthma who receive their primary asthma care from allergists and those who receive their care from generalists in a large health maintenance organization (HMO). METHODS: We conducted a cross-sectional study of patients with asthma in a large HMO (Kaiser Permanente, Northwest Region, Portland, Ore). Participants were 392 individuals aged 15 through 55 years with physician-diagnosed asthma, taking antiasthma medications, reporting current asthma symptoms, and receiving asthma care from an allergist or from a generalist. Primary outcomes include characteristics of asthma, health care utilization, and quality of life. RESULTS: Patients cared for by allergists tended to have more severe asthma than those cared for by generalists (P < .01). The allergists' patients tended to be older (38.6 +/- 9.6 years vs 35.7 +/- 12.6 years, P < .01), more atopic (91% vs 78%, P < .01), and more likely to report perennial (rather than seasonal) asthma (26% vs 36%, P < .04) than the generalists' patients. Patients receiving their primary asthma care from an allergist were considerably more likely than generalists' patients to report using inhaled anti-inflammatory agents (P < .01), oral steroids (P < .01), and regular (daily) breathing medications to control their asthma (P < .01). Allergists' patients were more likely to have asthma exacerbations treated in a clinic setting rather than an emergency department (P < .01). Furthermore, allergists' patients reported significantly improved quality of life as measured by several dimensions of the SF-36 scale (physical functioning, role emotional, bodily pain, and general health; P < .05). CONCLUSIONS: These findings suggest that specialist care of asthma is of benefit for patients with asthma in a large HMO. Specifically, the allergists' patients conformed more closely to national asthma management guidelines and reported better quality of life than did the generalists' patients.

Ethics of allocating intensive care unit resources.

ICU clinicians commonly make decisions that allocate resources. Because of the high cost of ICU care, these practitioners can expect to be involved in the growing dilemma of trying to meet increasing demand for healthcare services within financial constraints. In order to participate meaningfully in a societal discussion over fairness in allocating scare and expensive resources, ICU practitioners should have more than a superficial knowledge of the principles of distributive justice. Distributive justice refers to fairness in the distribution of limited resources and benefits. Fairness refers to giving equal treatment to all those who are the same with regard to certain morally significant characteristics and treating in a different manner those who are not the same. Although theoretical issues remain unresolved as to which characteristics should be most significant, the United States has a strong cultural value that regards individuals as inherently valuable and having equal social worth. From this, it is likely that only an egalitarian approach to allocation of lifesaving healthcare resources will be acceptable. Studies of how ICU resources have been allocated during times of scarcity indicates that, in general, when beds are scarce, the average severity of illness of those admitted to the ICU increases. However, in some hospitals, political and economic factors appear to play important roles in determining who has access to scarce ICU beds. Of great concern is documentation of a widespread pattern in which fewer hospital resources, including ICU resources, are provided to seriously ill patients of minority status or with low levels of insurance reimbursement. How society's values get translated into allocation decisions is another unresolved issue. One recent example of how this occurred is the Oregon Medicaid Plan. This plan extended Medicaid coverage to additional people in poverty, despite the same amount of state and federal funds. This was accomplished by not reimbursing what were regarded as marginally beneficial services on the basis of medical and community input. Portents of how society might be involved in the future of health care are illustrated by the argument that society should limit access to all therapies except palliative care solely on the basis of advanced age. Until an open consensus develops in U.S. society about how to allocate scarce healthcare resources, the delivery of ICU care will continue to be at risk of covert, de facto rationing based on ability to pay, race, or other nonmedical personal characteristics.

Behavioral characteristics of children with stool toileting refusal.

OBJECTIVE: To determine if children with stool toileting refusal have more behavior problems than matched children who are toilet trained. DESIGN: Case-control study. SETTING: Suburban private pediatric practice. PARTICIPANTS: Children 30 to 48 months old who had achieved bladder control but refused to defecate on the toilet were identified as cases. Controls were sex- and age-matched children who were fully toilet trained. MEASURES: Total behavior problems were assessed using a semi-structured behavior screening interview with the child's parents. The parents also completed the Child Behavior Checklist for ages 2 to 4 and either the Toddler Temperament Scale (30 to 36 months old) or the Behavioral Style Questionnaire (36 to 48 months old). Child compliance with adult instructions was measured during a room clean-up task. RESULTS: Children with stool toileting refusal were not found to have more behavior problems than the matched children who were toilet trained. There were no differences between the two groups in compliance during the room clean-up task. There was a trend toward children with stool toileting refusal having a more difficult temperament, and these children were reported to have more problems with constipation and painful bowel movements than the controls. CONCLUSIONS: Children with stool toileting refusal do not have more behavior problems than controls who are toilet trained. Parents do report higher rates of constipation and painful defecation, but it is not clear whether this is a cause or effect of stool toileting refusal.

Periodicity of asthma, emphysema, and chronic bronchitis in a northwest health maintenance organization.

STUDY OBJECTIVE: Since seasonal patterns in morbidity may identify triggers provoking hospital-based care for airflow obstruction, this study examined seasonal variation in patterns of hospitalizations for asthma, chronic bronchitis, and emphysema. DESIGN AND SETTING: The data for this analysis were derived from the abstracted medical records of a large health maintenance organization, Kaiser Permanente, Northwest region, over the period 1979 to 1987. PATIENTS: In all, 2,060 primary hospital discharges for asthma and 1,121 primary hospital discharges for the combination chronic bronchitis/emphysema were observed. RESULTS: The monthly patterns varied for asthma and chronic bronchitis/emphysema, and also varied by age and sex. For young children 0 to 14 years, asthma hospitalizations peaked primarily in the fall. In contrast, for young children 0 to 14 years, hospitalizations for chronic bronchitis/ emphysema peaked in the fall/winter months. Seasonal variation decreased as age increased for chronic bronchitis/emphysema, such that for the 65+ year group, there was no seasonal variation. CONCLUSION: A better understanding of the causes of the age-specific seasonal patterns in these obstructive respiratory diseases may help to reduce the morbidity that is associated with them.

Self-reported food reactions and their associations with asthma.

The role of food reactions in asthma has not been well described. The objectives of this study were to evaluate the types of self-reported reactions to foods in asthmatic patients, and to determine the association between self-reported food reactions and self-reported severity of asthma and asthma health care utilization. We characterized 914 patients, aged 3-55 years, in a large health maintenance organization. We characterized the patients according to demographic data (age, sex, occupation, SES, marital status) and their asthma according to duration, triggers, severity (symptoms, FEV1 percentage predicted) and presence of atopy. Overall, 414 (45.3%) participants, primarily women, reported adverse reactions to food, particularly milk, red wine, eggs, chocolate, and peanuts. Those with food reactions were more likely to report having ever been hospitalized for breathing problems than those without food reactions (31% vs. 22%, two-tailed p = 0.004) although their asthma was not worse. Self-reported food reactions, particularly in females, may be associated with increased asthma health care utilization, and such patients may require closer health care management.

A revised teacher rating scale for reactive and proactive aggression.

A teacher rating scale of reactive aggression, proactive aggression, and covert antisocial behavior was evaluated in a normative sample of third- to fifth-grade predominantly white lower middle class boys (N = 186). Factor analysis revealed independent and internally consistent Reactive Aggression (six reactive items), and Proactive Aggression (five proactive items, five covert items) factors. Although the factors were intercorrelated (r = .67), and each factor was significantly correlated with negative peer social status (r = .26 for each, controlling for grade), the independence of the factors was supported by the unique relation of Reactive Aggression with in-school detentions (r = .31), controlling for Proactive Aggression and grade. These results supported the reliability and validity of Reactive and Proactive Aggression as rated by teachers, which should facilitate further research of these constructs.

Use of an automated prescription database to identify individuals with asthma.

We used medication-dispensing information for 4 years (1/1/87 through 12/31/90) to examine the utilization of anti-asthma medications among 175,562 members of a large health maintenance organization. A total of 297,863 anti-asthma medications was dispensed during the study period, over one-half of which (55%) were beta-agonists, followed by aminophylline preparations (23%) and inhaled corticosteroids (13%). Next, we compared the predictive value of three algorithms for identifying individuals with asthma: (1) two or more beta-agonist dispensings, (2) both a beta-agonist and an inhaled corticosteroid dispensing, and (3) five or more total anti-asthma dispensings. We performed chart reviews for 40 subjects aged 5-45 years in each of these three groups and made a clinical judgment, based on all available information in the chart, as to whether each patient had asthma. Two levels of certainty were used: "any asthma" and "definite asthma." All 120 charts reviewed presented a clinical picture consistent with asthma. However, patients identified by the algorithm that included both a beta-agonist and an inhaled corticosteroid were more likely to meet our criteria for "definite" asthma and more likely to have moderate to severe asthma. These results demonstrate the feasibility of using an automated outpatient pharmacy database to identify patients with asthma.

Parental knowledge and attitudes toward children with AIDS: influences on educational policies and children's attitudes.

Surveyed AIDS-related knowledge and attitudes of parents and their children to provide descriptive information on views about school policies concerning HIV-infected children and to test hypotheses regarding links between parents' and children's AIDS-related knowledge and attitudes. Results indicate that parents desire more information about presence of persons with AIDS (PWA) in the schools than is permissible by law and that a significant minority of parents objected to allowing HIV-infected students in schools. As predicted, more accurate parental knowledge of AIDS and knowing a PWA were associated with greater willingness to allow their children to interact with PWA and with greater acceptance of allowing HIV-infected children to attend regular classes. Support was also found for links between parents' and children's attitudes toward PWA. Implications for educating parents about AIDS transmission and inclusion of parents in the implementation of AIDS educational programs are discussed.