The epidemiology of dengue fever in Palau.

BACKGROUND: Dengue fever has been a longstanding problem in Palau, and Public Health programs were implemented in 2001 to conduct surveillance for cases of the disease. Epidemiologic analysis of dengue fever cases in Palau is needed to describe disease occurrence in Palau and to help target prevention and control efforts. METHODS: Case data were collected from the Palau Ministry of Health's Reportable Disease Surveillance System. Descriptive epidemiology was performed on the case data, and spatial analysis was used to assess the distribution of dengue fever cases in Palau. RESULTS: Between January of 2001 and June of 2006, 676 cases of dengue fever occurred in Palau, and sporadic outbreaks without seasonality were noted. Characteristics of the case population included being male (57.8%), being under the age of 20 (mean age = 23.4 years), being Palauan (88.2%), having an indoor occupation (91.7%), and having no history of travel outside of Palau during the estimated exposure period (96.3%). Most cases also lived in urban areas of Palau (92.0%), and the disease rate was significantly higher in urban areas compared to rural areas (3941.8 versus 1175.7 cases per 100,000, respectively for the 5.4-year study period; p = 0.0007). CONCLUSION: This study supports the idea that dengue fever is still endemic in Palau. Control and prevention measures should be continued, and targeted toward urban areas and populations at increased risk of this disease.

Head lice treatments and school policies in the US in an era of emerging resistance: a cost-effectiveness analysis.

BACKGROUND: Head lice are a common infection in school-age children worldwide. Several authorities in the US have recommended different treatments and school policies in order to control this disease. Recent concerns of emerging lice resistance worldwide raise the necessity to reassess the current recommendations. OBJECTIVES: To perform a cost-effectiveness analysis (from the US caregiver perspective) of three head lice treatments commonly used in the US, permethrin 1%, malathion 0.5% and the lice comb, in order to evaluate the cost effectiveness of different treatments in the current era, and to explore the effect of different factors in this analysis. METHODS: We used a decision-tree model to represent the costs and effectiveness of the different treatment strategies. A patient/caregiver perspective was applied, with a time horizon of 2 weeks. Probabilities of treatment success or failure of the three treatments were based on the literature. Effectiveness was measured as the successful eradication of head lice, and costs - including the costs of the treatment, the physician co-pay and the costs of days out of school - were calculated. One-way and multi-way analyses were performed using decision analysis software (Treeage Pro Healthcare 2008). RESULTS: Combing was dominated by permethrin 1%. The incremental cost-effectiveness ratio of malathion 0.5% versus permethrin 1% was $US161.75 per cure. For caregivers whose willingness to pay is <$US161.75 per cure, permethrin 1% is the most cost-effective option. For those with a willingness to pay of > or =$US161.75 per cure malathion 1% may offer the highest net monetary benefit. Twenty percent of the uncertainty in the model is due to variation in permethrin 1% resistance, and approximately 73% of the total variability of the model is attributed to the number of days the student has to be out of school because of the school's policy. CONCLUSIONS: Our study suggests that permethrin 1% was the most cost-effective treatment for those with a willingness to pay of <$US162 per cure. Sensitivity of lice to permethrin and the specific school head lice policy had major effects on the model. Thus, informing communities in a given geographical area about the degree of head lice resistance and sensitivity is necessary in order for the public to make a rational decision regarding treatment. Schools' head lice policies have a major effect on the cost of head lice treatments.

What should students learn about complementary and alternative medicine?

With thousands of complementary and alternative medicine (CAM) treatments currently being used in the United States today, it is challenging to design a concise body of CAM content which will fit into already overly full curricula for health care students. The purpose of this article is to outline key principles which 15 National Center for Complementary and Alternative Medicine-funded education programs found useful when developing CAM course-work and selecting CAM content. Three key guiding principles are discussed: teach foundational CAM competencies to give students a framework for learning about CAM; choose specific content on the basis of evidence, demographics and condition (what conditions are most appropriate for CAM therapies?); and finally, provide students with skills for future learning, including where to find reliable information about CAM and how to search the scientific literature and assess the results of CAM research. Most of the programs developed evidence-based guides to help students find reliable CAM resources. The cumulative experiences of the 15 programs have been compiled, and an annotated table outlining the most highly recommended resources about CAM is presented.

Barriers, strategies, and lessons learned from complementary and alternative medicine curricular initiatives.

Fifteen U.S. academic programs were the recipients of a National Center for Complementary and Alternative Medicine R25 Education Grant Program to introduce curricular changes in complementary and alternative medicine (CAM) in their institutions. The authors describe the lessons learned during the implementation of these CAM education initiatives. Principal investigators identified these lessons along with discovered barriers and strategies, both those traditionally related to medical and nursing education and those unique to CAM education. Many lessons, barriers, and strategies were common across multiple institutions. Most significant among the barriers were issues such as the resistance by faculty; the curriculum being perceived as too full; presenting CAM content in an evidence-based and even-handed way; providing useful, reliable resources; and developing teaching and assessment tools. Strategies included integration into existing curriculum; creating increased visibility of the curriculum; placing efforts into faculty development; cultivating and nurturing leadership at all levels in the organization, including among students, faculty, and administration; providing access to CAM-related databases through libraries; and fostering efforts to maintain sustainability of newly established CAM curricular elements through institutionalization and embedment into overall educational activities. These lessons, along with some detail on barriers and strategies, are reported and summarized here with the goal that they will be of practical use to other institutions embarking on new CAM education initiatives.

Documenting procedures and deliveries during family practice residency: a survey of graduates' experiences, preferences, and recommendations.

BACKGROUND AND OBJECTIVES: The University of Washington Family Practice Residency Network (UW Network) is in the process of implementing a Palm Pilot-based procedure and delivery documentation system throughout 16 residency programs. Our study examined the experiences of past UW Network graduates in obtaining hospital privileges and in documenting procedures and deliveries. METHODS: A survey was mailed to 201 1999 and 2000 UW Network graduates, asking them questions about their experiences obtaining hospital privileges after graduation and documenting procedures and deliveries during their training. RESULTS: A total of 124 surveys (62% response rate) were analyzed. Ninety-four percent of the respondents had applied for hospital privileges, and 84% received all the privileges they requested. Forty-four percent indicated they had to provide some written documentation to get hospital privileges, but only 7% had to provide more than a numeric total of procedures or deliveries. Respondents predominantly used log cards and Palm Pilots for data collection. Palm Pilots were preferred over log cards, and the Palm Pilot systems received higher satisfaction ratings. CONCLUSIONS: For the majority of graduates, detailed delivery and procedure information was not necessary to obtain hospital privileges. Nevertheless, there are other reasons to document training experiences, and graduates strongly advise family practice residents to record their procedure and delivery experiences. Family practice residency programs should consider giving house staff handheld computers to record the procedures they perform.

The effects of the 1997 Balanced Budget Act on family practice residency training programs.

BACKGROUND AND OBJECTIVES: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States. METHODS: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. RESULTS: A total of 435 (96%) of the programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988-1997 to 4.8 per year in the 4 years following passage of the BBA. CONCLUSIONS: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

Accounting for graduate medical education funding in family practice training.

BACKGROUND AND OBJECTIVES: Medicare provides the majority of funding to support graduate medical education (GME). Following the flow of these funds from hospitals to training programs is an important step in accounting for GME funding. METHODS: Using a national survey of 453 family practice residency programs and Medicare hospital cost reports, we assessed residency programs' knowledge of their federal GME funding and compared their responses with the actual amounts paid to the sponsoring hospitals by Medicare. RESULTS: A total of 328 (72%) programs responded; 168 programs (51%) reported that they did not know how much federal GME funding they received. Programs that were the only residency in the hospital (61% versus 36%) and those that were community hospital-based programs (53% versus 22%) were more likely to know their GME allocation. Programs in hospitals with other residencies received less of their designated direct medical education payment than programs that were the only residency in the sponsoring hospital (-45% versus +19%). CONCLUSIONS: More than half of family practice training programs do not know how much GME they receive. These findings call for improved accountability in the use of Medicare payments that are designated for medical education.

Assessing physicians' continuing medical education (CME) needs in the U.S.-associated Pacific jurisdictions.

OBJECTIVE: To assess the self-perceived continuing medical education (CME) needs of physicians in American Samoa, Commonwealth of the Northern Mariana Islands, Guam, Federated States of Micronesia, Republic of the Marshall Islands, and the Republic of Palau. METHODS: Questionnaire-based survey of all physicians. RESULTS: Responses obtained from a total of 143 physicians in the region provided information on training backgrounds, previous experiences with CME, local access to regular CME sessions, perceived priority educational needs and preferred methods of CME delivery. CONCLUSIONS: Overall 64% of respondents had attended a formal CME event in 1999 or 2000, and 71% had access to local weekly or biweekly CME. However the perceived usefulness of these events varied by region. Priority learning needs were identified by physicians including non-communicable diseases such as diabetes, hypertension, cardiac disease; communicable diseases such as tuberculosis, HIV/AIDS and tropical diseases; as well as skills such as EKG and X-ray interpretation, trauma management and cardiac life support. Information on the most pressing educational needs and desired methods of delivery will be crucial in planning CME in this region.