Prevention for the 21st century: setting the context through undergraduate medical education.

The generation of medical students now being taught will be practicing into the middle of the next century. They will be expected to provide an expanding array of clinical preventive services and be responsible for the health and well-being of entire populations and communities. Although prevention principles are being taught in many contexts, most medical schools do not have adequate curriculum-tracking systems that allow them to track the delivery of education and training in disease prevention and health promotion. The Bureau of Health Professions of the Health Resources and Services Administration (HRSA) and the Association of Teachers of Preventive Medicine have worked on several projects that have culminated in the development of a set of core competencies in preventive medicine for undergraduate medical education. In 1997 they convened a task force of medical educators from a broad array of basic science and clinical disciplines representing major U.S. medical teaching societies. The task force reviewed and updated the 1984 Inventory of Knowledge and Skills Relating to Disease Prevention and Health Promotion so that it would be relevant to faculty in diverse specialty areas and could be integrated throughout the medical curriculum. They then created a list of competencies that are essential from the perspective of each discipline and all disciplines. The article gives the context for teaching preventive medicine, presents the core competencies, and serves as the introduction to a supplement to Academic Medicine on teaching preventive medicine throughout the undergraduate medical curriculum.

Problem-based learning in ophthalmology: a pilot program for curricular renewal.

OBJECTIVES: To gain experience with problem-based learning as a demonstration project in a medical school's curriculum renewal effort and determine if using a single facilitator to circulate among the small groups would yield positive results. DESIGN: We developed 16 cases around 4 ophthalmic problems that were used in 3-hour small-group sessions during the Introduction to Clinical Medicine semester of the second-year curriculum. A single faculty member facilitated the small groups of 4 students each that were created by self-division at each of 5 sessions. SETTING: A state-supported large Midwestern medical school. PARTICIPANTS: All students (N = 75) enrolled in the Introduction to Clinical Medicine course prior to their standard introductory ophthalmology lectures. MAIN OUTCOME MEASURES: A 5-item pretest, related to each of that day's clinical problems, was administered at the beginning and again at the end of the session as a posttest. A satisfaction questionnaire with Likert-type questions was also completed by the students at the close of the session. RESULTS: Knowledge scores showed statistically significant gains with a mean of 1.7 points. Student satisfaction was very positive--85% stated that they learned more than they would have in the traditional format and 93% agreed that they enjoyed the problem-based learning format. CONCLUSIONS: A single facilitator successfully managed small groups of students in a modified problem-based learning format that produced significant knowledge gains and high student satisfaction. This positive experience was one of the factors that led to adoption of problem-based learning into the curriculum.

Peer reviewing and curating the health care information infrastructure: experiences and recommendations.

As part of a digital health sciences library's continuous quality improvement process, a digital textbook of common medical problems was created which contained links to authoritative medical information on the Internet for patients and health care providers. The accomplishments of this project were the: 1) Identification of 50 common medical problems, 2) Development of a methodology for identifying authoritative medical information related to these problems, 3) Creation of a digital textbook containing links to this information with a problem-based interface, 4) Development of a methodology to allow local peer review of this information, and 5) Evaluation of the use of the information and the local peer review methodology.

Community health assessment: diagnosis and prescription.

Community health assessments are ideally a joint effort by all the major health care providers in the community, working in concert with local government, business, and concerned community groups. A noble activity, no doubt, but clearly a lot of trouble. Physicians, whose potential to contribute to community assessments is obvious, frequently avoid them. Whether in management or clinical practice, they ask: Is this really worth my time? Will it make any difference? Isn't there a better way? But, rightly or wrongly, physicians often have a disproportionate amount of influence on the community assessment process. That influence, whether you attribute it to respect, credibility, or power, adds value to the process. The most important quality the physician brings to the process is genuine concern for his or her patients that generalizes to the health of the entire community.

Surveying smokeless tobacco use, oral lesions and cessation among high school boys.

We surveyed 821 Iowa teenage boys to establish patterns of smokeless tobacco use, occurrence of oral lesions and the effect of lesions on attitudes about quitting, current use and plans for future use. Results suggest that young ST users who currently have a lesion or have experienced lesions may be particularly receptive to discussion of quitting options and other information about ST health effects. Dentists and other oral health professionals should initiate ST intervention when establishing a lesion history or on discovering a lesion at examination.

The COMMIT dental model: tobacco control practices and attitudes.

The National Cancer Institute's program to help dentists reduce tobacco use among their patients is part of the Community Intervention Trial for Smoking Cessation, a 22-community, randomly controlled trial of an intervention program for smoking cessation. Results of COMMIT baseline surveys of dentists in the 11 intervention communities are presented.

Survival from out-of-hospital cardiac arrest: effects of patient age and presence of 911 Emergency Medical Services phone access.

The purpose of this investigation was to determine factors associated with survival from out-of-hospital cardiac arrest, including effects of 911 Emergency Medical Services telephone access and the age of patient. Subjects included 1,753 prehospital cardiac arrest patients in Iowa. Patient survival status and other variables were compared for patients with access to a 911 service with those who did not, and for different age categories, using univariate associations and multivariate logistic regression analysis. The presence of 911 telephone access was significantly associated with survival from out-of-hospital cardiac arrest (9.18% versus 5.35% survival for 911 versus no 911 groups, respectively). This association was partially the result of the significant association of 911 with decreased time from collapse to call for help, decreased time to cardiopulmonary resuscitation (CPR), and decreased time to first shock (if in ventricular fibrillation [VF]). Younger age was significantly associated with survival in univariate analyses (8.94% versus 6.26% survival for younger versus older age groups, respectively), but this was not an independent association, which is indicated by the lack of significance of age in the multivariate model.

Risk factors for adolescent cigarette smoking. The Muscatine study.

Smoking among adolescents is a developmental phenomenon with several factors exerting an influence on cigarette use at different times. We examined the longitudinal influences of several behavioral and social variables on the smoking status of 443 students followed from early to late adolescence. Of the factors examined, association with friends who smoke and previous smoking status were consistently associated with an adolescent's future smoking status. Other factors, such as attachment to father or to mother, parental supervision, extracurricular activity, perceived negative and positive effects of smoking, and academic involvement, were all related to late adolescent smoking status. These observations suggest that strategies that influence smoking behavior need to be directed not only to the individual child but also to influences within the child's home and school environment.

Demographic and health characteristics of elderly smokers: results from established populations for epidemiologic studies of the elderly.

Although smoking has been shown to be associated with excess morbidity and mortality, most studies have focused on young and middle-aged rather than elderly smokers. We examined the demographic characteristics and physical and psychological health of elderly cigarette smokers in four population-based studies (N = 3,673, 3,811, 2,811, and 4,165) of persons 65 years of age and older. Although there was substantial geographic variation in the percentages of smokers, the demographic and health characteristics of smokers were similar across the sites. Most women had never smoked, but most men were former or current smokers. The percentage of never smokers was highest in the "oldest old." Among the elderly ever smokers, men were more likely to have quit than women, and the relative percentage of former smokers increased with age. Current smokers were generally more likely to consume alcohol than never smokers. In this age group, cigarette smoking was typically associated with higher rates of physical disease and symptoms, poorer self-perceived health status, and higher levels of depressive symptoms. Based on these four large geographically diverse population surveys, cigarette smoking remains an important health burden and public health challenge among the elderly.

Attitudes, knowledge, and beliefs as predictors of exercise intent and behavior in schoolchildren.

Physical education programs represent an important gateway for encouraging young people to develop life-long exercise habits. In this study of middle school students (N = 603), attitudes toward physical education, knowledge about the benefits of exercise, and beliefs about one's abilities were assessed to determine their influence on exercise intent and current exercise behavior. As predicted, perceived benefits of exercise, current exercise behavior, attitudes toward physical education, self-esteem, and gender contributed significantly and independently to exercise intent (total variance explained = 37%). Exercise intent, outside sports activities, perceived benefits of exercise, gender, and attitudes toward physical education contributed significantly and independently to current exercise behavior (total variance explained = 27%). Programs that make attending physical education a pleasant experience and that explain specific benefits of exercise can influence exercise intent and can enhance students' sense of self-esteem, both of which may increase future exercise behavior.

Should dentists advise smokers to stop?

This study surveyed 391 dentists to determine their current practices with patients who smoke. About two-thirds of respondents (71%) said they advise smokers to stop. Although most respondents advised patients of negative health effects of smoking, few provided suggestions to patients, referred them to smoking cessation programs, provided self-help materials, or scheduled follow-up sessions. Recent evidence suggests that even brief counseling interventions can help some patients stop smoking.

Community differences in blood pressure levels and drinking water sodium.

In a study conducted in 1980-1981, the authors surveyed over 2000 school children in eight Iowa communities whose drinking water sodium levels varied from less than 10 to greater than 300 mg/liter. Children in grades 2-5 had four blood pressures, skinfold, height, weight, and heart rates measured while in school. The range of the difference between mean blood pressures by community was less than 4 mmHg for systolic and fourth phase diastolic. An association between blood pressure and water sodium level was not demonstrated before or after adjustment for covariates. In a subsample of over 200 households in four communities, the authors examined the relationship of blood pressures in adults to water sodium level. Blood pressure means for adults by community varied less than 4 mmHg for systolic and diastolic measurements. This variance was not explained by sodium level in the drinking water. These surveys do not substantiate previous reports of a positive association between drinking water sodium levels and blood pressure levels.

Respiratory symptoms and pulmonary function in welders of mild steel: a cross-sectional study.

Pulmonary function measurements, respiratory symptoms, smoking history, and occupational history were obtained from 91 male welders of mild steel, with mean welding exposure of 108 months, and 80 male factory controls. Nonsmoking welders compared to nonsmoking controls reported higher frequencies of respiratory symptoms and the differences were statistically significant for two symptoms: phlegm, and episodes of cough and phlegm. In comparisons of smoking welders and smoking controls, no significant differences were found in the prevalence of respiratory symptoms. Nonsmoking welders and smoking welders, compared to respective controls, did not have significantly decreased mean values of forced vital capacity or forced expired volume in 1 sec. Mean mid-expiratory flow rates and forced expiratory flow rates at 75% of forced vital capacity were lower, but not significantly different, for welders, compared to controls. These decrements in peripheral flow rates could be trivial or they could represent the initial stages of chronic obstructive pulmonary disease. Long-term follow-up, provided by a large prospective study, is needed to make this distinction.

Ischemic heart disease mortality in Iowa farmers. The influence of life-style.

Analysis of 62,000 deaths in Iowa men aged 20 to 64 years from 1964 to 1978 indicates that Iowa farm men younger than 65 years have lower than expected mortality for all causes and for ischemic heart disease. Using data gathered by the Iowa Lipid Research Clinics (LRC) Program Prevalence Study, we compared levels of known cardiovascular risk factors in farmers with those of nonfarmers residing in the same rural county. Farm men smoked less frequently (19% v 44%) and engaged in exercise more frequently (83% v 40%) than nonfarmers. Treadmill performance in farm men indicates a higher level of fitness in farmers. Farm people consumed more total calories and cholesterol, but drank less alcohol than nonfarmers. Farm men had significantly higher serum cholesterol levels. High-density lipoprotein cholesterol levels were also higher in farmers. However, when adjusted for age and exercise status, farmers and nonfarmers had similar lipid levels. The results of the LRC survey suggest that the lower mortality rates of Iowa farmers are a reflection of a life-style that includes vigorous exercise and little consumption of alcohol and tobacco.

Cancer incidence in humans: relationship to plasma lipids and relative weight.

Surveillance was done on cancers in subjects in rural Iowa for 6 years after they participated in a cardiovascular risk factor-screening program. Among 5,565 men and women 20-94 years old at screening, 131 persons were identified as having cancers. Each cancer patient was matched to a control without cancer, and differences in antecedent plasma cholesterol and triglyceride levels and relative weight were sought. Mean relative weight at screening was lower among cancer patients of both sexes than among controls. Plasma cholesterol levels were lower among male patients and higher among female patients than among controls, with the differences more prominent for those less than 60 years old at screening. In males, the lower cholesterol levels occurred only in those with neoplasms developing within 24 months of screening. The higher cholesterol levels among female patients with cancers limited to gonadal hormone-related sites were not time-dependent. Triglyceride levels were not significantly different between cancer patients and controls in any analytic group, but triglyceride levels did closely parallel cholesterol alterations. A minimum of 1% of the cohort had diagnosed cancers before the screening program.

Alcohol and hypertension: epidemiologic and experimental considerations. The Lipid Research Clinics Program.

Most epidemiologic studies suggest that alcohol consumption is associated with increased blood pressure levels and an increased prevalence of hypertension. A review of experimental studies of the blood pressure effects of acute alcohol administration to man and acute and chronic administration to animals does not clearly support the epidemiologic findings, which suggest that other direct or indirect factors besides a simple pharmacologic effect of alcohol may be operative. Several endocrine and renal mechanisms have been postulated, and indirect factors related to both alcohol use and blood pressure pathogenesis cannot be firmly excluded. Preliminary data from the Lipid Research Clinics (LRC) population studies generally show a positive association between alcohol and blood pressure, although women and young men reporting no alcohol use had higher systolic pressures than those reporting low levels of alcohol intake. LRC findings also suggest that the blood pressure elevations associated with use of oral contraceptives appear to be independent of those associated with alcohol. Some preliminary epidemiologic findings and circumstantial evidence suggest that the alcohol-blood pressure relationship may be due in part to the timing of blood pressure measurement during physiologic alcohol withdrawal. Although further verification is needed, this hypothesis implies that the pattern of alcohol consumption and the interval between last use and blood pressure measurement may be as important as the amount of alcohol consumed in explaining the relationship between alcohol and blood pressure.