Clinical, laboratory and ultrasonographic findings in 94 cows with type-1 abomasal ulcer.

INTRODUCTION: This study included 94 cows aged 2.1 to 12.0 years (5.2 ± 2.05 years) that were examined at a referral clinic because of type-1 abomasal ulcer. The most common clinical findings were poor general health status (94%), partial or complete anorexia (93%), congested scleral vessels (89%), decreased skin surface temperature (76%), decreased or absent faecal output (72%), abdominal guarding (59%), tachypnoea (56%), rumen atony (53%) and positive percussion and simultaneous auscultation and/or ballottement and simultaneous auscultation on the right side (53%). The most common laboratory findings were hypokalaemia (68%), positive base excess (60%) and azotaemia (51%). The chloride concentration of rumen fluid was increased in 48% of the cows. The diagnosis of type-1 ulcer was made during laparotomy and/or postmortem examination. One or more concurrent diseases were diagnosed in 97% of the cows. Seventy-eight (83%) cows were euthanased immediately after the initial examination, during laparotomy or after unsuccessful treatment, and eight (8.5%) cows died, and all were examined postmortem. Eight (8.5%) cows were discharged and six of these made a complete recovery.

INTRODUCTION: La présente étude a inclus 94 vaches âgées de 2,1 à 12,0 ans (5,2 ± 2,05 ans) qui ont été examinées dans une clinique de référence en raison d'un ulcère de la caillette de type 1. Les signes cliniques les plus courants étaient un mauvais état de santé général (94%), une anorexie partielle ou complète (93%), des vaisseaux scléraux congestionnés (89%), une diminution de la température de la surface de la peau (76%), une diminution ou une absence de débit fécal (72%), une défense abdominale (59%), de la tachypnée (56%), une atonie du rumen (53%) et une percussion positive avec auscultation simultanée (PSA) et / ou ballottement et auscultation simultanée (BSA) du côté droit (53%). Les résultats de laboratoire les plus courants étaient l'hypokaliémie (68%), l'excès de base positif (60%) et l'azotémie (51%). La concentration en chlorure du liquide du rumen a augmenté chez 48% des vaches. Le diagnostic d'ulcère de type 1 a été posé lors de la laparotomie et/ou de l'autopsie. Une ou plusieurs maladies concomitantes ont été diagnostiquées chez 97% des vaches. Soixante-dix-huit vaches (83%) ont été euthanasiées immédiatement après l'examen initial, pendant la laparotomie ou après un traitement infructueux, et huit vaches (8,5%) sont mortes. Toutes ont été examinées post-mortem. Huit vaches (8,5%) sont sorties de clinique et six d'entre elles ont complètement récupéré.

Clinical and laboratory findings in 60 cows with type-3 abomasal ulcer.

INTRODUCTION: This study involved 60 cows aged 1.9 to 13 years (mean 4.8 ± 2.3 years) with type-3 abomasal ulcer. The most common clinical signs were, in decreasing order of frequency, partial or complete anorexia (98%), obtunded demeanour (95%), decreased skin surface temperature (78%), congested scleral vessels (73%), abdominal guarding (61%), tachypnoea (58%), fever (58%) and tachycardia (55%). One or more concomitant disorders were diagnosed in 86% of the cows. The most common abnormal laboratory findings were hypokalaemia (75%), shortened glutaraldehyde test time (46%) and hyperfibrinogenaemia (43%). The diagnosis of type-3 abomasal ulcer was made in all cows during laparotomy and/or at postmortem examination. Forty-eight (80%) cows were euthanased immediately after the initial examination, during laparotomy or after unsuccessful treatment. Twelve (20%) cows were treated with a solution of sodium chloride and glucose administered via an indwelling jugular catheter, antibiotics, metamizole or flunixin, and discharged from the clinic. Ten cows were still in production two years later.

INTRODUCTION: Cette étude portait sur 60 vaches âgées de 1,9 à 13 ans (moyenne de 4,8 ± 2,3 ans) atteintes d'un ulcère de la caillette de type 3. Les signes cliniques les plus fréquents étaient, par ordre de fréquence décroissante, une anorexie partielle ou complète (98%), un comportement apathique (95%), une diminution de la température de la peau (78%), des vaisseaux scléraux congestionnés (73%), une défense abdominale (61%) de la tachypnée (58%), de la fièvre (58%) et tachycardie (55%). Un ou plusieurs troubles concomitants ont été diagnostiqués chez 86% des vaches. Les résultats de laboratoire anormaux les plus fréquents étaient une hypokaliémie (75%), une durée réduite du test du glutaraldéhyde (46%) et une hyperfibrinogénémie (43%). Le diagnostic d'ulcère de la caillette de type 3 a été posé chez toutes les vaches au cours d'une laparotomie et/ou lors de l'examen post mortem. Quarante-huit (80%) des vaches ont été euthanasiées immédiatement après l'examen initial, pendant la laparotomie ou après un traitement infructueux. Douze (20%) vaches ont été traitées avec une solution de chlorure de sodium et de glucose administrée via un cathéter jugulaire à demeure, des antibiotiques, du métamizole ou de la flunixine et ont quitté la clinique. Dix de ces vaches étaient encore en production deux ans plus tard.

The AMA Residency Training in Adolescent Preventive Services Project: report of the working group. The American Medical Association.

PURPOSE: To improve resident education in provision of adolescent preventive health care. The American Medical Association (AMA) Residency Training in Adolescent Preventive Services Project Working Group convened to identify specific goals and objectives (G&Os) for pediatric and family medicine resident education in adolescent clinical preventive services and recommend strategies to achieve these G&Os. METHODS: Iterative review process involving members of the working group, nine experienced teaching faculty and 16 resident physicians from family medicine and pediatric training programs, and an advisory board. RESULTS: We achieved consensus on appropriate G&Os for pediatric and family medicine residency education in adolescent clinical preventive services. Faculty and residents expressed concerns about achieving G&Os because of challenges to implementing effective training and evaluation strategies. Suggestions for achieving G&Os included development of an adolescent clinical preventive services curriculum and evaluation program that could be adapted for use in a variety of training program structures. Faculty and residents anticipated the success of a training curriculum would be influenced by: (a) availability of adequate numbers of skilled teaching faculty; (b) availability of time and support for faculty development and teaching efforts; and (c) exposure of residents to adequate numbers of adolescent patients in settings where there are clear expectations for delivery of comprehensive preventive services. CONCLUSIONS: The AMA Residency Training in Adolescent Preventive Services Project Working Group presents G&Os for organizing training experiences in adolescent clinical preventive services in family medicine and pediatric residency training programs and recommends strategies to achieve these G&Os.

Implementing community-oriented primary care projects in an urban family practice residency program.

BACKGROUND: Clinics interested in pursuing community-oriented primary care (COPC) have struggled with the implementation of its theory. Although we are still early in the COPC transformation process, the HealthPartners Family Practice Residency Program has had several successful COPC projects during our 10 years of experience. This article describes these projects and the 8 lessons learned, including some that differ from traditional COPC teaching and practice. In our experience, clinics should select a topic or problem that creates a passion within their clinic. Projects can start small within the clinic and expand outward into larger portions of the urban community. Partnerships begin the process of extending into the community and increasing the project's impact. The evaluation of projects should begin with clinic-based data. A physician champion and a nonphysician staff person increase the success of the project. Resident involvement is enhanced with concrete tasks and community connections. Ultimately, the project needs to be institutionalized within the clinic to survive. The whole COPC endeavor is a long, slow process that requires time, energy, and committed individuals. In our experience, COPC is a journey, not an end, and there are many rich rewards to be found along the way.

Adolescent preventive services.

Today, there are significant risks to the health of teenagers. Drugs (tobacco, alcohol, steroids and others), sex (pregnancy, STDs, date rape), nutrition (obesity and eating disorders), and violence (abuse, fighting) are unfortunately a part of many teens' lives. These risks increase throughout the teen years. Since each risk has a strong behavioral component, we hope to modify the behavior and minimize the risk. Prevention and health promotion are an important part of health care for teens. Primary care providers, such as family physicians, are in an excellent position to provide teen preventative care that is comprehensive and specific to the needs of each teen.

A curriculum for multicultural education in family medicine.

BACKGROUND AND OBJECTIVES: To deliver effective medical care to patients from all cultural backgrounds, family physicians need to be culturally sensitive and culturally competent. Our department implemented and evaluated a 3-year curriculum to increase residents' knowledge, skills, and attitudes in multicultural medicine. Our three curricular goals were to increase self-awareness about cultural influences on physicians, increase awareness about cultural influences on patients, and improve multicultural communication in clinical settings. Curricular objectives were arranged into five levels of cultural competence. Content was presented in didactic sessions, clinical settings, and community medicine projects. METHODS AND RESULTS: Residents did self-assessments at the beginning of the second year and at the end of the third year of the curriculum about their achievement and their level of cultural competence. Faculty's evaluations of residents' levels of cultural competence correlated significantly with the residents' final self-evaluations. Residents and faculty rated the overall curriculum as 4.26 on a 5-point scale (with 5 as the highest rating). CONCLUSIONS: Family practice residents' cultural knowledge, cross-cultural communication skills, and level of cultural competence increased significantly after participating in a multicultural curriculum.

Pharmaceutical services for a homeless population.

Participation of pharmacist volunteers in the medication program of a countrywide health care program for homeless persons is described. Pharmacist volunteers were brought in to manage medications for a health care program serving homeless persons in Ramsey County, Minnesota. After the pharmacy program was structured, volunteers were recruited from the community. Pharmacists duties initially focused on product management but were expanded to include establishing and monitoring the program formulary; reviewing patient records and prescriptions for allergies, potential drug interactions, and appropriate dosage; counseling patients on medication use; and consulting with other members of the health care team. The pharmacists' efforts led to improvements in monitoring and stocking of necessary medications. The cost of the pharmacy program decreased from $1800 a month to as little as $300 a month. The value of donated supplies and medications increased from $8,600 in 1991 to over $122,000 in 1994. Pharmacist volunteers helped to improve the cost-effectiveness and quality of medication use in a homeless population.

School-based health centers and managed care health plans: partners in primary care.

School-based clinics provide important access to health care for adolescents. For the past 20 years in St. Paul, Minnesota, Health Start has been a nonprofit organization providing comprehensive primary care services in the city's public high schools. Over the past decade, Minnesota has seen the growth of managed care plans for both the private and public (Medicaid) sectors. For the past several years, Health Start has been building relationships with managed care plans in order to coordinate care for adolescents. Since managed care plans differ in their management, reimbursement, and service delivery methods, Health Start has developed several models of partnership with managed care plans for the delivery of primary care to adolescents enrolled in school.

Use of a 'Health Habits Questionnaire' to improve health promotion counseling.

A 10-item patient "Health Habits Questionnaire" was developed that included counseling topics recommended by the US Preventive Services Task Force. Patient education brochures for each of these topics were designed and displayed in examination rooms. The questionnaires were to be given to every adult presenting to a family medicine residency clinic for a physical examination. Charts of patients receiving physical examinations were audited. Of 368 visits, 206 questionnaires were completed. Patients who completed the questionnaires were significantly more likely to have chart documentation of counseling about seat-belt use, exercise, stress, alcohol and other drug use, and dental health. The topic areas that had no significant improvement in documentation had higher counseling documentation rates than those that improved. The Health Habits Questionnaire appears to be a useful tool to improve counseling documentation, particularly for those habits that may otherwise receive little counseling.

Health promotion counseling in residency training.

This report describes health promotion counseling attitudes and practices in a family medicine residency that attempted to encourage such counseling. A patient "Health Habits Questionnaire" and matching patient education booklets were developed and distributed. Six grand rounds presentations on counseling were given. On three occasions, residency physicians completed questionnaires about counseling. Despite good personal health habits and positive attitudes toward counseling, the residency physicians had only moderate confidence in their counseling ability and infrequently documented counseling. The residents reported significant improvement in their ability to counsel patients about smoking cessation. Overall, the curriculum appeared to have a limited effect on health promotion.

Maternal serum alpha-fetoprotein testing: physician experience and attitudes and their influence on patient acceptance.

BACKGROUND: Maternal serum alpha-fetoprotein (MSAFP) testing is complex and controversial. Although patient response to testing has been studied extensively, physician experience with and attitudes toward the test have not been investigated. The purpose of this study was to describe family physician experience with MSAFP testing and determine if physician characteristics and attitudes influence whether the test is offered and whether patients accept it. METHODS: Eight hundred forty-nine Minnesota members of the American Academy of Family Physicians who provide prenatal care were surveyed by mail. Statistical analyses were performed, comparing physician characteristics, their offering of the test, and patient acceptance of the test. RESULTS: The survey response rate was 84%. Eighty-seven percent of the physicians offered MSAFP testing, most of them routinely. However, relatively few patients chose to have the test done. Physicians had concerns about the cost of the test and its effect on maternal anxiety. The strongest predictor of offering the test was whether the physician agreed it was "medically-legally necessary." CONCLUSIONS: Although most Minnesota family physicians offer MSAFP testing they have concerns about the test and its limitations and appear to convey these concerns to their patients.