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.

Vitamin A deficiency and xerophthalmia in western Yemen.

OBJECTIVE: To determine the prevalence of xerophthalmia and the extent of vitamin A deficiency in western Yemen. DESIGN: A stratified cluster sample of children aged 1-5 years with clinical examination for signs of xerophthalmia as well as blood serum survey. SETTING: The 18 districts of western Yemen, of which 10 clusters were chosen at random. SUBJECTS: All children aged 1-5 years resident in the cluster sites (n = 2438). MAIN OUTCOME MEASURES: Clinical signs of xerophthalmia, a history of night blindness, serum retinol levels in a random sample of clinically normal children (n =338) in addition to all children with xerophthalmia. RESULTS: Night blindness was found in 0.5% of the children, Bitot's spots in 1.7%, corneal ulceration in 0.04% and corneal scars in 0.04% Of the subsample, 7.2% (95% confidence interval [c.i.] 4.4-10.0%) had serum retinol values below 10 micrograms/dl; 63.0% (95% c.i. 57.6- 68.4%) had values below 20 micrograms/dl. CONCLUSIONS: Xerophthalmia and vitamin A deficiency are public health problems in western Yemen.

PIP: In June 1992, the Ministry of Health (MOH) of the Republic of Yemen, UNICEF/Sana'a, the Saudi Eye Foundation, and Helen Keller International joined together to screen 2438 children aged 1-5 from 18 rural districts in the Tihama region of Yemen for xerophthalmia (abnormal dryness of the eye due to a deficiency of tears), followed by trachoma (chronic eye infection characterized by granulations and scarring of the cornea) screening, blood sampling, and anthropometry and collection of morbidity prevalence data on a subsample (338 children). 2.21% of the children had active xerophthalmia. Boys were more likely to have xerophthalmia than girls (odds ratio [OR] = 2.1). Children aged 4-5 were more likely to have it than those under age 4 (OR = 2.9). In fact, no child aged 12-23 months had xerophthalmia. Most xerophthalmia cases (77.8%) had Bitot's spots. Bitot's spots cases tended to have the spots in both eyes (71%) and be children aged 4-5 (66.6%). The prevalence of Bitot's spots exceeded the minimum criteria for public health significance of xerophthalmia (1.72% vs. 0.50%). The prevalence of night blindness stood at 0.45%. One xerophthalmia case had keratomalacia and another had bilateral corneal scarring (0.04% each). 94% of the children with xerophthalmia who provided blood samples had serum retinol levels below 20 mcg/dl. Children with xerophthalmia had much lower retinol levels than those without xerophthalmia (11.4 vs. 18.8 mcg/dl; p .001). Likewise, children with night blindness had lower levels than those without night blindness (10.9 vs. 18.3 mcg/dl; p .001). Among the subsample, the proportion of children with deficient or marginal serum retinol levels ( 10 mcg/dl and 20 mcg/dl, respectively) exceeded the minimum criteria for public health significance of vitamin A deficiency (7.2% vs. 5% and 62.3% vs. 15%, respectively). 70% of children with marginal serum levels were 24-47 months old. Excess undernutrition existed at levels of 70% for below the 25th percentile norms, 78% for below the 10th percentile, and 71% for below the 5th percentile. These findings demonstrate that xerophthalmia and vitamin A deficiency are clear public health problems in western Yemen.

Risk factors for vitamin A deficiency in rural areas of the Philippines.

A survey of vitamin A deficiency was conducted in January and February 1991 on the island of Mindanao in the Philippines. Demographic, serum retinol, conjunctival impression cytology (CIC), anthropometric, and dietary data were collected from 248 preschool children in five randomly selected rural communities on the outskirts of Davao City. Twenty-nine per cent [95 per cent confidence interval (CI) 23-35 per cent] of preschool children had serum retinol levels below 20 micrograms/dl. Nearly 6 per cent (95 per cent CI 3-9 per cent) had serum retinol levels below 10 micrograms/dl. Thirty-two per cent (95 per cent CI 25-38 per cent) had abnormal CIC findings. The correlation between serum retinol and CIC results was poor. Recent history of diarrheal disease, reported night blindness, maternal education less than 9 years, and infrequent consumption of eggs, mangoes, and liver were associated with increased risk of vitamin A deficiency.

Transition to adult health care for adolescents and young adults with cancer.

As the prognosis for children and adolescents with cancer improves, we must reconsider how we will provide care to the adolescents and young adults who have survived these conditions. On the premise that the global needs of adults are best served by health care obtained in the adult health-care system, the case is made for transition from pediatric to adult-oriented health care for adolescents and young adults with cancer. The benefits of transition, barriers to implementation, and models of care are discussed.

Prevention of transfusion-associated graft-versus-host disease: selection of an adequate dose of gamma radiation.

To determine the optimal dose of gamma radiation necessary to inhibit T-lymphocyte function and prevent transfusion-acquired graft-versus-host disease (TA-GVHD), a donor plateletpheresis component was initially divided into ten 20-mL samples. One sample was not irradiated, while the other nine samples were treated with gamma radiation at doses ranging from 500 to 4500 cGy. T-lymphocyte function was subsequently measured by mixed lymphocyte cultures and mitogen stimulation assays. The results were assessed in each test by calculating the percentage of inhibition of each irradiated sample as compared to that of the unirradiated sample. The accuracy of the delivered dose of gamma radiation was measured with thermoluminescent dosimeters. It was concluded that a nominal dose of 3000 cGy (actual dose delivered, 2898 cGy) is the appropriate amount of gamma radiation needed to eliminate T-lymphocyte-mediated graft-versus-host disease.