Longitudinal residency training in family medicine: not ready for prime time.

Many family medicine educators have called for changing the family practice residency curriculum from a series of block rotations to a longitudinal curriculum. A longitudinal curriculum is one in which residents are based in the family practice center every day or nearly every day of all 3 years of their residency training. Residents learn most of the clinical content offamily medicine through experiences with patients from their continuity clinics, under supervision of family medicine faculty, rather than through specialty-specific block rotations supervised by specialists. An important purported benefit of longitudinal training is improved continuity of care between residents and their patients. Unfortunately, definitions of longitudinal training vary widely, and at least one study shows that supposedly longitudinal curricula do not result in better continuity of care. Further, there is some evidence that acquisition of knowledge by residents may be better with intensive block rotations than with longitudinal training. Thus, the supposed benefits of longitudinal residency training remain unproven.

Critical requirement for the membrane-proximal cytosolic tyrosine residue for CD28-mediated costimulation in vivo.

The YMNM motif that exists in the CD28 cytoplasmic domain is known as a binding site for phosphatidylinositol 3-kinase and Grb-2 and is considered to be important for CD28-mediated costimulation. To address the role of the YMNM motif in CD28 cosignaling in primary T cells, we generated transgenic mice on a CD28 null background that express a CD28 mutant lacking binding ability to phosphatidylinositol 3-kinase and Grb-2. After anti-CD3 and anti-CD28 Ab stimulation in vitro, the initial proliferative response and IL-2 secretion in CD28 Y189F transgenic T cells were severely compromised, while later responses were intact. In contrast to anti-CD3 and anti-CD28 Ab stimulation, PMA and anti-CD28 Ab stimulation failed to induce IL-2 production from CD28 Y189F transgenic T cells at any time point. Using the graft-vs-host reaction system, we assessed the role of the YMNM motif for CD28-mediated costimulation in vivo and found that CD28 Y189F transgenic spleen cells failed to engraft and could not induce acute graft-vs-host reaction. Together, these results suggest that the membrane-proximal tyrosine of CD28 is required for costimulation in vivo. Furthermore, these results indicate that the results from in vitro assays of CD28-mediated costimulation may not always correlate with T cell activation in vivo.

Novel role of phosphatidylinositol 3-kinase in CD28-mediated costimulation.

Ligation of the CD28 surface receptor provides a major costimulatory signal for full scale T cell activation. Despite extensive studies, the intracellular signaling pathways delivered by CD28 ligation are not fully understood. A particularly controversial matter is the role of phosphatidylinositol 3-kinase (PI3K) in CD28-mediated costimulation. It is known that the binding site for PI3K and Grb-2 lies nested within the YMNM motif of the CD28 cytoplasmic domain. To elucidate the role of PI3K during CD28-mediated interleukin-2 (IL-2) production, CD28 YMNM point and deletion mutants were expressed in Jurkat cells. We then measured IL-2 promoter activation after CD28 ligation. Our results showed that the Y189F mutant, which disrupts binding by PI3K, and the YMNM deletion mutant both demonstrated reduced but significant activity for IL-2 promoter activation. In contrast, the N191A mutant, which retains PI3K binding ability, resulted in a complete abrogation of activity, suggesting that PI3K mediates a negative effect upon transcriptional activation of the IL-2 gene. Consistent with this idea, we found that the addition of a PI3K pharmacological inhibitor augmented IL-2 promoter activity, whereas coexpression of a constitutively active form of PI3K reduced this activity. Taken together, these data indicate that PI3K, when associated with the YMNM motif, may act as a negative mediator in CD28-mediated IL-2 gene transcription.

Health literacy: an important issue for communicating health information to patients.

"Health literacy" refers to an individual's ability to read, understand, and use the information necessary to obtain adequate health care. Because so much health-related information is provided to patients in written form, some degree of health literacy is essential. A review of the international medical and education literature was conducted to identify research on health literacy. Limited health literacy is a widespread problem in both non-industrialized and industrialized nations, and it is mostly related to deficient reading skills. Deficient reading skills are most prevalent among those with a limited educational background, but considerable research shows that limited reading skills exist even among those who have completed a formal education. Risk factors for limited literacy include poverty, membership in an ethnic minority group, advanced age, and other sociodemographic characteristics. Limited health literacy highly associated with poor health status, and literacy skills more accurately predict health status than education level, income, ethnic background, or any other sociodemographic variable. Individuals with limited literacy have higher rates of illness and more hospitalizations than individuals with more well-developed reading skills. Considerable effort has been directed at creating special health education materials for communicating with patients who have limited reading skills, but there is minimal evidence that these interventions have any effect on the health status of these individuals. In conclusion, poor health literacy is a common problem with important implications for health status. Limited data are available about how to best address the needs of patients with limited literacy skills.

Urological needs assessment for primary care practice: implications for undergraduate medical education.

PURPOSE: The majority of graduating medical students will become primary care physicians. We discuss what urological topics primary care physicians need to know, proficiency in urological skills of primary care physicians and undergraduate urological curriculum recommendations that would serve the needs of primary care physicians. MATERIALS AND METHODS: A written survey instrument was mailed to all 452 family practice residency directors in the United States. Subjects rated how well family practice physicians need to know urological topics and how proficient they must be in urological skills. RESULTS: A total of 329 responses were received (response rate 73%). Respondents indicated that they need to know urinary tract infection, sexually transmitted disease, epididymitis, benign prostatic hyperplasia diagnosis, hematuria and erectile dysfunction diagnosis very well. They indicated a greater need to know diagnostics than staging or management of prostate, bladder, renal or testis cancer (p <0.05). Among diagnostics respondents indicated that generalists should be highly proficient in urinalysis interpretation. Proficiency was ranked greater for interpretations of semen analysis than excretory urogram, abdominal computerized tomography or magnetic resonance imaging, or renal ultrasound (p <0.05). Proficiency in catheter insertion and circumcision was ranked highly, and vasectomy was ranked moderately. CONCLUSIONS: Primary care physicians need to know and be proficient in many urological topics and skills. They need to know diagnostics better than staging and management information, and urological infectious topics better than urological cancers. They need to be proficient in physical examination, urinalysis interpretation, catheter insertion, circumcision and vasectomy. Undergraduate medical education should reflect these needs.

Practical assessment of adult literacy in health care.

Low literacy is a pervasive and underrecognized problem in health care Approximately 21% of American adults are functionally illiterate, and another 27% have marginal literacy skills. Such patients may have difficulty reading and understanding discharge instructions, medication labels, patient education materials, consent forms, or health surveys. Properly assessing the literacy level of individual patients or groups may avoid problems in clinical care and research. This article reviews the use of literacy assessments, discusses their application in a variety of health care settings, and cites issues providers need to consider before testing. The authors describe informal and formal methods of screening for reading and comprehension in English and Spanish including the Rapid Estimate of Adult Literacy in Medicine, the Wide Range Achievement Test-3, the Cloze procedure, the Test of Functional Health Literacy in Adults, and others. Practical implications and recommendations for specific use are made.

Diagnostic evaluation of urinary incontinence in geriatric patients.

In most cases, the evaluation of urinary incontinence requires only a history, a physical examination, urinalysis and measurement of postvoid residual urine volume. The initial purposes of the evaluation are to identify conditions requiring referral or specialized work-up and to detect and treat reversible causes that may be present. If the patient does not appear to require referral and a reversible cause is not identified, the next step is to categorize the patient's symptoms as typical of either urge or stress incontinence and treat the patient accordingly. If treatment fails or a presumptive diagnosis of urge or stress incontinence cannot be reached, the final step would be to perform more sophisticated tests or refer the patient for testing to define the cause and determine the best treatment.

Helmet use among university bicyclists.

College-aged individuals are at risk for bicycle-related head injuries, but the risk of such injuries can be reduced by their use of bicycle helmets. The objective of this research was to measure the rate of bicycle helmet use by university bicyclists at a large public university in the southwestern United States at three different times. Bicyclists riding onto campus were observed as they rode through a main campus entrance in 1985, 1990, and 1994, and the percentage of bicyclists who were wearing a helmet was recorded. The bicyclists were unaware that their helmet use was being monitored. In 1985, 10% of bicyclists were wearing helmets; in 1990, only 4.4% wore helmets. In 1994, the proportion of helmet-wearing bicyclists had increased to 24%. Although the sample sizes were small, the 1994 increase was statistically significant. The reasons for the increase are unclear, and further study is needed to identify factors related to university bicyclists' use of bicycle helmets.

Literacy and performance on the Mini-Mental State Examination.

OBJECTIVE: Mini-Mental State Examination (MMSE) scores are associated with age, education, and ethnicity. The objective of this research was to determine the relationship between MMSE and literacy. DESIGN: Cross-sectional. SETTING: A Community population in Tucson, Arizona. PARTICIPANTS: Senior citizens in public assistance housing. MEASUREMENTS: MMSE score, reading level, and sociodemographic variables. MAIN RESULTS: A total of 214 subjects were tested. The mean age was 72.3 (+/- 8.01), and the mean education level was 10.3 years (range 0-20 years). Reading levels ranged from grade 0 (non-reader) to 8 (maximum value for the test used). with a mean of 4.8 (+/- 2.8). MMSE scores ranged from a mean of 21.9 (+/- 4.6) for non-readers to a mean of 28.0 (+/- 2.0) for subjects with > or = 8th grade reading skills. Multiple regression using reading level, education, age, and ethnicity as independent variables, and MMSE score as the dependent variable, showed the highest correlation was between MMSE and reading level (R2 = .265). Education level made only a small additional contribution; age and ethnicity did not enter the regression equation. Correlations between reading level and individual MMSE subsections were highest between reading level and MMSE language items (r = .499). CONCLUSIONS: The correlation between MMSE score and reading skills is stronger than the correlation with other sociodemographic variables. Proper interpretation of MMSE scores requires knowledge of patients' reading levels.

Literacy skills and communication methods of low-income older persons.

The objectives of this study were to (a) characterize the literacy skills of low-income, community-dwelling, older adults, (b) determine how they obtain information, and (c) determine whether they have difficulty understanding written information provided by clinicians. We studied 177 subjects (mean age 72.2, range 60-94). None had cognitive or visual impairments that precluded assessing literacy. Reading skills were tested, sociodemographic data were recorded, and information was collected on whether subjects have trouble understanding information given to them by health providers. Data analysis determined if literacy was associated with how subjects obtain and understand medical information. The subjects' mean reading skills were at grade level 5, below those of the general US population. One-fourth of subjects reported difficulty understanding written information from clinicians; this was more frequent among poor readers (P = 0.0002). Ninety-seven percent of subjects, regardless of literacy, reported that television was their primary source of information. Health information for low-income seniors should be transmitted through literacy-appropriate communication methods.