The Veterans Affairs Learners' Perceptions Survey: the foundation for educational quality improvement.

PURPOSE: The U.S. Department of Veterans Affairs (VA) supports 8,700 resident positions nationally to enhance quality of care for veterans and to educate physicians. This study sought to establish a yearly quality indicator to identify and follow strengths and opportunities for improvement in VA clinical training programs. METHOD: In March 2001, the VA Learners' Perceptions Survey, a validated 57-item questionnaire, was mailed to 3,338 residents registered at 130 VA facilities. They were asked to rate their overall satisfaction with the VA clinical training experience and their satisfaction in four domains: faculty/preceptor, learning, working, and physical environments using a five-point Likert scale. Questionnaires were received from 1,775 residents (53.2%). A full analysis was conducted using 1,436 of these questionnaires, whose respondents were categorized in four training programs: medicine (n = 706), surgery (n = 291), subspecialty (n = 266), and psychiatry (n = 173). RESULTS: On a scale of 0 to 100, residents gave their clinical training experience an average score of 79. Eighty-four percent would have recommended VA training to peers, and 81% would have chosen VA training again. Overall, 87% were satisfied with their faculty/preceptors, 78% with the learning environment, and 67% with the working and physical environments. The survey was sensitive to differences in satisfaction among the trainee groups, with residents in internal medicine (IM) the least satisfied. CONCLUSION: The VA Learners' Perceptions Survey is the first validated survey to address comprehensive satisfaction issues in clinical training. The survey highlights strengths and opportunities for improvement in VA clinical training and is the first step toward improving education.     

Comparison of Two Formulations of Nifedipine During 24-Hour Ambulatory Blood Pressure Monitoring

Study Objective . To determine if one commercial extended-release formulation of nifedipine (Adalat CC) is as effective as another (Procardia XL) in controlling blood pressure over 24 hours. Design . Open-label, randomized, crossover study. Setting . University-affiliated family medicine clinic. Patients . Fifteen patients with stage 1–4 primary hypertension. Interventions . Procardia XL or Adalat CC once/day was titrated to achieve blood pressure control. The effective dose was continued for 4 weeks, washed out for 1 week, and reinstituted with other study drug. Measurements and Main Results . Twenty-four-hour ambulatory blood pressure was recorded the conclusion of each treatment phase. Treatment phases were compared for mean 24-hour blood pressure, mean daytime (6:00 a.m.–10:00 p.m.) and mean nighttime blood pressure, and mean blood pressure load (percentage of blood pressure measurements < 140/90 mm Hg daytime and > 120/80 mm Hg nighttime). Thirteen patients completed the study. No statistically significant difference was seen in mean 24-hour blood pressure (138/86 mm Hg for Procardia XL vs 137/85 mm Hg for Adalat CC), daytime or nighttime blood pressure, or blood pressure load. Two patients experienced clinically significant adverse effects while taking Adalat CC. Conclusions . In these patients with primary hypertension, Adalat CC was as effective as Procardia XL at controlling blood pressure for 24 hours. Blood pressure, heart rate, and adverse effects should be monitored 2–4 weeks after any exchange of Adalat CC for Procardia XL.     

Prevention of HIV-1 gp120-induced neuronal damage in the central nervous system of transgenic mice by the NMDA receptor antagonist memantine

To investigate the in vivo role of NMDA receptor stimulation in HIV-1-related CNS neurotoxicity, we evaluated the neuroprotective potential of the NMDA receptor antagonist memantine in transgenic mice which have gp120-induced CNS damage. Brains of mice treated chronically with memantine and of untreated controls were analysed for structural damage by laser scanning confocal microscopy of sections immunolabeled for microtubule-associated protein-2 (MAP-2) and synaptophysin. Qualitative and quantitative analysis of confocal images revealed that memantine treatment substantially decreased neuropathology in gp120 transgenic mice; this included statistically significant improvements in both dendritic and presynaptic terminal density. These results provide in vivo evidence that gp120 can activate neurotoxic pathways that can ultimately result in aberrant NMDA receptor stimulation and neuronal damage in the CNS. They also suggest that clinically tolerated NMDA receptor antagonists may be useful in the prevention of neuronal damage in HIV-1-infected patients.     

Managed Care Organizations and Public Health: Exploring Collaboration on Adolescent Immunizations

ABSTRACT: Managed care organizations (MCOs) joined local and state public health agencies in a pilot effort to improve hepatitis B immunization rates of adolescents in an urban and a suburban/rural school district. The pilot also explored issues inherent in public and private collaboration on population health improvement.
Local public health agencies provided links to schools in their communities, took the lead in implementing school-based immunization programs, and provided health education materials. MCOs contributed financial support necessary for the project. The final cost per fully vaccinated student, not taking into account the work group's planning and coordination time, was little more than the catalog price of the vaccine alone.
Managed care organizations face challenges that complicate their participation and funding of school-based vaccinations: 1) Limited data on health plans of participating students complicate allocation of costs to each MCO; 2) Double-paying occurs for MCOs paying clinics a monthly, per-member rate that already includes adolescent immunizations; 3) When schools provide adolescent immunizations, MCOs lose the "hook" that draws adolescents to clinics for comprehensive health services.
When self-consenting is permitted, schools can achieve a high consent and completion rates for multi-dose adolescent immunizations such as hepatitis B. At the same time, MCOs have the responsibility to provide members with comprehensive care and should continue to examine both internal modifications and external partnerships as opportunities to improve their services to adolescents.     

Practical integration of [18F]-FDG-PET and PET-CT in the planning of radiotherapy for non-small cell lung cancer (NSCLC): the technical basis, ICRU-target volumes, problems, perspectives.

The value of positron emission tomography using [18F]-fluoro-deoxy-glucose (FDG-PET) for pretherapeutic evaluation of patients with non-small cell lung cancer (NSCLC) is beyond doubt. Due to the increasing availability of PET and PET-CT scanners the method is now widely available, and its technical integration has become possible for radiotherapy planning systems. Due to the depiction of malignant tissue with high diagnostic accuracy, the use of FDG-PET in radiotherapy planning of NSCLC is very promising. However, by uncritical application, PET could impair rather than improve the prognosis of patients. Therefore, in the present paper we give an overview of technical factors influencing PET and PET-CT data, and their consequences for radiotherapy planning. We further review the relevant literature concerning the diagnostic value of FDG-PET and on the integration of FDG-PET data in RT planning for NSCLC. We point out the possible impact in gross tumor volume (GTV) definition and describe methods of target volume contouring of the primary tumor, as well as concepts for the integration of diagnostic information on lymph node involvement into the clinical target volume (CTV), and the possible implications of PET data on the definition of the planning target volume (PTV). Finally, we give an idea of the possible future use of tracers other than [18F]-FDG in lung cancer.     

COMMUNITY PARTICIPATION OR COMMUNITY MANIPULATION? A CASE STUDY OF THE ILLAWARRA CANCER APPEAL-A-THON

Fashion parades, balls, raffles, and weekly deductions from thousands of workers' pay packets were integral to success of the Cancer Appeal-a-thon in the Illawarra region. In 1986–87 the Illawarra community was induced to contribute $1.5 million in order to purchase a linear accelerator for the Wollongong Hospital. The community agreed that a radiotherapy machine was the number one health service priority for the region. Or did it? Application of Alford's structural interests framework to this case-study reveals how failure to examine power relations between medical monopolizers, health care rationalizers and community participants results in an inability to recognise that alternative community needs — for cancer prevention, domiciliary care, or alternative therapies — might be unarticulated or unobservable, and in an inability to ask whether the community may be mistaken about, or unaware of, its own health needs. Specifically, the paper argues that, ‘community needs’ are easily manipulated or distorted by powerful interest groups and that the political context within which community needs are recognized, articulated and mobilized is the most important issue for community participation in the health policy-making process.