Additional Medical Care Research Articles

Increasing Access to Cholesterol Screening in Rural Communities Catalyzes Cardiovascular Disease Prevention

Despite increasing frequency, little evidence guides cholesterol screening in less traditional health care settings, such as rural health fairs. The Miller School of Medicine Department of Community Service (DOCS) is a student-run organization providing free basic health care to underserved South Florida communities. We retrospectively reviewed all new patients seen at 2007 DOCS rural fairs to describe their low-density lipoprotein (LDL) and high-density lipoprotein (HDL) values. In addition, we assessed if patient characteristics were associated with cholesterol abnormalities and whether patients with abnormalities who returned to a subsequent fair in 2008 or 2009 improved their cholesterol. Of 252 patients, 145 (58%) had an LDL cholesterol over 129 mg/dL and 61 (24%) had an HDL cholesterol below 40 mg/dL or 50 mg/dL for males and females, respectively. Baseline LDL cholesterol was not associated with body-mass index (BMI), age over 60 years, gender, healthy lifestyle habits, or insurance status. Of 36 patients with elevated LDL cholesterol and a follow-up screening, 24 (67%) reduced their LDL cholesterol by at least 16 mg/dL though reductions were not associated with BMI reduction, and 22 (61%) increased their HDL cholesterol by at least 5 mg/dL, trending with BMI reduction. Cholesterol screening at rural fairs can identify a high proportion of patients with abnormal cholesterol, including those who might not be considered at high risk. Although this may catalyze favorable cholesterol changes, the lack of an association with weight loss suggests patients seek additional medical care, which should be considered before offering cholesterol screening at fairs.

Prospective Longitudinal Evaluation of Quality of Life in Patients With Permanent Colostomy After Curative Resection for Rectal Cancer

The aim of this study was to evaluate health-related quality of life in patients with a colostomy immediately before and during the first year after surgery. Patients (aged ≥20 years) who were diagnosed with rectal cancer and scheduled to undergo curative surgery with a permanent colostomy were recruited for this study. Data were collected at 2 university hospitals in Tokyo. Participants were asked to complete a self-administered questionnaire regarding health-related quality of life before surgery and a mailed or hand delivered questionnaire to evaluate quality of life at 2, 6, and 12 months after surgery using the Short Form-36 version 2. For patients who responded at all 4 time points, the scores at each time point were compared using paired t tests to examine longitudinal changes in quality of life after surgery. Mean quality-of-life scores in most domains before surgery and during the first year after surgery were lower than the normal control in the norm-based scoring method. Scores at 2 months after surgery were lower than those before surgery. At 12 months after surgery, however, quality-of-life scores improved almost to the level observed before surgery, with the exception of the score in the social functioning domain. Statistical differences in scores between the time points of the survey were observed in the role-physical, bodily pain, and mental health domains. These results suggest that patients with permanent colostomy after curative resection for rectal cancer need additional medical support and care before surgery and during the first year after surgery.

Contribution of infectious disease consultation toward the care of inpatients being considered for community‐based parenteral anti‐infective therapy

In the acute care setting in a multidisciplinary healthcare environment, the contribution of infectious disease (ID) specialists to overall patient care is difficult to measure. This study attempts to quantify the contribution of ID specialists when consulted for an activity specific to ID practice, community-based parenteral anti-infective therapy (CoPAT). In February 2010, an electronic form for requesting ID consultations was introduced in the computerized provider order entry (CPOE) system at the Cleveland Clinic. This allowed for easy identification of ID consultations for CoPAT. Hospital records for all patients with CoPAT consultation requests between February 11, 2010 and May 15, 2010 were reviewed for specific defined contributions in the domains of optimization of antimicrobial therapy, significant change in patient assessment, and additional medical care contribution. Over a 3-month period, there were 263 CoPAT consultation requests via CPOE, of which 172 were initial consultations and 91 reconsultations. Antimicrobial treatment was optimized in 84%, a significant change in patient assessment made in 52%, and additional medical care contribution provided in 71% of consultations. In 33% of consultations, there was contribution in all 3 domains. CoPAT was deemed not to be necessary in 27%. For patients requiring CoPAT, effective care transition from the inpatient to outpatient setting was assured at least 86% of the time. Infectious disease consultation before discharge on parenteral antibiotics adds value by contributing substantially to inpatient care, and providing antimicrobial stewardship and continuity of care at a critical patient care transition point.

The process of identifying, solving and preventing drug related problems in the LIMM-study

To avoid negative effects of drug treatment and need for additional medical care, drug treatment must be individualised. Our research group has developed a model for clinical pharmacy which improves several aspects of the patient's drug treatment. This study describes the process behind these improvements, i.e. drug related problems identified by pharmacists within a clinical pharmacy service. Three wards at a department of internal medicine. Pharmacists performed systematic interventions during the patient's hospital stay, aiming to identify, solve and prevent drug related problems in the elderly. Identified drug related problems were put forward to the health care team and discussed. Information on identified problems, and their outcomes was collected and analysed. A questionnaire was used to evaluate the health care personnel's attitudes towards the process. The number of drug related problems identified by the clinical pharmacists, the proportion of problems discussed with the physicians, the proportion of problems adjusted by the physicians and whether pharmacists and physicians prioritised any subgroup of drug related problems when choosing which problems to address. Finally, we wanted to evaluate the health care personnel's attitudes towards the model. In total, 1,227 problem were identified in 190 patients. The pharmacists discussed 685 (55.8%) of the identified problems with the physicians who accepted 438 (63.9%) of the suggestions. There was no significant difference in which subgroup to put forward and which to adjust. There was a high response rate (84%) to the questionnaire, and the health care personnel estimated the benefits to be very high, both for the patients and for themselves. The process for identifying, solving and preventing drug related problems was good and the different types of problems were considered equally important. The addition of a clinical pharmacy service was considered very useful. This suggests that the addition of our clinical pharmacy service to the hospital setting add skills of great importance.

Financing of therapeutic rehabilitation in the context of other non-invasive medical treatment specialties

Methods of financing health care services constantly undergo changes. These changes involve both the allocated financial resources and average prices received for person-day of treating patients in hospital departments of various specialties. Thus, a constant monitoring of financing levels and service pricing in particular types of health care services is indispensable, since these issues are directly associated with the development or stagnation observed in particular branches of medicine. This paper aimed at verifying the hypothesis that the pricing of person-day in the field of inpatient therapeutic rehabilitation, especially involving children, is under priced in relation to an average value of a person-day received in specialties providing non-invasive hospital treatment, and comparable as regards the costs of services. An analysis and comparison of costs and incomes for medical units providing health care services in selected areas of inpatient therapeutic rehabilitation for children and non-invasive hospital medical treatment have been attempted. This analysis has been carried out on the basis of data provided by the regional branches of the National Health Fund (NFZ). Generally available information concerning the terms and conditions of contracting services and agreements that NFZ has entered into with service providers has been also used. A comparison of the conditions for providing services that service providers should meet in order to obtain financing within the framework of NFZ, shows that personnel costs of a department of pulmonary rehabilitation and department of general rehabilitation are lower by approximately 15% than personnel costs of a department of pediatrics, and 9% lower than for a department of pediatric neurology. However, an average pricing of person-day received by rehabilitation departments is about 3-fold lower than that received by departments of pediatrics and pediatric neurology. Departments providing non-invasive medical treatment admit a large variety of patients. This diversification of patients only in part coincides with patients admitted to rehabilitation departments. Thus, additionally average pricings of person-day at departments providing non-invasive medical treatment and departments of general rehabilitation with respect to selected diagnosis related groups of patients who manifest diseases treated in both types of departments, have been compared. The obtained results have confirmed gross under financing of inpatient rehabilitative services. Inpatient rehabilitative services offered for children are particularly undervalued. In this instance, service providers bear higher costs, resulting from, among other considerations, a larger average number of physiotherapists necessary to conduct rehabilitation, the requirement of assuming the full legal responsibility for children which necessitates additional educational care and 24-hours medical care, not only in the case of neurological rehabilitation, as well as providing nutrition adequate for children's ages, including five high-quality meals daily. Consequently, it is necessary to increase the pricing of inpatient rehabilitative services provided for children.

Sexual Abuse: A Strong Predictor of Outcomes After Colectomy for Slow-Transit Constipation

This study was designed to determine the impact of a history of sexual abuse on the outcomes of ileorectal anastomosis for slow-transit constipation. All patients undergoing subtotal colectomy and ileorectal anastomosis for slow-transit constipation by a single surgeon at a university hospital from 1991 to 2006 were identified. Age, time since surgery, psychiatric diagnoses, number of previous operations, and "functional" disorders were collected. Patients were questioned about a history of anal and vaginal sexual abuse. Use of alternative healthcare practitioners and remote postoperative physician visits for abdominal symptoms were elicited. Fifteen patients met study criteria, and 13 came for assessment. All were women, all were highly satisfied with the results of their surgery, and all said they would request the procedure again. Median age was 38 (range, 29-58) years, and time to follow-up was 97 (range, 25-166) months. Eleven subjects (85%) reported a current psychiatric condition being treated with psychotropic medication. Eight (62%) reported a history of sexual abuse, and seven (88%) reported both anal and vaginal abuse. Patients with a history of sexual abuse had a total of 32 operations before colectomy and 30 functional diagnoses, compared with a total of 3 operations and 3 functional diagnoses in the nonabused group (P = 0.001 and P = 0.0002, respectively). Similarly, seven of eight abused patients (88%) sought additional medical care for abdominal complaints after this surgery, compared with none of five in the nonabused group (P = 0.005). A history of sexual abuse should be sought in patients with slow-transit constipation, because it is a strong predictor of more functional diagnoses, more precolectomy operations, and more postcolectomy medical care for abdominal complaints.

Neues bei Kopfschmerzen 2009

Die Bedeutung des Themas Kopfschmerz wird durch neue epidemiologische Daten unterstrichen. Diese belegen die hohe Prävalenz von Kopfschmerzen auch in Deutschland sowie den hohen Bedarf an ärztlicher Versorgung, der bislang noch nicht ausreichend gedeckt ist. Bezüglich prädisponierender Risikofaktoren konnte für Erwachsene ein Zusammenhang zwischen Adipositas und chronischen Kopfschmerzen gezeigt werden, für Kinder auch eine Korrelation zwischen zunehmendem Körpergewicht und der Attackenzahl. Ob sich daraus therapeutische Implikationen ableiten lassen, ist noch nicht geklärt. Auffällig ist der Zusammenhang zwischen Schwindel und Migräne, die überzufällig zusammen auftreten. In der Akuttherapie muss die Bedeutung der Allodynie als Prädiktor einer verringerten Wirkung von Triptanen im Migräneanfall wohl revidiert werden, da sich die Befunde in doppelblinden Untersuchungen nicht reproduzieren lassen. In der Migräneprophylaxe gelang es nicht für Carisbamat eine Wirkung nachzuweisen. Valproat hatte in 2 großen Studien zur Migräneprophylaxe bei Kindern keine Überlegenheit gegenüber Placebo. Memantine zeigte keine eindeutige Wirksamkeit in der prophylaktischen Behandlung des chronischen Kopfschmerzes vom Spannungstyp. Das Dogma von der Unwirksamkeit von Migräneprophylaxen unter fortgesetztem Übergebrauch von Triptanen oder Analgetika lässt sich nicht mehr sicher aufrechterhalten. Es gibt Hinweise auf die Wirksamkeit nicht nur von Topiramat, sondern auch von anderen Prophylaktika bei weiterhin fortgesetztem Übergebrauch. In der Behandlung des chronischen, therapierefraktären Clusterkopfschmerzes bietet die bilaterale Nervus-occipitalis-Stimulation eine neue Therapieoption, für die zunehmend Daten zur Wirksamkeit publiziert werden. Auch die Radiofrequenzablation des Ganglion sphenopalatinum könnte eine weitere Therapieoption darstellen. Der Pseudotumor cerebri muss nicht zwangsläufig mit einer Stauungspapille einhergehen, im Zweifel ist eine Liquorpunktion bei chronischen Kopfschmerzen zum sicheren Ausschluss eines erhöhten Liquordruckes notwendig.

ICF-basierte multidisziplinäre Therapie bei Arthrose – Ein Fallbeispiel

Corrected by: ErratumPhysikalische Medizin, Rehabilitationsmedizin, Kurortmedizin 2009; 19(02): 119-119DOI: 10.1055/s-0029-1215576

Factors Affecting the Long-Term Care Preferences of the Elderly in Taiwan

This study sets out to investigate the preferences of the elderly in northern Taiwan with regard to various types of long-term care services. Taking into consideration sociodemographics, health condition, and access to such medical care services, our study examined both economic and family factors in an attempt to gain an understanding of the knowledge of and attitudes toward, the various types of long-term care among the elderly. An interview survey was carried out by local public health nurses among a sample of 562 elderly Taiwanese residents (people aged 65 years or older) from 7 counties/cities in northern Taiwan, all of whom had been selected by means of multistage sampling. The survey was conducted using a questionnaire based on the Andersen and Newman model of health care utilization, with the intention being to gain a better understanding of the related factors. The results indicate that both ethnic background and the requirement for additional medical care services had significant effects on the long-term care preferences of the elderly in Taiwan, a finding that should help to provide a better understanding of the preferences for and availability of such long-term care services among the elderly. Such improved understanding could result in improving the quality of life for the elderly, particularly if they feel that their preferences have been taken into consideration and their needs have ultimately been met.

Quality of Anticoagulation Care in Patients Discharged from a Pharmacist‐Managed Anticoagulation Clinic After Stabilization of Warfarin Therapy

To determine if transitioning patients from a pharmacist- managed anticoagulation clinic after stabilization of warfarin therapy to physician-managed care alters the quality of anticoagulation care. Retrospective medical record review. Pharmacist-managed, urban academic medical center-based outpatient anticoagulation clinic. Forty patients who were stabilized on warfarin therapy. Quality of anticoagulation care was measured by percentage of international normalized ratios (INRs) in target range, anticoagulation-related health care visits, and responses to satisfaction surveys. A significant decrease in anticoagulation control was observed on transition to physician-managed care. Before transition, 76% of all INRs were in target range versus 48% after transition (p<0.0001, chi(2) test). When performing paired analysis, a median 75% of each patient's INRs were therapeutic before transition compared with 36.5% after (p<0.0001, Wilcoxon signed rank test). Thirty-two percent of first INR values measured after transition from the clinic were in target range, and the median time to first follow-up INR was 41 days. The number of INR values above 4.5 and below 1.5 increased significantly after transition from the anticoagulation clinic (p<0.0001 and p=0.01, respectively, chi(2) test). Before transition from the anticoagulation clinic, two anticoagulation-related emergency department visits were reported in one patient. After transition, 13 cases of additional medical care were reported among seven patients; seven of the 13 cases required an office visit with the physician, and six resulted in emergency room evaluation. None of these cases resulted in hospitalization. Patient satisfaction with clinical care provided by the anticoagulation clinic was significantly higher before transition. Transition of patients from a pharmacist-managed anticoagulation clinic back to physician-managed anticoagulation care after stabilization of warfarin therapy was associated with a significant decrease in INR control, increased medical care related to anticoagulation, and decreased patient satisfaction.

AN EMPIRICAL STUDY ON HEALTH IN TAIWAN AND ITS LONG-TERM ADJUSTMENT*

This paper investigates the dynamic change of the population health status in Taiwan. Specifically, it provides insight into the empirical determinants of health production function and explores the nature of the long-term adjustment in health performance. For these purposes, panel data are used incorporating dynamic effects as well as controls for unobservable area-specific effect and area-invariant time effect. The findings are consistent with the earlier research in terms of the determinants of the health production function. The result of the present paper suggests that after decades of improvement in health care, people in Taiwan have lower age-adjusted mortality rates. Also, the decreases in mortality rates follow a rapid pace of long-term adjustment implying that health-care policy that focuses on the provision of medical care services substantially benefits the nation’s health. JEL Classification Numbers: I12, J78. The production of health has long been an interesting topic for economists. Whether health levels are measured by mortality rates, morbidity rates, work-days lost, selfevaluations of health status, physiological measures or whether the units observed are individuals or groups, there is little argument about the impacts of age, schooling, insurance, alcohol or tobacco consumption and environmental factors on health level. The present paper takes on this issue incorporating the cultural and health policy changes in Taiwan. The major objective of this paper is to provide more insight into the empirical determinants of the health production function. In addition, to understand how the health outcome changes over time, following the concept of Ozkan (2001), the long-term adjustment of health measures is also discussed. In doing so, this empirical model captures important features of national health investment behaviour: a district area has a long-run equilibrium target level of health status that is assumed to be a function of several areaspecific characteristics and to vary over time and/or over areas. Also, an adjustment process takes place that involves lags in adjusting to changes in the equilibrium target level. It seems to be intuitively incorrect to define an equilibrium health level because health is like any of the normal goods that people do not get enough of. However, Thornton (2002) argues that additional medical care utilization is relatively ineffective in improving a nation’s health. The diminishing rate of return in most kinds of investment (including investment in health production) implies the existence of an equilibrium level of health status. Previous studies often use the mortality rate to measure the population health condition. Therefore, in the present paper three levels of mortality rates (toddler’s mortality rate, *W e thank David Cornberg, participants at the 2004 Western Economic Association meetings, and anonymous referees for greatly improving the paper. We also thank the National Science Council of Taiwan for its research funding under number NSC 90-2415-H-130-003. The funding support received from the Center for Humanities and Social Sciences, and the National Policy Research Center is greatly appreciated.

The perioperative cost of Infuse bone graft in posterolateral lumbar spine fusion

Background context There is mounting evidence supporting the efficacy of bone morphogenetic protein (BMP) for both anterior interbody and posterolateral lumbar fusion. However, the relative cost of BMP remains an important concern for physicians, hospitals, and payers. Purpose The purpose of this study is to report on the perioperative costs for patients treated with rhBMP-2 as compared with an iliac crest bone graft (ICBG) supplemented with graft extenders. Study design/setting A prospective randomized controlled trial of rhBMP-2/ACS (Infuse Bone Graft; Medtronic Sofamor Danek, Memphis, TN) versus ICBG±graft extender for lumbar spine fusion in patients over 60 years old. Patient sample One hundred two patients over 60 years old who required a posterolateral lumbar spine fusion randomized between receiving rhBMP-2/ACS or ICBG. Outcome measures All health-care costs over the first 3 months after surgery. Methods As part of a prospective randomized trial of rhBMP-2/ACS versus ICBG±graft extender for lumbar spine fusion, all costs over the first 3 months after surgery were directly recorded by a dedicated coder funded by Norton Healthcare, Louisville, KY. A dedicated research nurse also followed all patients throughout their hospital stay and posthospitalization recovery to identify any adverse events or additional outpatient medical care. Results Fifty patients received rhBMP-2/ACS and 52 underwent ICBG harvest. The mean hospital cost for the index admission was $24,736 for the rhBMP-2/ACS group and $21,138 for the ICBG group. Mean inpatient physician costs were $5,082 in the rhBMP-2/ACS group and $5,316 in the ICBG group. Costs associated with posthospital rehabilitation averaged $4,906 in the rhBMP-2/ACS group versus $6,820 in the ICBG group. Total payer expenditure for the 3-month perioperative period averaged $33,860 in the rhBMP-2/ACS group and $37,227 in the ICBG group. Conclusions The hospital carries the cost burden associated with the utilization of rhBMP-2/ACS. In contrast, the payer in a Diagnosis-Related Group (DRG) model achieves a net savings, based primarily on the decreased payment for inpatient rehabilitation, but also on decreased hospital reimbursement, physician costs, and other outpatient services.

UNMET NEED FOR ADDITIONAL MEDICAL CARE FOR SICK CHILDREN IN MOTHER’S VIEW IN RURAL BANGLADESH: IMPLICATIONS FOR IMPROVING CHILD HEALTH SERVICES

While a country's health policy aims to provide health services to all who need them, very little in known about unmet need for additional medical care from users' perspectives in Bangladesh. This study examined unmet medical need (defined as whether a mother felt that, to manage sickness, her child had required medical care that was not available, regardless of reasons and medical care sought) of 2123 under-15 sick children by illness and child's socioeconomic characteristics in rural Bangladesh. The 1996 Health and Socioeconomic Survey conducted in Matlab recorded children's chronic (a disease or a condition lasting 3 months or more) and acute (a disease or a condition with a rapid onset and a short, severe course) morbidity, medical care sought to combat illness and unmet needs for additional medical services in mothers' views to manage the illness. The survey also recorded household socioeconomic data. Logistic regression was used to examine the data. The results reveal that unmet needs for additional medical care were 5.4% for children with acute illnesses, and 30.2% for children with chronic illnesses. For chronic illnesses, seeking medical care to manage illness from any health provider outside the home reduced unmet medical needs. Economic inequalities existed for both acute and chronic illnesses: the odds ratio of unmet medical needs for sick children of the least poor households was 0.42 (95% CI: 0.28-0.64) times that for sick children of the very poor households. The critically high unmet needs for children's chronic morbidity reveal that the chronic disease control programme in Bangladesh needs urgent revisiting and strengthening.

Follow-Up for Medical Care Among Drug Users With Hepatitis C

Prevalence of hepatitis C (HCV) in injection drug users (IDUs) is high and once HCV has been detected, follow-up medical care is essential. Six hundred and one current and former IDUs who tested positive for HCV antibodies received referrals for medical care. Twenty-four percent (147) of participants returned to be interviewed regarding their medical follow-ups. Of these, only 42% (61) had sought additional medical care in the form of further liver or blood tests or liver ultrasound. Four variables predicted seeking medical care: (a) ever being in residential drug treatment, (b) ever trading sex for money, (c) self-reported homelessness, and (d) living in one's own apartment or house. Having income from a job was inversely associated with seeking medical care. Knowledge of HCV infection alone does not mean that IDUs will seek medical care. Additional education concerning medical care and treatment options are needed to address IDU needs.

Evaluating Health Insurance: A Review of the Theoretical Foundations

Over the last 50 years, the theoretical basis of the value of health insurance has transformed itself from one based primarily on a gain from risk avoidance and a welfare loss from the additional medical care purchased by those who are insured, to one based primarily on the welfare gain from the additional medical care purchased by those who are insured. This transformation reflects (1) an increasing realization of the importance of health care in the demand for insurance, and (2) an increasing recognition that insurance, even insurance that pays off by paying for care, acts to transfer income from the healthy to the ill. This article traces the development of the theory of the value of health insurance using the above two themes as the basis for its organization.

Diabetes Treatment Among VA Patients With Comorbid Serious Mental Illness

Diabetes Treatment Among VA Patients With Comorbid Serious Mental Illness

Controlled Delivery of High vs Low Humidity vs Mist Therapy for Croup in Emergency Departments

Children with croup are often treated with humidity even though this is not scientifically based, consumes time, and can be harmful. Although humidity using the traditional blow-by technique is similar to room air and no water droplets reach the nasopharynx, particles sized for laryngeal deposition (5-10 microm) could be beneficial. To determine whether a significant difference in the clinical Westley croup score exists in children with moderate to severe croup who were admitted to the emergency department and who received either 100% humidity or 40% humidity via nebulizer or blow-by humidity. A randomized, single-blind, controlled trial conducted between 2001 and 2004 in a tertiary care pediatric emergency department. A convenience sample of 140 previously healthy children 3 months to 10 years of age with Westley croup score of more than 1 or 2 or higher (scoring system range, 0-17); 21 families refused participation. Thirty-minute administration of humidity using traditional blow-by technique (commonly used placebo, n = 48), controlled delivery of 40% humidity (optimally delivered placebo, n = 46), or 100% humidity (n = 46) with water particles of mass median diameter 6.21 microm. A priori defined change in the Westley croup score from baseline to 30 and 60 minutes in the 3 groups. Groups were comparable before treatment. At 30 minutes the difference in the improvement in the croup score between the blow-by and low-humidity groups was 0.03 (95% confidence interval [CI], -0.72 to 0.66), between low- and high-humidity groups, 0.16 (95% CI, -0.86 to 0.53), and between blow-by and high-humidity groups, 0.19 (95% CI, -0.87 to 0.49). Results were similar at 60 minutes. Differences between groups in pulse and respiratory rates and oxygen saturation changes were insignificant, as were proportions of excellent responders; proportions with croup score of 0 at study conclusion; and proportions receiving dexamethasone, epinephrine, or requiring additional medical care or hospitalization. One hundred percent humidity with particles specifically sized to deposit in the larynx failed to result in greater improvement than 40% humidity or humidity by blow-by technique. This study does not support the use of humidity for moderate croup for patients treated in the emergency department. ClinicalTrials.gov Identifier: NCT00230841.

PARENTSʼ KNOWLEDGE AND PERCEPTION ABOUT CHILD DEVELOPMENT: EVIDENCE FROM A PRACTICE-BASED SURVEY

Purpose/Hypothesis: Parent reporting of their child's motor skills and collaboration with a health care professional is a key factor in identifying movement delays at an early age and initiating early intervention. This study examines parents' knowledge of early motor development and their understanding of the importance of early intervention. There is increasing evidence that early therapy services have a positive effect on developmental outcomes for young children with movement delays. Several studies report developmental and functional benefits for children receiving interventions.(Ketelaar M, Phys Ther 2001:81:1534–45, Brooks-Gunn J, McCarton C. Casey P et al., JAMA 1994;272:1257–62) Number of Subjects: 500 Parents were asked to complete a survey while in the waiting rooms of pediatrician's offices and the physical therapy department of Children's Memorial Hospital. Materials/Methods: Parents were surveyed about their understanding of early child development, their preferences for obtaining resource information regarding the general health of their child and for answers related to concerns about their children's motor skills. Results: *About one quarter (23.9%) of the parents surveyed reported that at some point they had been concerned about one of their children having a movement delay; 6.4% of the sample of parents surveyed reported having at least one child diagnosed with a movement delay. *Parents regard pediatricians and physician specialists as the most reliable sources of general child health information and identify them as the sources they would most often use if they had a concern about their children's motor skills. *Less than half of all parents report that they would talk to their child's pediatrician before 12 months if they had concerns about their child's motor skills. For the three months infant motor skills milestones, 80% of all parents would talk to their child's pediatrician later than what is recommended. Therefore, most parents would not reach out at this critical time. *For parents who did discuss concerns about their child's motor skills with a pediatrician, the majority were advised by their pediatrician to talk to a physician specialist or non-physician specialist right away; about 40% were advised to wait and see or to get more information before seeking additional medical care. Conclusions: The majority of parents surveyed were unaware that earlier screening of movement delays is critical. Research supports family engagement in early therapy for children with movement delays has an impact on a greater range of developmental outcomes (Lekskulchai and Cole, 2001). Clinical Relevance: The results of this study suggest that there are a number of ways to increase the early detection of movement delays in children. Increasing parents' familiarity with early childhood development will increase the reporting of and thus detection of a possible movement delay. More importantly, this knowledge would empower early collaborative discussion of concerns with the family pediatrician, which in turn would facilitate early intervention.

The evolving role of HIV counseling and testing in resource-limited settings: HIV prevention and linkage to expanding HIV care access

The role of voluntary counseling and testing (VCT)of HIV in resource-limited settings has recently broadened from primarily that of a prevention intervention to its identification as the key entry point into expanding access to life-saving antiretroviral therapy, additional HIV-specific medical care, and other support services. To fulfill this expanded mandate, calls for routine counseling and testing in diverse health care settings, in addition to other innovative approaches to traditional VCT, are emerging. The efficacy and cost-effectiveness of traditional facility-based VCT with respect to risk-behavior reduction of HIV have been demonstrated rigorously in resource-limited settings. Additional research is needed urgently to evaluate the feasibility, acceptability, and effectiveness of streamlined counseling and testing interventions that seek to reach as many individuals as possible to meet dual prevention and treatment goals.

Simple triage and rapid treatment: Does it predict transportation and referral needs in patients evaluated by disaster medical assistance teams?

Study objectives: Disaster preparedness and response has taken on a new urgency because of recent world events. Aspects of a disaster response that have not been fully evaluated or assessed for validity include triage and triage systems. A commonly used system is the modified Simple Triage and Rapid Treatment (START). In this system, patients are triaged to 1 of 4 categories: red, immediate care; yellow, delayed care; green, “walking wounded”; and black, unsalvageable. The START triage system is frequently used by disaster medical assistance teams (DMAT), and is the system used by the New Mexico DMAT (NMDMAT) during deployments. However, this model has not been assessed previously to determine whether it is a useful or appropriate tool in a DMAT deployment. Our goal is to determine whether the START system commonly used by DMATs is a useful predictor of patient referral and transportation needs in disasters. To our knowledge, this is the first evaluation of this triage tool in DMAT deployments.Methods: This is a retrospective cohort review of all patients treated by the NMDMAT after Hurricane Andrew (Florida, August 1992), Hurricane Iniki (Hawaii, September 1992), the Northridge Earthquake (California, January 1994), and the Houston flood caused by Tropical Storm Allison (Texas, June 2001). Medical records were reviewed for triage category, disposition, and mode of transportation. Patients were assigned 1 of 4 triage categories according to urgency for medical care: green, yellow, red, or black. Disposition was assigned to 1 of 2 categories: home or referral to additional medical care. Transportation was also assigned to 1 of 2 categories: private vehicle or emergency medical services (EMS). Data were compared for statistical significance using a χ2 test for trend.Results: One thousand six hundred fifty-eight patients treated during these disaster events were assigned the following triage categories: green 1,363 (82.2%), yellow 236 (14.2%), red 55 (3.3%), and black 0. A total of 226 (13.6%) patients required disposition to additional medical care: green 123 (9.0% of category, 7.4% of total), yellow 236 (31.4% of category, 4.5% of total), and red 29 (52.7% of category, 1.7% of total). Of these patients with a reported method of transportation, a total of 66 (46.2%) were transported by EMS: green 13 (20.3% of category), yellow 30 (55.6% of category), and red 23 (92.0% of category). All categories were statistically different (P<.005).Conclusion: A relatively low percentage of disaster patients treated by a DMAT team at 4 major deployments required referral for additional medical care. Compared with the green triage category, patients assigned a red triage category were 5 times more likely to require referral for additional medical care and nearly 5 times more likely to require EMS transportation. In this first-of-its-kind examination of the START system, a higher-acuity START category was associated with an increased likelihood of transfer to a hospital and may continue to be a useful tool in this respect in future DMAT deployments.