Application Of Medical Knowledge Research Articles

An Interpretable Data-Driven Medical Knowledge Discovery Pipeline Based on Artificial Intelligence.

Difficulty in knowledge validation is a significant hindrance to knowledge discovery via data mining, especially automatic validation without artificial participation. In the field of medical research, medical knowledge discovery from electronic medical records is a common medical data mining method, but it is difficult to validate the discovered medical knowledge without the participation of medical experts. In this article, we propose a data-driven medical knowledge discovery closed-loop pipeline based on interpretable machine learning and deep learning; the components of the pipeline include Data Generator, Medical Knowledge Mining, Medical Knowledge Evaluation, and Medical Knowledge Application. In addition to completing the discovery of medical knowledge, the pipeline can also automatically validate the knowledge. We apply our pipeline's discovered medical knowledge to a traditional prognostic predictive model of heart failure in a real-world study, demonstrating that the incorporation of medical knowledge can effectively improve the performance of the traditional model. We also construct a scale model based on the discovered medical knowledge and demonstrate that it achieves good performance. To guarantee its medical effectiveness, every process of our pipeline involves the participation of medical experts.

Purpose, subject matter and objectives of forensic medicine

It has been established that forensic medicine is a branch of medicine that deals with the application of medical knowledge and methods to resolve legal issues, in particular those related to death, injury and other types of violence. The main purpose of forensic medicine is to examine the bodies of the dead or injured in order to determine the cause of death or injury, as well as to determine the possible criminal element in the act. To do this, forensic physicians use methods of body examination, evidence collection and expert analysis.
 It has been generalised that forensic medical examination as a subject of forensic medicine is a scientific and practical research carried out by specially trained specialists with the aim of providing an objective assessment of medical issues in cases brought before a court. This examination may include determining the causes and circumstances of death, assessing injuries, determining the severity and possible consequences of injuries, examining the patient's medical history, and other medical issues that may be relevant to the resolution of court cases. The results of a forensic medical examination may be used as evidence in a court of law.
 It has been stated that the main tasks of forensic medicine as a branch of science are: study of human physiology and pathology, as well as the relationship of these processes with the knowledge of the cause of death and other traumatic injuries; development and improvement of methods for detection and assessment of traumatic injuries and their consequences, as well as establishment of the relationship between trauma and health consequences; detection of the impact of physical and chemical factors on human health, as well as establishment of the causes and consequences of the impact of these factors; determining the state of human health in the context of criminal investigation, including assessment of the state of alcohol or drug intoxication and its impact on human behaviour and actions; studying the relationship between the state of health and the crime committed, as well as establishing the facts of the presence and nature of injuries of victims.

Health disparities early learner simulation to improve interprofessional competencies

To date, interprofessional simulation has predominantly focused on advanced learners and practicing providers with a focus on application of medical knowledge. Our study sought to create and evaluate an interprofessional simulation for early learners in an experiential setting. First-year medical and pharmacy students, and second-term accelerated undergraduate nursing students participated in a face-to-face simulation focused on health disparities to improve interprofessional teamwork and communication skills. Student self-perceived competence was measured through completion of the Interprofessional Collaborative Competency Attainment Survey-Revised (ICCAS-R) (1 = poor; 3 = good; 5 = excellent), which was administered after simulation completion in a retrospective pre-/post-test manner. Activity assessment questions and students’ comparative ability to collaborate interprofessionally were also evaluated at the conclusion of the simulation. A total of 351 students participated in the simulation (178 medical, 41 accelerated undergraduate nursing, and 132 pharmacy). A significant increase in mean total (SD) ICCAS-R scores was seen in all students from 3.3 (0.6) to 4.0 (0.6) ( p < 0.001). Analysis of the six mean subscale scores (communication, collaboration, roles and responsibilities, patient-centered care, conflict management, and team functioning) for all student disciplines revealed a significant increase in self-reported interprofessional competencies ( p < 0.001 for all subscales). When asked to compare one's ability to collaborate interprofessionally now compared to prior to the simulated learning activity, 83% of students reported their ability as somewhat better or much better now. Medical, accelerated undergraduate nursing, and pharmacy student participation in an early learner simulation activity focused on teamwork, patient-centered care and health disparities, led to significant increases in self-reported interprofessional competencies.

The Medical Historical Cultural Foundations of Western Nasal Surgery from Ancient Greece to the Middle Ages

The manuscript aims to clarify the origins of Western rhinosurgery through the ancient texts of the greatest physicians of the past, up to the Byzantine Era, focusing on the “exchange of knowledge” between peoples. This excursus is carried out by quoting the texts of the greatest doctors of the past, such as Hippocrates, Galen and Celsus and by analysing the works of Byzantine authors such as Oribasius, Aetius, Antillus, which, more than others, represent the moment of fusion and interpenetration of Ancient Medical knowledge, paving the way for the Medieval Scholae Medicae in the West. The aim, therefore, is to fill that sort of "great gap" (from the foundation of Constantinople in the 4th century AD to the early Arab culture in the 11th century AD) due to the fact that figures such as Branca, Vianeo and, finally, Tagliacozzi, are considered direct actors of a recovery of the “ancient knowledge” of classic authors. This literature tends to less evaluate, instead, that important and huge cultural exchange -literally osmotic- in medical and surgical knowledge between peoples and civilizations, that find a trait d'union in the application of medical knowledge and surgical practical techniques matured in the Byzantine, Arab and Early Medieval period. In final analysis, through the History of Rhinosurgery, this paper aims to highlight how Western medical knowledge is made up of the ensemble of cultures which are apparently distant and different from each other, which merge themselves in a truly universal and transcultural knowledge: the Medical knowledge.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Deep Learning Model Incorporating Knowledge Representation Vectors and Its Application in Diabetes Prediction.

The deep learning methods for various disease prediction tasks have become very effective and even surpass human experts. However, the lack of interpretability and medical expertise limits its clinical application. This paper combines knowledge representation learning and deep learning methods, and a disease prediction model is constructed. The model initially constructs the relationship graph between the physical indicator and the test value based on the normal range of human physical examination index. And the human physical examination index for testing value by knowledge representation learning model is encoded. Then, the patient physical examination data is represented as a vector and input into a deep learning model built with self-attention mechanism and convolutional neural network to implement disease prediction. The experimental results show that the model which is used in diabetes prediction yields an accuracy of 97.18% and the recall of 87.55%, which outperforms other machine learning methods (e.g., lasso, ridge, support vector machine, random forest, and XGBoost). Compared with the best performing random forest method, the recall is increased by 5.34%, respectively. Therefore, it can be concluded that the application of medical knowledge into deep learning through knowledge representation learning can be used in diabetes prediction for the purpose of early detection and assisting diagnosis.

Doping as a Form of Institutional Maintenance in Professional Road Cycling

In this paper we explain the maintenance of a practice that departs from acceptable standards. Drawing on the case of professional road cycling we explore the use of doping as a kind of institutionalized practice. Sports doping in general has the potential to destroy public trust in sport and its wider positive effects. In cycling doping to enhance human performance became established in response to harsh working conditions and the demand for results, and despite disruption from anti-doping authorities, and many scandals, has hardly lessened. To explain this we use a model of institutional types that provides a critical account of this contested and contradictory activity. We confirm the importance of efforts both to normalize and conceal doping; we stress an often overlooked technical dimension of maintenance in the application of medical knowledge, and we show how doping across the sport relied on actor interactions and a system of institutional support.

Enhanced Learning and Retention of Medical Knowledge Using the Mobile Flash card Application Anki.

As medical schools condense the basic science phase of undergraduate medical education, it has become increasingly important to identify methods and tools that facilitate learning, mastery, and application of medical knowledge. One increasingly popular tool that promotes engagement with content is Anki, a web-based flash card system. Using Anki, medical students can access pre-made flash cards specifically tailored to prepare students for the United States Medical Licensing Exam (USMLE) Step 1 exam. The objective of this study was to identify Anki use and its association to USMLE Step 1 performance. In March 2020, medical students in years 2, 3, and 4 who had completed USMLE Step 1 were administered a survey to measure Anki usage. The survey was locally developed and was reviewed by survey experts on campus. Survey responses were paired with USMLE Step 1 results for analyses. Descriptive and inferential statistics were used for analysis. Anki usage was associated with higher USMLE Step 1 scores. Additionally, amongst those who used Anki, those with more consistent use had higher USMLE Step 1 scores and higher perceived levels of knowledge retention. This research suggests that Anki is an effective educational tool that should be recommended to medical students alongside other evidenced-based study tools, such as the popular question bank USMLE World. Future research should attempt to identify a relationship between Anki usage and future clinical performance to demonstrate the implications that Anki has on clinical skills. The online version contains supplementary material available at 10.1007/s40670-021-01386-9.

Implementation and preliminary evaluation of integrated curriculum of basic medicine for clinical students: taking Shanxi Medical University as an example

The integrated curriculums of basic medicine in Shanxi Medical University are as follows: nine basic medical courses were integrated into 10 medical modules, with additional training including PBL and TBL case discussion, clinical clerkship, flipped classroom and other non-integrated subjects etc. In order to assess the interest of students for integrated curriculum, their intrinsic motivation, as well as their comprehension and application of medical knowledge, we gave anonymous questionnaire to 149 students, 16 teachers in basic medicine, and 10 teachers in clinical medicine. Results showed that more than 90% students were willing to take the integrated curriculum and participate in PBL and TBL case discussion, and students who were unwilling to take the curriculum were less than 10%, they thought that the knowledge of new curriculum system was incoherent. The proportion of students from higher grade who were unwilling to participate in the flipped classroom was increased from 6.7% to 95.0%. Most of the teachers both in basic and clinic medicine believed that new curriculum system was helpful for students to comprehend basic medical knowledge and strengthen their discriminating ability, but did not function in improving students' practical ability. In the further reform on teaching, details like the coherence of knowledge and the content selected when self-studying should be improved. Key words: Basic medicine; Integrated curriculum; Application; Preliminary evaluation

Expert opinions in dermatology.

Apart from their medical responsibilities relating to the diagnosis, treatment and prevention of skin diseases, dermatologists may also be asked to provide expert medical opinions. In their role as medical experts, dermatologists provide their services not only to public institutions and courts but also to private clients. Expert dermatological opinions involve the application of medical knowledge and experience to an individual case as regards a specific legal question. The dermatological expert thus becomes an "assistant" to administrative and public agencies or courts. In addition to providing the required expert knowledge, the expert must maintain strict neutrality and avoid any bias. Expert opinions play a significant role in the field of occupational dermatology. In this context, it is important to make a distinction between scientific expert opinions - commissioned to determine whether the criteria for an occupational skin disease are met or to assess the degree of reduction in earning capacity - and the much more common "small expert opinions" relating to disease prevention ("dermatologist's procedure"). Moreover, expert medical opinions have become increasingly important with respect to medical malpractice issues, both in court proceedings and for investigations conducted by State Medical Chambers. For quality assurance of expert dermatological opinions, the Working Group for Occupational and Environmental Dermatology in particular offers certification courses. The same group also provides guidelines for expert opinions in occupational dermatology (Bamberg Recommendations).

Simulation-based Remediation in Emergency Medicine Residency Training: A Consensus Study.

IntroductionResident remediation is a pressing topic in emergency medicine (EM) training programs. Simulation has become a prominent educational tool in EM training and been recommended for identification of learning gaps and resident remediation. Despite the ubiquitous need for formalized remediation, there is a dearth of literature regarding best practices for simulation-based remediation (SBR).MethodsWe conducted a literature search on SBR practices using the terms “simulation,” “remediation,” and “simulation based remediation.” We identified relevant themes and used them to develop an open-ended questionnaire that was distributed to EM programs with experience in SBR. Thematic analysis was performed on all subsequent responses and used to develop survey instruments, which were then used in a modified two-round Delphi panel to derive a set of consensus statements on the use of SBR from an aggregate of 41 experts in simulation and remediation in EM.ResultsFaculty representing 30 programs across North America composed the consensus group with 66% of participants identifying themselves as simulation faculty, 32% as program directors, and 2% as core faculty. The results from our study highlight a strong agreement across many areas of SBR in EM training. SBR is appropriate for a range of deficits, including procedural, medical knowledge application, clinical reasoning/decision-making, communication, teamwork, and crisis resource management. Simulation can be used both diagnostically and therapeutically in remediation, although SBR should be part of a larger remediation plan constructed by the residency leadership team or a faculty expert in remediation, and not the only component. Although summative assessment can have a role in SBR, it needs to be very clearly delineated and transparent to everyone involved.ConclusionSimulation may be used for remediation purposes for certain specific kinds of competencies as long as it is carried out in a transparent manner to all those involved.

FORENSIC MEDICINE: THE STORY, CLINICAL NEXUS AND CHALLENGES OF THE PRACTICE IN NIGERIA

The synonym of forensic medicine is forensic pathology1,2. Also called legal medicine or medical jurisprudence3. Forensic medicine is a field that involves collection and analysis of medical evidence (samples) to produce objective information for use in the legal system2,3. It can therefore be aptly summed as the science that deals with the application of medical knowledge to legal questions. It is also extremely useful in cases where a patient dies without having made a definitive diagnosis2. The primary tool of forensic medicine has always been the autopsy2. Frequently used for identification of the dead, autopsies may also be conducted to determine the cause of death2. In cases of death caused by a weapon, for example, the forensic pathologist - by examining the wound - can often provide detailed information about the type of weapon used as well as important contextual information. In a death by gunshot, for example, he can determine with reasonable accuracy the range and angle of fire. Forensic medicine is a major factor in the identification of victims of disaster, such as landslide or plane crash4. In cause-of- death determinations, forensic pathologists can also significantly affect the outcome of trials dealing with insurance and inheritance5. Though the autopsy is performed by a forensic pathologist or a medical examiner, particularly during the investigation of criminal law cases and civil law cases in some jurisdictions2, Coroners and medical examiners are also frequently asked to confirm the identity of a corpse. The scope of modern day forensic medicine has expanded far beyond autopsies to include exciting subjects of anthropology; forensic odontology; forensic entomology; ballistics, fingerprint, crime scene and blood spatter analysis; toxicology; DNA; arson and fire investigation; evaluation of the sexual assault victim; forensic psychiatry (which is used to determine the mental health of an individual about to stand trial, and thus, his blameworthiness) and more1,2. It is therefore instructive that the forensic medical services cut across all specialities of medicine with the primary areas of medicine that are commonly involved and harnessed in forensic medicine practice being anatomy, pathology, and psychiatry. To render efficient and effective forensic services in any setting, the forensic pathologist works with a number of support staff including: accident scene investigator; autopsy technician; coroner; forensic investigator; legal consultant; trauma, emergency medicine or psychiatric nurse; sexual assault nurse examiner; social services investigator and/or advocate and more2 .

Centering Animals in Latin American History

Centering Animals in Latin American History

Effectiveness of a new short-stay unit for elective low complexity patients’ admissions to improve patient flow

Background/Objective: Specialized care in an acute hospital is the highest resource consuming type of health care. Performance improvement in health care should look for a better application of medical knowledge and resource consuming at the same time as managers locally redesigned processes and organizations in order to be more cost-effective at healthcare services delivery. The aim of this study was to demonstrate the effectiveness of creating a short-stay unit for elective patients as an alternative to the elective patients being admitted in an acute ward. Methods: We included all elective patients admitted in a university hospital between the 1st of January and the 31st of December 2007, as well as those admitted during the same period of 2009, after two hospital wards transformation into a short-stay unit. We used the Hospital General Database for collecting information on years 2007 and 2009. Main key performance indicators were length of stay, pre-surgery length of stay, rotation rate, discharge planning rate and cost. For statistical bivariate analysis, we used a Chi-squared for linear trend for qualitative variables and a T-test and a Wilcoxon signed ranks test and a Mann-Whitney test for non-normal continuous variables. Significance at p &lt; .05 was assumed throughout. Results: We included 10,678 patients, 4,423 during 2007 and 6,255 during 2009. Mean length of stay was 4.3 days (IC 95%: 4.09-4.51) in 2007 and 2.8 days (IC 95%: 2.61-3.01) in 2009 (p &lt; .05). Pre-surgery length of stay was reduced from 0.5 days (IC 95%: 0.44-0.56) in 2007 to 0.2 days (IC 95%: 0.17-0.23) in 2009 (p &lt; .05). The rotation rate was of 92 patients/bed in 2007 and of 126 patients/bed in 2009 (p &lt; .05). The median number of planned discharges grew from 43.05% in 2007 to 86.01% in 2009. Closing two hospital wards at weekends has generated savings of €805,376.32 through the reduction of 22 nurse employees. Conclusions: In conclusion, this approach to hospital bed management in a tertiary hospital has proven both possible and efficient. The creation of short-stay units for elective patient admissions allowed an increase in productivity per hospital bed due to a higher rotation rate and a reduction in human resources costs due to closing hospital wards at weekends.

Board 281 - Program Innovations Abstract How Do You Change a Resident in a Month? Using Simulation as Goal Directed Remediation of Resident Performance (Submission #164)

Introduction/Background Residency represents a complex amalgamation of acquiring medical knowledge, applying this knowledge to various clinical scenarios and ultimately learning how to deliver efficient and proficient care to patients. If any of these aspects are deficient in a resident, it jeopardizes the ultimate goal of residency, which is to develop competent physicians. And while assessing and remedying gaps in medical knowledge may seem relatively straight forward, the other aspects of resident competency (application of knowledge, delivery of care, etc.) are often much more subjective and remedies for deficiencies seem much more aloof. However, through individual learner assessment and the use of high fidelity simulation, it was our hope that we could objectively assess and remediate specific deficiencies and ultimately change the trajectory of a struggling resident. Methods Growing concerns were raised for a PGY-1 internal medicine resident regarding substantial gaps in application of medical knowledge, ability to triage patients based on severity of disease, and adaptation to a busy and high acuity service. These concerns were significant enough to warrant an individualized remediation plan in hopes of readying the resident for the rigors of their second year of residency. Due to limitations in scheduling, this formalized remediation was scheduled for an individual four week block. Prior to the initiation of the block, the resident was formally assessed by an expert in adult learning who utilized Kolb’s Learning Style Inventory so that we could better understand potential barricades to our learning plan. In this case, she was found to be a reflective learner (diverger) which was contrary to many of the teaching styles of the faculty. This allowed for greater insight into the potential discrepancies between learner and faculty and provided a latticework from which we could construct a more effective learning experience for the resident. Based on this assessment, a formalized program was created consisting of both bedside patient care (permitting for close one-on-one observation and immediate personalized feedback) and high fidelity, high stakes simulation. This culminated in a multifaceted scenario of several overlapping simulated patients designed to exploit many of the resident’s perceived limitations. The ability to triage patients and problems simultaneously and all aspects were recorded for the review of the program director. The resident performance substantially improved not only as measured by direct observation of attending physicians and subjective assessment by the resident but has also continued in ongoing faculty evaluations. Results: Conclusion The progression and maturation of learners throughout their residency has been historically subjective and variable. However, with the ongoing evolution of competency-based assessment, much greater scrutiny is going to be placed on resident milestones of performance. Simulation clearly offers a unique opportunity not only providing a controlled, safe environment for assessment but also allowing for enrichment of skills and remediation as necessary. Although labor intensive and time consuming, the investment of resources to better understand struggling residents’ learning styles and mental models is one that can have significant returns. In this case, the investment in time and resources completely changed a resident’s course of training, competency as judged by attending faculty and ultimately her overall efficacy as a physician. While not feasible on a global scale, the appropriate utilization of simulation in concert with the formalized assessment of mental models and learning styles has the potential to close significant gaps in learners’ education. This clearly not only benefits the learner and educators but also has the clear potential to improve patient safety in the process. Therefore, while resource utilization in a program like this is undoubtedly significan,t so is the return on investment.

Clinical and genomic data integration in support of biomedical research and clinical practice

Eric Neumann is a graduate from MIT and holds a PhD in neurobiology, developmental genetics, and pharmacology from Case Western Reserve University. He is a recognized expert in semantic information, and has worked on many information initiatives for the pharmaceutical and life sciences, including the W3C Semantic Web Healthcare and Life Science Interest Group (HCLSIG). Eric Neumann was the Global Head of Knowledge Management for Scientific and Medical Affairs within Sanofi-Aventis and the VP of Informatics at BG Medicine. He founded Genstruct (now Sleventa) and has also worked at Bolt, Beranek, and Newman (now BBN Technologies - Raytheon) on several advanced scientific computation projects over the span of several years. He is Founder and CTO of PanGenX, a personalized medicine company, whose mission is to optimize therapeutic care by facilitating the discovery and application of medical knowledge towards patient segmentation. Starting from the current definition of pharmacogeomics, in his talk Eric Neumann will show how it drives the personalized medicine vision, and will discuss what new forms of clinical and genomic information will be required for making clinical decision in personalized medicine. He will illustrate some available public data sources, showing what they still lack and the value of deep focus curation. He will contrast data vs. "Actionable Knowledge" and discuss how leveraging semantically linked data to help progress personalized medicine. He will also address large-scale analytics and argue about who will benefit from linked knowledge.

Clinico‐Histologic Conferences: Histology and disease

Providing a context for learning information and requiring learners to teach specific content has been demonstrated to enhance knowledge retention. To enhance students' appreciation of the role of science and specifically histology in clinical reasoning, disease diagnosis, and treatment, a new teaching format was created to provide clinical context, promote integration and application of science knowledge, and to foster peer teaching and learning: the Clinico-Histologic Conference (CHC) for the Mount Sinai School of Medicine Histology course. Teams of six students were each assigned specific disease processes and were charged with creating oral presentations and handouts that taught their classmates about the clinical manifestations, etiopathogeneses, diagnoses, and treatments of the assigned processes, along with comparisons of normal histology to the pathology of the disease. Each team also created four questions, some of which were used on Histology written examinations. The physician facilitator evaluated the presentation and handouts. About two-thirds of students agreed the CHC enhanced appreciation of the importance of histology, provided a context for integration and application of basic science to patient care and enhanced their ability to teach their peers. Student feedback demonstrated that the CHCs were successful in promoting teamwork, peer teaching, and the application of histology to diagnose diseases. The authors believe that teaching basic science content in this new format enhanced student learning and application of medical knowledge, and that this new teaching format can be adopted by other medical school courses.

Pharmacist Licensure: Time to Step It Up?

Pharmacist Licensure: Time to Step It Up?

Perspective: Anticipating the Challenges of Reforming the United States Medical Licensing Examination

The practice of medicine is a shared social contract between the medical profession and the public. Assessments for licensure should reflect competencies that patients expect of their physicians and should be patient-centered and mirror the progressive nature of medical education. The National Board of Medical Examiners recently accepted the recommendations of the Committee to Review the United States Medical Licensing Examination Program to align the examination sequence with two patient-centered decision points: when a student enters into supervised graduate training, and when a physician receives initial licensure for unsupervised practice. The revised examination program would aim to evaluate for the presence of at least minimum proficiency in all competencies that are measurable in a valid, reliable manner at each decision point, including the scientific foundation of medical practice, the application of medical knowledge to patient care, and the clinical skills relevant to practice level, whether measured by standardized patient-based assessments or other formats. Students, educators, educational leaders, and program directors have raised legitimate concerns about the anticipated changes. The anticipated costs, the changes' effect on basic science education, their impact on dual-degree candidates and international medical graduates, and the utility of score reporting are each of concern. Anticipated benefits include a closer alignment of assessments with the expectations of patients and licensing authorities, closer integration of the sciences fundamental to medical practice throughout the examination sequence, and an increased breadth of competency assessment. The authors believe that the benefits to patients and the profession will outweigh the acknowledged challenges the changes will pose to medical education.

Clinico‐Histologic Conferences (CHC): A New Endeavor in Teaching Histology

Clinico‐Histologic Conferences were developed for the histology course in the first year of medical school to: enhance the relevance of histology by providing a clinical context, foster peer teaching and learning through teamwork, and promote longitudinal integration and application of medical knowledge. Twenty‐four groups of six students each were assigned a disease and created a 10 min presentation with a handout with the objective of teaching the class about that disease. The students' oral presentation and handout focused on the salient features of the disease, i.e. description of the disease, including symptoms, findings, incidence (US &amp; other countries), age or gender or other predisposing factors and outcomes (morbidity, life expectancy); etiology of the disease (cause or origin of the disease, the basis of the cellular manifestation of the disease, and if known, the molecular/genetic defect.); diagnosis (lab tests, histological tests). A 5 min Q and A was at the end of each presentation with an expert MD facilitator present. The facilitator evaluated the students on their oral presentation (choice of content, format, and discussion to facilitate student understanding of the disease) and handouts (quality of information, format, clarity of information and graphics of histology/pathology of disease). There were also questions on the midterm and final exams related to the content taught in the CHCs.

Environmental Threats to Children's Health: A Challenge for Pediatrics: 2000 Ambulatory Pediatric Association (APA) Presidential Address

Public health accomplishments have dramatically improved children's lives. Sanitation programs, vaccines, better nutrition, surveillance and monitoring of disease, and the development of antibiotics have led to extraordinary reductions in infant and child mortality.1 Ambulatory pediatricians have contributed, through research, teaching, and advocacy, and especially through the delivery of improved medical care to this dramatic trend. Despite these advances, children are in trouble: