On-site Clinic Research Articles

Postpartum Health Services Requested by Mothers with Newborns Receiving Intensive Care.

Objectives Our pilot study aimed to build knowledge of the postpartum health needs of mothers with infants in a newborn intensive care unit (NICU). Methods Between May 2008 and December 2009, a Certified Nurse Midwife was available during workday hours to provide health care services to mothers visiting their infants in the NICU at a large tertiary care center. Results A total of 424 health service encounters were recorded. Maternal requests for services covered a wide variety of needs, with primary care being the most common. Key health concerns included blood pressure monitoring, colds, coughs, sore throats, insomnia and migraines. Mothers also expressed a need for mental health assessment and support, obstetric care, treatment for sexually transmitted infections, tobacco cessation, breastfeeding assistance, postpartum visits, and provision of contraception. Conclusions Our study suggests that mothers with babies in the NICU have a host of health needs. We also found that women were receptive to receiving health services in a critical care pediatric setting. Intensive care nurseries could feasibly partner with in-patient mother–baby units and/or on-site obstetric clinics to increase access to health care for the mothers of the high-risk newborns in their units. Modifications should be made within health care systems that serve high-risk infants to better address the many needs of the mother/baby dyad in the postpartum period.

School-Based Health Centers to Advance Health Equity: A Community Guide Systematic Review.

Children from low-income and racial or ethnic minority populations in the U.S. are less likely to have a conventional source of medical care and more likely to develop chronic health problems than are more-affluent and non-Hispanic white children. They are more often chronically stressed, tired, and hungry, and more likely to have impaired vision and hearing-obstacles to lifetime educational achievement and predictors of adult morbidity and premature mortality. If school-based health centers (SBHCs) can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can advance health equity. A systematic literature search was conducted for papers published through July 2014. Using Community Guide systematic review methods, reviewers identified, abstracted, and summarized available evidence of the effectiveness of SBHCs on educational and health-related outcomes. Analyses were conducted in 2014-2015. Most of the 46 studies included in the review evaluated onsite clinics serving urban, low-income, and racial or ethnic minority high school students. The presence and use of SBHCs were associated with improved educational (i.e., grade point average, grade promotion, suspension, and non-completion rates) and health-related outcomes (i.e., vaccination and other preventive services, asthma morbidity, emergency department use and hospital admissions, contraceptive use among females, prenatal care, birth weight, illegal substance use, and alcohol consumption). More services and more hours of availability were associated with greater reductions in emergency department overuse. Because SBHCs improve educational and health-related outcomes in disadvantaged students, they can be effective in advancing health equity.

APhA recognizes 2016’s Immunization Champions

Clinic, a walk-in clinic for patients aged 15 years and older, at a large Indian Health Service medical center in Phoenix. But providing only 10% of the vaccines given on campus, the clinic’s reach isn’t great enough for Van Lew. “We want vaccines addressed at every visit,” Van Lew said. Primary care alone, she noted, can’t cover all adult vaccines. Patients may have many specialty visits between less frequent primary care visits at the time immunizations are due. Van Lew aimed to standardize the approach to immunizations across the medical center campus. Through education campaigns, she has motivated nurses to embrace CDC recommendations to address immunizations at every visit. She successfully advocated for a protocol that would allow all nurses to offer routine vaccines anywhere on campus. In 2015, she provided 20 education sessions to more than 250 providers across specialties and professions to increase vaccine awareness, integrate vaccination into workflows, and devise better ways to use electronic health records and screening tools in this endeavor. Nationally, Van Lew has collaborated on research with CDC and the National Center for Immunization and Respiratory Diseases to better understand and improve adult vaccination rates. “I get involved in so many different arenas because there’s so many different ways we can impact vaccination rates—not just in the clinic.” In 2015, on Van Lew’s watch, more than 44,000 vaccines were administered to children and adults in her health system, substantially increasing immunization rates for zoster, human papillomavirus, tetanus, diphtheria, and pertussis.

Efforts at the Frontlines: Implementing a Hepatitis C Testing and Linkage-to-Care Program at the Local Public Health Level.

The national Viral Hepatitis Action Plan recommends strengthening partnerships among health departments, community-based organizations, and health-care providers for hepatitis services. We implemented a hepatitis C virus (HCV) testing and linkage-to-care program through a local health department using similar strategies reported for HIV care. The Durham County Department of Public Health received federal funding to conduct HCV testing and linkage to care in Durham, North Carolina. HCV antibody testing with reflex RNA was offered through a sexually transmitted disease clinic, a county jail, community testing sites (including a residential substance abuse recovery program), and a homeless clinic. People with evidence of HCV infection were linked to care through an HCV bridge counselor who provided education, incentives, and transportation, and scheduled appointments with HCV specialists at nearby academic centers and on-site clinics. From December 2012 through February 2014, we conducted 2,004 HCV tests, of which 326 (16.3%) were HCV antibody positive and 241 (12.0%) had detectable HCV RNA. Among the 241 people with HCV infection, 178 (73.9%) were men, and 133 (55.2%) were born between 1945 and 1965. Of 241 people with chronic HCV infection, 150 (62.2%) reported ever injecting drugs, eight (2.5%) were coinfected with HIV, and 123 (51.0%) were linked to care. At the local public health level, HCV testing and linkage to care can be facilitated with additional funding and by leveraging existing programs and provider networks to deliver a coordinated system of care.

The Future of Psychiatric Collaboration in Federally Qualified Health Centers.

Federally qualified health centers (FQHCs) provide comprehensive care to underserved and disadvantaged populations. FQHCs now comprise the largest primary care network in the United States. Currently, many FQHCs provide limited access to psychiatric services; and when such services are available, most use traditional on-site psychiatric clinics. The author reviews the rationale for increasing access to behavioral health care in FQHCs by adopting collaborative models of care, describes challenges to adopting these models in FQHCs, and discusses ways to increase the primary care team's ability to support patient self-care and family functioning.

Implementation of the AUA Castration Resistant Prostate Cancer Guidelines into Practice: Establishing a Multidisciplinary Clinic

IntroductionAUA (American Urological Association) published guidelines on the treatment of castration resistant prostate cancer in August 2013. Urologists have remained integral members of a multifaceted team of professionals treating patients with prostate cancer. We discuss approaches to implementing a guidelines based, multidisciplinary, advanced prostate cancer treatment clinic. MethodsA supplemented PubMed® search was performed to identify published literature evaluating the treatment of castration resistant prostate cancer. Attention was placed on studies assessing a multidisciplinary approach to treating patients with castrate resistant prostate cancer. A review of currently approved agents is provided with emphasis on administration from an integrated clinic. ResultsTreatment of patients with advanced prostate cancer remains a significant function of many urology clinics. Guidelines assist urologists with providing patients with the most appropriate care along with multispecialty collaboration. Several organizational approaches have been attempted, including all-in-one clinics, onsite clinics and virtual multidisciplinary clinics. Through close collaboration with medical oncologists, radiation oncologists and support staff patients with advanced prostate cancer can obtain the highest quality care. ConclusionsUrologists remain an integral member of the multidisciplinary approach to treating castrate resistant prostate cancer. AUA guidelines for castration resistant prostate cancer are a useful tool that can be incorporated into virtual multidisciplinary clinics. Through a team approach patients receive timely and appropriate care.

Maintenance of Clinical Endpoints After Discharge from a Pharmacist-Managed Risk Reduction Clinic at a Veterans Affairs Medical Center.

Diabetes, dyslipidemia, and hypertension are complex chronic disease states that often require close monitoring and frequent follow-up to achieve and maintain therapeutic control as determined by hemoglobin A1c (A1c), low-density lipoprotein (LDL), and blood pressure (BP). At the Charles George Veterans Affairs Medical Center (CGVAMC), physicians may refer their patients to the on-site pharmacist-managed Risk Reduction Clinic (RRC). Patients are discharged from the RRC once patient-specific therapeutic goals have been met for diabetes, dyslipidemia, and/or hypertension. This study investigated the change in A1c, LDL, and systolic blood pressure (SBP) after discharge from the CGVAMC RRC. To investigate (a) how clinical endpoints for diabetes, dyslipidemia, and hypertension change after discharge from the pharmacist-managed RRC at the CGVAMC; (b) the factors associated with worsening of monitoring parameters; and (c) the frequency of reconsultation to the RRC. In this single-center retrospective quality management study, patients were included if they had a completed consultation to the CGVAMC RRC between August 11, 2008, and January 1, 2011, for the management of type 2 diabetes, dyslipidemia, and/or hypertension. Patients were included if they were discharged from the RRC prior to October 1, 2011, due to goal attainment. Furthermore, it was required that patients have A1c, LDL, and SBP measurements, as applicable based on diagnoses, at least yearly during the first 2 years following discharge. Patients were excluded if they were discharged for any reason other than goal attainment or if they were followed by a specialty clinic related to the RRC, including the Diabetes PharmD, Diabetes MD, MIDAS (group diabetes), or MAGIC (group dyslipidemia) clinics. Data collection included patient demographics; date of and indication for consultation to the RRC; date of first RRC visit; date of discharge from the RRC; number of visits to the RRC; A1c, LDL, SBP, and weight at consultation to the RRC, at discharge, and during the 2 years following discharge from the RRC; and date of and indication for reconsultation to the RRC, as applicable. Two-tailed paired t-tests were used to compare A1c, LDL, and SBP at discharge from the RRC to A1c, LDL, and SBP during the follow-up period. Two-tailed unpaired t-tests were performed to determine which variables were associated with changes in the monitoring parameters after discharge from the RRC. One hundred forty-nine patients were included in this study. For all patients with a diagnosis of diabetes (N = 82), A1c rose from 6.49% to 6.79% (P < 0.001) during the first year and to 7.04% (P < 0.001) during the second year following discharge. For patients diagnosed with dyslipidemia (N = 137), LDL rose after discharge from 81.5 mg/dL to 90.8 mg/dL (P < 0.001) and to 90.9 mg/dL (P < 0.001), respectively. For patients diagnosed with hypertension (N = 132), SBP rose from 126.2 mm Hg to 131.5 mm Hg (P < 0.001) and to 133.9 mm Hg (P < 0.001), respectively. An increase in A1c after discharge was associated with lower discharge A1c (P = 0.014), higher consultation weight (P = 0.009), and higher discharge weight (P = 0.042). A rise in LDL was correlated to higher consultation LDL (P = 0.006), while higher SBP was associated with lower discharge SBP (P < 0.001). Twelve percent of patients were reconsulted to the RRC. A1c, LDL, and SBP rose after discharge from the pharmacist-managed risk reduction clinic, but these changes may not have been clinically significant based on the low reconsultation rate and values remaining close to generally accepted therapeutic goals. Patients likely to benefit from extending RRC services past goal attainment include those with higher A1c and LDL at the time of consultation and those with higher weight. As a result of this study, recommendations have been made to consider following up every 3-4 months for 2-3 additional visits for patients with baseline A1c > 8% and LDL > 115 mg/dL and those with weight > 220 pounds prior to discharging them from the CGVAMC RRC. Furthermore, we believe that all patients could benefit from extending follow-up to 6 months for 1-2 additional visits or as needed after their therapeutic goals have been reached.

Productivity losses attributable to headache, and their attempted recovery, in a heavy-manufacturing workforce in Turkey: implications for employers and politicians.

BackgroundHeadache disorders cause substantial productivity losses through absenteeism and impaired effectiveness at work (presenteeism). We had previously found these losses to be high in a mostly male, heavy-manufacturing workforce at Ford Otomotiv Sanayi AŞ (FO), in north-western Turkey. Here we aimed to confirm this finding in a year-long study to eliminate any effect of seasonal variation. The question then was how much of this lost productivity could be recovered by the effective provision of headache care.MethodsWe used the HALT-30 Index to estimate productivity losses, surveying FO’s entire workforce (N = 7,200) during annual health-checks provided by the company’s on-site health clinic. Then we established, and widely advertised, a headache clinic within the same health clinic, providing specialist care free for 15 months. Outcome measures were HALT-30, company sickness records and the HURT questionnaire.ResultsUsable data were collected from 5,916 employees (82.2 %; 5,485 males [92.7 %], 431 females [7.3 %]; mean age 32.5 ± 5.4 years). One-month headache prevalence was 45.4 % (n = 2,688). Productivity losses were reported by 968 employees (16.4 %) and, per affected employee, increased from 0.23 to 7.56 days/month as headache frequency increased (P <0005). Employees reporting headache on ≥15 days/month (n = 64; 1.1 %) accounted for 21.1 % of productivity losses, those with headache on 10–14 days (n = 104; 1.8 %) another 18.5 %. With increasing headache frequency, absenteeism/presenteeism ratio (overall 1:16) declined from about 1:4 to about 1:25 in those with headache on ≥10 days/month. Headache frequency and lost productivity were higher in females than males (P <0.0005). Both absenteeism and presenteeism rates declined after age 34 years (P <0.0005).Only 344 employees with headache (12.8 %) requested appointments, and only 211 (7.8 %) actually consulted. Attendance was related to headache frequency (P <0.0005). Too few returned for follow-up to allow useful outcome assessment.ConclusionThe high productivity losses in this young mostly male workforce correlated with but were not wholly explained by headache frequency. A small minority of employees with high-frequency headache contributed highly disproportionately to the productivity losses. These should be the target of interventions aimed at productivity recovery. It is not clear what form such interventions should take: making headache care optimally available is not of itself sufficient.

Assessing the impact of a primary care electronic medical record system in three Kenyan rural health centers.

Efficient, effective health care requires rapid availability of patient information. We designed, implemented, and assessed the impact of a primary care electronic medical record (EMR) in three rural Kenyan health centers. Local clinicians identified data required for primary care and public health reporting. We designed paper encounter forms to capture these data in adult medicine, pediatric, and antenatal clinics. Encounter form data were hand-entered into a new primary care module in an existing EMR serving onsite clinics serving patients infected with the human immunodeficiency virus (HIV). Before subsequent visits, Summary Reports were printed containing selected patient data with reminders for needed HIV care. We assessed effects on patient flow and provider work with time-motion studies before implementation and two years later, and we surveyed providers' satisfaction with the EMR. Between September 2008 and December 2011, 72 635 primary care patients were registered and 114 480 encounter forms were completed. During 2011, 32 193 unique patients visited primary care clinics, and encounter forms were completed for all visits. Of 1031 (3.2%) who were HIV-infected, 85% received HIV care. Patient clinic time increased from 37 to 81 min/visit after EMR implementation in one health center and 56 to 106 min/visit in the other. However, outpatient visits to both health centers increased by 85%. Three-quarters of increased time was spent waiting. Despite nearly doubling visits, there was no change in clinical officers' work patterns, but the nurses' and the clerks' patient care time decreased after EMR implementation. Providers were generally satisfied with the EMR but desired additional training. We successfully implemented a primary care EMR in three rural Kenyan health centers. Patient waiting time was dramatically lengthened while the nurses' and the clerks' patient care time decreased. Long-term use of EMRs in such settings will require changes in culture and workflow.

Men’s health: We need to talk

Men are losing the battle of the sexes when it comes to health. More men than women die in numerous disease state categories, including heart disease, lung and colon cancers, influenza, chronic liver disease, and more, according to CDC statistics. Pharmacists are in a position to encourage men to get important health screenings and can even provide screenings at the pharmacy's onsite clinic, if available. Pharmacists can also counsel men about prescription and OTC medications as well as answer questions about a broad range of health topics.

Changes in Skiing and Snowboarding Injury Epidemiology and Attitudes to Safety in Big Sky, Montana, USA: A Comparison of 2 Cross-sectional Studies in 1996 and 2013.

BackgroundDespite a risk of harm, the past 20 years have seen dramatically increased participation in snow sports such as skiing, and particularly, snowboarding. This period has also seen revolutions in piste maintenance and paradigm developments in the use of safety equipment. Consequently, the numbers and characteristics of injury may be very different from those traditionally quoted.PurposeTo compare and evaluate the injury patterns among skiers and snowboarders in a North American ski resort in 1996 and 2013.Study DesignCross-sectional study; Level of evidence, 3.MethodsQuestionnaire-based cross-sectional studies were carried out independently in a North American ski resort between the dates of March 6 and April 11 in both 1996 and 2013. Demographic data and information about incident circumstances were collected from injured patients who visited the local on-site clinic. Data were compared statistically to assess for significant changes in injury characteristics between the 2 time periods.ResultsThe 1996 report consisted of 148 injured participants, and the 2013 study included 156 participants. Results from 2013 demonstrated significant increases in helmet use, the number of snowboarders injured, and shoulder injuries. Injury was also more likely in those aged 46 to 55 years, those never having had professional instruction, or those with rented equipment. Significant reductions were seen in those injured with other people close by and in the 36- to 45-year age group. Overall, the knee was the most commonly injured body part in both periods (1996: 31%, n = 38; 2013: 33%, n = 36), although upper limb injuries were predominant in snowboarders.ConclusionSnow sports injury characteristics of patients presenting to a ski resort medical clinic have changed between 1996 and 2013. These findings can be used to further inform safety recommendations and areas to target with further research.

LifeWorks@TURCK

LifeWorks@TURCK

Examining Mental Health Illness in a Community Based Sample of Pregnant and Postpartum Youth: A Pilot Study

Background: One in five women will suffer from mental health (MH) disorders during their pregnancy or first year postpartum. These rates are even higher in adolescent mothers. In an attempt to optimize health outcomes for young mothers and their families, a multi-disciplinary clinic for pregnant and post-partum adolescents was established at a community based young parent’s outreach center in Ottawa in 2004 (St. Mary’s Home). An on-site psychiatric clinic was piloted at the center in 2013. The current study aimed to describe characteristics of patients using data obtained at initial assessment. Methods: A total of 36 patients were referred over the recruitment timeframe, of which 28 attended the first assessment and consented to participate. The patients completed a battery of psychological measures and assessment tools which screened for issues relating to mood, anxiety, attachment, level of functioning and distress, substance use, and coping skills. Our institution’s research ethics board approved the study. Results: Thirty nine percent of those assessed were adolescents (<18 years). The mean age of all participants was 19.4 years (+/-2.3 years). Just over 80% (82%) of assessments were initiated in the antenatal period. Approximately 1/5 of patients were rated as having severe mental health problems at intake when the Threshold Assessment Grid (TAG) was applied. Over 80% (82.1%) of the sample demonstrated moderate to severe levels of depression on the Edinburgh Postnatal Depression Scale (EPDS) and half of all participants reported anxiety levels in the moderate to severe level. In addition, the majority of participants experienced insecure anxiety-based and avoidance-based attachments with close relationships and low scores on measures of infant-attachment. At least 10% of the sample endorsed other symptoms that would suggest other possible mental health diagnoses, including drug and alcohol abuse (11% each) and panic syndrome (43%). Conclusions: Assessed patients demonstrated high rates of psychiatric morbidity and distress as evident by clinical scores on a number of different measures. It is vital that any program that offers care to pregnant and postpartum youth have sufficient resources to address these issues in order to help optimize overall health outcomes.

APhA names 2015 Immunization Champions

The APhA Immunization Champion Awards recognize individuals and organizations in the pharmacy profession, and friends and allies of pharmacy, who have made outstanding efforts to improve vaccination rates within their communities.

Telemedicine-based collaborative care for posttraumatic stress disorder: a randomized clinical trial.

Posttraumatic stress disorder (PTSD) is prevalent, persistent, and disabling. Although psychotherapy and pharmacotherapy have proven efficacious in randomized clinical trials, geographic barriers impede rural veterans from engaging in these evidence-based treatments. To test a telemedicine-based collaborative care model designed to improve engagement in evidence-based treatment of PTSD. The Telemedicine Outreach for PTSD (TOP) study used a pragmatic randomized effectiveness trial design with intention-to-treat analyses. Outpatients were recruited from 11 Department of Veterans Affairs (VA) community-based outpatient clinics serving predominantly rural veterans. Inclusion required meeting diagnostic criteria for current PTSD according to the Clinician-Administered PTSD Scale. Exclusion criteria included receiving PTSD treatment at a VA medical center or a current diagnosis of schizophrenia, bipolar disorder, or substance dependence. Two hundred sixty-five veterans were enrolled from November 23, 2009, through September 28, 2011, randomized to usual care (UC) or the TOP intervention, and followed up for 12 months. Off-site PTSD care teams located at VA medical centers supported on-site community-based outpatient clinic providers. Off-site PTSD care teams included telephone nurse care managers, telephone pharmacists, telepsychologists, and telepsychiatrists. Nurses conducted care management activities. Pharmacists reviewed medication histories. Psychologists delivered cognitive processing therapy via interactive video. Psychiatrists supervised the team and conducted interactive video psychiatric consultations. The primary outcome was PTSD severity as measured by the Posttraumatic Diagnostic Scale. Process-of-care outcomes included medication prescribing and regimen adherence and initiation of and adherence to cognitive processing therapy. During the 12-month follow-up period, 73 of the 133 patients randomized to TOP (54.9%) received cognitive processing therapy compared with 16 of 132 randomized to UC (12.1%) (odds ratio, 18.08 [95% CI, 7.96-41.06]; P < .001). Patients in the TOP arm had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 29.1) compared with those in the UC arm (from 33.5 to 32.1) at 6 months (β = -3.81; P = .002). Patients in the TOP arm also had significantly larger decreases in Posttraumatic Diagnostic Scale scores (from 35.0 to 30.1) compared with those in the UC arm (from 33.5 to 31.7) at 12 months (β = -2.49; P=.04). There were no significant group differences in the number of PTSD medications prescribed and adherence to medication regimens were not significant. Attendance at 8 or more sessions of cognitive processing therapy significantly predicted improvement in Posttraumatic Diagnostic Scale scores (β = -3.86 [95% CI, -7.19 to -0.54]; P = .02) and fully mediated the intervention effect at 12 months. Telemedicine-based collaborative care can successfully engage rural veterans in evidence-based psychotherapy to improve PTSD outcomes. clinicaltrials.gov Identifier: NCT00821678.

Exploring pharmacy and home-based sexually transmissible infection testing.

Background This study assessed the feasibility and acceptability of pharmacy and home-based sexually transmissible infection (STI) screening as alternate testing venues among emergency contraception (EC) users. The study included two phases in February 2011-July 2012. In Phase I, customers purchasing EC from eight pharmacies in Manhattan received vouchers for free STI testing at onsite medical clinics. In Phase II, three Facebook ads targeted EC users to connect them with free home-based STI test kits ordered online. Participants completed a self-administered survey. Only 38 participants enrolled in Phase I: 90% female, ≤29 years (74%), 45% White non-Hispanic and 75% college graduates; 71% were not tested for STIs in the past year and 68% reported a new partner in the past 3 months. None tested positive for STIs. In Phase II, ads led to >45000 click-throughs, 382 completed the survey and 290 requested kits; 28% were returned. Phase II participants were younger and less educated than Phase I participants; six tested positive for STIs. Challenges included recruitment, pharmacy staff participation, advertising with discretion and cost. This study found low uptake of pharmacy and home-based testing among EC users; however, STI testing in these settings is feasible and the acceptability findings indicate an appeal among younger women for testing in non-traditional settings. Collaborating with and training pharmacy and medical staff are key elements of service provision. Future research should explore how different permutations of expanding screening in non-traditional settings could improve testing uptake and detect additional STI cases.

Tuberculosis outbreak in an immigrant reception center in Israel: a clinical and epidemiologic perspective.

Tuberculosis (TB) outbreaks in congregate settings pose a public health concern and a clinical challenge. We report a TB outbreak involving 6 cases of active TB among 28 recent Ethiopian immigrants (EIs) in an immigrant reception center in Israel. The outbreak erupted several weeks after a meticulous pre-immigration TB screening of this group. All five culture-positive TB patients were infected with the CAS1_DELHI family, SIT 25 strain. Pulmonary involvement manifested as only a persistent cough without systemic symptoms. This outbreak occurred because of miscommunication among healthcare staff and between healthcare staff and the EI index case. It was fuelled by the staff ignorance of the social bonds within the group, and the sluggish once-monthly schedule of the on-site TB clinic operated at the reception center, which further lacked radiography facilities. This outbreak highlights the challenges of screening for active TB among immigrants and hard to reach groups.

Incorporating Breast Cancer Screening Program in the Medical Curriculum of Cebu Institute of Medicine

Introduction: The objective of the study was to describe the incorporation of breast cancer screening program in the medical curriculum of a medical school and determine its feasibility in finding breast cancer. Methods: From school year 2011 – 2012, a 3-hour module that assesses third year medical students’ proficiency in clinical breast examination (CBE) was incorporated into the pre-clinical clerkship program at the Cebu Institute of Medicine. The students who have satisfactorily completed the module were invited to participate in the Breast Cancer Control Outreach Program (BCAcop). Pertinent data included: number of participating consultants and students, number of patients seen as well as their demographic and clinical profile, breast cancer cases found. Results: Four BCAcop were conducted and 6 consultants supervised the medical students in the CBE modules and BCAcop. Seventy-seven medical students passed the CBE module and participated in BCAcop. A total of 254 patients with age range of 8 to 80 (mean32 years) attended the lay forum while 246 patients (96.9%) consulted at the on-site breast clinic. Among those examined, 146 patients (59.3%) had essentially normal breasts. Fibrocystic change was the most frequent diagnosis with 49 patients (19.9%), followed by fibroadenoma with 34 patients (13.8%). Six patients (2.4%) were suspected to have breast cancer. Four patients (66.7%) proceeded to have a biopsy and were confirmed. Two patients availed of treatment. Conclusion: Incorporating breast cancer screening program in the medical school curriculum encourages medical students to participate in breast cancer control outreaches where their basic knowledge and skills on clinical breast exam are reinforced with actual patient contact. Furthermore, women with breast cancer are found and offered treatment through this program. Key words: Breast cancer awareness, community outreach, clinical breast exam, medical students

Pro Bono Partnerships in Environmental Law

CLE can be a life-changing event in a law student’s education. It can open their eyes to the day-to-day operation of justice and provide them with examples of possible career paths they may never have thought existed. Yet it can also provide long-term benefits for CLCs and academics. Recent CLE models have moved towards partnerships with external organisations and away from on-site legal clinics. Some examples have exhibited success with a multidisciplinary approach involving students from non-law disciplines to provide a holistic approach to a CLC’s needs. Such a multidisciplinary approach is of particular benefit in community lawyering clinics where students are engaged in social change lawyering. The QUT/EDO partnership presents a new model in the environmental clinic landscape in Australia. Initial feedback suggests that the clinic has assisted students in gaining insight into the access to justice issues arising from mining activities and to raise the level of understanding and awareness among community members of their legal rights to protect the environment. Looking at ways to increase partnerships between universities and CLCs is of vital importance in the future, given recent federal government CLC funding cuts. The legal clinic model has great potential to evolve and contribute in ensuring the continued operation of legal initiatives to protect the environment in the public interest.

Worksite primary care clinics: a systematic review.

Despite levels of health spending that are higher per capita and as share of gross domestic product than any country worldwide, the US health care system is fragmented, technology and administration heavy, and primary care deficient. Studies of regional variations in US health care show similar "disconnects" between higher spending and better health outcomes. Faced with rising health benefit costs and suboptimal workforce health amid economic downturn, concerned US employers have implemented innovative payment and health care delivery strategies such as consumer-driven health plans and targeted prevention programs. The former may impose undue cost shifting, prohibitive out-of-pocket expenses, and health literacy challenges, while the latter have shown inconsistent near-term economic returns and long-term clinical efficacy. Employers have begun exploring more comprehensive health delivery platforms such as integrated worksite primary care clinics that have potential to cost-effectively address several pressing problems with current US health care: the growing primary care physician shortage, poor access to routine care, lack of coordinated and patient-centered treatment models, low rates of childhood immunizations, and "quality-blind" fee-for-service payment mechanisms. Such on-site medical clinics exploit one of the rare comparative strengths of the US health care system-its plentiful supply of highly skilled registered nurses-to offer workers and their dependents convenient, high-quality, affordable care. A relatively recent health care paradigm, worksite clinics must yet develop consistent reporting strategies and credible demonstration of outcomes. This review explores available evidence regarding worksite primary care clinics, including current rationale, historical trends, prevalence and projected growth, expected health and financial benefits, challenges, and future research directions.