{"title":"Policies, procedures, and the irony of protections.","authors":"C. Feudtner","doi":"10.1136/EWJM.176.1.22","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.22","url":null,"abstract":"","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"117 1","pages":"22"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82426093","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Have you wondered about our “hanging committee” on the wjm masthead? These knowledgeable and talented individuals volunteer a great deal of time and expertise to the journal. Experts in clinical epidemiology, statistics, and study design, they scrutinize all manuscripts previously subjected to peer review and found to merit serious consideration. They not only help decide on suitability for publication, but also provide methodologic advice and suggestions to prospective authors. The “hanging committee” is not where manuscripts are sent to their execution. Rather, the term derives from an old British Medical Association custom (and one shared by many other privileged groups in the United Kingdom), where a special committee served as final arbiter of whether, and precisely where and how, a new portrait of some dignitary should be hung. We are grateful for the support of this group of experts. We are lucky to have them.
你有没有想过我们在wjm报头上的“悬挂委员会”?这些知识渊博、才华横溢的人自愿为杂志贡献了大量的时间和专业知识。他们是临床流行病学、统计学和研究设计方面的专家，他们仔细审查了以前经过同行评审的所有手稿，并发现值得认真考虑。他们不仅帮助决定是否适合发表，而且还为未来的作者提供方法上的建议和建议。“绞刑委员会”并不是把手稿送到执行死刑的地方。相反，这个词源于英国医学协会(British Medical Association)的一个古老习俗(英国许多其他特权群体也有这个习俗)，即由一个特别委员会担任最终仲裁者，决定是否应该悬挂某个要人的新肖像，以及确切的地点和方式。我们感谢这一专家组的支持。我们很幸运能拥有他们。
{"title":"wjm's Hanging Committee","authors":"C. Feudtner","doi":"10.1136/ewjm.176.1.22-a","DOIUrl":"https://doi.org/10.1136/ewjm.176.1.22-a","url":null,"abstract":"Have you wondered about our “hanging committee” on the wjm masthead? These knowledgeable and talented individuals volunteer a great deal of time and expertise to the journal. Experts in clinical epidemiology, statistics, and study design, they scrutinize all manuscripts previously subjected to peer review and found to merit serious consideration. They not only help decide on suitability for publication, but also provide methodologic advice and suggestions to prospective authors. The “hanging committee” is not where manuscripts are sent to their execution. Rather, the term derives from an old British Medical Association custom (and one shared by many other privileged groups in the United Kingdom), where a special committee served as final arbiter of whether, and precisely where and how, a new portrait of some dignitary should be hung. We are grateful for the support of this group of experts. We are lucky to have them.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"14 1","pages":"22-22"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78253592","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The aim of this five-part series is to give you a basic system for looking at chest radiographs. It should enable you to say something sensible when presented with a study for interpretation and be confident that you are not missing serious disease when you view a radiograph on your own as a house officer. Let's start by looking at a normal chest radiograph (figure 1). Use this image as a reference point during the rest of the article. First, some technical details: Quickly look at the film to obtain some useful information about the patient: Figure 1 Normal chest radiograph (A) and diagram of structures (B) Male or female? Look for breast shadows (this will help you to notice whether a mastectomy has been done) Old or young? Try to use the patient's age to your advantage by making sensible suggestions. A 20-year-old is much less likely to have malignancy than someone who is 70 Good inspiration? It's easy to get tied up in knots over this—and sometimes not get any further. The hemidiaphragms should lie at the level of the sixth ribs anteriorly. The left hemidiaphragm is usually lower than the right Good penetration? You should just be able to see the lower thoracic vertebral bodies through the heart Is the patient's spine straight? The spinous processes of the thoracic vertebrae should be midway between the medial ends of the clavicles Most chest radiographs are taken posteroanterior (PA)—that is, the x-rays are shot through from the back of the patient to the x-ray plate in front of the patient. If the patient is too sick to stand up for this, an anteroposterior (AP) film will be done—that is, the x-rays are shot through from front to back. An AP film will always be labeled as AP, so if nothing is written on the film, it is safe to assume it is PA. PA films are preferred, particularly because the heart is not as magnified as on an AP film, making it easier to evaluate the lungs. Tip: You can avoid the whole PA/AP designation by describing all chest radiographs as “frontal”—that is, you are looking at the patient straight on You can summarize all the above information in a simple opening phrase: “This is a frontal chest radiograph of a young male patient. The patient has taken a good inspiration and is straight; the film is well penetrated.” While you are saying this, keep looking at the film: First look at the mediastinal contours—run your eye down the left side of the mediastinum and then up the right The trachea should be central. The aortic arch is the first convexity on the left, followed by the left pulmonary artery; notice that you can trace the pulmonary artery branches fanning out through the lung (see figure 1) Two thirds of the heart should lie on the left side of the chest, with a third on the right. The heart should take up no more than half of the thoracic cavity. The left atrium and left ventricle create the left border The right heart border is created by t
{"title":"Chest radiographs made easy.","authors":"E. Dick","doi":"10.1136/EWJM.176.1.56","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.56","url":null,"abstract":"The aim of this five-part series is to give you a basic system for looking at chest radiographs. It should enable you to say something sensible when presented with a study for interpretation and be confident that you are not missing serious disease when you view a radiograph on your own as a house officer. Let's start by looking at a normal chest radiograph (figure 1). Use this image as a reference point during the rest of the article. First, some technical details: Quickly look at the film to obtain some useful information about the patient: Figure 1 Normal chest radiograph (A) and diagram of structures (B) Male or female? Look for breast shadows (this will help you to notice whether a mastectomy has been done) Old or young? Try to use the patient's age to your advantage by making sensible suggestions. A 20-year-old is much less likely to have malignancy than someone who is 70 Good inspiration? It's easy to get tied up in knots over this—and sometimes not get any further. The hemidiaphragms should lie at the level of the sixth ribs anteriorly. The left hemidiaphragm is usually lower than the right Good penetration? You should just be able to see the lower thoracic vertebral bodies through the heart Is the patient's spine straight? The spinous processes of the thoracic vertebrae should be midway between the medial ends of the clavicles Most chest radiographs are taken posteroanterior (PA)—that is, the x-rays are shot through from the back of the patient to the x-ray plate in front of the patient. If the patient is too sick to stand up for this, an anteroposterior (AP) film will be done—that is, the x-rays are shot through from front to back. An AP film will always be labeled as AP, so if nothing is written on the film, it is safe to assume it is PA. PA films are preferred, particularly because the heart is not as magnified as on an AP film, making it easier to evaluate the lungs. Tip: You can avoid the whole PA/AP designation by describing all chest radiographs as “frontal”—that is, you are looking at the patient straight on You can summarize all the above information in a simple opening phrase: “This is a frontal chest radiograph of a young male patient. The patient has taken a good inspiration and is straight; the film is well penetrated.” While you are saying this, keep looking at the film: First look at the mediastinal contours—run your eye down the left side of the mediastinum and then up the right The trachea should be central. The aortic arch is the first convexity on the left, followed by the left pulmonary artery; notice that you can trace the pulmonary artery branches fanning out through the lung (see figure 1) Two thirds of the heart should lie on the left side of the chest, with a third on the right. The heart should take up no more than half of the thoracic cavity. The left atrium and left ventricle create the left border The right heart border is created by t","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"95 1","pages":"56-7"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77464666","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Headache is the most common complication after lumbar puncture (LP), with reported frequency rates ranging from 6% to 36% of patients.1 August Bier (1861-1949) was the first to describe the phenomenon of post-dural puncture headache in his patients and experienced the same effect when he had the procedure performed on himself.2 Most (90%) post-LP headaches occur within 3 days of the procedure and are characteristically described as being present when the patient is in the upright position and diminished in intensity when supine. The cause of post-LP headache is uncertain. One idea is that it is possibly due to low cerebrospinal fluid (CSF) pressure as a result of CSF leakage through a dural and arachnoid tear produced by the puncture that exceeds CSF production. The continuous decrease in CSF pressure may lead to subsequent stretching of pain-sensitive structures. Another notion is that cerebral vasodilatation, in addition to traction, is responsible for headache following LP. Various treatments for this condition are thought to be effective, even though its cause is unclear. Many of these are implemented routinely in daily practice—including increased fluids, bed rest, and caffeine—despite the lack of evidence of their effectiveness. There is no evidence supporting the use of increased fluids to prevent post-LP headache.1 The only prospective study of this intervention involved oral hydration. Dieterich and Brandt performed a prospective study of 100 age-matched, randomly allocated neurologic patients and found no correlation between the incidence of post-LP headache and the amount of fluid intake.3 Half of the patients were asked to drink 1.5 L of fluids per day during the 5 days after an LP, and the other half was asked to drink 3.0 L of fluids per day for the same period. The intensity of the headache was classified into four grades according to the severity and onset of symptoms after getting up from the LP. The proportion of symptom-free individuals was 64% in both groups of patients; therefore, the incidence of post-LP headache is independent of fluid intake. Another commonly held belief is that bed rest or various body positions after LP reduce the incidence of post-LP headache compared with immediate ambulation. But Carbaat and van Crevel performed a controlled prospective study that showed that no benefit was found with 24 hours of bed rest in preventing the headache.4 A diagnostic LP was performed in 100 neurologic patients by one investigator. Half of the patients were immediately mobilized, and the other half had bed rest. To account for the possibility of improved technique by the same investigator with successive LPs, the first 25 were immediately mobilized, the next 50 were given bed rest, and the last 25 were immediately mobilized. Follow-up was for 7 days, and no significant differences were found between the two groups. Other similar studies have confirmed these findings. Oral and intravenous administration of ca
{"title":"Myth: fluids, bed rest, and caffeine are effective in preventing and treating patients with post-lumbar puncture headache.","authors":"Wendy Lin, J. Geiderman","doi":"10.1136/EWJM.176.1.69","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.69","url":null,"abstract":"Headache is the most common complication after lumbar puncture (LP), with reported frequency rates ranging from 6% to 36% of patients.1 August Bier (1861-1949) was the first to describe the phenomenon of post-dural puncture headache in his patients and experienced the same effect when he had the procedure performed on himself.2 Most (90%) post-LP headaches occur within 3 days of the procedure and are characteristically described as being present when the patient is in the upright position and diminished in intensity when supine. The cause of post-LP headache is uncertain. One idea is that it is possibly due to low cerebrospinal fluid (CSF) pressure as a result of CSF leakage through a dural and arachnoid tear produced by the puncture that exceeds CSF production. The continuous decrease in CSF pressure may lead to subsequent stretching of pain-sensitive structures. Another notion is that cerebral vasodilatation, in addition to traction, is responsible for headache following LP. Various treatments for this condition are thought to be effective, even though its cause is unclear. Many of these are implemented routinely in daily practice—including increased fluids, bed rest, and caffeine—despite the lack of evidence of their effectiveness. There is no evidence supporting the use of increased fluids to prevent post-LP headache.1 The only prospective study of this intervention involved oral hydration. Dieterich and Brandt performed a prospective study of 100 age-matched, randomly allocated neurologic patients and found no correlation between the incidence of post-LP headache and the amount of fluid intake.3 Half of the patients were asked to drink 1.5 L of fluids per day during the 5 days after an LP, and the other half was asked to drink 3.0 L of fluids per day for the same period. The intensity of the headache was classified into four grades according to the severity and onset of symptoms after getting up from the LP. The proportion of symptom-free individuals was 64% in both groups of patients; therefore, the incidence of post-LP headache is independent of fluid intake. Another commonly held belief is that bed rest or various body positions after LP reduce the incidence of post-LP headache compared with immediate ambulation. But Carbaat and van Crevel performed a controlled prospective study that showed that no benefit was found with 24 hours of bed rest in preventing the headache.4 A diagnostic LP was performed in 100 neurologic patients by one investigator. Half of the patients were immediately mobilized, and the other half had bed rest. To account for the possibility of improved technique by the same investigator with successive LPs, the first 25 were immediately mobilized, the next 50 were given bed rest, and the last 25 were immediately mobilized. Follow-up was for 7 days, and no significant differences were found between the two groups. Other similar studies have confirmed these findings. Oral and intravenous administration of ca","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"48 1","pages":"69-70"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"77562131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
In Kathmandu, Nepal, capital of one of the world's poorest countries, a patient with a blind eye from a corneal scar can have sight-restoring corneal transplantation as easily as in San Francisco — for free if the person is too poor to pay. The corneal tissue is fresh and of high quality, often better than what is available to patients in the United States. The central figure in creating this remarkable situation is Dr Sanduk Ruit, who was born in a small village not far from the Tibetan border. His family were mountain people — caravan traders. His father stretched the family funds to send him to primary and secondary school in Darjeeling, a rugged 9-day journey on foot across the high pass at the Indian border. He trained at the All India Institute of Medical Sciences in Delhi, completed ophthalmology residency, and learned corneal transplantation surgery in Australia and Amsterdam. In 1996, he established the Nepal Eye Bank, which, as in western countries, was set up in the hospital. Initially, things were slow. So Ruit and his associates thought about how most of the deaths in Kathmandu occurred at home and not in a hospital. They realized that 40% of people who passed away were brought immediately to the Pashupati Temple on the banks of the holy Bagmati River for cremation at the ghats. They thought about the fears among the Hindus and Buddhists who believe in reincarnation and often believe that if the corneas are donated they will be reborn blind. After a dialogue with prominent Buddhist monks and Hindu priests, word went out that the body left behind after death is unimportant and that giving sight to someone blind would increase good karma for the family. In 1997, Ruit moved tissue procurement for the eye bank out of the hospital and onto the grounds of the Pashupati Temple. Two years later, the number of corneas collected by the Nepal Eye Bank had increased almost fivefold, the number of corneas distributed in Nepal had tripled, and the number of corneal transplantations performed at Tilganga Eye Hospital had more than doubled.1
{"title":"Dr Sanduk Ruit and corneal transplantation in Nepal.","authors":"D. Heiden","doi":"10.1136/EWJM.176.1.71","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.71","url":null,"abstract":"In Kathmandu, Nepal, capital of one of the world's poorest countries, a patient with a blind eye from a corneal scar can have sight-restoring corneal transplantation as easily as in San Francisco — for free if the person is too poor to pay. The corneal tissue is fresh and of high quality, often better than what is available to patients in the United States. The central figure in creating this remarkable situation is Dr Sanduk Ruit, who was born in a small village not far from the Tibetan border. His family were mountain people — caravan traders. His father stretched the family funds to send him to primary and secondary school in Darjeeling, a rugged 9-day journey on foot across the high pass at the Indian border. He trained at the All India Institute of Medical Sciences in Delhi, completed ophthalmology residency, and learned corneal transplantation surgery in Australia and Amsterdam. In 1996, he established the Nepal Eye Bank, which, as in western countries, was set up in the hospital. Initially, things were slow. So Ruit and his associates thought about how most of the deaths in Kathmandu occurred at home and not in a hospital. They realized that 40% of people who passed away were brought immediately to the Pashupati Temple on the banks of the holy Bagmati River for cremation at the ghats. They thought about the fears among the Hindus and Buddhists who believe in reincarnation and often believe that if the corneas are donated they will be reborn blind. After a dialogue with prominent Buddhist monks and Hindu priests, word went out that the body left behind after death is unimportant and that giving sight to someone blind would increase good karma for the family. In 1997, Ruit moved tissue procurement for the eye bank out of the hospital and onto the grounds of the Pashupati Temple. Two years later, the number of corneas collected by the Nepal Eye Bank had increased almost fivefold, the number of corneas distributed in Nepal had tripled, and the number of corneal transplantations performed at Tilganga Eye Hospital had more than doubled.1","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"43 1","pages":"71"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85241234","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A 42-year-old man presents to your clinic complaining of severe pain related to Kaposi's sarcoma. He has a 26-year history of substance misuse and was diagnosed at a different clinic as having AIDS in 1990, when he said that he had stopped using illicit drugs. He developed Kaposi's sarcoma in 1991, when he originally sought treatment of pain, again denying, continued substance misuse. Because there was documented evidence that he was still misusing drugs, he was referred to a psychologist for behavioral modification techniques. These helped him to stay off illicit drugs but failed to relieve his pain. He reverted to using, substances in an attempt to relieve his pain and was subsequently arrested and jailed for 18 months. The patient emerged "clean," but the number of lesions of Kaposi's sarcoma had escalated, as had his pain. He returned to the clinic to seek analgesia. Nonopioid medications were prescribed but did nothing to relieve the pain. The patient persisted in seeking pain relief but was thought to be merely seeking opiate drugs to fuel his opiate addiction, and so he was denied opioid treatment. The patient felt rejected and despondent but did not want to revert to misusing opiates. He comes to your clinic in the hope of finding a physician who will believe that he is in severe pain.
{"title":"Treating pain in patients with AIDS and a history of substance use.","authors":"Yael Swica, W. Breitbart","doi":"10.1136/EWJM.176.1.33","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.33","url":null,"abstract":"A 42-year-old man presents to your clinic complaining of severe pain related to Kaposi's sarcoma. He has a 26-year history of substance misuse and was diagnosed at a different clinic as having AIDS in 1990, when he said that he had stopped using illicit drugs. He developed Kaposi's sarcoma in 1991, when he originally sought treatment of pain, again denying, continued substance misuse. Because there was documented evidence that he was still misusing drugs, he was referred to a psychologist for behavioral modification techniques. These helped him to stay off illicit drugs but failed to relieve his pain. He reverted to using, substances in an attempt to relieve his pain and was subsequently arrested and jailed for 18 months. The patient emerged \"clean,\" but the number of lesions of Kaposi's sarcoma had escalated, as had his pain. He returned to the clinic to seek analgesia. Nonopioid medications were prescribed but did nothing to relieve the pain. The patient persisted in seeking pain relief but was thought to be merely seeking opiate drugs to fuel his opiate addiction, and so he was denied opioid treatment. The patient felt rejected and despondent but did not want to revert to misusing opiates. He comes to your clinic in the hope of finding a physician who will believe that he is in severe pain.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"42 1","pages":"33-9"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84982005","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Two months ago, I was in rural Uganda with a team of local researchers. Mud houses with grass roofs were connected by a maze of footpaths, and roads were few and far between. We were there to interview people in homes where children were affected by AIDS. Some of the children were living with an HIV-positive parent. Others were already orphans and had been taken in by a relative. It struck me, as we advanced awkwardly by van, how frequently we stopped at eligible homes to dispatch an interviewer. You could throw a stone from one household confronted with AIDS, and it would land in the neat garden plot of the next. This disease closes in on children from all sides in the hard-hit regions of East and Southern Africa. Children nurse their parents during prolonged illness and watch them suffer and die. Some even watch their guardians succumb to AIDS. They lose sisters and brothers, uncles and aunts, teachers and leaders. At the very least, they grow up sharing their meals with orphaned cousins. The US Bureau of the Census estimates that, by the end of 2000, 15.6 million children around the world had lost a mother or both parents to AIDS. By 2010, at least 44 million children will have lost a mother, father, or both parents to AIDS. Even these daunting figures exclude older orphans aged 15 years and older, children orphaned by war and other causes, orphans on the streets and in institutions, and children whose parents are ill with opportunistic infections of AIDS. Perhaps the unluckiest children of all are those infected from birth or in infancy. True, we can take heart in our slowly improving ability to reduce the transmission of HIV from mother to child. But already 1.5 million children in Africa are living with AIDS. And until HIV-positive mothers are kept alive, their virus-free children are sentenced to orphanhood and its attendant vulnerabilities.
{"title":"The effects of HIV infection and AIDS on children in Africa.","authors":"L. Gilborn","doi":"10.1136/EWJM.176.1.12","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.12","url":null,"abstract":"Two months ago, I was in rural Uganda with a team of local researchers. Mud houses with grass roofs were connected by a maze of footpaths, and roads were few and far between. We were there to interview people in homes where children were affected by AIDS. Some of the children were living with an HIV-positive parent. Others were already orphans and had been taken in by a relative. It struck me, as we advanced awkwardly by van, how frequently we stopped at eligible homes to dispatch an interviewer. You could throw a stone from one household confronted with AIDS, and it would land in the neat garden plot of the next. This disease closes in on children from all sides in the hard-hit regions of East and Southern Africa. Children nurse their parents during prolonged illness and watch them suffer and die. Some even watch their guardians succumb to AIDS. They lose sisters and brothers, uncles and aunts, teachers and leaders. At the very least, they grow up sharing their meals with orphaned cousins. The US Bureau of the Census estimates that, by the end of 2000, 15.6 million children around the world had lost a mother or both parents to AIDS. By 2010, at least 44 million children will have lost a mother, father, or both parents to AIDS. Even these daunting figures exclude older orphans aged 15 years and older, children orphaned by war and other causes, orphans on the streets and in institutions, and children whose parents are ill with opportunistic infections of AIDS. Perhaps the unluckiest children of all are those infected from birth or in infancy. True, we can take heart in our slowly improving ability to reduce the transmission of HIV from mother to child. But already 1.5 million children in Africa are living with AIDS. And until HIV-positive mothers are kept alive, their virus-free children are sentenced to orphanhood and its attendant vulnerabilities.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"205 1","pages":"12-4"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"80394933","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Most health care for members of federally recognized Indian tribes continues to be provided by the Indian Health Service (IHS). Through what is termed self-determination1 and self-governance,2 the tribes themselves are providing an increasing proportion of direct health care to Indians through payment arrangements with the IHS. A shift of Indian health services to the private sector is now occurring, however, especially in western states where the majority of American Indian people live. Because of certain historic trends, many American Indians are not part of the service population of the IHS and thus depend on non-IHS sources of care.3 In addition, a growing number of Indian people have non-IHS sources of medical coverage. For example, in one national sample (about 6500 persons), more than one in four Indians indicated having private insurance and more than 15% reported being covered by Medicaid or Medicare.4 Among Indians who reported having received ambulatory services outside the IHS system, 54.1% had private insurance coverage; 11.7% had IHS coverage only.5 More than 50% of respondents with private insurance and 40% of those with public insurance used a facility outside the IHS as their usual source of care.6 What has caused this shift? There are four main causes, which are interrelated. First is the growth in complexity of medical care beyond the scope of the community-oriented primary care provided by the IHS and tribal programs. Second, many states with large numbers of American Indians, such as California, Oregon, and Washington, lack inpatient IHS facilities. Third, many Indian people have migrated to urban locations outside the reach of IHS and tribal programs.7 Fourth, and perhaps the most important factor influencing Indians' use of private sector health services, is the growth of third-party payments. In addition to providing direct services, the IHS and the tribes also act as third-party payers by purchasing care through their contract health services program. In fiscal year 2000, this payment to private providers was approximately $395 million (IHS, unpublished data). The IHS estimates that its fiscal year 2000 service population was approximately 1.5 million persons.8 This service group, which increased by approximately 25% in the previous decade, is likely to continue its rapid growth. As the Indian population ages, however, the proportion of the IHS service population requiring care in the private sector will likely increase. This shift toward the private sector is important for all concerned. For the provider, it means increased attention to requirements for “culturally competent” care.9 The assumption that this is a matter for the IHS and tribes only is no longer true. Rendering culturally competent medical care to Indian patients requires attention to the social, cultural, and biomedical characteristics that tend to distinguish Indian people from other populations, especially among urban populations where most of t
{"title":"American Indians and the private health care sector: the growing use of private care by Indians has implications for patients, providers, and policymakers.","authors":"E. Rhoades","doi":"10.1136/EWJM.176.1.7","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.7","url":null,"abstract":"Most health care for members of federally recognized Indian tribes continues to be provided by the Indian Health Service (IHS). Through what is termed self-determination1 and self-governance,2 the tribes themselves are providing an increasing proportion of direct health care to Indians through payment arrangements with the IHS. A shift of Indian health services to the private sector is now occurring, however, especially in western states where the majority of American Indian people live. Because of certain historic trends, many American Indians are not part of the service population of the IHS and thus depend on non-IHS sources of care.3 In addition, a growing number of Indian people have non-IHS sources of medical coverage. For example, in one national sample (about 6500 persons), more than one in four Indians indicated having private insurance and more than 15% reported being covered by Medicaid or Medicare.4 Among Indians who reported having received ambulatory services outside the IHS system, 54.1% had private insurance coverage; 11.7% had IHS coverage only.5 More than 50% of respondents with private insurance and 40% of those with public insurance used a facility outside the IHS as their usual source of care.6 What has caused this shift? There are four main causes, which are interrelated. First is the growth in complexity of medical care beyond the scope of the community-oriented primary care provided by the IHS and tribal programs. Second, many states with large numbers of American Indians, such as California, Oregon, and Washington, lack inpatient IHS facilities. Third, many Indian people have migrated to urban locations outside the reach of IHS and tribal programs.7 Fourth, and perhaps the most important factor influencing Indians' use of private sector health services, is the growth of third-party payments. In addition to providing direct services, the IHS and the tribes also act as third-party payers by purchasing care through their contract health services program. In fiscal year 2000, this payment to private providers was approximately $395 million (IHS, unpublished data). The IHS estimates that its fiscal year 2000 service population was approximately 1.5 million persons.8 This service group, which increased by approximately 25% in the previous decade, is likely to continue its rapid growth. As the Indian population ages, however, the proportion of the IHS service population requiring care in the private sector will likely increase. This shift toward the private sector is important for all concerned. For the provider, it means increased attention to requirements for “culturally competent” care.9 The assumption that this is a matter for the IHS and tribes only is no longer true. Rendering culturally competent medical care to Indian patients requires attention to the social, cultural, and biomedical characteristics that tend to distinguish Indian people from other populations, especially among urban populations where most of t","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"23 1","pages":"7-9"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79339910","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Cancer in the developing world, of which the Islamic world is a substantial component, is characterized by far more advanced stages at diagnosis, fewer allocated resources for prevention and treatment, and higher incidence than in countries with more developed health systems.1 The top five cancers in the emerging world are (in descending order) stomach, lung, liver, breast, and cervix, and in developed countries the most common cancers are those of the lung, colorectum, breast, stomach, and prostate.2 In Indonesia, which has an estimated total cancer incidence of about 300,000 cases per year, only 10% are seen in the health care system.3 Similarly, only one cancer unit is available for about 120 million people in Bangladesh.4 Because preventive and curative services for cancer control are underdeveloped in many Islamic countries, the development of palliative care services is a more realistic option for most patients in these countries who have cancer. The available health care services in the Islamic world clearly do not meet patients' needs, and there is little sign that this situation will improve in the foreseeable future. Even if palliative care development is placed on an Islamic country's health care agenda, such development might be handicapped by technical and economic constraints. However, despite this gloomy picture, there are signs that palliative medicine is beginning to take off in the Islamic world. For example, the medical use of morphine for cancer pain control has been steadily increasing during the past few years in many Islamic countries.5 Once a palliative care program takes root in an Islamic country, it usually grows into a thriving service.3,6,7,8,9,10
{"title":"The future of palliative care in the Islamic world.","authors":"M. Al-Shahri","doi":"10.1136/EWJM.176.1.60","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.60","url":null,"abstract":"Cancer in the developing world, of which the Islamic world is a substantial component, is characterized by far more advanced stages at diagnosis, fewer allocated resources for prevention and treatment, and higher incidence than in countries with more developed health systems.1 The top five cancers in the emerging world are (in descending order) stomach, lung, liver, breast, and cervix, and in developed countries the most common cancers are those of the lung, colorectum, breast, stomach, and prostate.2 In Indonesia, which has an estimated total cancer incidence of about 300,000 cases per year, only 10% are seen in the health care system.3 Similarly, only one cancer unit is available for about 120 million people in Bangladesh.4 Because preventive and curative services for cancer control are underdeveloped in many Islamic countries, the development of palliative care services is a more realistic option for most patients in these countries who have cancer. The available health care services in the Islamic world clearly do not meet patients' needs, and there is little sign that this situation will improve in the foreseeable future. Even if palliative care development is placed on an Islamic country's health care agenda, such development might be handicapped by technical and economic constraints. However, despite this gloomy picture, there are signs that palliative medicine is beginning to take off in the Islamic world. For example, the medical use of morphine for cancer pain control has been steadily increasing during the past few years in many Islamic countries.5 Once a palliative care program takes root in an Islamic country, it usually grows into a thriving service.3,6,7,8,9,10","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"6 1","pages":"60-1"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75242073","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Stead and colleagues' study suggests that women with ovarian cancer want their physicians to discuss sexual issues with them but that such discussions are rare. Physicians in the study were uncomfortable discussing sex and lacked knowledge about the sexual problems that cancer can cause. If the Internet is anything to go by, cancer patient groups do better than health professionals in providing frank information about cancer and sexuality. For example, could you answer your patients' questions about when to avoid sex during cancer treatment or which sexual positions might be more comfortable? CancerBACUP, a cancer support and information service (www.cancerbacup.org.uk), gives explicit answers to both of these questions (www.cancerbacup.org.uk/info/sex/sex-9.htm). It also gives “solutions to sexual problems caused by cancer and its treatment” (www.cancerbacup.org.uk/info/sex/sex-5.htm), including pain during intercourse, loss of libido, changes in body image, and erectile dysfunction. Another valuable collection of resources on sexuality and cancer is Oncolink, from the University of Pennsylvania Cancer Center, Philadelphia: cancer.med.upenn. edu/psychosocial/sexuality. The site has information aimed at both providers and patients, and it includes fertility and reproductive issues. It also links to a guide to living with cancer, called “Taking Time,” from the National Cancer Institute, National Institutes of Health (cancernet.nci.nih.gov/taking_time/timeintro.html). One section of the guide explores how patients' self-image can be affected by cancer and how this can affect their relationships. Many web sites discuss the relationship between cancer and sexual identity. One of these is the Mautner Project (www.mautnerproject.org), a US organization dedicated to lesbians with cancer, their partners, and caregivers. The project campaigns for better cancer detection services for lesbians, and its web site gives the reasons why lesbians have higher rates of breast, cervical, and ovarian cancer than heterosexual women. The Gay and Lesbian Medical Association summarizes the research to date that suggests that lesbian, gay, bisexual, and transgender people may be disproportionately affected by certain cancers (www.glma.org/policy/hp2010/PDF/Cancer.pdf) and that all health professionals should receive “cultural competence training about sexual minority status.” Regardless of a patient's specific cancer type or sexual identity, when it comes to resolving sexual difficulties and concerns, a word of advice appears repeatedly on Internet sites: “communication.” Patients are encouraged to communicate their needs to their partners, and physicians are urged to do better at communicating information about sexual issues.
{"title":"Online resources on sexuality and cancer.","authors":"G. Yamey","doi":"10.1136/EWJM.176.1.19","DOIUrl":"https://doi.org/10.1136/EWJM.176.1.19","url":null,"abstract":"Stead and colleagues' study suggests that women with ovarian cancer want their physicians to discuss sexual issues with them but that such discussions are rare. Physicians in the study were uncomfortable discussing sex and lacked knowledge about the sexual problems that cancer can cause. If the Internet is anything to go by, cancer patient groups do better than health professionals in providing frank information about cancer and sexuality. For example, could you answer your patients' questions about when to avoid sex during cancer treatment or which sexual positions might be more comfortable? CancerBACUP, a cancer support and information service (www.cancerbacup.org.uk), gives explicit answers to both of these questions (www.cancerbacup.org.uk/info/sex/sex-9.htm). It also gives “solutions to sexual problems caused by cancer and its treatment” (www.cancerbacup.org.uk/info/sex/sex-5.htm), including pain during intercourse, loss of libido, changes in body image, and erectile dysfunction. Another valuable collection of resources on sexuality and cancer is Oncolink, from the University of Pennsylvania Cancer Center, Philadelphia: cancer.med.upenn. edu/psychosocial/sexuality. The site has information aimed at both providers and patients, and it includes fertility and reproductive issues. It also links to a guide to living with cancer, called “Taking Time,” from the National Cancer Institute, National Institutes of Health (cancernet.nci.nih.gov/taking_time/timeintro.html). One section of the guide explores how patients' self-image can be affected by cancer and how this can affect their relationships. Many web sites discuss the relationship between cancer and sexual identity. One of these is the Mautner Project (www.mautnerproject.org), a US organization dedicated to lesbians with cancer, their partners, and caregivers. The project campaigns for better cancer detection services for lesbians, and its web site gives the reasons why lesbians have higher rates of breast, cervical, and ovarian cancer than heterosexual women. The Gay and Lesbian Medical Association summarizes the research to date that suggests that lesbian, gay, bisexual, and transgender people may be disproportionately affected by certain cancers (www.glma.org/policy/hp2010/PDF/Cancer.pdf) and that all health professionals should receive “cultural competence training about sexual minority status.” Regardless of a patient's specific cancer type or sexual identity, when it comes to resolving sexual difficulties and concerns, a word of advice appears repeatedly on Internet sites: “communication.” Patients are encouraged to communicate their needs to their partners, and physicians are urged to do better at communicating information about sexual issues.","PeriodicalId":22925,"journal":{"name":"The Western journal of medicine","volume":"28 1","pages":"19-20"},"PeriodicalIF":0.0,"publicationDate":"2002-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"74865306","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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