Use of a eutectic mixture of local anesthetics for prolonged subcutaneous drug administration.

The efficacy of a eutectic mixture of local anesthetics (EMLA) in alleviating the pain associated with subcutaneous needle insertion for infusion of the iron-chelating agent, deferoxamine, was examined in 12 patients with homozygous beta-thalassemia. As reported by the patient using a 100-mm visual analogue scale, the pain of insertion was rated as significantly less after application of EMLA (mean +/- SD, 1.5 +/- 2.2 mm) than the pain associated with needle insertion without EMLA (34.8 +/- 33.5 mm, P = .005). Subsequently, in a double-blind randomized trial of 10 beta-thalassemia patients, EMLA was significantly better (5.7 +/- 8.2 mm) than placebo (27.0 +/- 22.8 mm, P = .01) in reducing the pain of needle insertion for deferoxamine infusion. No adverse effects were reported with the use of EMLA cream. These results suggest that EMLA may be effective in reducing the pain associated with needle insertion for subcutaneous deferoxamine infusion in beta-thalassemia patients, which may lead to improved compliance with this irritating, prolonged therapy. The safety of EMLA use in these patients, and others receiving regular parenteral therapy, should now be examined.

Teaching community-oriented primary care through longitudinal group projects.

BACKGROUND: Though community-oriented primary care (COPC) has been advocated as an effective way of addressing health problems of communities, it is neither widely understood nor frequently practiced. Because COPC requires an extended period of time, as well as an approach and skills not generally learned in medical training, effectively incorporating COPC training into medical education is difficult and not frequently attempted. This paper describes a COPC curriculum for family practice residents based on required participation in a longitudinal group project. METHODS: Residents participated in successive groups that completed a COPC project over a 2-year period. Twenty-two of 26 PGY-2 residents completed an attitude and knowledge test before and after participation in the curriculum. A qualitative evaluation of the curriculum was also performed. RESULTS: Pretest and posttest responses showed significant improvement in residents' knowledge about COPC and a small but significant decline in attitudes toward COPC. Residents' reactions to the curriculum in the qualitative evaluation were both positive and negative. Residents enjoyed the group process and found it intellectually stimulating. Many reported, however, that they did not feel ownership of the project, that working through the four-step systematic COPC process was slow and cumbersome, and that they had learned only part of the COPC process. Residents consistently reported becoming more aware of the importance of discussing the focus of the project (i.e., childhood discipline or domestic violence) with their patients and feeling more comfortable initiating such discussions. CONCLUSIONS: A COPC curriculum based on required participation in a 2-year group project promoted completion of substantial projects. There were trade-offs in resident experience, including loss of continuity for individual residents. Effectively teaching COPC and engaging residents in community-oriented activities remains a challenge.

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.