Browsing by Author "Puschel, Klaus"
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- ItemCancer advocacy in residency education: From principles to competencies(2024) Puschel, Klaus; Thompson, Beti; Rioseco, Andrea; Leon, Augusto; Goic, Carolina; Fuentes, Isabella; Vescovi, ZdenkaIntroduction: The global cancer burden is increasing. Current global evidence indicates there will be a 47% rise of cancer cases for the period 2020-2040. The cancer rate differential also is evident within countries and regions. Efforts have been used to reduce the health disparities; however, the inequity prevails. One potential way to help reduce the disparity is through advocacy by physicians. Methods: Two recent systematic review articles on advocacy among physicians note that physicians are unlikely to be taught advocacy in medical education, and also note there are no advocacy competencies or skill sets that are either taught or valued in medical education. We explore literature and develop a model to understand the components of advocacy in medical education, specifically in resident training. We follow the model's main components by examining principles of advocacy, relevant domains of advocacy, and competencies and values for advocacy education. Results: Four ethical principles of advocacy education are identified: beneficence, non-maleficence, autonomy, and justice. These principles must be applied in meaningful, culturally sensitive, respectful, and promotion of the well-being ways. Three domains are identified: the practice domain (provider-patient interaction), the community domain (provider-community collaboration), and the health policy domain (the larger social environment). Advocacy occurs differently within each domain. Finally, competencies in the form of knowledge, skills, and values are described. We present a table noting where each competency occurs (by domain) as well as the value of each knowledge and skill. Policy summary: The significance of including advocacy instruction in medical education requires a change in the current medical education field. Besides valuing the concept of including advocacy, principles, domains, and competencies of inclusion are critical. In summary, we encourage the inclusion of advocacy education in resident medical programs so physicians become competent medical providers at diverse levels of society.
- ItemClinical and serological profile of asymptomatic and non- severe symptomatic COVID-19 cases: Lessons from a longitudinal study in primary care in Latin America(2021) Puschel, Klaus; Ferreccio, Catterina; Penaloza, Blanca; Abarca, Katia; Rojas, Maria-Paulina; Tellez, Alvaro; Moore, Philippa; Maria Cea, Ana; Wilson, Carlos; Cid, Vicente; Montero, JoaquinBackground: Chile has one of the highest incidences of COVID-19 infection in the world. Primary care can play a key role in early detection and containment of the disease. There is a lack of information on the clinical profile of patients with suspected COVID-19 in primary care, and controversy on the effectiveness of rapid serologic tests in the diagnosis and surveillance of the disease. Aim: To assess the effectiveness of rapid serologic testing in detection and surveillance of COVID-19 cases in primary care. Design & setting: A longitudinal study was undertaken, which was based on a non-random sample of 522 participants, including 304 symptomatic patients and 218 high -risk asymptomatic individuals. They were receiving care at four primary health clinics in an underserved area in Santiago, Chile. Method: The participants were systematically assessed and tested for COVID-19 with transcriptase- polymerase chain reaction (RT-PCR) and serology at baseline, and were followed clinically and serologically for 3 weeks. Results: The prevalence rate of RT-PCR confirmed COVID-19 cases were 3.5 times higher in symptomatic patients (27.5%; 95% confidence interval [CI] = 22.1 to 32.8) compared with asymptomatic participants (7.9%; 95% CI = 4.3 to 11.6). Similarly, the immune response was significantly different between groups. Sensitivity of serologic testing was 57.8% (95% CI = 44.8 to 70.1) during the third week follow- up and specificity was 98.4% (95% CI = 95.5 to 99.7). Conclusion: Rapid serologic testing is ineffective for detecting asymptomatic or non- severe cases COVID-19 at early stages of the disease, but can be of value for surveillance of immunity response in primary care. The clinical profile and immune response of patients with COVID-19 in primary differs from those in hospital- based populations.
- ItemCurriculum reform at the Pontificia Universidad Catolica de Chile School of Medicine(SOC MEDICA SANTIAGO, 2016) Cisternas, Marcela; Rivera, Solange; Sirhan, Marisol; Thone, Natalie; Valdesa, Claudia; Pertuze, Julio; Puschel, KlausThe career of Medicine at the Pontificia Universidad Catolica de Chile was established from the beginning (1929), with a classical Flexner curriculum design. In seven years, the career is divided in three cycles: basic sciences, clinics and internship. It obtained Chilean accreditation and fulfilled American Association of Medical Colleges accreditation requirements. Changes in the Chilean epidemiological profile and health system, and new teaching methods in medicine, stimulated a process of deep curricular analysis, identifying strengths and weaknesses of the medical career. The curricular strengths were well-developed scientific and clinical components, fully committed students and faculties, well defined learning objectives and excellent clinical campuses. Curricular weaknesses included a poor vertical and horizontal integration, few student centered methodologies and a weak emphasis concerning doctor's professionalism. Subsequently, the whole community of teachers, students and medical educators worked on the design of a new curriculum, establishing a new graduate profile and designed it oriented by learning objectives, of six years of duration, with an optimized course sequence that melds basic science and clinical concepts, with strong emphasis on humanities and professionalism. It prioritizes an early contact with patients from the first year and expands teaching methods. The main objective of this process was to achieve a new curriculum with an integrative structure. This was implemented in 2015 with an approved protocol to evaluate the outcomes.
- ItemEffectiveness of a brief intervention based on the '5A' model for smoking cessation at the primary care level in Santiago, Chile(OXFORD UNIV PRESS, 2008) Puschel, Klaus; Thompson, Beti; Coronado, Gloria; Huang, Ying; Gonzalez, Loreto; Rivera, SolangeChilean women have the highest smoking rates in Latin America. Prevalence in this population is about 40%. There are no national programs for smoking cessation at the primary care level. This study explores the feasibility and effectiveness of a brief counseling intervention targeted to women smokers of childbearing age who seek primary care in Santiago, Chile. A quasi-experimental design was used to compare the effect of an intervention based on the '5A' model developed by the National Cancer Institute in the United States and the standard care provided in two control clinics. Women smokers seeking care at the three primary care clinics were contacted during a 2 months period and offer to participate in the study. Sampling was stratified according to the age groups to ensure comparability between cohorts. Quotas were calculated for each age group. Participants were asked about their willingness to quit, self-efficacy, smoking behavior, addiction level as well as support received for smoking cessation. After 18 months of intervention all women were re-evaluated. A total of 773 women were recruited for the study; 76% of them completed the trial. Women smokers are characterized by a large percentage of light smokers with a low self-efficacy for quitting and with very low information on where and how to get assistance to quit. At study end, 15.2% of women reported quitting smoking at least for 1 month in the intervention clinic versus 7.8% in one of the control clinics (p < 0.05) and 14.6% in the second control clinic (p = NS). Over 70% of women in the intervention clinic were asked, assessed and received advice for quitting in comparison with < 15% in the control clinics (p < 0.01). To conclude, a primary care intervention based on the '5A' model for smoking cessation is feasible and can have a significant effect in reducing smoking prevalence in this population.
- ItemFamily functioning style and health: opportunities for health prevention in primary care(ROYAL COLL GENERAL PRACTITIONERS, 2012) Garcia Huidobro, Diego; Puschel, Klaus; Soto, GabrielaScores on the Family Functioning Style Scale, validated in Chile, are correlated with the extent of common health problems, particularly mental and psychosocial health problems, in a primary care population
- ItemFamily intervention to control type 2 diabetes: a controlled clinical trial(OXFORD UNIV PRESS, 2011) Garcia Huidobro, Diego; Bittner, Marcela; Brahm, Paulina; Puschel, KlausMethods. Patients with T2DM from three primary care clinics in Santiago, Chile were randomly selected for inclusion if they had a recent HbA1c >= 7%, were between 18 and 70 years old and lived with a family member. Patients from one clinic received the family oriented intervention; patients from the other two (control) clinics received standard care. The intervention involved family members in care and included family counselling during clinic visits, family meetings and home visits. The primary outcome was HbA1c, measured at 6 and 12 months.
- ItemLong-term Mammography Utilization after an Initial Randomized Intervention Period by all Underserved Chilean Women in the Clinics(2022) Puschel, Klaus; Rioseco, Andrea; Soto, Gabriela; Palominos, Mario; Leon, Augusto; Soto, Mauricio; Thompson, BetiSimple Summary Chile has one of the highest rates of breast cancer in Latin America. In Chile, underserved women have lower rates of mammography screening than their medium-to-high-level counterparts and higher morbidity and mortality rates of breast cancer. After a successful randomized controlled trial of low-socioeconomic-status women in a primary care clinic, we used the RE-AIM (Reach, Effectiveness, Adoption, Maintenance) framework to establish the long-term effects of that intervention. After ten years, women at the low-SES intervention clinic continued to show higher mammography rates compared to women at middle-SES clinics; further, these results continued to be above the national rates for low-socioeconomic-status peers. The RE-AIM framework indicates some of the factors that may have contributed to this successful long-term effect among marginalized women in Chile. Chile has one of the highest rates of breast cancer in Latin America. Mammography rates among women, especially those of low socioeconomic status (SES), are thought to contribute to high breast cancer morbidity and mortality. A successful randomized controlled trial among women aged 50 to 70 in a low-SES primary care clinic in Chile led to a significant increase in mammography screening rates in a two-year intervention trial. This study assesses the sustainability of the intervention after ten years and identifies factors that might have been associated with a long-term effect using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. The mammography rates among women aged 50 to 70 in the low-SES intervention clinic were compared to two populations of women aged 50 to 70 from middle-SES clinics and to national data. Qualitative data were used to answer questions of adoption, implementation, and maintenance, while quantitative data assessed the reach and effectiveness. After ten years, low-SES women at the intervention clinic maintained significantly higher mammography screening rates vs. middle-SES women at the comparison clinics (36.2% vs. 30.1% and 19.4% p < 0.0001). Women of a low SES at the intervention clinic also had significantly higher screening rates compared to women of a low SES at a national level (44.2% vs. 34.2% p < 0.0001). RE-AIM factors contributed to understanding the long-term difference in rates. Mailed contact, outreach interventions, and the integration of health promoters as part of the Community Advisory Board were important factors associated with the effects observed. This study provides information on factors that could contribute to reducing the social gap on breast cancer screening.
- ItemMammogram screening in Chile: Using mixed methods to implement health policy planning at the primary care level(CHURCHILL LIVINGSTONE, 2011) Puschel, Klaus; Thompson, BetiBreast cancer has the highest incidence of all cancers among women in Chile. In 2005, a national health program progressively introduced free mammography screening for women aged 50 and older: however, three years later the rates of compliance with mammographic screening was only 12% in Santiago, the capital city of Chile. This implementation article combines the findings of two previous studies that applied qualitative and quantitative methods to improve mammography screening in an area of Santiago. Socio-cultural and accessibility factors were identified as barriers and facilitators during the qualitative phase of the study and then applied to the design of a quantitative randomized clinical trial. After six months of intervention, 6% of women in the standard care group, 51.8% in the low intensity intervention group, and 70.1% in the high intensity intervention group had undergone a screening mammogram. This review discusses how the utilization of mixed methods research can contribute to the improvement of the implementation of health policies in local communities. (C) 2011 Elsevier Ltd. All rights reserved.
- ItemScreen-detected breast cancer is associated with better prognosis and survival compared to self-detected/symptomatic cases in a Chilean cohort of female patients(2021) Walbaum, Benjamin; Puschel, Klaus; Medina, Lidia; Merino, Tomas; Camus, Mauricio; Razmilic, Dravna; Navarro, Maria Elena; Dominguez, Francisco; Cordova‑Delgado, Miguel; Pinto, Mauricio P.; Acevedo, Francisco; Sánchez, CésarPurpose The implementation of national breast cancer (BC) screening programs in Latin America has been rather inconsistent. Instead, most countries have opted for “opportunistic” mammogram screenings on the population at risk. Our study assessed and compared epidemiological, clinical factors, and survival rates associated with BC detected by screening (SDBC) or self-detected/symptomatic (non-SDBC) in Chilean female patients. Methods Registry-based cohort study that included non-metastatic BC (stage I/II/III) patients diagnosed between 1993 and 2020, from a public hospital (PH) and a private university cancer center (PC). Epidemiological and clinical data were obtained from medical records. Results A total of 4559 patients were included. Most patients (55%; n = 2507) came from PH and were diagnosed by signs/ symptoms (non-SDBC; n = 3132, 68.6%); these patients displayed poorer overall (OS) and invasive disease-free survival (iDFS) compared to SDBC. Importantly, the proportion of stage I and “luminal” BC (HR + /HER2 −) were significantly higher in SDBC vs. non-SDBC. Finally, using a stage/subset-stratified age/insurance-adjusted model, we found that nonSDBC cases are at a higher risk of death (HR:1.75; p < 0.001). In contrast, patients with PC health insurance have a lower risk of death (HR: 0.60; p < 0.001). Conclusion We confirm previous studies that report better prognosis/survival on SDBC patients. This is probably due to a higher proportion of stage I and luminal-A cases versus non-SDBC. In turn, the survival benefit observed in patients with PC health insurance might be attributed to a larger proportion of SDBC. Our data support the implementation of a systematic BC screening program in Chile to improve patient prognosis and survival rates.
- ItemThe interdisciplinary and psychosocial gap in cancer survivorship: A longitudinal study in a Latin American Cancer Center(2021) Puschel, Klaus; Leon, Augusto; Arancibia, Victor; Aubel, Paula; Velasquez, Cristian; Saez, Sebastian; Vines, Eugenio; Leon, Augusto G. H.; Thompson, Beti; Are, ChandrakanthBackground and Objectives There is lack of information on the quality of care provided to the rapidly increasing population of cancer survivors in Latin America. Our study attempts to address this gap and to identify areas needed to be improved.