Care-seeking behavior for upper respiratory infections.

BACKGROUND: Many recent efforts to reduce unnecessary medical services have targeted care of upper respiratory infections (URIs). We tested whether patients who seek care very early in their illness differ from those who seek care later and whether they might require a different approach to care. METHODS: We surveyed by telephone 257 adult patients and 249 parents of child patients who called or visited one of 3 primary care clinics within 10 days (adults) or 14 days (parents) of the onset of uncomplicated URI symptoms. Those who contacted the clinic within the first 2 days of illness were compared with those who made contact later. RESULTS: Although 28% of adults and 41% of parents contacted their clinic within the first 2 days of symptom onset, we found very few differences in the characteristics of the caller or patient between those who called early and later. The illnesses of those who called early were not more severe, and they did not have different beliefs, histories, approaches to medical care, or needs. The only clinician-relevant difference was that adult patients calling in the first 2 days had a greater desire to rule out complications (84.7% vs 64.1% calling in 3-5 days and 70.6% calling after 5 days of illness, P < or = .05). CONCLUSIONS: Those who seek medical care very early for a URI do not appear to be different in clinically important ways. If we are going to reduce overuse of medical care and antibiotics for URIs, clinical trials of more effective and efficient strategies are needed to encourage home care and self-management.

Occupational attainment, smoking, alcohol intake, and marijuana use: ethnic-gender differences in the CARDIA study.

OBJECTIVES: To evaluate the prospective interrelationship of smoking, alcohol intake, marijuana use, and educational and occupational attainment of Black and White young adults. METHODS: Logistic or mixed model linear regression were used to evaluate relationships between self-reported substance use, ethnicity, gender, college graduation, and four measures of occupational attainment. RESULTS: College graduation in the next 10 years was negatively associated with smoking and marijuana use, but not daily alcohol consumption in all ethnic and gender groups. In Whites, marijuana use was associated with less prestigious occupations and lower family income, while smoking was unrelated and moderate daily drinking was positively associated. In Blacks, marijuana use was generally unrelated to occupational measures, while smoking and daily alcohol consumption were negatively associated. CONCLUSIONS: Relationships between smoking, marijuana use, daily drinking, and occupational attainment were not universally negative in this age group. Substance use, particularly smoking, is associated with reduced occupational attainment in Blacks compared with Whites after considering sociodemographic factors potentially limiting educational progression and occupational attainment.

Characteristics and experiences of parents and adults who want antibiotics for cold symptoms.

OBJECTIVE: To characterize people who want antibiotics for cold symptoms and to suggest reasons for antibiotic expectations. DESIGN: Cross-sectional telephone survey in the spring of 1997 (March 10 to May 16). SETTING: Three primary care clinics in metropolitan Minneapolis, Minn. PARTICIPANTS: Two hundred forty-nine parents of symptomatic children and 256 symptomatic adults contacting their medical provider (primary care physician, nurse practitioner, or physician assistant) for care of cold symptoms. MAIN DEPENDENT MEASURE: Wanting an antibiotic prescription for cold symptoms. RESULTS: Thirty percent of parents and 50% of symptomatic adults wanted an antibiotic prescription. Factors associated with desire for antibiotics differed between groups. Parents who wanted antibiotics for their children were more likely than other parents to report severe symptoms (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.16-3.85), to want relief for their child (OR, 2.63; 95% CI, 1.34-5.46), and to believe that antibiotic therapy helps cold symptoms (OR, 1.95; 95% CI, 1.08-3.55). Symptomatic adults who wanted antibiotics were more likely than other symptomatic adults to report severe cold symptoms (OR, 2.10; 95% CI, 1.22-3.67) that have lasted too long (OR, 2.40; 95% CI, 1.31-4.49), to previously have recovered faster with antibiotic therapy (OR, 2.82; 95% CI, 1.65-4.89), and to be confident that they know how to treat the cold (OR, 1.79; 95% CI, 1.03-3.16). They were less likely to believe that too many people take antibiotics for a cold (OR, 0.57; 95% CI, 0.33-0.98). CONCLUSIONS: Parents may be amenable to clinical messages that other treatments may be more effective than antibiotics in managing cold symptoms. Experiences of symptomatic adults may conflict with this message. Previous cold-related medical management and drug resistance might need to be discussed with adult patients.

Consumer responses to health plan report cards in two markets.

BACKGROUND: Health plans can compete on quality when consumers have helpful information. Report cards strive to meet this need, but consumer responses have not been measured. OBJECTIVES: The objectives of this study were (1) to compare consumer responses to report cards in 2 markets, (2) to determine how personal characteristics relate to exposure, and (3) to assess the perceived helpfulness of the report cards. RESEARCH DESIGN: A postenrollment survey was used. SUBJECTS: The study included 784 employees of Monsanto (St Louis, 1996) and 670 employees of a health care purchasing cooperative (Denver, 1997). DEPENDENT MEASURES: The dependent measures were (1) exposure, specifically remembering the report card, and intensity of reading it and (2) perceived helpfulness in learning about plan quality and in deciding to stay or switch. RESULTS: Except for remembering seeing the report card (Denver, 47%; St Louis, 55%), the 2 groups did not differ. Forty percent read most or all of the report card; 82% found the report helpful in learning about quality; and 66% found it helpful in deciding to stay or switch. Employees who used patient survey information in their plan decision were more likely to remember seeing the report card (odds ratio [OR], 4.85), to read it intensely (OR, 2.84), and to find it helpful in learning about plan quality (OR, 3.04) and deciding whether to stay or switch plans (OR, 2.64). CONCLUSIONS: Although the 2 samples differed markedly, their responses to report cards were similar. Exposure and helpfulness were related more to employee preferences for the type of information than to their health care decision needs.

Patient beliefs about the characteristics, causes, and care of the common cold: an update.

BACKGROUND: Many people seek medical care for cold symptoms. The cold-related knowledge and beliefs of adults seeking medical care for themselves or their children may not correspond with current medical opinion. METHODS: A total of 249 parents of symptomatic children and 257 symptomatic adults who sought medical advice in the spring of 1997 from 1 of 3 primary care clinics in the Minneapolis-St. Paul, Minnesota, area were surveyed by telephone 48 to 96 hours after contact with the medical system. RESULTS: Of the adults seeking care for a child or themselves, 44% believed viruses alone cause the common cold: an additional 42% believed both viruses and bacteria play a role. Most thought rest (97%) and nonprescription medications (63%) were helpful for colds, which was consistent with published reports. Contrary to medical reports, however, most felt vitamin C (67%) and the inhalation of steam (70%) reduced cold symptoms, and 44% believed antibiotics help colds (chi2=19.57; P=.0002). But 85% believed colds could resolve on their own. CONCLUSIONS: Those adults seeking medical care for uncomplicated colds are misinformed about the primary cause of the common cold, the use of prescription medications for treating cold symptoms, and the effectiveness of some palliative care techniques. Care providers should address these perceptions rather than enabling overuse of antibiotics.

Effects of ankle sprain in a general clinic population 6 to 18 months after medical evaluation.

OBJECTIVE: To assess the 1-year outcome of standard medical care of acute ankle sprains in a general clinic-based population. DESIGN: A self-administered survey was mailed to all adult patients who presented to a health system provider for evaluation of ankle sprain. SETTING: A regional primary care health system. PARTICIPANTS: Four hundred sixty-seven (66.5%) of 702 patients with ankle sprains evaluated by a system physician from April 1, 1995, to March 31, 1996. MAIN OUTCOME MEASURES: Prevalence and severity of self-reported ankle pain, swelling, perceived instability, and perceived weakness 6 to 18 months after medical evaluation. RESULTS: Most patients sought medical evaluation shortly after injury and were immobilized or braced; 32.7% reported formal or home-based physical therapy. Six to 18 months after injury, 72.6% reported residual symptoms. Of these, 40.4% reported at least 1 moderate to severe symptom, most commonly perceived ankle weakness; 40.3% were unable to walk 1 mile; and 43.3% were unable to jump or pivot on the ankle without symptoms. Factors associated with moderate to severe residual symptoms were reinjury of the ankle (odds ratio [OR], 7.21; 95% confidence interval [CI], 4.14-12.68), activity restriction longer than 1 week (OR, 2.04; 95% CI, 1.25-3.32), and limited weight bearing longer than 28 days (OR, 2.16; 95% CI, 1.28-3.63). CONCLUSIONS: Residual lifestyle-limiting symptoms are common 6 to 18 months after an ankle sprain. Ankle sprains may be more problematic than generally thought, or standard medical treatment may be inadequate. Further studies evaluating treatment regimens are needed to identify effective methods to reduce the long-term functional limitations of ankle sprain in general clinic populations.

Knowledge and perception of fall-related risk factors and fall-reduction techniques among community-dwelling elderly individuals.

BACKGROUND AND PURPOSE: Falls are a major cause of death and disability among older adults. Fall-related knowledge among community-dwelling elderly individuals, however, is unknown. The purposes of this study were to assess the perception of falling as a health problem, to determine the perceived importance of fall-related risk factors, and to identify personal characteristics and attitudes associated with perceived importance of fall-related risk factors among community-dwelling elderly people. SUBJECTS AND METHODS: Resident council meeting attendees in 3 apartment buildings for elderly persons completed a self-administered survey (N=120). Items assessed factors influencing falls by the respondents (n=52) or falls among elderly persons (n=68). The data were analyzed by chi-square test, analysis of variance, and linear regression. RESULTS: Falling during the previous month was reported by 10.1% of the subjects. Eighty-six percent of the subjects considered falling to be a preventable health problem and viewed falling as a moderately important concern compared with other health concerns. Exterior environmental factors such as pavement conditions and handrails were perceived as most likely to cause falls. The perceived personal likelihood of falling due to these risk factors was markedly lower compared with the perceived risk for other elderly persons. CONCLUSION AND DISCUSSION: The community-dwelling elderly individuals studied considered falls to be preventable and understood the importance of fall-related risk factors, but they did not consider themselves to be susceptible to falling.

Marijuana use and medically attended injury events.

STUDY OBJECTIVE: This study evaluated the relation between self-reported marijuana use and 3-year incidence of injury. METHODS: We conducted a retrospective cohort study of adult Kaiser Permanente Medical Care Program members who underwent multiphasic health examinations between 1979 and 1986 (n=4,462). Injury-related outpatient visits, hospitalizations, and fatalities within 3 years of examination were determined. RESULTS: Outpatient injury events totaled 2,524; 1,611 participants (36%) had at least 1 injury-related outpatient visit. Injury-related hospitalizations (n=22) and fatalities (n=3) were rare. Among men, there was no consistent relation between marijuana use and injury incidence for either former users (rate ratio, 1.15; 95% confidence interval [CI], .97 to 1.36) or current users (rate ratio, 0.97; 95% CI, .81 to 1.17), compared with those who had never used marijuana. Among women, former and current users showed little difference in their rate of later injury compared with never users; the rate ratios were 1.05 (95% CI, .87 to 1.26) and 1.20 (95% CI, 1.00 to 1.44), respectively. No statistically significant associations were noted between marijuana use and cause-specific injury incidence in men or women. CONCLUSION: Among members of a health maintenance organization, self-reported marijuana use in adult men or women was not associated with outpatient injury within 3 years of marijuana use ascertainment.

Severe brachial plexus injury as a result of snowmobiling: a case series.

BACKGROUND: Documented snowmobile-related fatalities and injuries have increased; however, reports of peripheral nerve injuries are rare. METHODS: This case series describes a cluster of severe disabling brachial plexus injuries incurred during snowmobiling. Medical record abstraction was used to identify relevant patient and event characteristics. RESULTS: All study patients were younger male snowmobile drivers. All incidents occurred at speeds in excess of 40 mph. Blood alcohol concentrations exceeded legal intoxication limits in most cases. Complete damage of the brachial plexus occurred in four of the six patients; severe disability occurred in all cases. Five of the six patients sustained associated orthopedic shoulder complex injuries. CONCLUSION: This first report of severe peripheral nerve damage may signal the advent of more severe nonfatal snowmobile-related injuries that mimic motorcycle-related injuries, because the maximum attainable speeds of snowmobiles have increased. Surveillance of snowmobile-related injuries is warranted to identify the full spectrum of snowmobile injuries and recommend public safety measures.

Improving cancer pain management in communities: main results from a randomized controlled trial.

The purpose of this randomized controlled community trial is to evaluate the effects of a community intervention utilizing opinion leaders and educational strategies on the cancer pain management knowledge, attitudes, and the practices of physicians and nurses, and cancer pain reported by patients. Six Minnesota communities participated in the study. The three communities randomized to the intervention received educational programs over 15 months. The clinical community opinion leaders participated in a minifellowship, developed community task forces, and interacted with their peers. This strategy was reinforced with community outreach programs, clinical practice guidelines, educational materials, and media events. The primary study end point was patients' pain intensity score. Comparing intervention to control communities, pain prevalence declined slightly, pain management index improved slightly, pain intensity scores increased slightly, patient and family attitude scores did not change, and physicians' and nurses' knowledge and attitude scores improved slightly. None of these changes, however, reached statistical significance. Participation in at least one intervention program improved physicians' and nurses' knowledge and attitude scores that approached statistical significance. Our results suggest that community opinion leaders combined with other educational programs may improve cancer pain management, but this strategy requires further study. The results suggest that more intense intervention application may be effective. Effective strategies to improve cancer pain management remain elusive.

Lifetime cocaine use and cardiovascular characteristics among young adults: the CARDIA study.

OBJECTIVES: Cocaine is a central nervous system stimulant associated with cardiovascular disease risk factors, morbidity, and mortality. Despite these demonstrated relationships, it has been difficult to assess the long-term cardiovascular consequences of cocaine use. METHODS: The Coronary Artery Risk Development in Young Adults study provides an opportunity to evaluate the association of lifetime cocaine use with cardiovascular disease risk factors in a randomly sampled biethnic cohort of men and women of varied socioeconomic status, aged 20 to 32 in 1987. RESULTS: More extensive cocaine use experience was associated with being White, older, and less educated, regardless of sex. Higher levels of licit and illicit substance use behavior were reported by those reporting more extensive cocaine experience; however, most cardiovascular disease risk factors such as systolic and diastolic blood pressure, heart rate, hypertension, physical activity, and anthropometric measurements were not related to lifetime cocaine experience. CONCLUSIONS: In this age group, the detrimental cardiovascular effects of cocaine may be limited to acute effects. Further studies are needed to determine whether continued exposure is related to cardiovascular disease risk factors later in life.

Cocaine use and characteristics of young adult users from 1987 to 1992: the CARDIA Study. Coronary Artery Risk Development in Young Adults.

OBJECTIVES: This study examined the relationship of sociodemographic factors and use of substances other than cocaine to cocaine use from 1987 to 1992 in a cohort of Black and White men and women 20 to 32 years of age. METHODS: Data were collected as part of the Coronary Artery Risk Development in Young Adults study. Self-reported cocaine use was analyzed through chi-square tests and repeated measures analyses of variance to determine the bivariate and multivariate relationships of sociodemographics and substance use behaviors to cocaine use over the 5-year period. RESULTS: Cocaine use declined in Whites but remained stable in Blacks from 1987 to 1992. Cross-sectional results showed that use was related to being Black, male and in the older half of the cohort, single, and unemployed; it was also related to higher levels of other substance use in 1987 and 1992. Over time, the magnitude and strength of the relationship were consistent for each variable except for increased odds of cocaine use among the unemployed and Blacks in 1992. CONCLUSIONS: Sociodemographic characteristics and substance use behavior consistently identify individuals at risk for cocaine use. As a result, intervention programs should be targeted at these high-risk groups.

Patients and family members: the role of knowledge and attitudes in cancer pain.

Cancer pain theoretically comprises sensory, affective, and cognitive dimensions, implying that patients and family members perceive and report cancer pain based on these factors. The study reported here investigated the relationship between specific knowledge and attitudes (cognitive factors), and patients' and family members' reports of pain due to cancer. The relationship between cognitive factors and reports of cancer pain was investigated in interviews with 122 patients and their family members. Pain was measured using the Brief Pain Inventory; knowledge and attitudes were measured using a form previously developed by the authors. Patients' and family members' reports of patient pain and performance status were highly correlated, although family members consistently reported more pain and disability. Using regression analysis, cognitive factors were strongly related to family reports of patients' pain (R2 = 0.27), but contributed little to explaining pain reported by patients themselves (R2 = 0.06). Improved understanding of patients' pain assessments depends on further investigation of other cognitive factors and of sensory and affective factors. Family members' assessments of pain are significantly related to appropriate knowledge and attitudes.

Temporomandibular joint iontophoresis: a double-blind randomized clinical trial.

This double-blind study evaluated the short-term effect of iontophoretic delivery of dexamethasone on the signs and symptoms of temporomandibular disorders in patients who had concurrent temporomandibular joint disc displacement without reduction and capsulitis. Twenty-seven patients with this clinical diagnosis were randomized to one of three groups: treatment group (dexamethasone sodium phosphate and lidocaine hydrochloride); control group (lidocaine hydrochloride); and placebo group (pH-buffered saline). Pretreatment and posttreatment data included items to calculate Helkimo's Anamnestic Dysfunction index, Helkimo's Clinical Dysfunction index, the Symptom Severity Index, and the Craniomandibular Index (CMI). The CMI is composed of the Dysfunction index (DI) and Muscle index. Analysis of variance showed no baseline differences on these measures between the three groups. Pretreatment and posttreatment values were compared with the paired t tests. Posttreatment, the treatment group had an increased mean maximal active mandibular opening of 6 mm (P = .02), increased mean lateral excursion of 1.2 mm to the noninvolved side (P = .05), and reduced mean DI scores of 0.51 to 0.39 (P = .01); no statistically significant decrease in pain symptoms was reported. Analysis of variance showed a significant difference in the DI scores (P = .04) between groups from pretreatment to posttreatment, with the treatment group showing the greatest improvement in the DI scores relative to the other two groups. No other questionnaire items, exam items, or resultant indexes showed changes in any of the groups at P < or = .05. These results suggest that iontophoretic delivery of dexamethasone and lidocaine was effective in improving mandibular function, but not in reducing pain, in temporomandibular disorders patients who had concurrent temporomandibular joint capsulitis and disc displacement without reduction.

Alcohol consumption and physical fitness among young adults.

The relationship between alcohol consumption and physical fitness was analyzed using data from the baseline examination of the Coronary Artery Disease Risk Development In Young Adults study (CARDIA), a longitudinal study of the evolution of risk factors for cardiovascular disease in Black and White men and women aged 18-30 years. Two parameters of submaximal exercise treadmill testing were evaluated: time to heart rate 130 and duration of the treadmill test. In men and women qualified for treadmill testing, time to reach heart rate 130 was positively associated with ethanol intake. The relationship between fitness and ethanol intake persisted in sex-specific analysis after adjustment for age, ethnicity, systolic blood pressure, sum of subscapular and triceps skinfolds, and physical activity level. The magnitude and strength of the relationship were greater in women than in men. A negative interaction between ethanol intake and smoking status was evident. Linear regression coefficients in men were 0.29 sec to heart rate 130/ml ethanol/day in nonsmokers and -0.06 sec to heart rate 130/ml ethanol/day in smokers. Linear regression coefficients in women were 1.07 sec to heart rate 130/ml ethanol/day in nonsmokers and 0.23 sec to heart rate 130/ml ethanol/day in smokers. Men and women who smoked showed 31 sec longer time to heart rate 130, regardless of ethanol intake. Mean daily ethanol intake was positively associated with duration of treadmill testing in women, but weakly associated with duration in men. These results show increased physical fitness as ethanol intake increased in women and nonsmoking men and mildly decreased physical fitness as ethanol consumption increases among men who smoke.(ABSTRACT TRUNCATED AT 250 WORDS)

Postural differences between asymptomatic men and women and craniofacial pain patients.

A forward head position and rounded shoulders have been implicated in the development or perpetuation of craniomandibular disorders. Since women seek treatment for these problems more frequently than men, postural differences may account for the increased incidence of symptoms in women. The purposes of this study were (1) to compare the sagittal head and shoulder posture of asymptomatic men and women and (2) to compare the posture of asymptomatic and symptomatic women to determine differences in sagittal plane posture. Subjects were 20 asymptomatic men and women volunteers and nine consecutive women patients presenting for evaluation and treatment of craniomandibular pain. The subjects were compared using a valid, reliable, computer-assisted slide digitizing system called the Postural Analysis Digitizing System (PADS). Asymptomatic men and women did not differ in the postural characteristics associated with craniomandibular disorders. Sagittal posture does not appear to be a gender-related factor in these disorders. Symptomatic women, however, do display these postural characteristics to a greater extent than asymptomatic women. Evaluation and treatment of postural dysfunction should be included in the management of these patients.

General and histopathological results of a two-year study of rats fed semi-purified diets containing casein and soya protein.

Two semi-purified diets, identical except for protein (soya or casein), and a Purina chow diet were fed to groups of Sprague-Dawley rats and compared over a 22-month period for effects on body weight, organ weight, feed consumption, feed efficiency, protein efficiency, organ-to-body-weight ratios, certain organ mineral levels, gross pathology and histopathology. Feed efficiency, protein efficiency, body weight, and most organ weights were higher in the groups fed soya and casein, while feed consumption and most organ-to-body-weight ratios were relatively lower. Significant increases in the final pathology findings in the groups fed soya and casein included nephrocalcinosis (in females), hepatocellular vacuolization, gastric trichobezoars (hairballs), ulcerative pododermatitis (hock ulcers) and splenomegaly. This study demonstrates that the long-term feeding of semi-purified diets is feasible. Moreover, the differences observed between the protein sources, that is, soya and casein, were minimal, which suggests that either protein source is acceptable for long-term feeding studies.

Quantitative assessment of head and shoulder posture.

Posture of the head, neck, and shoulders has long been recognized as a factor contributing to the onset and perpetuation of cervical pain dysfunction syndromes. Treatment regimens frequently include exercises and instruction for postural correction. Clinical assessment of posture, however, tends to be subjective in nature. The purpose of this study was to determine the reliability of a new objective technique of posture measurement and to establish normal standards for the technique. This study used a computer-assisted slide digitizing system called Postural Analysis Digitizing System (PADS) to determine characteristic values for head and shoulder girdle posture and characteristic range of motion for head protraction-retraction and shoulder protraction-retraction in a sample of able-bodied young men. PADS is a modification of a two-dimensional slide digitizing system developed for measuring trunk range of motion. Twenty male subjects were photographed in a neutral position, the maximally protracted position, and the maximally retracted position of the head and scapula. Ten subjects were evaluated once, and ten were evaluated twice. The slide photographs were analyzed using a computer-assisted digitizing system. Well-defined anatomic landmarks were used to determine angular relationships in the head, neck, and shoulders. The reliability of the system was tested by calculating an intraclass correlation coefficient, student t-test, and the percent error for each position. The positions were considered reproducible, and reliability of the system was considered adequate for postural analysis. Mean values for the positions were 28.48 degrees, 51.97 degrees, and 62.09 degrees for head protraction, the neutral position, and head retraction, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of physical therapy intervention on incisal opening after temporomandibular joint surgery.

A retrospective study of 58 postoperative patients who underwent temporomandibular joint surgery was done to determine the effect of a physical therapy treatment program of ultrasound, superficial heat, and exercise on incisal opening 6 to 12 months after surgery. Twenty-nine of the subjects had surgery and physical therapy intervention, while 29 had surgery only. Patients referred for physical therapy had more complaints of pain and significantly less incisal opening after surgery than those not referred for physical therapy. Both groups, however, had achieved a comparable amount of incisal opening 6 to 12 months after surgery. Chi square analysis indicated that patients with an incisal opening of less than 30 mm postoperatively were more likely to have an incisal opening of 40 mm 6 to 12 months after surgery if they received physical therapy treatments. Patients having more than 30 mm of incisal opening a month after surgery showed a greater tendency to achieve more than 40 mm of opening if physical therapy was included in the postoperative management.