Ventriculoperitoneal shunts in children on peritoneal dialysis: a survey of the International Pediatric Peritoneal Dialysis Network.

OBJECTIVE: The aim of this study was to inform best evidence-based practice by collating and disseminating the experiences of members of the International Pediatric Peritoneal Dialysis Network with children having concurrent ventriculoperitoneal shunts (VPS) and peritoneal dialysis catheters (PDC). METHODS: An online questionnaire was created and distributed to all 135 centers participating in the International Pediatric Peritoneal Dialysis Network; the overall response rate was 56 %. RESULTS: A total of 18 patients with a concurrent VPS and PDC were reported. The children were 0-12 (mean 6.8) years old at the time of placement of the second indwelling device (PDC or VPS). In 15 cases, the PDC was inserted post-VPS. On average, the two catheters were present concurrently for 23 (range 1-60) months. There were 20 episodes of peritonitis observed in 11 of the 18 patients during a period of 392 months at risk, which is a peritonitis rate of 1/19.6 months. Only one patient developed both a VPS infection and an episode of peritonitis, and these events were temporally unrelated. No episodes of an ascending shunt infection or meningitis occurred in association with any episode of peritonitis, and no other complications of catheter dysfunction were described. CONCLUSIONS: The rate of peritonitis, the absence of any documented ascending or descending infections and the lack of catheter dysfunction during the period of observation suggests that the presence of, or need for, a VPS should not preclude PD as a safe option for children requiring renal replacement therapy.

Leg symptoms in peripheral arterial disease: associated clinical characteristics and functional impairment.

CONTEXT: Persons with lower-extremity peripheral arterial disease (PAD) are often asymptomatic or have leg symptoms other than intermittent claudication (IC). OBJECTIVE: To identify clinical characteristics and functional limitations associated with a broad range of leg symptoms identified among patients with PAD. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional study of 460 men and women with PAD and 130 without PAD, who were identified consecutively, conducted between October 1998 and January 2000 at 3 Chicago-area medical centers. MAIN OUTCOME MEASURES: Ankle-brachial index score of less than 0.90; scores from 6-minute walk, accelerometer-measured physical activity over 7 days, repeated chair raises, standing balance (full tandem stand), 4-m walking velocity, San Diego claudication questionnaire, Geriatric Depression Score Short-Form, and the Walking Impairment Questionnaire. RESULTS: All groups with PAD had poorer functioning than participants without PAD. The following values are for patients without IC vs those with IC. Participants in the group with leg pain on exertion and rest (n = 88) had a higher (poorer) score for neuropathy (5.6 vs 3.5; P<.001), prevalence of diabetes mellitus (48.9% vs 26.7%; P<.001), and spinal stenosis (20.8% vs 7.2%; P =.002). The atypical exertional leg pain/carry on group (exertional leg pain other than IC associated with walking through leg pain [n = 41]) and the atypical exertional leg pain/stop group (exertional leg pain other than IC that causes one to stop walking [n = 90]) had better functioning than the IC group. The group without exertional leg pain/inactive (no exertional leg pain in individual who walks

Measuring satisfaction with mammography results reporting.

OBJECTIVE: To assess factors associated with patient satisfaction with communication of mammography results and their understanding and ability to recall these results. DESIGN: Cross-sectional telephone survey. SETTING: Academic breast imaging center. PATIENTS: Two hundred ninety-eight patients who had either a screening or diagnostic mammogram. MEASUREMENTS AND MAIN RESULTS: Survey items assessed waiting time for results, anxiety about results, satisfaction with several components of results reporting, and patients' understanding of results and recommendations. Women undergoing screening exams were more likely to be dissatisfied with the way the results were communicated than those who underwent diagnostic exams and received immediate results (20% vs 11%, P =.05). For these screening patients, waiting for more than two weeks for notification of results, difficulty getting in touch with someone to answer questions, low ratings of how clearly results were explained, and considerable or extreme anxiety about the results were all independently associated with dissatisfaction with the way the results were reported, while age and actual exam result were not. CONCLUSIONS: Patients undergoing screening mammograms were more likely to be dissatisfied with the way the results were communicated than were those who underwent diagnostic mammograms. Interventions to reduce the wait time for results, reduce patients' anxiety, and improve the clarity with which the results and recommendations are given may help improve overall satisfaction with mammography result reporting.

The role of inadequate health literacy skills in colorectal cancer screening.

Colorectal cancer is ideally suited for early detection strategies that are likely to improve survival rates. Screening with either a fecal occult blood test (FOBT) or flexible sigmoidoscopy has been shown to identify precancerous polyps or cancers in early stages. However, persons with limited education and of lower socioeconomic status infrequently participate in screening programs in general and have very low rates of colorectal screening. Low literacy, which is common among persons with limited education and low income, may be an overlooked factor in understanding patients' decision making about colorectal cancer screening. This article provides information from focus groups about colorectal cancer screening, which we examine in the context of relevant literature on cancer screening and literacy. Using the health belief model, we examine the association between inadequate health literacy skills and low rates of colorectal cancer screening. The theoretical model also provides insights into strategies for improving knowledge, attitudes, and beliefs and screening rates for this challenging patient population.

The association of demographic factors and physical illness with personality change in a community sample of elderly African Americans.

In a community-based dementia study of African Americans age 65 and older living in Indianapolis, key informants were asked to assess the types of personality change in all subjects. Information was also collected on demographic factors, cognitive functioning, physical well-being, and medical illness. Twenty-nine percent of subjects without dementia had reported personality change. Reports of personality change were significantly associated with being male, having poor daily functioning scores, suffering from physical disability, and having a history of cancer.

Impact of same-day screening mammography availability: results of a controlled clinical trial.

BACKGROUND: We conducted a prospective controlled clinical trial in an urban academic general medicine practice to test the effect of same-day mammography availability on adherence to physicians' screening mammography recommendations. PATIENTS AND METHODS: Participants were a consecutive sample of 920 female patients aged 50 years or older who had received a physician's recommendation for screening mammography at an office visit and had no active breast symptoms, history of breast cancer, or a mammogram within the previous 12 months. Women were assigned to same-day screening mammography availability (intervention group) or usual screening mammography scheduling (control group). MAIN OUTCOME MEASURES: Three-, 6-, and 12-month rates of adherence to physicians' recommendations for screening mammography. RESULT: Twenty-six percent of women in the intervention group obtained a same-day screening mammogram. At 3 months, 58% of the women in the intervention group underwent the recommended screening mammography compared with 43% of the women in the control group (P<.001), increasing to 61% and 49% at 6 months (P<.001), and 268 (66%) of 408 vs 287 (56%) of 512 at 12 months (P = .003). The difference between the intervention and control groups 3-month adherence rates was most marked among women aged 65 years or older (58% vs 34%; P<.001), women who were not employed (54% vs 36%; P<.001), and women with a history of having had either no mammograms (39% vs 20%; P = .02) or only 1 to 2 mammograms (57% vs 38%; P<.001) within the last 5 years. CONCLUSIONS: Same-day mammography availability increased 3-, 6-, and 12-month screening mammography adherence rates in this urban academic general medicine practice. The effect was most marked among women aged 65 years or older, women who were not employed, and those who had had fewer than 3 mammograms in the last 5 years. The efficacy of this intervention in other settings still needs to be demonstrated.

Do clinical breast examination skills improve during medical school?

PURPOSE: To assess the effects of stage of training, gender, and specialty interest on medical students' breast cancer knowledge, attitudes, and clinical breast examination (CBE) skills as a case study of the progression of physical examination skills during medical education. METHOD: In 1996, questionnaires assessing breast cancer knowledge and attitudes were administered to 493 premedical and first-, second-, and third-year medical students at Northwestern University Medical School. Silicone breast models were used to evaluate the CBE proficiency of a subset of 151 students. RESULTS: Breast cancer knowledge was positively correlated with stage of training (r = .62), with significant differences between all levels (p < .001). In contrast, first-year medical students attained the highest mean lump-detection sensitivity (61.5%), followed by second-year (53.9%) and third-year (43.5%) students (p < .001, first- vs third-year students; p < .10, second- vs third-year students). There was no significant difference in specificity among the four stages. CONCLUSIONS: The results suggest that breast cancer knowledge and attitudes are not related to CBE proficiency, which is a practiced tactile skill. The decline in lump-detection sensitivity with increased stage of training may demonstrate the need for increased attention to palpation skills during the clinical years. These findings are consistent with those of earlier reports that suggest the need for the reinforcement of physical examination skills during clinical education.

Factors influencing exercise performance in patients with left ventricular dysfunction. SOLVD Investigators. Studies of Left Ventricular Dysfunction.

BACKGROUND: The determinants of exercise performance are multifactorial and incompletely understood in patients with symptomatic left ventricular (LV) dysfunction, with much less information regarding asymptomatic LV dysfunction. This study assessed the hemodynamics and neurohormonal factors influencing exercise performance in patients with LV ejection fractions > or =0.35, both symptomatic and asymptomatic, enrolled in Studies of LV Dysfunction. METHODS AND RESULTS: We studied 103 patients enrolled prospectively in Studies of LV Dysfunction before randomized therapy; 38 were symptomatic and 65 had no or minimal symptoms. By using rest-exercise gated equilibrium radionuclide ventriculography and cuff blood pressure, we assessed the heart rate, LV and right ventricular (RV) volumes and ejection fractions, total peripheral resistance, the LV peak systolic pressure/end systolic volume ratio as an index of contractility, and plasma renin and norepinephrine at rest and during maximal graded supine bicycle ergometer exercise. Changes between rest and exercise were evaluated as indices of cardiovascular reserve. The cumulative workload ranged from 120 to 2,100 watt-min. At rest, the LV ejection fraction was 0.30 in asymptomatic patients and 0.25 in symptomatic patients, respectively (P < .0004). During exercise, asymptomatic patients had greater increases in heart rate, systolic blood pressure, LV ejection fraction, and cardiac output than symptomatic patients (P > or = .05). Combining all patients, the strongest univariate correlates of exercise workload were the ability to increase heart rate (r = 0.70), the pressure/volume ratio (r = 0.63), and systolic blood pressure (r = 0.55), and to decrease the total peripheral resistance (r = -0.47) with moderate correlations for the ability to increase LV and RV ejection fractions (r = 0.33 and 0.35, respectively) (P < .0008). By multivariate analysis, workload was modeled best by the changes in four factors: heart rate, systolic blood pressure, and the LV and RV ejection fractions (R2 = 0.54, P < .001). CONCLUSION: Exercise performance and its hemodynamics differed in patients with symptomatic and asymptomatic LV dysfunction. Rather than features at rest, the reserve capacities for increasing heart rate, systolic blood pressure, and the LV and RV ejection fractions were the predominant cardiac mechanisms related to greater exercise performance.

Typhoid fever in the United States, 1985-1994: changing risks of international travel and increasing antimicrobial resistance.

BACKGROUND: Typhoid fever is a potentially fatal illness common in the less industrialized world. In the United States, the majority of cases occur in travelers to other countries. METHODS: We reviewed surveillance forms submitted to the Centers for Disease Control and Prevention, Atlanta, Ga, for patients with culture-confirmed typhoid fever between 1985 and 1994. RESULTS: The Centers for Disease Control and Prevention received report forms for 2445 cases of typhoid fever. Median age of patients was 24 years (range, 0-89 years). Ten (0.4%) died. Seventy-two percent reported international travel within the 30 days before onset of illness. Six countries accounted for 80% of cases: Mexico (28%), India (25%), the Philippines (10%), Pakistan (8%), El Salvador (5%), and Haiti (4%). The percentage of cases associated with visiting Mexico decreased from 46% in 1985 to 23% in 1994, while the percentage of cases associated with visiting the Indian subcontinent increased from 25% in 1985 to 37% in 1994. The incidence of typhoid fever in US citizens traveling to the Indian subcontinent was at least 18 times higher than for any other geographic region. Complete data on antimicrobial susceptibility to ampicillin, chloramphenicol, and trimethoprim-sulfamethoxazole were reported for 330 (13%) Salmonella Typhi isolates. Isolates from 1990 to 1994 were more likely than isolates from 1985 to 1989 to be resistant to any of these antimicrobial agents (30% vs 12%; P<.001) and to be resistant to all 3 agents (12% vs 0.6%; P<.001). CONCLUSIONS: American travelers to less industrialized countries, especially those traveling to the Indian subcontinent, continue to be at risk for typhoid fever. Antimicrobial resistance has increased, and a quinolone or third-generation cephalosporin may be the best choice for empirical treatment of typhoid fever.

New World hantaviruses.

Since the initial description in 1993 of hantavirus pulmonary syndrome and its novel aetiological agent, Sin Nombre virus, our knowledge of the epidemiology of New World hantaviruses has continued to evolve. After the identifying outbreak in the southwestern US, four hantaviruses have been identified in North America with specific rodent hosts and associated with a number of sporadic cases. This stability of case recognition in North America is in contrast to the multiple outbreaks and endemic cases in South America. Despite a plethora of New World hantaviruses and new evidence of person-to-person transmission, the ecological and personal determinants of this human infection remain a mystery.

Effectiveness of a skin cancer control educational intervention for internal medicine housestaff and attending physicians.

OBJECTIVES: To evaluate the effects of a brief educational program on beliefs, knowledge, and behaviors related to skin cancer control among internal medicine housestaff and attending physicians. DESIGN: Randomised controlled trial. SETTING: Urban academic general medicine practice. PARTICIPANTS: Internal medicine housestaff and attending physicians with continuity clinics at the practice site. INTERVENTION: Two 1-hour educational seminars on skin cancer control conducted jointly by a general internist and a dermatologist. MEASUREMENTS AND MAIN RESULTS: Self-reported attitudes and beliefs about skin cancer control, ability to identify and make treatment decisions on 18 skin lesions, and knowledge of skin cancer risk factors were measured by a questionnaire before and after the teaching intervention. Exit surveys of patients at moderate to high risk of skin cancer were conducted 1 month before and 1 month after the intervention to measure physician skin cancer control practices reported by patients. Eighty-two physicians completed baseline questionnaires and were enrolled in the study, 46 in the intervention group and 36 in the control group. Twenty-five physicians attended both sessions, 11 attended one, and 10 attended neither. Postintervention, the percentage of physicians feeling adequately trained increased from 35% to 47% in the control group (p = .34) and from 37% to 57% in the intervention group (p = .06). Intervention physicians had an absolute mean improvement in their risk factor identification score of 6.7%, while control physicians' mean score was unchanged (p = .06). Intervention and control physicians had similar increases in their postintervention lesion identification and management scores. Postintervention, the mean proportion of patients per physician stating they were advised to watch their moles increased more among intervention physicians than control physicians (absolute difference of 19% vs -8%, p = .04). Other changes in behavior were not significant. CONCLUSIONS: Although we observed a few modest intervention effects, overall this brief skin cancer education intervention did not significantly affect primary care physicians' skin cancer control attitudes, beliefs, knowledge, or behaviors. A more intensive intervention with greater participation may be necessary to show a stronger impact on attitudes and knowledge about skin cancer control among primary care physicians.

Age-related differences in breast carcinoma knowledge, beliefs, and perceived risk among women visiting an academic general medicine practice.

BACKGROUND: This study assessed whether age-related differences in breast carcinoma knowledge and perceived risk exist among women in a primary care setting and whether these women's beliefs about the best age to begin screening mammography reflect those of their physicians. METHODS: Consecutive women ages 30-70 years who visited an academic general medicine practice were asked to complete a questionnaire assessing breast carcinoma knowledge, beliefs, and perceived risk. Women's risk estimates were compared with individual risk probabilities derived from the Gail model. Women's beliefs about when to begin screening mammography were compared with the beliefs of the attending physicians in the practice. Questionnaire results were compared across age groups. RESULTS: Six hundred seventy-four women completed the survey. Overall, knowledge scores were negatively correlated with age (correlation coefficient = -0.30, P = 0.001). The level of knowledge about the benefits of mammography was high across all age groups. In contrast, knowledge that breast carcinoma incidence increases with age was poor. Only 28% of all women recognized that breast carcinoma is more common among women age 65 years than among women age 40 years. Among all women, 26% underestimated their risk of developing breast carcinoma in the next 10 years, 32% correctly estimated their risk, and 42% overestimated their risk. Fifty-five percent thought that mammography should begin when a woman is age 30-35 years. In contrast, all surveyed physicians recommended that a woman start undergoing mammography at age 40 years or older. CONCLUSIONS: In this primary care setting, older women had poorer breast carcinoma knowledge than younger women but were equally likely to appreciate the benefits of mammography. Most women were unaware that age is a risk factor for breast carcinoma. Improved education of females by their physicians may resolve some of the observed discrepancies regarding the optimal age to begin screening mammography.

Acute and long-term effects of the angiotensin-converting enzyme inhibitor, enalapril, on adrenergic activity and sensitivity during exercise in patients with left ventricular systolic dysfunction.

Patients with heart failure and left ventricular systolic dysfunction exhibit increased adrenergic activity but blunted adrenergic responsiveness. We studied patients enrolled in the Studies of Left Ventricular Dysfunction, examining exercise responses of heart rate (HR) and plasma norepinephrine (PNE). Eighty-seven patients were studied before randomization; 65 of these were examined 1 year after randomization to placebo or enalapril. Compared with prevention trial (asymptomatic) patients, patients in the treatment trial (symptomatic) had higher resting HR and PNE levels and less increase in HR with a greater increase in PNE with exercise. Acute administration of enalapril increased the resting HR in patients in the prevention trial only but had no significant effect on PNE. After 1 year of therapy, patients in the prevention trial exhibited no change. Within the treatment trial, the placebo group displayed both a higher peak PNE and increase in PNE with exercise than did the enalapril group, whose HR response was maintained in spite of a reduction of exercise PNE. We conclude that (1) compared with asymptomatic patients, symptomatic patients with reduced left ventricular ejection fraction manifest greater resting and exercise adrenergic activity, with blunted HR response; and (2) in symptomatic patients, 1 year of enalapril treatment effected an augmented HR response to adrenergic stimulation, supporting an interaction between the renin/angiotensin and adrenergic nervous systems. Normalization of adrenergic tone and response likely contributes to the benefits of long-term angiotensin-converting enzyme inhibitor therapy.

Effect of breast-tissue characteristics on the outcome of clinical breast examination training.

PURPOSE: To compare the effects of clinical breast examination (CBE) training on lump-detection rates in simulated premenopausal and postmenopausal breast tissue. METHOD: Two sets of six silicone models were made with background breast tissue simulating premenopausal tissue (most nodular, least soft) and postmenopausal breast tissue (least nodular, most soft) respectively. Eighteen lumps were located in each set of models. In September 1994, 82 housestaff and attending physicians with outpatient practices in the Division of General Internal Medicine at Northwestern University Medical School were randomized to a CBE-teaching intervention or a control group. Lump-detection rates for the two sets of models were measured before and after the teaching intervention. Analysis of covariance was used to analyze the effect of CBE training on examination sensitivity and specificity, controlling for baseline rates. RESULTS: CBE training increased lump-detection rates similarly and significantly in models simulating premenopausal and postmenopausal tissue, respectively. Specificity declined after training in models simulating postmenopausal tissue (p = 0.02) but was unchanged in models simulating premenopausal tissue (p = 0.54). CBE training had greater influence on sensitivity among house-staff than among attending physicians (p = 0.02). CONCLUSION: CBE training similarly affects lump detection in simulated premenopausal and postmenopausal breast tissue, but adversely affects specificity in simulated postmenopausal tissue only.

Lump detection is enhanced in silicone breast models simulating postmenopausal breast tissue.

We varied the softness and nodularity of silicone breast models to assess the effects of age-related breast tissue characteristics on lump detection. In two sets of six silicone breast models manufactured to simulate premenopausal and postmenopausal breast tissue, respectively, 82 internal medicine attending and housestaff physicians more readily detected lumps among models simulating older breast tissue. The proportion of models with one or more false-positive findings was higher among models simulating postmenopausal breast tissue. We conclude that age-related changes in breast tissue most likely contribute to the higher sensitivity of clinical breast examination in older women.

Skin cancer control practices among physicians in a university general medicine practice.

Physician counseling about sun protection and routine screening for skin cancer in high-risk individuals have been widely recommended. The purpose of this study was to assess the skin cancer control practices and knowledge among physicians in a university-based general medicine practice. Fifty-two physicians completed a survey on attitudes toward, behaviors in, and knowledge of skin cancer control. In addition, the ability of general medicine residents and attending physicians to correctly identify and make biopsy recommendations for ten photographed skin lesions was compared with that of third-year medical students and dermatology residents and attendings. The results of the survey illustrate a need for improving primary care physicians' knowledge and identification of skin cancer risk factors, and increasing the frequency and consistency with which they perform skin cancer prevention counseling and complete skin examination in high-risk patient groups.

Adherence to screening mammography recommendations in a university general medicine clinic.

OBJECTIVE: To determine factors predicting adherence to a health care provider's screening mammography recommendation in a general internal medicine practice. DESIGN: Prospective observational study. SETTING: An urban academic general internal medicine practice. PATIENTS: Three hundred forty-nine asymptomatic women, aged 50 years and older, without prior history of breast cancer, who received a health care provider's recommendation for screening mammography. MEASUREMENT: Independent variables were: patient age, race, insurance type, educational level, and duration of affiliation with the practice; visit type; and health care provider gender and level of training. Dependent variables were acceptance of the recommendation and adherence, defined as undergoing mammography within three months of the recommendation. RESULTS: Overall, 193 (55%) of the women underwent the recommended mammography. Two hundred ninety-eight (85%) initially agreed to the recommendation, and of these, 190 (64%) completed mammography within three months. By univariate analysis, acceptance of the recommendation decreased significantly with increasing age (p < 0.01), and by race (African-Americans 89% vs whites 82%, p = 0.05). Only age remained independently predictive of acceptance in a multiple variable analysis. Among women who accepted the recommendation, adherence varied significantly according to race (white 70% vs nonwhite 59%, p = 0.05), insurance type [Medicare as only insurance 45%, Medicaid 66%, non-health maintenance organization (non-HMO) private 62%, HMO 73%, p = 0.03], and health care provider training (attending physicians 73%, residents 58%, nurse practitioners 47%, p = 0.02). In a logistic regression analysis, insurance type and health care provider training remained independently predictive of adherence. CONCLUSION: Acceptance of screening mammography recommendations decreases with age. Among the women who agreed to the recommendation for screening mammography, insurance type and health care provider level of training best predicted adherence.