Internists' attitudes towards terminal sedation in end of life care.

OBJECTIVE: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide (PAS), and explore characteristics of internists who support terminal sedation but not assisted suicide. DESIGN: A statewide, anonymous postal survey. SETTING: Connecticut, USA. PARTICIPANTS: 677 Connecticut members of the American College of Physicians. MEASUREMENTS: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics. RESULTS: 78% of respondents believed that if a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation (diminish consciousness to halt the experience of pain). Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents (47%) were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients (p = 0.02) and attending religious services more frequently (p<0.001). CONCLUSIONS: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide.

Computed tomography of the head before lumbar puncture in adults with suspected meningitis.

BACKGROUND: In adults with suspected meningitis clinicians routinely order computed tomography (CT) of the head before performing a lumbar puncture. METHODS: We prospectively studied 301 adults with suspected meningitis to determine whether clinical characteristics that were present before CT of the head was performed could be used to identify patients who were unlikely to have abnormalities on CT. The Modified National Institutes of Health Stroke Scale was used to identify neurologic abnormalities. RESULTS: Of the 301 patients with suspected meningitis, 235 (78 percent) underwent CT of the head before undergoing lumbar puncture. In 56 of the 235 patients (24 percent), the results of CT were abnormal; 11 patients (5 percent) had evidence of a mass effect. The clinical features at base line that were associated with an abnormal finding on CT of the head were an age of at least 60 years, immunocompromise, a history of central nervous system disease, and a history of seizure within one week before presentation, as well as the following neurologic abnormalities: an abnormal level of consciousness, an inability to answer two consecutive questions correctly or to follow two consecutive commands, gaze palsy, abnormal visual fields, facial palsy, arm drift, leg drift, and abnormal language (e.g., aphasia). None of these features were present at base line in 96 of the 235 patients who underwent CT scanning of the head (41 percent). The CT scan was normal in 93 of these 96 patients, yielding a negative predictive value of 97 percent. Of the three misclassified patients, only one had a mild mass effect on CT, and all three subsequently underwent lumbar puncture, with no evidence of brain herniation one week later. CONCLUSIONS: In adults with suspected meningitis, clinical features can be used to identify those who are unlikely to have abnormal findings on CT of the head.

Health risk behaviors and health perceptions in the Peruvian Amazon.

Behavioral health risk factor and health belief data for the indigenous population of the Peruvian Amazon are unavailable. Therefore, we conducted structured interviews of adults living in 5 towns in the remote Amazon region of Peru. Respondents (n = 179) were 67% women with a mean age of 35.4 years. The average household size was 6.7 people. A majority (72%) were unable to see a doctor when needed because of lack of money and distance. Only 6% reported excellent health, and nearly half (49%) reported fair health. Forty-eight percent drank alcohol and 73% smoked. Only 34% thought mosquitoes cause malaria, but 98% were using mosquito nets. In conclusion, our findings indicate the indigenous population of the Peruvian Amazon has limited access to basic health care. Although most of those surveyed use mosquito netting, few know that mosquitoes transmit malaria. Tobacco and alcohol use are major behavioral health risk factors.

An integrated residency in internal and preventive medicine.

The importance of preventive and population-based principles in clinical practice is widely acknowledged. The challenge of imparting these principles in either undergraduate or postgraduate medical education has, however, not been fully met. The necessary skills are provided comprehensively by preventive medicine residency programs, but at the expense of clinical training. Sequential residencies in primary care and preventive medicine, the currently available means of obtaining thorough preparation in both clinical and population-based principles, represent an inefficient, generally unappealing, and non-integrated approach. In response to these concerns, and in an effort to make preventive medicine training appeal to a wider audience, the authors developed and implemented a residency program fully integrating internal and preventive medicine. The program meets, and generally exceeds, the requirements of both specialty boards over a four-year period. The program provides extensive training in clinical, preventive, and public health skills, along with case management and cost-effective care, conferring the MPH degree and leading to dual board eligibility. The model is ideally wed to the demands of the modern health care environment in the United States, is extremely attractive to applicants, and may warrant replication both to train academic and administrative leaders and to raise the standards of preventive and public health practice in primary care.

Perils, pitfalls, and possibilities in talking about medical risk.

Virtually every course of medical action is associated with some adverse risk to the patient. Discussing these risks with patients is a fundamental duty of physicians both to fulfill a role as trusted adviser and to promote the ethical principle of autonomy (particularly as embodied in the doctrine of informed consent). Discussing medical risk is a difficult task to accomplish appropriately. Challenges stem from gaps in the physician's knowledge about pertinent risks, uncertainty about how much and what kind of information to communicate, and difficulties in communicating risk information in a format that is clearly understood by most patients. For example, a discussion of the risk of undergoing a procedure should be accompanied by a discussion of the risk of not undergoing a procedure. This article describes basic characteristics of risk information, outlines major challenges in communicating risk information, and suggests several ways to communicate risk information to patients in an understandable format. Ultimately, a combination of formats (eg, qualitative, quantitative, and graphic) may best accommodate the widely varying needs, preferences, and abilities of patients. Such communication will help the physician accomplish the fundamental duty of teaching the patient the information necessary to make an informed and appropriate decision.

Comparison of frequencies of atrial fibrillation after coronary artery bypass grafting with and without the use of cardiopulmonary bypass.

This study compared the incidence of postoperative atrial fibrillation in a group of 34 patients undergoing coronary artery bypass graft surgery without the use of cardiopulmonary bypass and cardioplegia with a control group of 747 patients undergoing coronary artery bypass graft surgery using cardiopulmonary bypass and standard cardioplegia. A trend toward a lower incidence of postoperative atrial fibrillation was found in the group that underwent coronary artery bypass graft surgery without the use of cardiopulmonary bypass (n = 0.06).

Dietary fat consumption in a cohort of American adults, 1985-1991: covariates, secular trends, and compliance with guidelines.

PURPOSE: To examine compliance with the guideline for dietary fat (i.e., 30% of total daily colonies) and covariates of fat intake in a cohort of adults using both 24-hour recall and food frequency questionnaire (FFQ). DESIGN: Prospective, observational cohort study over 5 years. SETTING: Community-based sample in Reno, Nevada. SUBJECTS: Equal numbers of male and female, lean and overweight adults (n = 508), recruited from 1985 to 1986, of whom 348 completed all relevant surveys. MEASURES: Subjects underwent repeated anthropometric measures and completed extensive surveys on diet, weight cycling, lifestyle, and physical activity. RESULTS: Mean fat intake by 24-hour recall declined from 36.9% to 33.6% of calories between years 1 and 5 (p < .001), while calorie intake increased (p = .2). As measured by FFQ at year 2, mean fat intake was 39.1% of calories, and only 11.8% of subjects were in compliance with the guideline for dietary fat intake. Fat intake by FFQ at year 2 was statistically higher than by 24-hour recall in year 1 for lean women (p = .02) and lean men (p = .02), but not for the overweight of either gender, and was significantly higher than the year 5 24-hour recall for all categories of gender and weight (p < .001). Calorie intake, gender, and body mass index were significant in regression models that explained less than 10% of total variability in fat intake (r2 = .08; p < .01). CONCLUSIONS: Compliance with the nationally recommended level of dietary fat intake was poor in this cohort, especially as measured by FFQ. Variability in fat intake was largely unexplained by host characteristics, including education. Further study is required to corroborate secular trends in population fat intake, elucidate the determinants of such intake, and identify cost-effective strategies for reducing the consumption of dietary fat.

Image analysis combined with visual cytology in the early detection of recurrent bladder carcinoma.

BACKGROUND: Early detection of recurrent transitional cell carcinoma of the bladder (TCC) is important to permit early treatment, which produces maximal preservation of the bladder and maximum survival. METHODS: This retrospective cohort study attempted to determine the period of time over which urinary DNA image analysis combined with visual cytology is useful in the early detection of recurrent TCC of the bladder. The authors believe this study is unique in that it measured the effectiveness of this test (image analysis plus visual cytology combined) at varying times before clinical diagnosis of recurrence was made. The cohort was comprised of 175 urologic patients from urologic practices across the U.S. Data, collected between January 1991 and February 1994, included cystoscopy, biopsy, DNA image analysis, and visual cytologic reports. RESULTS: Sixty patients in the cohort were found to have active TCC whereas 115 patients had a history of, but no active, disease during the follow-up period. As expected, the sensitivity and specificity of DNA image analysis in combination with visual cytology, and DNA image analysis alone, were greatest when urinary samples were obtained close to the time of diagnosis. In general, the longer the interval from the combined tests to the time of diagnosis, the lower the sensitivity. The combined tests had predictive value up to 3 months prior to clinical diagnosis when any detectable cytologic abnormality was considered positive. At the optimal cutoff points as determined from receiver operating characteristic curves, sensitivity increased when DNA image analysis was supplemented with visual cytology. CONCLUSIONS: The combination of DNA image analysis and visual cytology provides a better method for the early detection of recurrent TCC than DNA image analysis alone. This test potentially may be useful in providing information regarding bladder tumor recurrence up to 3 months prior to clinical evidence of disease.

End-of-life decisions in HIV-positive patients: the role of spiritual beliefs.

OBJECTIVE: To describe the role of spiritual beliefs in HIV-positive patients' end-of-life decisions. DESIGN: Inperson, cross-sectional survey. SETTING: An HIV/AIDS floor of an urban, university teaching hospital. PATIENTS: Ninety hospitalized HIV-positive patients. MAIN OUTCOME MEASURES: Prior discussions about advance directives, possession of a living will (written advance directive), fear of death, professions of hope and purpose in life, religious beliefs and practices, guilt about HIV infection, and perception of HIV as punishment. RESULTS: Of 104 eligible patients, 90 agreed to be interviewed. Twenty-four per cent of patients had discussed their resuscitation status with a physician and 17% possessed a living will; 44% of patients felt guilty about their HIV infection, 32% expressed fear of death, and 26% felt their disease was some form of punishment. Prior discussions about resuscitation status were less likely in those who perceived HIV as punishment (P=0.009) and more likely in those who believed in God's forgiveness (P=0.043). A living will was more common in those who prayed daily (P=0.025) and in those whose belief in God helped them when thinking about death (P=0.065). Fear of death was more likely in those who perceived HIV as punishment (P=0.01) or felt guilty about having HIV (P=0.039), and less likely in those who read the Bible frequently (P=0.01) or attended church regularly (P=0.015). Outcome measures did not vary significantly according sex, race, HIV risk factors, or education level. CONCLUSIONS: In this HIV-positive population, spiritual beliefs and religious practices appeared to play a role in end-of-life decisions. Discussions about end-of-life decisions may be facilitated by a patient's belief in a forgiving God and impeded by a patient's interpretation of HIV infection as punishment. Health-care providers need to recognize patients' spiritual beliefs and incorporate them into discussions about terminal care.

Utilizing national nosocomial infection surveillance system data to improve urinary tract infection rates in three intensive-care units.

OBJECTIVE: To reduce catheter-related urinary tract infection rates in three intensive-care units to at or below the National Nosocomial Infection Surveillance System pooled mean for similar units. DESIGN: A nursing team, physician team, and laboratory team reviewed and revised protocols and procedures for better catheter management. SETTING: A 500-bed community teaching hospital. INTERVENTIONS: The teams developed medical indications for urinary catheter placement and criteria that allowed the registered nurse to remove a catheter without a physician's order when no longer medically necessary. They created a computer prompt to assure a urinalysis accompanied all urine cultures. RESULTS: After introducing the new protocols, the incidence density of catheter-related urinary tract infections fell 17% in the surgical intensive-care unit, 29% in the medical intensive-care acute unit, and 45% in the coronary intensive-care acute unit. The registered nurses' compliance in removing the catheter per protocol was 88%. Physician ordering of a concomitant urinalysis with each urine culture achieved 93%. CONCLUSIONS: A multidisciplinary approach assisted in reducing catheter-associated urinary tract infections in three intensive-care units, although not to the extent desired. The teams are investigating preconnected and antimicrobial-coated catheters further.

A case-control study of maternal knowledge of malnutrition and health-care-seeking attitudes in rural South India.

INTRODUCTION: In India, approximately 20 percent of children under the age of four suffer from severe malnutrition, while half of all the children suffer from undernutrition. The contributions of knowledge and attitudes of nutrition-conscious behaviors of the mothers to childhood malnutrition has been unclear. The purpose of this study was to explore maternal knowledge of the causes of malnutrition, health-care-seeking attitudes and socioeconomic risk factors in relation to children's nutritional status in rural south India. METHODS: A case-controlled study was conducted in a rural area in Tamil Nadu, India. Thirty-four cases and 34 controls were selected from the population of approximately 97,000 by using the local hospital's list of young children. A case was defined as a mother of a severely malnourished child under four years of age. Severe malnutrition was defined as having less than 60 percent of expected median weight-for-age. A control had a well-nourished child and was matched by the location and the age of the child. Interviews obtained: (1) socioeconomic information on the family, (2) knowledge of the cause of malnutrition and (3) health-care-seeking attitudes for common childhood illnesses, including malnutrition. RESULTS: Poor nutritional status was associated with socioeconomic variables such as sex of the child and father's occupation. Female gender (OR = 3.44, p = .02) and father's occupation as a laborer (OR = 2.98, p = .05) were significant risk factors for severe malnutrition. The two groups showed a significant difference in nutrition-related knowledge of mild mixed malnutrition (OR = 2.62, p = .05). No significant difference was apparent in health-care-seeking attitudes. Based on their traditional beliefs, the mothers did not believe that medical care was an appropriate intervention for childhood illnesses such as malnutrition or measles. DISCUSSION: The results suggested that the gender of the child and socioeconomic factors were stronger risk factors for malnutrition than health-care availability and health-care-seeking attitudes. The father's occupation was a more accurate indicator for malnutrition than household income. These results suggest a need for intensive nutritional programs targeted toward poor female children and their mothers.

PIP: The contribution of maternal nutritional knowledge and attitudes to children's nutritional status was investigated in a case-control study conducted in a rural area in Tamil Nadu, India. 34 cases (mothers of a severely malnourished child under 4 years of age) and 34 controls (mothers of a well-nourished age- and location-matched child) were selected from the Christian Medical Center and Hospital registry. The 68 mothers interviewed were predominantly young (mean age, 25 years), poor, and illiterate (67.6%). Severe malnutrition, defined as less than 60% of expected weight-for-age, was significantly associated with female gender (odds ratio (OR), 3.44) and father's occupation as a laborer (OR, 2.98), as opposed to a civil servant or private sector professional. Knowledge of the role of lack of food or nutrition in mild marasmus-kwashiorkor mixed malnutrition was significantly higher among controls (59%) than cases (35%), but there were no significant differences in health-seeking behaviors. In general, mothers from this area did not regard medical care as an appropriate intervention for malnutrition or measles. Only 28% of mothers indicated they would seek medical care for malnutrition. Conversely, medical care was considered indicated for diarrhea, colds, and worms. These findings indicate a need for intensive nutritional programs targeted toward the families of low-income female children.

The burn camp experience: variables that influence the enhancement of self-esteem.

Since 1982, there have been summer camps for children and adolescent burn survivors. Although the primary focus of camp is to have "fun," the principal goal is psychosocial readjustment through peer interactions and the resulting enhancement of self-esteem (SE). This study was initiated to test the hypothesis that the burn camp experience enhances the SE of campers. Forty-three campers at the Connecticut Burns Care Foundation Summer Camp were invited to participate in this study with the Rosenberg Self-Esteem Scale. The age range was 8 to 18 years (mean 12 years). The extent of previous burn injury ranged from 10% to 98% total body surface area (mean 40%). The interval between hospital discharge and camp experience was 4 to 144 months (mean 54 months). Thirty-seven percent of the children demonstrated an increase in SE to varying degrees, whereas 30% showed no change, and 3% exhibited a decrease in SE. This study failed to support the working hypothesis.

Depression in former school-age mothers and community comparison subjects.

This paper examines the lifetime prevalence and correlates of major depressive disorder in a cohort of former school-age mothers and compares the prevalence and correlates to those found in women of the same age, ethnicity, and geographical location as the school-age mothers. The sociodemographic characteristics show some striking differences. The former young mothers were less likely to be on public assistance (19% vs 42%), but were more likely to be working (78% vs. 55%), to have completed high school or college and to meet the DSM-III criteria for depression (10.7% vs. 4.9%) than the sample of community women. The only factor related to depression in the former school-age mothers was a diagnosis of drug/alcohol abuse or dependence.

Rainbow reviews. VII: Recent publications of the National Center for Health Statistics.

In this article, selected recent publications of the National Center for Health Statistics (NCHS) are reviewed. In particular, data from a recent NCHS report on hearing loss were found to be consistent with a prediction made in a preview article in this series that there would be an increase in high-tone hearing loss among persons who were exposed to loud music as teenagers and young adults, beginning in the late 1960s, although the data were not specific enough to be considered proof. In addition, the article discusses: (1) recent data on home health care, (2) new insights on how people remember and report on preventive examinations and tests, (3) a comparison of vital statistics in the United States and the Russian Federation, and (4) trends in births to unmarried women.

PTSD symptoms in urban adolescent girls: compounded community trauma.

OBJECTIVE: To describe the assessments for exposure to violent events and posttraumatic stress disorder (PTSD) symptoms in a population of urban adolescent girls. METHOD: Seventy-nine urban adolescent girls attending an adolescent medicine clinic were assessed via clinician-assisted self-report measures called the Adolescent Self-Report Trauma Questionnaire. The questionnaire gathered information on demographics, exposure to community and domestic violent events, and PTSD symptoms. RESULTS: The adolescents experienced between 8 and 55 different types of community and domestic violent events, with the mean number of violent events being 28. Hyperarousal cluster symptoms were present in 90%, reexperiencing clusters symptoms in 89%, and avoidance cluster symptoms in 80%, while 67% met symptom criteria for PTSD. Increased number of types of violent events was positively correlated with meeting PTSD criteria (p = .01) and with increased PTSD severity scores (p = .001). CONCLUSIONS: These urban adolescent girls have experienced prolonged and repeated exposure to multiple types of community as well as domestic violent events, via multiple modalities of contact, over time. They reported a high percentage of PTSD symptoms across all three symptom clusters. The authors propose the concept of "compounded community trauma" and discuss its marked impact on female adolescent development.

Assessing the value of a short-term residential drug treatment program for homeless men.

Cocaine and other substance abuse has been found to be a contributing or primary cause of homelessness in urban men. This project evaluated the effectiveness of the Grant Street Partnership (GSP), a shelter-based treatment program for homeless, cocaine-abusing men, consisting of 90 days of residential treatment and 6 months of aftercare. We tested the hypothesis that the 182 men randomized to the GSP group, as compared to the 112 men randomized to a "usual services" group, would show significantly greater improvement over time in the areas of drug use and residential and economic stability. An 80% response rate was achieved overall for the five follow-up points. Cocaine use, defined as use of cocaine at least once in the prior 30 days, declined from about 90% at baseline for both groups to 11% in the GSP group and 55% in the control group at 21 months. The GSP group was also more likely than the usual services group to have achieved residential stability by the time of the 9 month follow-up. Neither group experienced an improvement over time in employment status.

Thyroid lymphoma. The case for combined modality therapy.

BACKGROUND: Radiation therapy with or without surgery is generally considered standard treatment for lymphoma of the thyroid. Because of the small number of cases, the role of chemotherapy or combined modality treatment is difficult to determine. METHODS: The published literature was analyzed, supplemented by a series from Yale, for the incidence of local and distant relapse after radiation therapy, chemotherapy, or combined modality treatment for Stage I-II thyroid lymphoma. Patients with advanced disease or in whom radiation was probably inadequate were excluded. Only patients receiving an anthracyline-based regimen were considered in the group with chemotherapy. Patients receiving single agents or non-anthracycline-based regimens were excluded from analysis or, if they also received radiation, were included in the group that received radiation only. RESULTS: Including a series from Yale, a total of 211 patients with Stage IE and IIE thyroid lymphoma were identified. Distant and overall relapse rate were significantly lower in the group that received combined modality treatment. Local relapse was also less, but the difference was not statistically significant. In a small number of patients with disease confined to the neck, the results with radiation were similar to combined modality treatment if the mediastinum was included in the treatment port. CONCLUSION: Although mucosa-associated lymphoma tissue lymphomas are thought to have a low distant recurrence rate and are therefore often treated with local therapy alone, a review of the published literature suggests that 30% of thyroid lymphomas with clinically localized disease will have a distant relapse. The addition of chemotherapy to radiation significantly lowered distant and overall recurrence.

Variations in maximum amplitude of facial expressions between and within normal subjects.

Definitive proof of efficacy of preventions and therapeutic interventions, and of risk factors in lower motor neuron facial paralyses continue to be confounded by the lack of repeatable quantitative measures of outcome. Clinical and research experience with human facial expression repeatedly demonstrates wide variations between subjects. To our knowledge, little information is available to isolate and describe the differences in dynamic facial expression between and within normal subjects. The purpose of this study is to use a statistical model to analyze the components of the observed variations of maximum amplitude measurement of image change during normal human subject facial expressions. Seventeen consecutive normal adult human subjects with no current or past evidence of facial nerve or ear disease were studied. Videotapes of command facial expressions were taken using specific and standardized conditions. The tapes were analyzed using a new computer-assisted image-change analysis program capable of generating dimensional data for the maximum amplitude of expression. These data were statistically analyzed using a General Linear Model with Nested variables to isolate and define component variations and errors. The General Linear Model predicted 88% of the observed total variation (p < 0.05).* A model performance this high suggests that most of the important independent variables were being studied. The major component of the variations was the difference among (between) subjects. Seventy-seven percent of the predicted variation was due to this difference (p < 0.05). Little of the variation (1%) seemed to be within-subjects. Test-retest agreement was acceptable.(ABSTRACT TRUNCATED AT 250 WORDS)