Metabolic aspects of myocardial disease and a role for L-carnitine in the treatment of childhood cardiomyopathy.

OBJECTIVES: A multicenter retrospective study was conducted to investigate the possible metabolic causes of pediatric cardiomyopathy and evaluate the outcome of patients treated with L-carnitine. METHODS: Seventy-six patients diagnosed with cardiomyopathy were treated with L-carnitine in addition to conventional cardiac treatment, and 145 patients were treated with conventional treatment only. There were 101 males and 120 females between 1 day and 18 years old. Cardiomyopathy diagnoses included dilated (148 patients), hypertrophic (42 patients), restrictive (16 patients), mixed diagnosis (11 patients), and 4 with an unknown type. Of 76 L-carnitine-treated patients, 29 (38%) had evidence to suggest a disorder of metabolism, and of 145 control patients, 15 (10%) were suspected to have a disorder of metabolism. These metabolic disorders were thought to be the cause for the cardiomyopathy of the patients. The duration of L-carnitine treatment ranged from 2 weeks to >1 year. Information was collected on length of survival (time-to-event), clinical outcome, echocardiogram parameters, and clinical assessments. Data were collected at intervals from baseline to study endpoint, death, transplant, or last known follow-up visit. RESULTS: L-Carnitine-treated patients were younger than control patients and had poorer clinical functioning at baseline, yet they demonstrated lower mortality and a level of clinical functioning and clinical severity comparable to control patients on conventional therapy by the end of the study. An analysis of the interaction between clinical outcome and concomitant medications unexpectedly revealed that the population of patients treated with angiotensin-converting enzyme (ACE) inhibitors (40% of patients) had significantly poorer survival (although their greater likelihood for poor survival may possibly have made them more likely to receive ACE inhibitors). CONCLUSION: Results suggest that L-carnitine provides clinical benefit in treating pediatric cardiomyopathy. There is a need for further exploration of potential explanatory factors for the higher mortality observed in the population of patients treated with ACE inhibitors.

Variation in hospital charges for total joint arthroplasty: an investigation of physician efficiency.

Total joint arthroplasty is a common procedure for which consistent, clinically satisfactory outcomes are expected. Data from 796 total joint procedures performed by 20 surgeons at one center were evaluated to identify sources of variability in costs (as measured by hospital charges) where clinical outcome is expected to remain constant. Stepwise multivariate regression characterized the contribution of six variables to hospital charges listed in order of explanatory power: postoperative length of stay, surgical time, patient preoperative morbidity, units of blood transfused, perioperative complications, and procedure type (hip or knee) accounted for 46% of variability in hospital charges (multiple R2). In a subsequent analysis, after statistical adjustment for preoperative comorbid diagnoses, the sampling distribution of mean values for surgical time, total units of blood transfused, and total hospital charges were summarized and compared among surgeons. Despite adjustment for comorbid diagnoses, substantial variation and significant differences remained between surgeons in markers of resource utilization and "surgical efficiency." These findings suggest there is substantial variability in hospital charges not attributable to patient characteristics or category of procedure--a distinct and economically significant portion of this variability is practitioner specific.

Effect of an educational program on medical students' conversations with patients about advance directives: a randomized trial.

Advance directives, such as the durable power of attorney for health care (DPAHC), help patients and physicians make end-of-life health care decisions. Medical education should prepare student physicians to be knowledgeable about and comfortable with discussing advance directives. The authors developed an educational module for the third-year medical school curriculum and conducted a randomized trial to evaluate in students its effect on various outcome measures regarding the DPAHC. Over a six-week period, students who received written material about the DPAHC and a two-hour seminar significantly increased knowledge about and reported increased skill, comfort, and experience with the DPAHC.

Demographic differences in health status of homeless adults.

OBJECTIVE: To determine how the physical health of homeless adults varies by the demographic characteristics of age, gender, ethnicity, lifetime length of homelessness, and work status. PARTICIPANTS: A community-based sample of 529 homeless adults. STUDY DESIGN: In multivariate analyses, the authors studied the independent contributions of five demographic groups to variations in 12 physical health measures (based on self-reports from face-to-face interviews, screening physical examinations, and venous blood samples). MEASUREMENTS AND MAIN RESULTS: Older persons were more likely to have a functional disability (p < 0.001), chronic disease (p < 0.001), and greater risk of dying (p < 0.001), but less likely to abuse substances (p < 0.001). Men were more likely than women to be substance users (p < 0.001) and to have a greater risk of dying (p < 0.001). Whites and blacks were less likely than respondents in other ethnic groups to have an abnormal blood test (p < 0.001). Persons homeless longer were more likely to be substance users (p < 0.001) and to have experienced trauma (p < 0.001). Working for pay was not related to any of our health measures. CONCLUSIONS: Age and gender contributed most to the understanding of differences in health status among homeless adults. Since the homeless have a wide variety of physical, mental, social, and substance-abuse problems, primary care providers are in the best position to provide the broad-based care needed by such persons.

Reduction of high-risk sexual behavior among heterosexuals undergoing HIV antibody testing: a randomized clinical trial.

BACKGROUND: We evaluated the effect of HIV antibody testing on sexual behavior and communication with sexual partners about AIDS risk among heterosexual adults at a clinic for sexually transmitted diseases. METHODS: We randomized 186 subjects to receive either AIDS education alone (the control group) or AIDS education, an HIV antibody test, and the test results (the intervention group). These subjects were then followed up 8 weeks later. RESULTS: At follow-up, mean number of sexual partners decreased, but not differently between groups. However, compared with controls, HIV antibody test intervention subjects, all of whom tested negative, questioned their most recent sexual partner more about HIV antibody status (P less than 0.01), worried more about getting AIDS (P less than 0.03), and tended to use a condom more often with their last sexual partner (P = 0.05): 40% of intervention subjects vs 20% of controls used condoms, avoided genital intercourse, or knew their last partner had a negative HIV antibody test (P less than 0.005). CONCLUSION: HIV antibody testing combined with AIDS education increases concern about HIV and, at least in the short term, may promote safer sexual behaviors. Additional strategies will be necessary if behaviors risky for HIV transmission are to be further reduced.

The effect of valproic acid on plasma carnitine levels.

Plasma total, free, and acyl carnitine levels were determined in four groups of children: (1) those treated with valproic acid as monotherapy (n = 43), (2) those treated with valproic acid plus other antiepileptics as polytherapy (n = 91), (3) those treated with other antiepileptic drugs alone (n = 43), and (4) normal patients (n = 89). The mean free carnitine level was significantly lower in both the valproic acid monotherapy (29.9 mumol/L) and polytherapy (21.4 mumol/L) groups compared with normal subjects (36.8 mumol/L); it was also significantly lower than that in patients treated with other antiepileptic drugs (36.7 mumol/L). Comparison of valproic acid polytherapy and monotherapy yielded significantly lower free carnitine levels in the polytherapy group. The ratios of acyl to free carnitine for monotherapy (0.41) and polytherapy (0.45) were significantly higher than that in the normal group (0.25). This study indicates that a general decrease in the carnitine pool should be anticipated in patients taking valproic acid polytherapy and, to a lesser degree, monotherapy. Carnitine levels in the group taking other drugs did not differ from normal.

Characteristics of journal clubs in psychiatric training.

We surveyed the membership of the American Association of Directors of Psychiatric Residency Training (AADPRT) regarding the presence and characteristics of journal clubs in their general and child psychiatry residency training programs. Responses were obtained from 141 general residency programs and 76 child psychiatry programs. Eighty-six percent (N=180) offered at least one required and/or voluntary journal club, and many offered multiple journal clubs. Higher effectiveness ratings were associated with journal clubs that had mandatory participation, met frequently, were held in a convenient location, reviewed articles on original research, emphasized and taught research methods, and had regular faculty participation. Higher attendance ratings were associated with daytime meetings, smaller residency programs, required clubs, clubs that met more often and for shorter lengths of time within the hospital, and clubs that show continuity in faculty participation. Descriptions of various formats and inducements reported may be useful to other programs wishing to establish or improve journal clubs.

Health, homelessness, and poverty. A study of clinic users.

When seeking medical care, homeless persons often turn to health centers that were designed to treat the poor who have homes. To provide for effective medical care, personnel in such facilities need to know how the health care needs of the homeless are different from those of other clinic users. To compare the physical health of these two groups, we conducted a health survey and screening physical examination of 464 patients who attended the general adult and homeless clinic sessions of one of the main neighborhood health centers in Los Angeles County, California. As compared with the poor who have homes, homeless persons were more likely to have dermatological problems (32% vs 21%), functional limitations (median, 2 vs 0 per person), seizures (14% vs 6%), chronic obstructive pulmonary disease (21% vs 12%), social isolation, serious vision problems (22% vs 12%), foot pain, and grossly decayed teeth (median, 1 vs 0 per person). We conclude that to care more optimally for homeless adults, health centers must pay attention to their functional disabilities, substance abuse, skin abnormalities, vision impairment, dental problems, and foot problems.

Differences in health status between older and younger homeless adults.

The Institute of Medicine has placed a priority on determining the special health-care needs of elderly homeless persons. As part of a community-based study of 521 homeless adults in two beach communities of Los Angeles, we compared the demographic characteristics and health of older (age rangek 50-78, n = 61) and younger (age range, 18-49, n = 460) homeless individuals. Compared with younger adults, older adults were more likely to be white (85% versus 61%), veterans (59% versus 27%), retired (36% versus 3%), and living in a vehicle (21% versus 8%). Older adults were more likely to report having a chronic disease (69% versus 49%), functional disabilities, no informal social contacts during the previous month (49% versus 27%), observed high blood pressure (42% versus 22%), elevated creatinine (11% versus 2%), and elevated cholesterol (57% versus 36%). Older adults were less likely to have a toothache (3% versus 30%), report psychotic symptoms (25% versus 42%), and to be illegal drug users (15% versus 55%). Although they are chronologically younger, the constellation of health and functional problems of older homeless adults resemble those of geriatric persons in the general population. We suggest that geriatricians could play a significant role in training other primary-care providers to evaluate and treat socially isolated older homeless adults in a more comprehensive way than is currently standard in practice (e.g., interdisciplinary team care and emphasis on functional status, rehabilitative medicine, and assessment for sensory impairment).

Physician satisfaction under the Ontario Health Insurance Plan.

To determine the level of professional satisfaction experienced by physicians practicing in Ontario, Canada, a probability sample of 1,028 physicians was surveyed; 69% responded. The majority of Ontario doctors were at least moderately satisfied with each of 16 aspects of their work, and the percentage who were dissatisfied exceeded 15% for only four aspects. Factor analysis suggested the presence of four underlying satisfaction facets: satisfaction with quality of care, with the rewards of practice, with patients, and with the practice environment. Multivariate regression analysis supported the validity of the four-facet model and demonstrated a consistent association between lower satisfaction and younger age, lower income, and the perception that it is difficult to obtain fair reimbursement for medical services (P less than 0.05). Least satisfied physicians were most likely to have participated in the June, 1986 Ontario doctors' strike (P less than 0.001). Despite some misgivings, the majority of physicians practicing under the Ontario Health Insurance Plan in 1987 were satisfied with their professional lives. They were least satisfied with their ability to make administrative decisions and to manipulate the system for the benefit of their patients. Policymakers should be cognizant of the effects various strategies may have upon physician satisfaction as they consider new approaches to health care organization.

Physicians' perceptions about increased glove-wearing in response to risk of HIV infection.

Glove-wearing attitudes of 375 physicians, representing 56% of all physicians surveyed, were ascertained. Although the majority were comfortable with their current glove use, 33% preferred wearing them more frequently. The most common reasons for not wearing gloves were a low likelihood of disease transmission and fear of offending patients. Many physicians felt that more frequent glove use in examining human immunodeficiency virus- (HIV)-positive patients might reduce rapport and diminish the adequacy of physical examination procedures, but only 11% felt that increased glove use would compromise overall care of HIV-positive patients. With regard to all patients, 33% felt that increased glove use in examinations would compromise care. Additionally, 56% of physicians stated that they were somewhat concerned about HIV infection. Glove-wearing preferences were significantly associated with greater concern about infection, a younger age and more frequent exposure to blood and body secretions. Contact with high-risk patient groups was not associated with glove-wearing preferences.

Physicians' attitudes toward substance abuse and drug testing.

Responding to a survey, 303 physicians provided opinions about permissibility of substance use among eight occupational groups, appropriateness of drug-screening programs by employers, and the role of physicians in managing substance abuse problems. The majority felt that neither drugs nor alcohol should be used at lunch by any individuals, but that alcohol and to some degree marijuana use was permissible after work or on weekends. Physicians could not agree about reliability or use of drug-testing programs. However, most believed that employee drug screening was more appropriate after evidence of poor job performance rather than screening all employees or applicants.

Substance abuse and mental health status of homeless and domiciled low-income users of a medical clinic.

Data were collected on indicators of mental health status and substance abuse among 214 homeless and 250 domiciled but impoverished patients who sought care in a community medical clinic in a California beach community. Although both groups had a high prevalence of problems, homeless patients were significantly more likely to have been hospitalized for alcohol or mental problems, to have been arrested because of drinking, and to have experienced delirium tremens. Homeless persons were also more likely to have made a suicide attempt, to have experienced recent psychotic symptoms, and to be dissatisfied with life. The findings suggest that primary medical care settings serving the poor and homeless may present an excellent opportunity for delivering mental health services and that psychiatrists should expand their involvement in such settings.

Professional vs. personal factors related to physicians' attitudes toward drug testing.

Questionnaires concerning attitudes toward alcohol and drug testing in the workplace, personal experiences with these substances, professional experiences in treating abuses, religious and political ideology and other personal and professional characteristics were completed by 303 internists, family physicians, gastroenterologists and psychiatrists. Drug testing was most favored by those who more strongly believed in the efficacy of treatment for abusers, the seriousness of the drug problem, the illegality of drug abuse and that marijuana use should not be permissible. Many other personal but almost no professional characteristics were correlated with attitudes toward drug testing. Physicians' opinions about drug testing strongly reflected personal ideologies rather than medical training or clinical experience.

Recent sexual behaviors among homosexual men seeking primary medical care.

We studied the sociodemographic characteristics, knowledge, and beliefs about acquired immunodeficiency syndrome transmission and sexual practices of 823 gay or bisexual men seeking primary care. During the previous 2 months, 64% had engaged in at least one sexual behavior considered unsafe. These patients compared with those having safer sex, were younger, of lower socioeconomic status, and from a racial minority, especially Latino. The unsafe group also had more sexual partners, engaged in sexual acts more often, felt less in control over their sexual behavior, used recreational drugs more frequently, and were less likely to talk about safe sex with partners. The unsafe group had less adequate knowledge about human immunodeficiency virus transmission but felt safer from the risk of acquired immunodeficiency syndrome even when engaging in unsafe sex. Educational programs dealing more directly with belief systems and the potential addiction to recreational drugs and sexual behaviors need to be developed for primary care settings.

Assessing the physical health of homeless adults.

Information on the physical health of homeless adults is potentially biased either by sampling strategy or by measurement of physical health. Studies that used comprehensive health measures (self-reported and objective measures) relied on samples from shelters or hotels. However, more representative community-based studies relied on self-reports or ratings. We conducted the first study to use both a community-based sample (N = 529) and comprehensive measures of health (an interview, a limited physical examination, and blood testing). Shelter dwellers compared with homeless persons sampled elsewhere were less likely to have used illegal drugs, to have been victimized, to have injured skin, and to have elevated aspartate aminotransferase levels and mean corpuscular volumes. Sixty-two percent of persons observed to have high blood pressure were unaware of their condition. Sampling only shelter dwellers, or relying only on reports of illness by homeless adults, may mask or underestimate existent health problems that are revealed by community-based sampling techniques and more objective measures.

Attitudes toward mental illness prevention in routine pediatric practice.

Attitudes toward preventive mental health activities with high-risk children in clinical practice were surveyed in 316 pediatricians. Although generally positive attitudes were expressed regarding appropriateness and efficacy of such activities, uncertainty was expressed regarding the ethical issues and knowledge on which such activities rest. Pediatricians perceived serious barriers to preventive activities related to financial, educational, and time factors. Pediatricians whose personal health beliefs favored an internal locus of control were more positively inclined toward preventive activities. Studies relating reported attitudes and beliefs to actual practice patterns are necessary. Pediatricians also require additional training in mental health-related preventive activities.

Risk factors associated with participation in the Ontario, Canada doctors' strike.

To identify factors associated with participation in the 1986 Ontario, Canada doctors' strike, we surveyed 1,028 physicians; 69 percent responded, of whom 42 percent participated in the strike. Risk factors for participation included income greater than $135,000, being a surgeon or gynecologist, having previously "opted out" of the Ontario Health Insurance Plan, being professionally dissatisfied, being politically conservative, favoring political activism by physicians, holding a positive view of the social consequences of extrabilling, and perceiving family, associates, patients and the public to favor the strike. Eighty percent of strikers, but 32 percent of non-strikers, met criteria we established for four strike-prone groups: the "economically rational," the "ideologically committed," the "professionally disaffected," and the "socially malleable." Respondents belonging to one or more of these groups were much more likely to have participated in the strike (64 percent vs 17 percent). Strategies to deal with physician militancy should address the multiplicity of motives that appeared to have influenced doctors in Ontario.

Physician attitudes toward the "laying on of hands" during the AIDS epidemic.

Attitudes of 227 faculty and 148 housestaff physicians toward touching patients were studied in relationship to socio-demographic and job characteristics, previous exposure to and concern about HIV infection, and attitudes toward glove-wearing. Although a majority of the physicians felt that touching patients was personally satisfying, facilitated healing, and established rapport, such positive attitudes were more to be likely expressed by the younger physicians and those who worked longer hours, spent more time in primary care, and spent less time teaching. Positive attitudes were also related to less favorable attitudes toward glove-wearing and greater belief that more frequent glove use would have a negative effect on patient care.