The management of patients with attention-deficit hyperactivity disorder by family practitioners.

BACKGROUND: The objective of this study was to describe the practices of family practitioners in Missouri in the treatment of patients with ADHD. METHOD: The 634 Diplomats of the American Board of Family Practice of Missouri were surveyed. RESULTS: Respondents considered stimulant medication to be effective treatment for ADHD; methylphenidate was the drug of choice. Most respondents (79%) reported recommending behavioral management to parents. Reported efficacy of stimulants (item 2) and use of behavior management (item 8) were related in the negative direction, while reported efficacy of stimulants and using stimulants alone (item 13) were related in the positive direction. CONCLUSIONS: Family practitioners in Missouri used accepted treatments for ADHD, but in general, practices were not entirely consistent with the current standard of care. Physicians' belief in the efficacy of stimulants may have prejudiced them against multimodal treatment.

Resident partnerships: a tool for enhancing ambulatory training.

BACKGROUND AND OBJECTIVES: This study examined resident partnerships and their effect on graduates' practice patterns. METHODS: The study authors surveyed graduates from a residency program that used resident partnerships. We also surveyed the graduates' current practice partners, and they served as a comparison group. RESULTS: The graduates' response rate was 86%, and their current practice partners' response rate was 61%. Graduates from a partnership program rated themselves better trained for outpatient medicine and more comfortable communicating with other physicians and working within a patient care team; they were also slightly less likely to practice inpatient medicine. Reported benefits during residency included enhanced availability for continuity clinics, more emotional and intellectual support, and more flexible work schedules. CONCLUSIONS: Graduates valued partnerships during their training and reported being better prepared to work with other physicians in ambulatory settings.

Resident partnerships: an effective strategy for training in primary care.

BACKGROUND AND OBJECTIVES: To facilitate resident training in the ambulatory setting, a few family practice residency programs use a partnership system to train residents. Partnerships are pairs of residents from the same year that rotate together on inpatient services. We identified and characterized the advantages and disadvantages of partnership programs in family practice residencies. METHODS: We conducted a national survey of family practice residencies, followed by phone interviews with residency directors of programs with partnerships. RESULTS: A total of 305 of 407 (75%) residencies responded; 10 programs fit our definition of partnership. Program directors were positive about resident partnerships. Benefits included improved outpatient continuity, enhanced medical communication skills, and emotional and intellectual support. Disadvantages were decreased inpatient exposure and difficulty coordinating residents' schedules. CONCLUSIONS: Directors were favorable about partnerships, which seem to be an underutilized technique to improve residency training.

Skeletal muscle extra-aortic counterpulsation in dogs with dilated cardiomyopathy.

Skeletal muscle extra-aortic counterpulsation was performed in seven dogs with dilated cardiomyopathy. A left latissimus dorsi dynamic descending thoracic aortomyoplasty was used as the autologous counterpulsator. Pulse train stimulation in diastole was used to initiate contraction and fibre type transformation. Two of the dogs died within 48 hours of surgery. The device was successfully activated in the five remaining dogs, but in one individual it failed within 48 hours of activation. Serial echocardiographic examinations of dogs in which the device functioned successfully (n = 4) showed trends towards the decrease in the left ventricular systolic internal dimension, left ventricular diastolic internal dimension, E-point to septal separation and left atrial diameter in systole seven to 14 days following the procedure, although these changes failed to persist in the long-term. The results suggest that skeletal muscle for cardiac assistances such as extra-aortic muscle counterpulsation, might be a therapeutic option for dogs with cardiac failure due to dilated cardiomyopathy.

Rural hospital closures and access to services.

This article examines the implications resulting from the closure of 25 rural hospitals during 1990. The implications are evaluated by estimating travel distance and time to the nearest open hospitals. In addition, the types of services offered in the hospitals studied were measured to provide a view of potential change in access to services. The average travel distance and time to the nearest hospital after closure was 25.7 miles and 30.2 minutes, respectively. In most cases, the remaining hospitals offered a broader scope of services than did the hospitals that closed. A possible interpretation is that the hospital closures resulted in a tradeoff between breadth of services and rapid access for emergency conditions.

Market shares for rural inpatient surgical services: where does the buck stop?

Utilization of surgical services by rural citizens is poorly understood, and few data are available about rural hospitals' surgical market shares and their financial implications. Understanding these issues is particularly important in an era of financially stressed rural hospitals. In this study information about rural surgical providers and services was obtained through telephone interviews with administrators at Washington state's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data were used to measure market shares and billed charges for rural surgical services. ZIP codes were used to assign rural residents to a hospital service area (HSA) of the nearest hospital, providing the geographic basis for market share calculations. "Total hospital expenses" from the American Hospital Association Guide were used as a proxy for hospital budget, and the surgical financial contribution was expressed as a ratio of billed surgical charges to total hospital expense. For rural hospitals as a whole, 21 percent of admissions and 43 percent of billed inpatient charges resulted from surgical services. In 1989, 27,202 rural Washington residents were hospitalized for surgery. Overall, 42 percent went to the closest rural hospital, 14 percent went to other rural hospitals, and 44 percent went to urban hospitals. The presence of surgical providers markedly increased local market shares, but a substantial proportion of basic surgical procedures bypassed available local services in favor of urban hospitals. For example, about one-third of patients needing cholecystectomies, a basic general surgery of low complexity, bypassed local hospitals with staff surgeons.(ABSTRACT TRUNCATED AT 250 WORDS)

Rural hospital inpatient surgical volume: cutting-edge service or operating on the margin?

Surgical services are an important part of modern health care, but providing them to isolated rural citizens is especially difficult. Public policy initiatives could influence the supply, training, and distribution of surgeons, much as they have for rural primary care providers. However, so little is known about the proper distribution of surgeons, their contribution to rural health care, and the safety of rural surgery that policy cannot be shaped with confidence. This study examined the volume and complexity of inpatient surgery in rural Washington state as a first step toward a better understanding of the current status of rural surgical services. Information about rural surgical providers was obtained through telephone interviews with administrators at Washington's 42 rural hospitals. The Washington State Department of Health's Commission Hospital Abstract Recording System (CHARS) data provided a count of the annual surgical admissions at rural hospitals. Diagnosis-related group (DRG) weights were used to measure complexity of rural surgical cases. Surgical volume varied greatly among hospitals, even among those with a similar mix of surgical providers. Many hospitals provided a limited set of basic surgical services, while some performed more complex procedures. None of these rural hospitals could be considered high volume when compared to volumes at Seattle hospitals or to research reference criteria that have assessed volume-outcome relationships for surgical procedures. Several hospitals had very low volumes for some complex procedures, raising a question about the safety of performing them. The leaders of small rural hospitals must recognize not only the fiscal and service benefits of surgical services--and these are considerable--but also the potentially adverse effect of low surgical volume on patient outcomes. Policies that encourage the proper training and distribution of surgeons, the retention of basic rural surgical services, and the rational regionalization of complex surgery are likely to enhance the convenience and safety of surgery for rural citizens.

Tangible assistance: a simple measure of social support predicts pregnancy outcome.

The association between tangible assistance, a single-item measure of social support, and serious perinatal complications was prospectively measured in 548 rural pregnant women. Those 38 women who reported no or one reliable helper in the third trimester (low tangible assistance) had a higher rate of poor outcomes (at least one of the following: neonatal death, transfer to neonatal intensive care unit, birthweight less than 2500 g or 5-min Apgar score less than 7) than those with 2 or more helpers (13.2% vs. 5.7%, p = 0.08). All of the increase in poor outcomes occurred in women with high sociodemographic risk (at least one of the following: age less than 18, no male partner, or less than high school education). In this subgroup of 121 women, the difference in poor perinatal outcomes was striking (28.6% vs. 7.6%, p = 0.03). The association between tangible assistance and poor outcome remained after controlling for biomedical risk. A simple question about the availability of supportive companions may be clinically useful.

Physician staffing of small rural hospital emergency departments: rapid change and escalating cost.

We surveyed all 37 rural Washington state hospitals with fewer than 100 beds to determine how rural emergency departments are staffed by physicians and to estimate rural hospital payments for emergency department physician services. Only five hospital emergency departments (14%) were still covered by the traditional rotation of local practitioners and billed on a fee-for-service basis. Ten hospitals (27%) paid local private practitioners to provide emergency department coverage. Twelve other hospitals (32%) hired visiting emergency department physicians to cover only weekends or evenings. The remaining 10 rural emergency departments (27%) were staffed entirely by external contract physicians. Thus, 86 percent of rural hospitals contracted for emergency department coverage, and 59 percent obtained some or all of this service from nonlocal physicians. Most of the 32 hospitals with some form of contracted services have changed to this emergency department coverage in the last few years. The cost of these services is high, particularly for the smallest hospitals that have fewer than eight emergency department visits per day and pay physician wages of nearly $100 per patient visit. Emergency staffing responsibility has shifted from local practitioners to the hospital administrators because of rural physician scarcity and a desire to improve quality and convenience. The cost of these changes may further undermine the economic viability of the smaller rural hospitals.

Lack of seasonal variability for recurrent otitis media in very young children.

BACKGROUND: Effective strategies are available to prevent recurrent otitis media (ROM). Because epidemiologic studies have demonstrated marked seasonal variation in acute otitis media (AOM), clinical guidelines often recommend cessation of prophylactic measures during the summer. Unfortunately, those studies did not separately assess seasonal variation in children with ROM, the group most likely to benefit from preventive measures. METHODS: The charts of 648 children who had at least one diagnosis of AOM were reviewed to count AOM rates by calendar month and age. Children with at least three infections in a 6-month period were assigned to a ROM group and analyzed separately. Seasonal variability was statistically assessed using the ranked-sums method of Hewitt. RESULTS: The criterion for ROM was met by 176 children (27%), who had 1096 episodes of AOM and accounted for 52% of all infections. In the ROM group, the monthly infection rate remained above 10% for the first 2 years of life. There was no seasonal variation in the ROM group under 1 year of age. The recurrence risk for those who met the ROM criterion was very high: first month, 32%; second month, 30%; third month, 22%; fourth month, 20%. CONCLUSIONS: The youngest otitis-prone children show a high rate of infection in the summer months and a very high rate of recurrence. In these children, decisions about beginning or continuing preventive measures should not be influenced by the season of the year.

Development of an opiate-based anaesthetic technique for use in dogs with cardiomyopathy.

An opiate-based anaesthetic technique has been developed for use in dogs with end-stage heart failure due to dilated cardiomyopathy. It has been used in dogs undergoing translocation of the left latissimus dorsi around the descending thoracic aorta to create an autologous counterpulsation system. Anaesthesia was induced with barbiturate (10 mg/kg thiopentone) and fentanyl (500 micrograms) and maintained by an infusion of fentanyl (0.5 micrograms/kg/minute) [corrected] in addition to halothane (0.1 to 0.5 per cent) and nitrous oxide (20 to 60 per cent). This technique provided safe anaesthesia for major intrathoracic surgery.

The prevalence of Mycoplasma pneumoniae in ambulatory patients with nonstreptococcal sore throat.

Several studies have implicated Mycoplasma pneumoniae as an important cause of nonstreptococcal pharyngitis in certain clinical settings. This study was performed to determine the prevalence of M. pneumoniae infection in family practice patients with sore throats and to identify patient characteristics predictive of this infection. M. pneumoniae throat cultures were obtained from 419 patients aged five years or older who were seen in one of four family practice offices with a complaint of sore throat. The overall prevalence of M. pneumoniae infection was 13%. It was characterized by more frequent hoarseness and less frequent complaint of postnasal drip when compared with other nonstreptococcal infections. Compared to patients with streptococcal pharyngitis, M. pneumoniae patients revealed a strikingly dissimilar clinical presentation. In particular, while pharyngitis is predictive of streptococcal infections, its presence did not predict M. pneumoniae infection. Recently developed rapid office-based tests for M. pneumoniae may allow timely diagnosis of this common and formerly elusive pathogen. Further study is required to validate the utility of such methods and to evaluate the efficacy of treatment.

The use of lignocaine-prilocaine local anaesthetic cream for pain-free venepuncture in laboratory animals.

An assessment was made of the effects of topical application of a eutectic mixture of local anaesthetics (EMLA cream) in a number of species of laboratory animals. Application of EMLA cream enabled percutaneous insertion of catheters into the cephalic vein in dogs and cats and the marginal ear vein in rabbits without causing any detectable pain or discomfort. Application to the tail in rats prior to percutaneous cannulation of the lateral tail vein did not produce a significant reduction in the behavioural responses to venepuncture. EMLA cream represents a useful refinement of current techniques for intravenous injection in some species, and is especially valuable when the procedure is to be undertaken by an inexperienced operator.

Obstetric care in rural Missouri: the loss of rural general and family practitioners.

Family and general practitioners have historically provided a substantial portion of obstetric care in rural parts of the United States, including Missouri. The authors surveyed 328 rural general physicians to determine their participation in obstetrics. Their findings show a dramatic loss of physician obstetric services in rural Missouri and suggest that the dilemma is not likely to be easily remedied.

Association between life stress and serious perinatal complications.

The association between stressful life changes, social supports, and serious complications of pregnancy was measured in 513 women obtaining prenatal care in four rural family practices. Those women whose life change score (LCS) increased from the second to the third trimester had a significantly higher rate of poor outcomes (neonatal death, transfer to a neonatal intensive care unit, birthweight less than 2500 g or 5-minute Apgar score less than 7) than those whose LCS did not increase (9.2% vs 3.9%, P = .015). This effect of increasing stress was present even after controlling for demographic and standard obstetric risk factors. High life change scores at 20 weeks' gestation and 34 weeks' gestation were not individually associated with poor outcomes. Those with low social support did not have a statistically significant higher rate of complications, and social support did not buffer the adverse effects of increasing stress. This study shows that serious and clinically important complications of pregnancy are related to stressful life change independent of biomedical risk.

Clinical and demographic factors associated with high levels of depression symptoms.

Beck Depression Inventory (BDI) scores were analyzed from 427 consecutive, nonpregnant, adult family medicine patients to delimit demographic and clinical parameters which would predict high levels of depression symptoms. BDI scores at or above the chosen cutoff score of 17 were present in 51 patients (12%). Unemployment, less than high school education, high usage of inpatient and outpatient services, complaints of nervousness or of a functional nature, and chronic illness were shown by univariate and multiple regression analyses to be associated with BDI scores in the depressed range. Nearly half of patients with certain combinations of risk factors (eg, less than high school education and functional complaint) scored in the depressed range. The reason for the visit, as stated by the patient, only rarely provided a reason to suspect depression. Whether or not clinicians decide to use a depression screening test, the presence of these demographic and clinical factors should prompt a search for depression. Educational efforts to improve recognition of depression in primary care should focus on awareness of clinical and demographic factors rather than on stereotypic, but rare presentations of depression.

Activities of the attending physician in the ambulatory setting: what part is teaching?

The attending physician is a valuable resource in the ambulatory care teaching setting. To describe the nature of attending physician activities, seven faculty physicians were observed during 214 three-hour clinic sessions at two sites of a family medicine training program. Only 53% of attending physician time involved clinical teaching activities, with only half of this portion spent in consultation with or seeing the patients of trainees. The patient volume of the clinic session did not affect total time spent in consultation, but the rate at which trainees consulted attending physicians decreased during busier sessions. This study represents a first step toward understanding the educational, organizational, and economic implications of attending physician activities in the ambulatory setting.