Evaluation of a screening interview for restless legs syndrome.

OBJECTIVES: We evaluated a fully structured interview for restless legs syndrome (RLS) for potential use in primary care settings and in epidemiological research. METHODS: Seventy-four veterans were recruited at Veterans Affairs outpatient clinics. The interview was administered telephonically by trained non-clinicians (time 1) and readministered face to face (time 2). A physician conducted gold standard examinations. We calculated sensitivity, specificity and reproducibility. RESULTS: Reproducibility was low (kappa = 0.34, P < 0.01), but was higher for interviews repeated within 1 year (kappa = 0.55, P < 0.01). Including those reporting > or =3 symptoms as cases, sensitivity ranged from 63% (time 1) to 75% (time 2). Specificity ranged from 88% to 71%. CONCLUSIONS: The sensitivity and specificity reported here are lower than previously reported in specialty care. This interview for RLS might be useful for preliminary screening of patients with related complaints if followed by additional diagnostic maneuvers or might be used in observational epidemiological research.

Pregnancy-induced hypertension and duration of sexual cohabitation.

OBJECTIVE: To evaluate the possible association between duration of sexual cohabitation and the risk of pregnancy-induced hypertension (PIH). STUDY DESIGN: A matched case-control design in which each case of PIH was compared with three controls. Information was obtained about use of barrier contraception, duration of intercourse prior to pregnancy and paternity. RESULTS: Sixty-eight cases were included in the study. For primiparous women, a shorter duration of sexual cohabitation without contraception was associated with a small and nonsignificant risk of PIH. For multiparous women, a greater length of time since stopping use of barrier contraception was associated with a greater risk of PIH. CONCLUSION: Advising nulliparous women to prolong the duration of sexual cohabitation prior to conception in an effort to decrease the risk of PIH is not justified, based on the findings of this study.

Correlation of menstrual cycle at time of breast cancer surgery to disease-free and overall survival.

The timing of surgery during the menstrual cycle of premenopausal breast cancer patients was correlated with their disease-free survival (DFS) and overall survival (OS). The study included 150 premenopausal patients treated for breast cancer between 1977 and 1992. The data were analyzed using three different menstrual cycle phase categorization schemes: (1) days 0 to 6 and 21 to 32 vs 7 to 20; (2) days 0 to 2 and 13 to 32 vs 3 to 12; and (3) days 0 to 14 vs 14 to 32. Two different surgery dates used for analysis were biopsy date and definitive surgery date. There was no association of the timing of surgery with OS. Only one categorization scheme correlated with DFS (scheme No. 2), and this correlation was significant using either surgery or biopsy dates. Thus, premenopausal breast cancer patients who have biopsy and/or definitive surgery during their perimenstrual phase (days 0 to 2 or after day 13) of the menstrual cycle may have a longer DFS than patients operated on during their midcycle phase (days 3 to 13); however, this may not affect overall survival.

Survey of the educational roles of the faculty of anatomy departments.

The anatomy dissection laboratory is a unique experience where medical students begin the transition from layman to physician, and may be a student's first experience with death. Attitudes developed there may influence interactions with future patients and their families. Consequently, anatomy faculty are in a position to recognize emotional issues that students may confront and to guide them toward becoming humane physicians. We surveyed anatomy faculty to assess acceptance of this expanded role and their means of meeting these obligations. A spokesperson for the anatomy department at each US and Canadian medical or osteopathic college (n = 142) was surveyed. One hundred three (73%) questionnaires were returned. Respondents overwhelmingly (93% agree or strongly agree) accept an educational role that includes helping students to become caring physicians and dealing with death and dying. Seventy-nine percent agree or strongly agree that the anatomy laboratory can affect students later relationships with patients. Time for laboratory orientation is limited (55%, 1 hour or less) and is used to address technical topics, such as rules for student behavior. Most departments (58%) have four or more memorial activities to acknowledge the contribution of the donors. The anatomy faculty who responded to the survey accept responsibility for acculturating preclinical students to medicine. Respondents identified additional orientation topics and expanded memorial activities to accomplish this goal.

Use of the Centers for Disease Control and Prevention childhood lead poisoning risk questionnaire to predict blood lead elevations in pregnant women.

OBJECTIVE: To assess the accuracy of a questionnaire developed by the Centers for Disease Control and Prevention (CDC), given to pregnant women for identification of children at risk for lead poisoning. METHODS: The study population consisted of all 314 new prenatal patients enrolled in health department clinics in 1990-1992. Lead was measured in venous blood, and patients completed written questionnaires to gather information about lead exposure risk factors. The relationship between elevated maternal blood lead levels (at or greater than 10 micrograms/dL or 0.483 mumol/L) and responses to the CDC questionnaire and other questions were examined using chi 2 statistical analysis. RESULTS: Two hundred ninety-nine women provided responses to questions about lead exposure risk. Thirty-nine women (13%) had elevated blood lead levels. A woman with a positive response to at least one CDC question was more likely to have elevated blood lead than a woman who answered negatively to all four CDC questions (relative risk = 2.39, 95% confidence interval 1.17-4.89; P = .01). Using the CDC definition of high risk ("yes" to at least one question), the questionnaire had a sensitivity of 75.7% and a negative predictive value of 93.1%. A questionnaire that combined housing conditions, smoking status, and high consumption of canned foods had a sensitivity of 89.2% and a negative predictive value of 96.4%. A high prevalence of elevated blood lead in children living with women with elevated blood lead was observed. CONCLUSION: Querying pregnant women about risk factors for lead exposure can aid in assessing prenatal lead exposure risk. The sensitivity and negative predictive value of the CDC questionnaire, when used with high-risk women, are comparable to its reported accuracy in young children.

Identification of obesity: waistlines or weight? Nutrition, Exercise, and Obesity Research Group.

BACKGROUND: Obesity can be divided into "general" and "central." Since abnormal glucose and lipid metabolism are more strongly associated with central obesity, it may not be adequate to use a general measure, such as a weight-for-height index, to assess for obesity. An index of central obesity, such as the waist-to-hip ratio, might be more appropriate. METHODS: Nurses measured height and weight for the body mass index (BMI = kilograms of mass divided by the square of the height in meters) and girths for the waist-to-hip ratio (WHR) in 414 patients aged 45 years and over. Patients completed an obesity-related questionnaire. RESULTS: Fifty-seven percent of patients had an elevated BMI. Fifty percent of men (95% confidence interval [CI], 46 to 55) and 78% of women (95% CI, 75 to 80) had central obesity based on elevated WHRs. Using an elevated WHR as the standard for central obesity, elevated WHR as the standard for central obesity, elevated BMI had a positive predictive value of only 64% and a negative predictive value of 68% in men. For women, the corresponding positive and negative predictive values were 84% and 31%, respectively. CONCLUSIONS: The data indicate that the practice of using only scales to identify "overweight" patients should be reevaluated since doing so will miss patients at risk. In primary care patients, particularly those 50 years of age and over, weight-for-height indices such as the BMI result in underdiagnosis of central obesity.

The cost of laparoscopic versus open cholecystectomy in a community hospital.

This retrospective study reviewed the hospital and professional costs, charges, and reimbursements for laparoscopic cholecystectomy (lap chole) and open cholecystectomy (open chole) and compared the two procedures. There was no significant difference in hospital costs between lap and open chole procedures; however, there were marked differences in the categories of costs for each procedure. The mean total (hospital and professional) charge was 8% greater for lap chole. The mean total (hospital and professional) reimbursement for patients with private insurance was 23% greater for lap chole, but no significant difference was seen for patients on Medicare or Medicaid. Lap chole patients returned to work 11 days sooner than open chole patients; this can result in a 69% decrease in short-term disability costs to employers. The clinical variables that significantly affect total charges and reimbursement are discussed.

Predictors of nonattendance at the first newborn health supervision visit.

Failure to attend the first newborn health supervision visit is an important problem for the Continuity Care Clinic of Children's Hospital Medical Center of Akron, Ohio. The goal of this study was to use objective data from the neonatal record to identify newborns at high risk of failure to attend. Clinical and social risk factors of the mother and newborn were abstracted from the neonatal progress notes of 319 infants. The relative risk (RR) of nonattendance was calculated for each factor, and rules for predicting failure to attend were evaluated. The best predictors were multiparous mother (RR = 2.4, P = .01), no telephone in home (RR = 2.6, P = .002), and unmarried teenage mother (RR = 5.8, P = .05). Newborns who had a medical problem and had a adult mother were more likely to attend (RR = 0.4, P = .02). These risk factors were easily identifiable from the medical record at birth. Because interventions may be labor-intensive, it is important to target the families at the highest risk.

Serum potassium concentrations in trauma patients.

Hypokalemia occurs in 50% to 68% of trauma patients. To investigate the pathophysiology of these changes in serum potassium, we prospectively studied 133 trauma patients. Among the patients who had hypokalemia, the serum potassium usually decreased within 1 hour of trauma and returned to normal within 24 hours without significant potassium replacement. In bivariant analysis, age, admission systolic blood pressure, cardiac injury, and serum epinephrine level were associated with admission serum potassium value (K1), whereas sex, mechanism of injury, number of organ systems injured, blood glucose, serum alcohol, arterial pH, Injury Severity Score, trauma score, estimated blood loss, and urine potassium were not significantly related to K1. But in a multiple regression model, the only significant independent variables were age, arterial pH, and serum epinephrine level.

Antigenic stimulation and multiple myeloma. A prospective study.

BACKGROUND: A causal relationship between antigenic conditions and multiple myeloma was suggested by case reports. Although controlled studies identified associations with individual conditions, they failed to give overall support to the hypothesis. Using a prospective cohort representative of the U.S. population, the authors hypothesized that immune-stimulating conditions are a risk factor for multiple myeloma. METHODS: The First National Health and Nutrition Examination Survey cohort of 14,407 persons were interviewed from 1971 to 1975 by the National Center for Health Statistics. Vital status with cause of death and hospitalizations were ascertained from 1982 to 1985 and in 1986. From the initial questionnaire, four risk factors were constructed: allergies (asthma, hives, hay fever, food allergies, and other allergies); autoimmune conditions (arthritis, thyroid disease and/or medication, rheumatic fever, diabetes, pernicious anemia); chronic bacterial conditions (chronic bronchitis or emphysema, chronic cough, tuberculosis, ulcers); and inflammatory conditions (gout, gallstones, recurrent or chronic enteritis, pleurisy). RESULTS: Eighteen multiple myeloma (MM) cases were documented. The rate ratio (RR) of MM increased as the number of reported inflammatory conditions increased (one condition, RR = 2.0, 95% confidence interval [CI] = 1.2-3.3; 2 or more conditions, RR = 4.3, 95% CI = 1.5-12.4). The RR of myeloma also increased (P = 0.0002) with time since start of inflammatory conditions (RR = 1.6 for every 10 years of exposure). When cases were restricted to those with more than five years of follow-up, myeloma risk increased with the number of inflammatory conditions (two conditions, RR = 4.6, 95% CI = 1.5-13.8). CONCLUSIONS: Although the number of cases is small and exposure may be misclassified, the prospective nature of the study design strengthens the results of the study.

Patients' attitudes regarding chaperones during physical examinations.

BACKGROUND: This study was undertaken to determine the preference of patients concerning the presence of a chaperone during physical examination of the breasts, genitals, rectum, heart and lungs, or abdomen. The study was designed to quantify preference differences between male and female patients and between teenagers and adults, and to determine whether the sex of the examining physician influenced chaperone preference. METHODS: Preference survey data were obtained from 251 female subjects and 201 male subjects over the age of 13 years who visited a family practice center in a midwestern urban community. RESULTS: The majority of patients of either sex and all ages did not care if a chaperone was present. However, substantial proportions of adult women (29%) and female teenagers (46%) preferred that a chaperone be present during a breast, pelvic, or rectal examination by a male physician. Thirty-six percent of adult women and 63% of female teenagers wanted a chaperone present during a first examination of these regions. Adults of both sexes felt the nurse would be the best chaperone, whereas teenagers ranked a parent first and the nurse second. Patients indicated that they felt comfortable asking for a chaperone. CONCLUSIONS: Although most patients have no strong preference, female patients, especially female teenagers, should be given the option of having a chaperone present during an examination of the breasts, pelvis, or rectum by a male physician.

The impact of a patient survey or a physician reminder on the provision of adolescent preventive health care.

BACKGROUND: The objective of this study was to determine if the use of a patient survey or a chart stamp could increase the implementation of adolescent preventive health care in a family practice center. METHODS: Subjects were all patients 13 to 18 years old (date of birth 1972 to 1977), who visited the Aultman Family Practice Centers from October 1, 1989, through September 30, 1990 (N = 801 patient visits). Three different 1-month interventions (patient questionnaire, physician stamp, and both patient questionnaire and physician stamp) as well as a 1-month control period were implemented. The effect of the intervention on adolescent preventive health care was measured by review of documentation in the patient's chart. RESULTS: Those charts that indicated that either the questionnaire or stamp had been used showed significantly more documented discussion of issues relating to mood, injury, sexuality, exposure to toxins, and lifestyle (all P < .01). These discussions most commonly took place during a visit for a physical examination. The percentage of visits with documented discussions did not vary significantly according to type of reminder, nor with any physician or patient characteristic. CONCLUSIONS: The use of a reminder, especially in the context of an office visit for a physical examination, significantly increased the implementation of adolescent preventive health care in this family practice center.

Emergency room resuscitative thoracotomy: when is it indicated?

This study was designed to examine the results of emergency room resuscitative thoracotomy (ERRT) and to formulate cost-effective indications for this procedure. A retrospective study was performed of 28 patients who had ERRT at St. Elizabeth Hospital Medical Center, Youngstown, Ohio, during the 4 years from July 1985 through June 1989. The prognostic factors analyzed included mechanism and site of injury, signs of life (SOL), vital signs (VS), age, gender, and prehospital care. The overall survival rate of ERRT was 7% (2 of 28 patients). The survival rate was 18% (2 of 11 patients) with penetrating trauma, and 0% (none of 17 patients) with blunt trauma. The best survival rate was 66% in the subgroup of patients with penetrating trauma and SOL present at the scene and in the emergency room (ER), (two of three patients). Our observations were combined with those of 23 studies from the literature involving 2294 trauma patients who had ERRT. Using meta-analysis, the survival rate was 11% overall. Improved survival was noted for patients with penetrating trauma compared with patients with blunt trauma (14% vs. 2%, p < 0.01). There were no survivors in the group of patients with no SOL at the scene, and there were no neurologically intact survivors among blunt trauma patients with no SOL upon arrival at the ER. An algorithm based on mechanism of injury and presence or absence of SOL at the scene and in the ER is proposed. This algorithm would decrease the number of ERRTs performed by 41% without decreasing the number of neurologically intact survivors.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of osteoporosis risk factors and physician intervention.

To determine the prevalence of osteoporosis risk factors and the probability of physician risk recognition and intervention, the medical records of a cohort of 243 women aged 40 to 65 years were reviewed retrospectively. A historical cohort design was used. Risk factors present before the start of the study were identified. Osteoporosis risk recognition (discussion, problem list), osteoporosis specific intervention (counseling about risk, or estrogen or calcium supplementation), or nonspecific intervention (dietary, exercise, smoking, or alcohol counseling) were recorded over a 3-year follow-up period. Seventy-four percent of the women had two or more risk factors. The most common were perimenopausal or postmenopausal status (73%) and absence of estrogen supplementation (ever) (65%). During the period of the study, 46 women (19%) had received an osteoporosis-specific intervention. One hundred eleven women (46%) had received one of the above or a less specific intervention. The medical records of only 25 women (10%) documented an assessment of osteoporosis risk. Only menopausal status predicted osteoporosis intervention, and the probability of intervention decreased as the total number of risk factors increased. The data identify three groups of women who could benefit from increased risk-reduction strategies: premenopausal women, perimenopausal or postmenopausal women who have never previously taken supplemental estrogens, and women with multiple risk factors.

Unintentional injuries. Risk factors in preschool children.

Successful strategies for preventing childhood injuries require better understanding of injury epidemiology. A case-control study was designed to identify risk factors for injury among preschool patients of a university-affiliated, community-based family practice center. Thirty-four children who were injured during a 1-year period and 36 age- and sex-matched controls were included. A description of the injury incident and data from each child's medical record and a parent interview were recorded. All injuries were relatively minor. The following were associated with increased injury risk: a history of a chronic medical condition; weight in the lowest 25th percentile of the national distribution; birth order of third or later in the family; maternal education higher than the high school level; and, possibly, a history of previous injury.

Correlates of screening mammography in a family practice setting.

The medical records of 243 asymptomatic women aged 50 years or older were reviewed at a community-based family practice center to determine the proportion who had been referred for a screening mammogram and to identify correlates of mammography referral. Patient demographic characteristics, breast cancer risk factors, and characteristics of past patient-physician encounters were considered. Between July 1, 1981, and July 1, 1987, 40 (16 percent) of the women had received a mammography referral from their currently assigned physician. All but two of the women had actually obtained the mammogram. The primary predictors of mammography referral were the known risk factors for breast cancer: a family history of breast cancer (prevalence rate ratio [PRR] = 9.3, P = .001) and a history of benign breast disease (PRR = 7.9, P = .002). Other predictors included having a Papanicolaou test performed by the current physician (PRR = 4.1, P = .03), having a test for stool occult blood returned by the patient (PRR = 10.2, P = .003), having been instructed in smoking cessation by the current physician (PRR = 10.0, P = .05), and, possibly, being a former smoker (PRR = 4.6, P = .09). Patient demographic characteristics, other known breast cancer risk factors (age, obesity, alcohol use, and pregnancy history), and the sex of the physician were not predictive.

A case-control study of skin cancer in the tire and rubber manufacturing industry.

A case-control study was conducted in the tire and rubber manufacturing industry to examine the association of squamous cell carcinoma of the skin with rubber manufacturing materials presumed to be contaminated by polycyclic aromatic hydrocarbons. Sixty-five cases were compared to 254 matched controls for exposure to carbon black, extender oils, lubricating oils, rubber solvents, and rubber stock. Both magnitude and duration of exposure were compared using data from company personnel records. Rubber stock and lubricating oils were associated with skin cancer. The relative risk (RR) associated with the highest levels of rubber stock exposure was 2.2, and with the highest level of lubricating oil exposure it was 6.5. In analysis of subgroups of study members, the associations were strongest among workers who were born after 1900 (rubber stock, RR = 11.6; lubricating oil, RR = 4.5) and among workers whose skin cancer was diagnosed before the age of seventy (rubber stock, RR = 23.2; lubricating oil, RR = 28.3).

Multiple myeloma and family history of cancer. A case-control study.

A hospital-based case-control study was done to examine the hypothesis that persons with a family history of multiple myeloma (MM) or other cancers are at increased risk of multiple myeloma. Study members were 439 cases of multiple myeloma and 1317 matched controls seen at the Duke University Medical Center. Only 3 cases and 4 controls reported multiple myeloma in their families. The relative risk (RR) was 2.3, but the 95% confidence interval (CI) was 0.5-10.1, allowing no firm conclusion about the risk associated with familial MM. A family history of cancer of any type resulted in a relative risk of MM of 1.4 (CI: 1.1-1.8). This association was strongest (RR = 2.5, CI: 1.1-5.3) among young study members (age less than or equal to 49). A family history of hematologic malignancy (ICD 200-208) resulted in a RR of 2.4 (95% CI: 1.4-4.0). The data also suggested that a family history of lung cancer, breast cancer, and genitourinary cancer may be associated with increased risk of myeloma in older persons.

Socioeconomic status and risk of multiple myeloma.

A case control study was conducted to test the hypothesis that socioeconomic status is positively associated with multiple myeloma incidence. One hundred and fifty-three myeloma cases and 459 controls were identified at the Duke University Medical Center at Durham, North Carolina. Study members were interviewed regarding indicators of socioeconomic status. The association of myeloma with family income (current and highest), education, occupation, home ownership, dwelling size, and an index of crowding in the home was examined by estimating relative risks. Among these indicators, only home ownership showed any association with multiple myeloma incidence (RR = 1.6, 95% CI: 1.0-2.6). The association of multiple myeloma with socioeconomic status that has been seen in earlier studies may have been due to underascertainment of disease in less advantaged groups. This association is disappearing as access to health care becomes more uniform across socioeconomic groups.