BACKGROUND: In 1989, the federal government mandated that the Agency for Health Care Policy and Research (AHCPR) appoint expert panels to develop clinical practice guidelines to define standards for the provision and quality of health care. There is uncertainty about physicians' awareness and attitudes concerning guidelines. METHODS: We surveyed 992 members of the New York State Academy of Family Physicians. In addition to demographic data, respondents were questioned about awareness of AHCPR guidelines for depression in primary care, urinary incontinence, and pressure ulcers in adults; knowledge of the diagnosis and treatment of depression; and general attitudes about guidelines. RESULTS: Three mailings produced a response rate of 53.2%. While 90.5% of respondents treat depression in their primary care practices, only 33.6% are aware of the existence of the guidelines on depression 1 year after publication. Only 13.1% of respondents have a copy of the guidelines. Physicians are slightly less aware of the guidelines on urinary incontinence and pressure ulcers (30.0%). Respondents are generally knowledgeable about the diagnosis and treatment of depression, and board certification is correlated with increased knowledge about the treatment of recurrent depression. Logistic regression analyses demonstrate that female family physicians, those living in larger communities, and physicians with 3 or more years of training are most likely to have positive attitudes toward guidelines. CONCLUSIONS: The AHCPR guidelines failed to reach their targeted audience. Specific strategies derived from survey data can identify physicians who may most benefit from educational interventions.

Adult↗

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Mechanism of action and clinical effects of antiprogestins on the non-pregnant uterus.

Considerable progress has been made in elucidating the mechanism of action of antiprogestins. The biological response to a progesterone antagonist depends on many factors. The usual effect is that of an antagonist, but progesterone agnostic or even antioestrogenic or oestrogenic effects have also been observed. The present review focuses on the clinical applications of antiprogestins in the non-pregnant uterus. Whereas high doses of antiprogestins block ovulation, low doses impair endometrial development without affecting ovulation, hormonal levels or bleeding patterns Indeed, the endometrium is the tissue which is the most sensitive to antiprogestins. The effect of antiprogestins is to produce a delay in endometrial maturation and to postpone the appearance of the implantation window. This concept of 'endometrial contraception' requires further testing in humans, although the principle has been proven in monkeys. In contrast to the low doses of mifepristone which delay endometrial maturation, a minimum dose of 50 mg is required to produce endometrial bleeding. Late luteal phase antiprogestin administration does not disturb ovulation, hormonal levels or bleeding patterns. This has clinical application, and mifepristone has been used together with prostaglandins in women with delayed menses to successfully prevent implantation. Mifepristone has also been shown to be an effective post-coital agent. However, when used on a regular basis once monthly at the end of the cycle as a potential contraceptive, the results are disappointing. Because of their antiproliferative and anti-oestrogenic effects on the endometrium, antiprogestins are also used in the treatment of oestrogen-dependent conditions such as endometriosis and fibromyomas. In humans, chronic administration of high doses of antiprogestins has on rare occasions been associated with endometrial hyperplasia, presumably a consequence of unopposed oestrogen activity. This does not occur with low doses (1 mg daily for 5 months).

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Brundtland's World Health Organization: a test case for United Nations reform.

Gro Harlem Brundtland, who became Director General of the World Health Organization in July 1998, has created a small revolution at the WHO headquarters in Geneva. She is in the process of changing how WHO works, how it interacts with other parts of the United Nations system, and how it enlists ministries, whole governments, universities, and other private organizations to improve health in the world. Here, the Editor describes the reorganization, the new people and resources, and prospects for setting a precedent in United Nations reform.

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How organized medical care can advance public health.

Explore the source record for details and available documents.

Humans↗

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Havana revisited.

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Cuba↗

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Hemorrhoids: associated pathologic conditions in a family practice population.

BACKGROUND: Hemorrhoidal disease is an affliction that in referral populations coexists with other significant anorectal diseases. Published texts recommend aggressive procedures to diagnose associated pathologic conditions and as an aid for planning the extirpation of these diseases. Procrastination in management is said to be characteristic of both patient and primary care physician. The purpose of this study was to ascertain whether patients with hemorrhoids in the general population are truly at high risk for significant anorectal disease. METHODS: Charts of 173 patients with hemorrhoids from a nonselected population were reviewed for treatment management, associated anorectal disease, and sequelae. RESULTS: A small subpopulation of persons aged more than 55 years was identified who may be at higher risk for colon polyps. Anoscopy, barium enema, fecal occult blood testing, and complete blood counts had very low yields. These findings differ significantly from data collected on highly selected populations that suggest hemorrhoids rarely exist alone. CONCLUSIONS: It appears that family physicians have not been cavalier in their attitudes toward and management of this common ailment. Clinical investigation of hemorrhoids should be initiated based on clinical impression from evaluating symptoms and signs combined with age-specific screening recommendations.

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