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PubMed1994

Acute pain management of the chronic pain patient on opiates: a survey of caregivers at University of Washington Medical Center.

OBJECTIVE: The provision of acute pain management for the chronic pain patient can pose a challenge. We sought to characterize management issues. SUBJECTS/SETTING: An anonymous survey was distributed to 270 physicians and 212 nurses at University of Washington Medical Center (UWMC) in an attempt to characterize management issues. DESIGN: Caregivers were queried regarding treatment modalities, efficacy of anxiolysis, patient attributes, concern of the quantity of medication, criteria for patient evaluation, and other management issues. RESULTS: Of the respondents, 61.8% were physicians, and 38.2% were nurses. The mean duration in practice was 7.7 years. The responses from the two groups were similar. Seventy-five percent reported using different pain-evaluation techniques for chronic pain patients than those utilized for the "average" patient. Pain scores were used frequently in the average patient, whereas ability to perform activities was used more commonly in the chronic pain patient (p < 0.0001). Half of the respondents expressed concern regarding the amount of medication used and level of sedation. The same proportion found anxiolysis to be a helpful adjunct. The use of a time-contingent "pain cocktail" as an oral medication was a useful strategy for 88% of respondents. The least labor-intensive modality reported was patient-controlled analgesia (PCA) for 84.5% of respondents; intravenous opiate fusion, 5.3%; and epidural analgesia, 11.2%. CONCLUSIONS: The survey describes caregiver concerns regarding this patient population, including medication use, sedation, length of hospital stay, and evaluation techniques.

Academic Medical Centers↗

PubMed2002

Ethical communication in clinical trials. Issues faced by data managers in obtaining informed consent.

BACKGROUND: Informed consent has been proposed as the optimal method for ensuring the ethical entry of patients into clinical trials. However, it is known that problems with informed consent exist from the perspective of both patients and physicians. This has led to the suggestion that a third party, such as a research nurse or data manager, should be responsible for obtaining informed consent. The objective of this study was to explore the views of data managers concerning the nature, challenges, and rewards of their role and the similarities and differences between their role and that of physicians in obtaining informed consent. METHODS: Four focus groups in three large teaching hospitals were conducted. Twenty-one data managers who were involved in cancer or pain clinical trials participated. The focus groups were audiotaped, transcribed, and subjected to content analysis to identify themes. RESULTS: Data managers identified three primary roles complementary to that of physicians: information provision, quality assurance of the informed consent process, and ongoing support during the trial. Despite expressed concern that medical and drug company interests may lead to subtle coercion of the patient, participants did not support the notion that they may be solely responsible for the consent process. Participants described a range of ethical dilemmas they confronted, including patients asking them for medical details they could not provide and situations in which they felt that informed consent was compromised in some way, for example, dealing with situations in which the patient appeared to be entering the trial for the wrong reasons due to misunderstanding, need, or passivity. Effective functioning of the multidisciplinary team assisted data managers in performing their role. A range of training needs were identified, particularly communication skills training and trial start-up briefing. CONCLUSIONS: The issues raised by these data managers have important implications for the successful conduct of clinical trials, particularly the need for an integrated, multidisciplinary approach at all levels of the informed-consent process.

Adult↗

PubMedDate not supplied

Having children after breast cancer.

Having children after breast cancer is an important clinical issue. Evidence from clinical studies on pregnancy subsequent to breast cancer has not shown a survival disadvantage. Clinical experience suggests that desire for children, support from family, and quality of life issues are also important factors in decisions about pregnancy. This qualitative study was done (1) to identify reasons why young women decide to become pregnant after breast cancer; (2) to describe concerns about subsequent pregnancy; (3) to describe helpful behaviors in decision making; and (4) to explore the meaning of having children after breast cancer. Twenty-three women were identified who had early-stage breast cancer and became pregnant after breast-conserving surgery and radiation therapy. Sixteen women participated in a semi-structured interview. Qualitative data were analyzed for content. Results indicate that pregnancy subsequent to breast cancer is a powerful stimulus for young women to "get well" again. Reasons for subsequent pregnancy were related to the women's developmental age. Young women expressed concerns about the potential for future disease recurrence, about breast self-examination and mammography during pregnancy, and about surviving to see their children grow up. Perceived helpful behaviors included developing a realistic perspective, living with uncertainty, love and support of spouse, and delineating differences between personal and medical decision making.

Adult↗

PubMed2005

BRCA1/2 testing in hereditary breast and ovarian cancer families II: impact on relationships.

Members of hereditary breast and ovarian cancer (HBOC) families often express concern during genetic counseling about the impact of BRCA1/2 testing on close relatives. Yet whether there are likely to be adverse effects of either the decision to undergo genetic testing or the results of testing on family relationships is unknown. One purpose of this study was to assess the impact on close family relationships. Within a randomized trial of breast cancer genetic counseling methods, members of 13 HBOC families were offered BRCA1/2 testing for a known family mutation. The Family Relationship Index (FRI) of the Family Environment Scale (FES) was used to measure perceived family cohesion, conflict, and expressiveness at baseline and again 6-9 months following the receipt of test results, or at the equivalent time for those who declined testing. Participants (n = 212) completed baseline and follow-up questionnaires. Comparisons were made between testers and non-testers as well as between those who tested positive and negative for the family mutation. One hundred eighty-one participants elected to undergo genetic testing (85%) and 47 (26%) were identified to have a mutation. After adjusting for baseline family relationship scores, counseling intervention, gender and marital status, non-testers reported a greater increase in expressiveness (P = 0.006) and cohesion (P = 0.04) than testers. Individuals who tested positive reported a decrease in expressiveness (P = 0.07), although as a trend. Regardless of test decision or test result, those who were randomized to a client-centered counseling intervention reported a decrease in conflict (P = 0.006). Overall, study results suggest that undergoing genetic testing and learning ones BRCA1/2 status may affect family relationships. Those individuals who declined testing reported feeling closer to family members and more encouraged to express emotions to other family members demonstrating potential benefit from the offer of testing. Since those who tested positive reported feeling less encouraged to express their emotions within the family, we recommend helping clients to identify others with whom they feel comfortable sharing their thoughts and feelings about their positive gene status and increased cancer risk.

BRCA1 Protein↗

PubMed2006

Exploring beliefs and practice of opioid prescribing for persistent non-cancer pain by general practitioners.

Persistent non-cancer pain is a common reason for consultation in primary care but treatment options, including non-opioid analgesics, are limited, and neither strong evidence nor established guidelines address when and how primary care doctors should prescribe opioid analgesics for persistent non-cancer pain. The aim of this study was to investigate associations between doctors' prescribing patterns for persistent non-cancer pain in primary care and their personal and practice characteristics and beliefs about appropriateness and risks of opioids. A pilot survey sampled beliefs concerning the need for and risks of opioid prescribing for persistent non-cancer pain among volunteers from primary care practices and postgraduate educational events, using a self-report questionnaire, and related these beliefs to their reported opioid prescribing. One quarter of the sample prescribed no opioids for persistent non-cancer pain. Prescribing opioids was predicted by moderate belief in the appropriateness of opioids within certain constraints, and to a lesser extent by younger age. While some beliefs distinguished prescribers from non-prescribers, predicting non-prescribing was poor. Both prescribers and non-prescribers expressed concern about the risks of opioids. In addition, most primary care doctors were dissatisfied with their training on pain; few had prescribing guidelines; and neither training nor guidelines influenced prescribing. In conclusion, whether or not GPs prescribe opioids for persistent non-cancer pain is mainly determined by their personal beliefs about appropriateness of opioids for this problem.

Adult↗

PubMed2003

Experiencing the loss of mobility: perspectives of older adults with MS.

PURPOSE: The purpose of this study was to develop an understanding the experience and meaning of mobility loss among older adults with multiple sclerosis (MS). This work is part of a larger study on the health concerns and service needs of older adults with MS. METHODS: Twenty-seven people with MS (mean age = 62 years, range = 55-82) were interviewed using a phenomenological approach. RESULTS: Thematic analysis found that three factors contributed to participants' experience of mobility as a person with MS: reality of having MS, mobility needs, and contextual factors. Participants discussed how the reality of MS meant variability in their ability to get around and the importance of trying to remain in control over their mobility experiences. The experience of mobility lead participants to mourn losses, take action, and contemplate their futures. They expressed concerns about the continual declines in their mobility, losing independence, becoming a burden on caregivers, and the potential for having to move into a nursing home. CONCLUSIONS: Findings provide insight into the experience of mobility loss among older adults with MS, and point to potential strategies that can be used to help people cope with and adapt to these losses.

Activities of Daily Living↗

PubMed2001

Parents who report using illicit drugs: findings and implications from the DRUGNET study.

In recent years, a national discussion has emerged concerning what parents should tell their children about their own past drug use. DRUGNET is an ongoing, on-line survey of successful, healthy, adults who occasionally use illicit drugs. This paper reviews data from a subset of this survey, namely, those respondents who were parents with self-reported use of at least one illicit drug. The sample (n = 325) was predominantly white men who reported having above average education and household incomes. Their mental health as measured by the General Well-being Schedule was similar to the national norm. Respondents reported using drugs to manage parental stress and expressed concerns over how to communicate with their children and legal risks related to their own drug use. The limitations and the implications of these data are discussed.

Adolescent↗

PubMed2004

Predictors of acceptance of hepatitis B vaccination in an urban sexually transmitted diseases clinic.

BACKGROUND: Individuals who use sexually transmitted disease (STD) clinics are at high risk for hepatitis B virus (HBV). While HBV vaccine is frequently offered to clients in this setting, reported vaccination rates are low. More information is needed about HBV vaccine knowledge, attitudes, beliefs, and behavior among high risk populations. The current study assesses these issues at an urban STD clinic. METHODS: A survey assessing knowledge, attitudes, and beliefs concerning HBV vaccine was administered to individuals seeking services at an STD clinic before seeing the physician. Immediately after the clinical visit these individuals were interviewed and asked whether they had accepted vaccination and their reasons for acceptance or rejection. RESULTS: Fifty percent of unvaccinated study subjects elected to receive an HBV vaccine dose at the current visit. Significant predictors in a multiple logistic regression model for choosing to be vaccinated were: having a vaccinated acquaintance, perceived risk of disease, perceived healthfulness of vaccine, and clinician's recommendation. Knowledge regarding hepatitis B risks and outcomes was not related to vaccine choices. Patients expressed concern about vaccine safety and provider motivation. CONCLUSIONS: The role of acquaintances and the physician are central to the decision to be vaccinated, as are risk perception and familiarity with the vaccine. Mistrust of the medical establishment and of vaccines is a barrier to acceptance of HBV vaccine.

Adolescent↗

PubMed1991

Public opinion about AIDS before and after the 1988 U.S. government public information campaign.

In October, 1987, the Centers for Disease Control mounted a massive public information campaign to alert the public to the dangers of AIDS and to provide information about its transmission and prevention. Using data from two Gallup surveys, one just before the campaign began and the other several months after its conclusion, we examine changes in public information and misinformation about transmission, in concern about AIDS as an epidemic, and in reported behavior to avoid exposure to AIDS. We conclude that although some changes in knowledge did take place, these were essentially a continuation of trends beginning before the public information campaign and continuing well after its conclusion. For these and other reasons, we argue that the effects of the campaign on public information were minimal. However, between 1987 and 1988 there was a small but statistically significant increase in reported condom use, an increase paralleled by increased condom sales between 1986 and 1988. In addition, there was a substantial increase in the number of people expressing concern about AIDS as an epidemic for the population at large. The campaign may well have contributed to both of these changes.

Acquired Immunodeficiency Syndrome↗

PubMed2001

Genitourinary medicine services in the United Kingdom are failing to meet current demand.

Recent increases in the incidence of sexually transmitted disease (STD) in the UK have given rise to concerns over the ability of genitourinary medicine (GUM) services to cope with increased demands. We conducted a postal survey to assess the capacity of GUM clinics to meet patient demand for both routine and emergency consultations. A questionnaire was sent to all lead GUM physicians in the UK. The response rate was 80%. In some clinics, patients had to wait for up to 28 days for routine appointments. Urgent appointment patients were seen within 24 h by only 54% of clinics and some had to wait for at least one week (5% of clinics). Prolonged waiting times were reported nationwide in addition to widely expressed concerns about the increasing workload. Additional resources should be made available to GUM services if the population's sexual health is to be improved.

Female↗

PubMed2000

Complimentary journeys to the World Congress of Gastroenterology--an inquiry of potential sponsors and beneficiaries.

UNLABELLED: One of the most effective tools of pharmaceutical marketing is the distribution of gifts to physicians whose magnitude remains ill defined. This anonymous survey determines the frequency with which physicians receive travel awards from drug companies to attend International Medical Conventions and attempts to obtain the recipients' opinion on ethical and legal issues related to such sponsorships. METHODS: A questionnaire was mailed to all members of the German Gastroenterological Association who had attended the most recent World Congress of Gastroenterology and to 30 pharmaceutical companies. Questions concerned the physician's role at the congress, the mode of payment for travel, lodging and convention fees as well as the attendees' opinion on ethical and legal issues related to sponsoring by pharmaceutical companies. RESULTS: 78% of the contacted physicians returned the questionnaire. 67% (95% CI [55, 80]) of them received compensation for their travel expenses by industry, and the majority of them stated that they would not have attended the congress if such sponsoring had not occurred. More than two thirds believed that sponsoring by drug companies neither interferes with ethical and legal issues nor affects prescribing behavior. Such opinions were more frequently expressed by sponsored than nonsponsored attendees (p = 0.003). 20% of the contacted drug companies returned the questionnaire, one of whom expressed concerns regarding the ethics of sponsorships. CONCLUSIONS: International conventions would suffer from a significant deprivation of attendance if the attendees' expenses were not subsidized by industry. Recognition of ethical and legal issues related to such sponsoring appears to be limited and requires further discussion within the medical community.

Attitude of Health Personnel↗

PubMed2006

Early clinical experience with CardioCard - a credit card-sized electronic patient record.

QUESTIONS UNDER STUDY: CardioCard is a CDROM of credit card size containing medical information on cardiac patients. Patient data acquired during hospital stay are stored in PDF format and secured by a password known to patients only. In a consecutive series of patients, we assessed acceptance and utility of this new information medium. METHODS AND RESULTS: A questionnaire was sent to all patients who had received CardioCard over a one-year period. The questionnaire was returned by 392 patients (73%). 44% of patients had the card with them all the time. The majority of patients (73%) considered the CardioCard useful (8% not useful, 19% no statement) and most (78%) would even agree to bear additional costs. Only 5% worried about data security. In contrast, 44% would be concerned of data transmission via internet. During an observation period of 6 (SD 3) months, data were accessed by 27% of patients and 12% of their physicians. The proportion of card users was lower among older patients: < or = 50 years (y), 39%; 51.60 y, 38%; 61.70 y, 26%; >70 y, 16% and particularly among older women: 61.70 y, 9%; >70 y, 5%. Technical problems during data access occurred in 34%, mostly due to incorrect handling. CONCLUSIONS: A majority of patients considered CardioCard as useful and safe. Lack of hardware equipment or insufficient computer knowledge, but not safety issues were the most important limitations. As patients expressed concerns regarding protection of privacy if data were accessible via internet, this would remain a strong limiting factor for online use.

Adult↗

PubMed2004

Staff attitudes to a daily otolaryngology ward round.

This survey investigates the attitudes of medical and nursing staff towards the daily otolaryngology ward rounds in a teaching hospital. Initial, open-ended questionnaires generated themes from which a structured questionnaire was constructed. Respondents indicated on a Likert scale the extent to which they agreed or disagreed with statements concerning their attitudes towards the ward round. Thirty-five members of staff were surveyed. The overall response rate was 74.3 per cent (n = 26). The majority of staff agreed that the ward round was a constructive use of their time and served to promote team spirit. It allowed for adequate communication between medical and nursing staff but there was uncertainty about the provision of adequate patient communication. The nursing staff agreed that the ward round provided a valuable learning experience. There was uncertainty about this among the medical staff. There was agreement in both groups that patients find the ward round to be reassuring. A significant majority of staff expressed concerns over maintenance of patient confidentiality. These findings could be used to inform changes in the departmental ward round structure. Specific attention should be directed to discussing sensitive issues in a more private setting and maximizing educational opportunities for junior medical staff.

Attitude of Health Personnel↗

PubMed1991

Developing an integrated traditional/clinical health system in the Yukon.

The introductory steps have been taken in Yukon. Elders have met and voiced their concerns and initial contacts have been made with government officials, medical and legal consultants. A proposal is now being developed to obtain funding to design a suitable model for an integrated Yukon Indian/clinical health care system. One of the next steps, following on the advice of the Elders, should be for communities to establish their own projects to record the plants and practices used, with the assistance of their Elders. The communities should also identify people who use traditional practices who are willing to come forward. They could then come together with the Elders to discuss their concerns. Beyond that, representatives from the traditional system will need to meet with representatives of the mainstream system, to discuss areas of co-operation. Once the "content" has been identified, the model for integrating the two health systems can be addressed. This will necessitate further meetings of Yukon Territorial Government officials, legal advisors, medical advisors, and Yukon First Nations representatives. The proposal currently being developed will build on the initial steps which have been taken. The Yukon Territorial Government has indicated a willingness to look at ways of including traditional health care practices for patients who wish to use them. The receptivity of government and Yukon medical profession and the expressed concerns of the Elders indicate that now is the time to proceed.

Health Services↗

PubMed1991

A national study of AIDS and residency training: experiences, concerns, and consequences.

OBJECTIVE: To examine residents' experiences in the care of patients with the acquired immunodeficiency syndrome (AIDS), and to examine factors that may influence their attitudes about such care. DESIGN: Cross-sectional, self-administered questionnaire survey conducted in 1989. PARTICIPANTS: All senior internal medicine and family medicine residents in ten geographically representative states who were identified through the 1986 National Residency Matching Program. MEASUREMENTS AND MAIN RESULTS: Seventy-four percent of residents reported that patients with AIDS accounted for 5% or more of general medicine admissions, and 50% of residents reported that they were currently following one or more human immunodeficiency virus (HIV)-infected patients in their continuity clinics. Among residents who had provided ambulatory care to patients with AIDS, 77% felt that it was an excellent educational experience, and among those who planned to do general primary care in their future practices, 74% planned on providing primary care to patients with AIDS. However, 61% expressed concerns about the adequacy of their training in AIDS ambulatory care. A greater amount of contact with outpatients who had AIDS, but not with inpatients who had AIDS, was associated with residents' intending to provide AIDS primary care in their future practices. Among all residents, 23% reported that, if given a choice, they would not provide care to any patients with AIDS, and 23% reported that they would not work in an area with a high prevalence of AIDS because of concern about contracting the syndrome. Nine percent of residents reported that they had been exposed to a blood-contaminated needlestick from an HIV-seropositive patient. CONCLUSIONS: Although most residents have substantial contact with inpatients and outpatients with AIDS, most still find their education in AIDS ambulatory care to be deficient. A minority of residents would prefer not to care for patients with AIDS. Residency curricula should include training and experience in ambulatory AIDS care, explicitly address negative attitudes toward caring for patients with AIDS, and include programs to reduce needlestick exposures.

Acquired Immunodeficiency Syndrome↗

PubMed1987

Drinking patterns in general practice patients.

Patients from 47 group practices recruited from the Medical Research Council's general practice research framework participated in a study involving the collection of information about smoking, drinking, exercise and dieting and weight. This paper is concerned with the data on alcohol consumption obtained in the first stage of the study in which a self-administered questionnaire, the health survey questionnaire, was distributed by hand or by post to patients registered with the participating practices.Of the 25496 men who completed the questionnaire, 83.6% stated that they had been drinking in the previous three months compared with 69.2% of the 36657 women. For both sexes, abstinence rates were significantly lower in the younger age groups (P<O.001). Of the men, 7.6% admitted to a weekly alcohol consumption of 35 units or more and 2.7% women were drinking 21 units per week or more.Of the 1948 male excessive drinkers 45.9% expressed concern about their drinking through a positive CAGE response and/or self assessment of a drinking problem, while for the 989 female excessive drinkers the figure was 44.1%. A positive response to these questions was strongly related to alcohol consumption and was more frequent among women than men at most levels of consumption.

Adolescent↗

PubMedDate not supplied

Concerns in a primary care population about genetic discrimination by insurers.

PURPOSE: Fear of genetic discrimination might deter participation in research or therapy. This is a major impetus for laws limiting insurers' use of genetic information, yet there is little information about the extent of this fear in the general population and how it varies by social factors. METHODS: This study measures concern about insurance problems relating to genetic testing, as part of primary-care screening for hereditary hemochromatosis (iron overload). Data come from a multiethnic, primary care-based survey of 86,859 adults in five field centers in the United States (AL, CA, DC, HI, OR), and one in Canada (Ontario). Logistic regression was used to model the probability of agreeing to the question "Genetic testing is not a good idea because you might have trouble getting or keeping your insurance." RESULTS: Overall, 40.0% of participants agreed. Adjusting for other characteristics, African Americans and Asians were much less likely (OR = 0.52 and 0.39), and Hispanics were more likely (OR = 1.124), than Caucasians to express concern about insurance discrimination. Participants under 65 years old, US residents, and those without a high school diploma were substantially more likely to be concerned (ORs ranging from 1.4-1.6), as were participants with lower mental health scores. Education showed a nonlinear relationship, with significantly higher concern among both those with less than a high school education and those with a college degree, compared to high school graduates. CONCLUSIONS: Concern about genetic discrimination varies substantially by race and other demographic factors and by nationality. One possible explanation for lower concern about Canadians and by people over 64 is that both groups are covered by social insurance for health care (Medicare). However, US residents in states with some legal protections against genetic discrimination had more, not less, concern than either Canadians or US residents in states with no legal protections.

Adult↗

PubMed2003

Knowledge, attitudes and behaviours of caregivers regarding children's exposure to environmental tobacco smoke among Arabic and Vietnamese-speaking communities in Sydney, Australia.

OBJECTIVE: The aim of this study was to inform the design of a culturally appropriate health communication campaign addressing exposure of young children to Environmental Tobacco Smoke (ETS) in homes and cars, targeted at caregivers of children aged 0-6 years in the Arabic and Vietnamese-speaking communities in Sydney, Australia. DESIGN: Nine focus groups (five Arabic and four Vietnamese) were conducted by qualified bilingual facilitators, recorded, transcribed, then translated and analysed qualitatively. RESULTS: Results revealed concerning levels of knowledge, attitudes and behaviours regarding children's exposure to ETS. A poor understanding existed regarding what constituted passive smoking and the severity and extent of harm that ETS has on children. Smoking attitudes and behaviours described were not always consistent with the concern expressed about children's vulnerability to smoke. Initial changes in smoking patterns at home since the arrival of children were not always sustained. Despite awareness of the harm caused by smoking in the presence of their children, some caregivers continued to smoke in closed environments. Others felt it was sufficient protection to smoke in another room, with doors and/or windows open or by ensuring that visible smoke did not reach the child directly, whilst some smoked in the home or car only when children were not present. Smoking attitudes and behaviours in the presence of children were influenced by cultural and social norms associated with smoking. The desire to be sociable and hospitable often superseded concerns for children's health. CONCLUSION: The findings suggest that an effective communication campaign focusing on ETS and children in the Arabic and Vietnamese-speaking communities in Sydney should attempt to address knowledge deficits regarding ETS, as well as tackling entrenched culturally related attitudes and behaviours associated with smoking which are strongly linked to sociability and hospitality.

Adult↗