Search PubMed⌕ Search

SEARCH · Search PubMed

Results for “Procedures”

Search indexed PubMed citations on genomics, clinical trials, systematic reviews and public health. Explore titles, authors and supplied subject terms, then open the PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 1,099 records · Page 61Linked to original sources
PubMed1995

Diagnostic video-assisted thoracoscopic procedures.

OBJECTIVE: The authors evaluated the effectiveness and the limitations of video-assisted diagnostic thoracoscopy. SUMMARY BACKGROUND DATA: The initial successes achieved with the use of video-assisted diagnostic thoracoscopic techniques has lead to an enthusiastic propagation of its use by thoracic surgeons as well as by some pulmonologists. However, detailed analyses of the diagnostic yield and potential limitations of this technique in relation to the roentgenographic and pathologic presentations of the patients are necessary to ensure its safe and effective application. METHODS: From July 1991 to December 1993, 102 diagnostic video-assisted thoracoscopic procedures were performed. All patients received other preoperative diagnostic workups without a definitive diagnosis. The initial roentgenographic presentations of these patients included 42 pulmonary nodules, 23 interstitial processes, 11 parenchymal infiltrates, 6 pleural effusions, 10 mediastinal tumors, and 10 mediastinal lymphadenopathies. If the procedure was completed without minithoracotomy or extension of any port site, then it was defined as an exclusive thoracoscopic biopsy (ETB); if the procedure was completed with the assistance of minithoracotomy (4-6 cm), then it was defined as a supplementary thoracoscopic biopsy (STB). RESULTS: Ninety-two of the pathology reports (90.2%) were interpreted as conclusive. Of these, 35 tumors were malignant and 67 benign. Ten pathology reports were inconclusive and on initial roentgenography had presented as pulmonary infiltrates (4 cases), pulmonary nodule (2), pleural effusion (2), interstitial process (1), and mediastinal lymphadenopathy (1). Seventy-six procedures (74.5%) were completed thoracoscopically and were classified as ETB. The remaining 26 procedures (25.5%) were completed with minithoracotomy and were classified as STB. The underlying diseases in the STB group were carcinoma (8 cases), Hodgkin's lymphoma (3), sarcoidosis (3), tuberculosis (2), interstitial pneumonitis (2), organizing pneumonia (2), mesothelioma (1), and miscellaneous disease (5). The reasons given for minithoracotomy were diffuse intrapleural adhesion (10 cases), technical inexperience (8), inability to localize the lesion (5), problems with anesthesia (1), poor patient tolerance (1), and unknown (1). Four patients (3.9%) experienced complications and three (2.9%) died while in the hospital. CONCLUSIONS: Diagnostic thoracoscopy provides high diagnostic yield with very low risk. However, 25.5% of the procedures require minithoracotomy to obtain adequate tissue for definitive diagnosis. This finding supports the assertion that diagnostic thoracoscopy should be performed only by experienced thoracic surgeons who can extend the procedure when indicated.

Adolescent↗
PubMedDate not supplied

Prospective trial using Virtual Vision as distraction technique in patients undergoing gastric laboratory procedures.

To determine whether distraction techniques using Virtual Vision, an audiovisual system integrated into a modified pair of glasses, improves tolerance to routine gastric laboratory procedures, a prospective study of 50 patients was done. Patients were allowed to view/hear a travelogue tape during testing. Patients and registered nurses, who performed the procedure, were asked their interpretation of Virtual Vision as a device that improved patient tolerance, impaired the patient's ability to follow directions, or impaired the nurse's ability to perform the procedure. Patients graded the procedure from 1 (unbearable) to 5 (reasonably comfortable) and were asked whether they would use the device for a repeat procedure. For those who had undergone previous procedures, patients were queried regarding their preference for routine testing or Virtual Vision. Improved tolerance to procedures was noted in 82% of the patients as perceived by nurses and patients. Eighteen percent of the nurses and 8% of the patients thought that the auditory insert and glasses impaired the patient's ability to cooperate with the test, whereas 88% and 86%, respectively, thought that Virtual Vision was a valuable distraction technique. Using an ordinal scale for testing tolerance, patients graded their test at a mean of 3.8 (SD 1.25) and 82% expressed a desire to use the system in conjunction with future testing. Twenty-six of 33 patients (79%) who had undergone previous gastric laboratory testing preferred distraction techniques using Virtual Vision to conventional testing. Distraction techniques using a system such as Virtual Vision have the potential to improve patient tolerance to routine gastric laboratory studies.

Adolescent↗
PubMed1984

Procedural skills training in the internal medicine residency.

To determine whether there was agreement on a core of procedural skills that all internal medicine residents should be able to perform, faculty members and residents at the University of Pennsylvania and the University of Nebraska were surveyed regarding 72 procedures. Nineteen procedures were indicated by 90 percent or more of the respondents as those that should be learned by the graduates. In response to a second survey, many senior residents said they did not feel competent to perform these 19 procedures, and many did not recall that their performance on procedures had been evaluated. Thus, despite any regional or institutional influences, there was agreement on a core of procedural skills that should be required of all physicians completing the general internal medicine residency. It is important that training programs assess whether or not the procedures they consider essential are being mastered by their residents.

Clinical Competence↗
PubMed1985

Office procedural skills in family medicine.

In a study of 131 residents, 34 faculty members, and 236 graduates at nine family practice residency programs in Iowa, 29 office and outpatient procedural skills (for example, repair of lacerations) were identified as representing the ideal core content for family practice residency training, and another 11 procedures (for example, endometrial biopsy) were identified as elective procedures. The faculty members' responses that residents were taught these 40 procedures by direct supervision were much higher than third-year residents' reports of having been supervised while performing them. There was a positive relationship between the percentage of residents who reported having been supervised and the percentage who felt competent to perform the procedures. There was strong agreement among faculty members, residency graduates, and the residents that residents should be evaluated by direct observation of their performance of both core and noncore procedures. Therefore, the view that evaluation by direct observation would be resisted by residents is not supported by this study. As a result of these findings, the authors encourage programs to establish processes for assessing and documenting residents' performances of office and outpatient procedures.

Clinical Competence↗
PubMed2000

A comparison of standard-setting procedures for an OSCE in undergraduate medical education.

PURPOSE: To compare four standard-setting procedures for an objective structure clinical examination (OSCE). METHODS: A 12-station OSCE was administered to 84 students in each of the final (fourth-) year medical classes of 1996 and 1997 at Dalhousie University Faculty of Medicine. Four standard-setting procedures (Angoff, borderline, relative, and holistic) were applied to the data to establish a cutoff score for a pass/fail decision. RESULTS: The procedures yielded highly inconsistent results. The Angoff and borderline procedures gave similar results; however, the relative and holistic methods gave widely divergent results. The Angoff procedure yielded results reliable enough to use in decision making for a high-stakes examination, but would have required more judges or more stations. CONCLUSIONS: The Angoff and borderline procedures provide reasonable and defensible approaches to standard setting and are practical to apply by non-psychometricians in medical schools. Further investigation of the other procedures is needed.

Education, Medical, Undergraduate↗
PubMed1998

A simultaneous comparison of three neonatal pain scales during common NICU procedures.

OBJECTIVE: This study evaluated neonatal pain scales during procedures commonly performed in a neonatal intensive care unit. DESIGN: Evaluated were the Neonatal Infant Pain Scale (NIPS), the Comfort scale, and a new scale known as the Scale for Use in Newborns (SUN). Four procedures were scored: intubation, intravenous catheter insertion, endotracheal tube suctioning, and diaper changes. Scoring was done before, during, and after each procedure. Thirty-three patients were tested during 68 procedures with 1,428 scale scores. RESULTS: All scales demonstrated significant changes. In before-versus-during for each procedure, the increase in pain scale score was significant for the NIPS, Comfort scale, and SUN. All three scales also demonstrated a return to baseline (before-vs.-after) for the four procedures, except for the Comfort scale, which remained elevated (p < .05) following diaper change. The NIPS had a significantly larger coefficient of variation (CV, 188% +/- 99%), whereas the Comfort scale and SUN had small CVs (27% +/- 5% and 33% +/- 8%, respectively). In evaluating potential confounding influences, it was found that infants > 2.5 kg on sedative or analgesic medications appeared to have procedure-related accentuation and sustained elevation in scale scores, whereas swaddling seemed to provide little added benefit. CONCLUSIONS: The pain scale scores identify changes in an infant's behavior/physiologic state. It is unclear whether these changes are totally "pain specific." In comparing the three scales, the SUN overall was a preferable tool because of its ease of use, scale symmetry, and scoring consistency.

Birth Weight↗
PubMedDate not supplied

Development of preventive maintenance procedures.

A large number of in-house preventive maintenance (PM) programs, which call for varying degrees of thoroughness in the checkout of patient care instrumentation, are currently in existence throughout the country. This paper discusses the types of preventive maintenance, or PM procedures, which can be used by a clinical engineering department; the rationale for drafting different types of PM procedures in-house; and some long-term considerations affecting hospital-based inspection programs. Three types of PM procedures are described and compared: general checks; generic procedures; and, specific procedures. An outline is provided for writing a PM procedure; and, a call is made for a national guideline for writing preventive maintenance procedures.

Equipment Safety↗
PubMed1989

Abdominoplasty combined with other major surgical procedures: safe or sorry?

The clinical records of 563 patients undergoing either abdominoplasty alone or in combination with other major surgical procedures were reviewed in order to determine the relative safety of combined procedures. One-hundred-seventeen patients had abdominoplasty alone; 230 had abdominoplasty with either an intraabdominal or major pelvic procedure with or without an additional major aesthetic procedure; 216 had abdominoplasty with one or more major aesthetic procedures (without intraabdominal or pelvic procedures). The rates of occurrence of major complications, including death, pulmonary embolus, and infection, among the three groups were examined. Also examined were morbidity factors such as length of hospital stay and the need for blood transfusion. In this study, the only risk factor identified in predicting major morbidity, specifically the occurrence of pulmonary embolus, was obesity, not the complexity of the surgical procedure.

Abdomen↗
PubMed1991

The biomechanical effects of deep tissue support as related to brow and facelift procedures.

The adverse effects of increased tension across a healing wound are well known. However, the effect of closing a wound in layers in order to decrease tension on the epidermis has been a source of controversy. It is hypothesized that deep tissue support decreases skin tension upon wound closure. In order to clarify this issue, a two-part study was designed to address the immediate effects of deep tissue support in vitro using fresh-frozen cadavers and in vivo on patients undergoing scheduled surgery. Closing skin tension was measured at standard reference points in coronal brow lift and rhytidectomy procedures performed with and without galeal closure and superficial musculoaponeurotic system (SMAS) procedures, respectively. Deep tissue support was found to significantly (p less than 0.05) decrease skin tension at the time of skin closure at standard reference points in coronal brow lift and rhytidectomy procedures performed on fresh-frozen cadavers. Similar significant (p less than 0.05) decreases in closing skin tension also were found in vivo in patients undergoing similar surgical procedures. Stress relaxation was not found to play a significant role in contributing to this immediate decrease in closing skin tension. It would appear, therefore, that deep tissue support, in the form of galeal closure and an SMAS procedure in coronal brow lift and rhytidectomy procedures, respectively, provides increased viscoelastic support, producing immediate significant decreases in closing skin tension in these procedures. The beneficial effects on wound healing, scar formation, tension-related trophic skin changes, and possible improved long-term results are discussed.

Adult↗
PubMed1998

TRAM flap perforator ligation and the delay phenomenon: development of an endoscopic/laparoscopic delay procedure.

Despite its versatility in breast reconstruction, the TRAM flap is at times subject to ischemic compromise, especially in certain high risk populations. A preoperative delay procedure can decrease the likelihood of TRAM flap failure or fat necrosis, but the required extent of this delay procedure is not clearly defined. In an attempt to augment flap vascularity while reducing surgical dissection and morbidity, six distinct delay procedures and a nondelayed control were compared in a rat TRAM flap model (n = 8 for all groups). An important feature that was incorporated into several groups was the ligation of the contralateral rectus perforators through minimal skin incisions (endoscopic analogy, groups 4 to 7). The most effective delay procedure was the combination of contralateral rectus perforator ligation and ipsilateral dominant pedicle ligation (group 7), which was achieved with two minimal skin incisions and no significant flap undermining. This procedure reduced the flap necrosis from 63.2 +/- 5.8 percent (control) to 13.5 +/- 3.3 percent (p < 0.001). After completion of the animal studies, clinical application of a "minimally invasive" TRAM flap delay procedure was then undertaken in eight high risk patients with only modest ischemic compromise. Although the clinical experience is too early to draw definite conclusions, we feel that "endoscopic delay" has potential as a modality that will increase flap vascularity but minimize the morbidity of the preliminary procedure.

Animals↗
PubMed2002

Outcomes of scapula stabilization in obstetrical brachial plexus palsy: a novel dynamic procedure for correction of the winged scapula.

Among the late consequences of obstetrical brachial plexus palsy is winging of the scapula, a functional and aesthetic deformity. This article introduces a novel surgical procedure for the dynamic correction of this clinical entity that involves the dynamic transfer of the contralateral trapezius muscle and/or rhomboid muscles and anchoring to the affected scapula. In more severe cases of scapula winging, the contralateral latissimus dorsi muscle may also need to be transferred to achieve dynamic scapula stabilization. The outcomes of this novel surgical procedure were analyzed in relation to the effect on abduction, external rotation, growth of the scapula, and distance of the scapula from the posterior midline. The results were analyzed in 26 patients who underwent this procedure and had adequate follow-up. The mean patient age was 6.39 years. Fourteen (54 percent) had a diagnosis of Erb palsy, and 12 (46 percent) had a diagnosis of global paralysis. All 26 patients had an additional secondary procedure performed prior to or simultaneously with the scapula stabilization procedure. In 19 patients, the contralateral trapezius was transferred and anchored to the medial border of the winged scapula alone, but in seven cases the underlying rhomboid major was transferred along with the trapezius muscle to provide sufficient scapula stabilization. In five cases in which the scapula winging was severe, the contralateral latissimus dorsi muscle was transferred at a second stage. After this procedure, all patients demonstrated improved scapula symmetry. The mean increase in abduction was 18 degrees (p < 0.001), the mean increase in external rotation was 19 degrees (p < 0.001), and the mean increase in anterior flexion was 12 degrees (p = 0.015). The improvement of the relative position of the winged scapula on the posterior thorax was analyzed by measuring the distance of the inferior angle of both scapulae from the midline, then calculating the difference between normal and affected sides and comparing this value before and after the scapula stabilization procedure. This value preoperatively was 3.24 cm; postoperatively it decreased to 0.36 cm (p < 0.001), demonstrating a statistically significant improvement.

Adolescent↗
PubMed1996

Confidence in performance of pediatric emergency medicine procedures by community emergency practitioners.

OBJECTIVE: To survey a cohort of physicians who work in general community emergency departments (ED) in order to assess their comfort levels in performing urgent and emergent medical procedures on children. METHODS: One hundred seventeen emergency physicians were surveyed at 23 institutions within the referral base of Hasbro Children's Hospital, a tertiary care pediatric ED. Physicians rated their comfort levels (4-point scale: 1 = comfortable, 2 = moderately comfortable, 3 = uncomfortable but would perform in an emergency, 4 = uncomfortable and would never perform) for all procedures in which the American Academy of Pediatrics recommends competence for pediatric emergency physicians. RESULTS: Sixty (51%) physicians completed the survey. Residency training included internal medicine, family practice, surgery, general practice, pediatrics, and emergency medicine, while only 32 (53%) were Board certified in emergency medicine. All respondents treated pediatric patients. Over 25% were uncomfortable (level 3 or 4) with performing certain potentially life-saving pediatric procedures. These included cardioversion, defibrillation, external pacing, nasal intubation, needle cricothyrotomy, rapid sequence intubation, laryngoscopy, tracheostomy replacement, chest tube placement, vascular cutdowns, emergency childbirth, pericardiocentesis, intraosseous line placement, infant subdural and ventriculoperitoneal (V-P) shunt taps, and upper airway foreign body removal. Over 25% of respondents were also uncomfortable with non-life-saving procedures such as temperomandibular joint (TMJ) reductions, tooth reinsertions, rape evaluations, suprapubic taps, tympanocentesis, retrograde urethrograms, thoracentesis, paraphimosis reduction, ear foreign body removal, and pain management. CONCLUSION: While emergency physicians within the catchment area of a tertiary care children's hospital feel comfortable with most pediatric procedures, they express a significant degree of discomfort with many potentially life-saving skills. Because of the infrequent need for many of these interventions in children, the high levels of discomfort are not surprising. These procedures may most comfortably be performed at pediatric centers but can be accomplished well at all EDs if personnel are adequately trained. A strong working relationship with pediatric emergency centers and an enhanced teaching of these procedures may increase comfort levels with these potentially life-saving measures.

Attitude of Health Personnel↗
PubMed2000

Incidence of intravascular uptake in lumbar spinal injection procedures.

STUDY DESIGN: Multicenter, prospective, observational study. OBJECTIVES: To document the incidence of and factors associated with intravascular uptake during lumbar spinal injection procedures. SUMMARY OF BACKGROUND DATA: In prior reports, the incidence of inadvertent intravascular needle placement during contrast-enhanced, fluoroscopically guided lumbar spinal injection procedures has been incidentally noted to range from 6.4% to 9.2%. We present the first systematic prospective documentation of intravascular uptake of contrast dye during different types of lumbar injection procedures. METHODS: Fifteen interventional spine physicians in seven centers recorded data regarding intravascular uptake during 1219 contrast-enhanced, fluoroscopically guided lumbar spinal injection procedures. RESULTS: The overall incidence of intravascular uptake during lumbar spinal injection procedures as determined by contrast enhanced fluoroscopic observation is 8.5%. Caudal and transforaminal routes have the highest rates at 10.9% and 10.8%, respectively, followed by zygapophyseal joint (6.1%), sacroiliac joint (5.3%), and translaminar (1.9%) injections. Intravascular uptake is twice as likely to occur in those patients over rather than under 50 years of age. Preinjection aspiration failed to produce a flashback of blood in 74% of cases that proved to be intravascular upon injection of contrast dye. CONCLUSION: The incidence of intravascular uptake during lumbar spinal injection procedures is approximately 8.5%. The route of injection and the age of the patient greatly affect this rate. Absence of flashback of blood upon preinjection aspiration does not predict extravascular needle placement. Contrast-enhanced, fluoroscopic guidance is recommended when doing lumbar spinal injection procedures to prevent inadvertent intravascular uptake of injectate.

Adolescent↗
PubMed2002

Transpedicular decompression and pedicle subtraction osteotomy (eggshell procedure): a retrospective review of 59 patients.

STUDY DESIGN: Outcomes of transpedicular decompression and/or osteotomy were analyzed retrospectively. OBJECTIVES: To determine the effectiveness of decompression and correction, fusion stability, procedural safety, neurologic outcome, complication rates, and overall patient outcomes. SUMMARY OF BACKGROUND INFORMATION: The "eggshell" procedure is reserved for complex reconstructive problems in the treatment of acute trauma, deformity, tumor, or infection. The technique encompasses a range of procedures from simple transpedicular decompression and posterior fusion to more complex procedures, including transpedicular vertebrectomy and strut-grafting or pedicle subtraction (closing wedge) osteotomy with posterolateral fusion. These procedures are completed through a single posterior midline incision, with anterior spinal canal decompression a transpedicular approach, accompanied by a posterior or posterolateral fusion and internal fixation. METHODS: From 1990 to 1998, 59 "eggshell" procedures were performed for 37 deformity cases and 22 tumor or infection cases. Forty-two patients had a minimum 2-year follow-up, averaging 4.5 +/- 2.5 years. Thirty-six patients were available for patient interview, physical examination, and radiographic analysis. Outcome data were collected using SF-36 and SRS instruments. RESULTS: No patients worsened neurologically, and all incomplete spinal cord injuries improved. All patients achieved solid fusion radiographically. Correction with osteotomy averaged 26 degrees. Systemic complication rates were low with a pulmonary complication rate of 5%. Blood loss averaged 2342 mL. Overall patient outcomes were below population norms, but patient satisfaction was very high. CONCLUSION: Overall, the results suggest that the "eggshell" procedure is a reliable and safe technique to achieve anterior decompression of the spinal canal and posterior stabilization through a single approach.

Adolescent↗
PubMed2004

Immunohistochemical evaluation of hormone receptors in breast cancer: which scoring system is suitable for highly sensitive procedures?

To evaluate hormone receptors immunohistochemically, standardized staining procedures and scoring systems are required. The authors previously reported that highly sensitive procedures affected basic factors for technical validation. The aim of the present study was to show the characteristics of scoring systems for highly sensitive procedures. To examine how highly sensitive procedures enhance the staining intensity and increase the positive cell population, two different staining methods were compared. To evaluate scoring systems, three systems--cell counting score, modified immunoreactive score, and H score--were compared using the same samples stained by an autostaining system. It was found that the highly sensitive procedure increased the positive cell population, especially in breast cancers with a low enzyme immunoassay (EIA) level of less than 100 fmol/mg, and strengthened the staining intensity. This enhancement led to a correlation in a logarithmic curve rather than a linear correlation by all three scoring systems. The results showed that scoring systems including a factor of staining intensity did not have an absolute advantage because boosted staining intensity by highly sensitive procedure did not reflect EIA value or protein contents accurately. To the authors' knowledge, there is no report discussing the nonlinear correlation between biochemical and immunohistochemical assay by highly sensitive procedures; however, it is important to select a scoring system and threshold based on nonlinear correlation.

Breast Neoplasms↗
PubMed2004

Operative technique of a new decompression procedure for Kienböck disease: partial capitate shortening.

A new decompression procedure for Kienböck disease, namely "partial capitate shortening," was developed. Patients in Lichtman stages 2 and 3A, independent of the ulnar variance, are candidates for this procedure. This procedure can dramatically reduce compressive forces on the lunate almost as much as a traditional decompression procedure of the capitate (capitate shortening combined with capitate-hamate fusion) and much more than the decompression procedure of the forearm bone such as radial shortening. We surmise that our procedure will allow better lunate revascularization. Although the scaphoid progressively adopts an abnormal palmarflexed position after capitate shortening combined with capitate-hamate fusion, partial capitate shortening can maintain normal carpal alignment, resulting in better joint congruency around the scaphoid and range of motion of the wrist. Moreover, partial capitate shortening allows minimal invasion and is an easy technique without bone grafting. Both operating and immobilizing time are shortened, and there are no secondary problems in the distal radioulnar and/or ulnocarpal joint often seen after radial osteotomy procedures.

Journal Article↗
PubMed2004

Fingertip replantation using the subdermal pocket procedure.

Restoration of finger length and function are the goals of replantation after fingertip amputation. Methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. To increase the survival rates for composite grafts, the subcutaneous pocket procedure has been used as a salvage procedure. The subdermal pocket procedure, which is a modification of the subcutaneous pocket procedure, was used for replantation of 17 fingertips in 16 consecutive patients. Eight fingertips experienced guillotine injuries and the other nine fingertips experienced crush injuries. Revascularization of one digital artery without available venous outflow was performed for six fingers, and composite graft techniques were used for the other 11 fingers. The success rate was 16 of 17 cases. The difference in success rates for guillotine versus crush injuries was statistically significant. Comparison of patients with arterial anastomoses and patients without arterial anastomoses also indicated a statistically significant difference. Thirteen fingertips survived completely. One finger, demonstrating complete loss and early termination of the pocketing procedure, was amputated on the eighth postoperative day. Two fingers were partially lost because of severe crushing injuries. One finger demonstrated partial loss of more than one quarter of the fingertip, which required secondary revision, because the patient was a heavy smoker. The pocketing period was 8 +/- 1 days (mean +/- SD, n = 6) for the fingers revascularized with one digital arterial anastomosis and 13.3 +/- 1.9 days (n = 10) for the fingers successfully replanted with composite graft techniques. The mean active range of motion of the interphalangeal joint of the three thumbs was 65 +/- 5 degrees, and that of the distal interphalangeal joint of the other 11 fingers was 51 +/- 11 degrees. The static two-point discrimination result was 6.4 +/- 1.0 mm (n = 14) after an average of 11 +/- 5 months of follow-up monitoring. Compared with other methods, the subdermal pocket procedure has the advantages of exact subdermal/subdermal contact, a shorter pocketing period, and more feasible observation. The method can offer an alternative salvage procedure for fingertip amputations with no suitable vessels available for microsurgical replantation.

Adolescent↗
PubMed2004

Written clinic procedures enhance delivery of HIV "prevention with positives" counseling in primary health care settings.

BACKGROUND: The Institute of Medicine recommends prevention counseling in primary health care settings to help HIV-infected individuals reduce the risk of transmitting HIV to others ("prevention with positives"). In this study, we assessed receipt of HIV prevention counseling by patients seen in clinics funded by the Ryan White CARE Act, a major source of support for HIV primary care. METHODS: Six hundred fourteen HIV-infected patients completed an exit survey immediately after an HIV primary care visit at 16 clinics in 9 states. Patient characteristics and frequency of receipt of HIV prevention counseling were measured. Clinic approaches to HIV prevention were coded as clinics with written procedures, clinics where individual providers initiated counseling because of a personal sense of responsibility, and clinics with no procedures. RESULTS: HIV-infected patients in clinics with written procedures were significantly more likely to report receiving HIV prevention counseling in the last 6 months than were patients in clinics with no procedures (odds ratio [OR] = 3.17, 95% confidence interval [CI]:1.24-8.06; P < 0.02). In clinics where individual providers initiated counseling and in clinics with no procedures, patient characteristics such as race, gender, and sexual orientation were associated with receipt of prevention counseling. These differences were not observed in clinics with written procedures, however. CONCLUSION: Written procedures provide an important guide for clinic staff and increase the likelihood that patients receive prevention with positives counseling irrespective of patient characteristics.

Adolescent↗