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Preventive care attitudes of medical students.

Presently developing attitudes of future physicians towards preventive medicine will likely provide either a major impetus for or barriers to the inclusion of preventive medicine content in medical school curricula and in other formats of physician education. In turn, attitudes about preventive care and its role in medical practice will continue to have a large influence on how much disease prevention and health promotion emphasis physicians provide in their practices. Consequently, it becomes important to study how medical students' attitudes evolve during the process of medical education. Furthermore, to the extent that we can better understand how desired attitudes can be developed and nurtured, the practice of preventive medicine may become more purposeful. Beginning and third-year medical students were surveyed with a 100-item questionnaire designed to assess their attitudes regarding: the relative importance of 20 specific preventive services to the practice of medicine and the adequacy of preclinical coursework for preparing them to offer preventive care in medical practice. The confidence of third year students' in the ability of primary care physicians to provide these specific services was also assessed. Preventive care service areas about which third-year students expressed high confidence in the ability of physicians to provide were: immunizations, health screening physicals, blood pressure control, cancer detection education, family planning, health counseling/education, and sexually transmitted disease prevention. Services that students had low confidence in the ability of physicians to provide were: smoking cessation, nutrition counseling/education and weight reduction.(ABSTRACT TRUNCATED AT 250 WORDS)

Attitude of Health Personnel↗

Social relationships and health: the relative roles of family functioning and social support.

The associations between social relationships and health have been examined using two major research traditions. Using a social epidemiological approach, much research has shown the beneficial effect of social supports on health and health behaviors. Family interaction research, which has grown out of a more clinical tradition, has shown the complex effects of family functioning on health, particularly mental health. No studies have examined the relative power of these two approaches in explicating the connections between social relationships and health. We hypothesized that social relationships (social support and family functioning) would exert direct and indirect (through depressive symptoms) effects on health behaviors. We also hypothesized that the effects of social relationships on health would be more powerfully explicated by family functioning than by social support. We mailed a pilot survey to a random sample of patients attending a family practice center, including questions on depressive symptoms, cardiovascular health behaviors, demographics, social support using the ISEL scale, and family functioning using the FEICS scale. FEICS is a self-report questionnaire designed to assess family emotional involvement and criticism, the media elements of family expressed emotion. Eighty-three useable responses were obtained. Regression analyses and structural modelling showed both direct and indirect statistically significant paths from social relationships to health behaviors. Family criticism was directly associated (standardized coefficient = 0.29) with depressive symptoms, and family emotional involvement was directly associated with both depressive symptoms (coefficient = 0.35) and healthy cardiovascular behaviors (coefficient = 0.32). The results support the primacy of family functioning factors in understanding the associations among social relationships, mental health, and health behaviors. The contrasting relationships between emotional involvement and depressive symptoms on the one hand and emotional involvement and health behaviors on the other suggest the need for a more complex model to understand the connections between social relationships and health.

Adult↗

Patient satisfaction with communication in general surgery: problems of measurement and improvement.

The research reported here is taken from a pilot inquiry into patient experiences of general surgery provided in National Health Service hospitals. This study sought to identify how the cross section of patients facing general surgery experienced communication and information problems particular to their surgical 'settings', how such discontent is understood or rationalised by them, and consequently how it would be reported to relatives or researchers. Drawing on interviews with patients and surgical staff, the paper explores the range of communication difficulties facing certain types of patient which arise from the hospital setting and the routines and rituals of service providers. While it is concluded that communication should be explored with some reference to disease classification, this should not divert attention from the general context of care to the unique circumstances of patient or surgeon. It is questioned whether patients are always disposed to rationalise their difficulties in terms of 'dissatisfaction' in the way required by survey research. Drawing on interview-generated comments by patients and staff, the paper illustrates less obvious validity problems for patient satisfaction studies, and addresses briefly questionnaire design which may account for them.

Adult↗

Knowledge of the human immunodeficiency virus among final year dental students.

A sound basis of knowledge about HIV infection and AIDS is essential to allow students to develop as dentists who undertake appropriate measures during clinical practice. In addition, it is also likely that possessing appropriate information may instil confidence in their own ability to diagnose and then manage patients infected by HIV. A questionnaire designed to test the knowledge of final year dental students in the UK was completed by 60.5% of students in 15 out of the 16 dental schools in the UK. Generally, the students rated the teaching they had received about cross-infection precautions, virology, sterilization practice and procedures and recognition of blood-borne virus risk groups as adequate or more than adequate. However, there was a lower degree of satisfaction expressed for instruction in the management of blood-borne virus carriers and the performance of barrier dentistry. Most dental students were aware of the association of hairy leukoplakia, oral Kaposi's sarcoma, oral candidiasis as a whole, and thrush as one clinical variant, with HIV infection but there was a much lower level of knowledge of erythematous candidiasis, HIV-associated salivary gland disease, oral melanotic hyperpigmentation and idiopathic thrombocytopenic purpura. This study highlights some important gaps in the knowledge of final year dental students about HIV and AIDS.

AIDS-Related Opportunistic Infections↗

A comparison of primary dysmenorrhoea and intrauterine device related pain.

A pain questionnaire designed to measure sensory, affective, evaluative and temporal components of pain was administered to 119 patients with primary dysmenorrhoea and 75 patients with intrauterine device (IUD) related pain. In addition "self-report" information was obtained on the behavioural effects of pain, global ratings and biographical details of these patients. It was found that dysmenorrhoea and IUD related pain were generally similar in nature. This led to the conclusion that IUD insertion does not in general lead to an exacerbation of presenting dysmenorrhoea, nor does it radically alter the type of sensations experienced by the patient. While no differences between patient groups emerged, the implications of the different pain components did vary. Thus, pain intensity scores were reflected in a larger sensory component with IUD users, whereas with dysmenorrhoea the affective component predominated. The results show sufficient consensus in the two patient groups of word adjectives used to describe their pain, to allow the development and evaluation of a rapid card sort system for pain assessment.

Abdomen↗

Psychoactive substance use: some associated characteristics.

A questionnaire designed to assess the prevalence of psychoactive substance use and its relation with: (a) central nervous system risk factors, (b) associated disorders (allergies, migraine-type headaches, developmental dyslexia history, smoking, suicide attempt, and sleep disorders), and (c) cognitive-type symptoms, was given to a general population sample of 1,879 university students (mean age = 24.0) from Bogotá (Colombia, South America). A prevalence of 3.4% of self-reported psychoactive substance use was found. Results indicated that the incidence of some risk factors of minor brain injury or dysfunction, smoking, suicide attempt, and headache was higher among the self-reported psychoactive substance users than among nonusers. Cognitive-type symptoms, except suicide ideation, did not differ between drug users and nonusers. Current results point to a significant association between psychoactive substance use and depressive symptoms, and there was no significant association between psychoactive substance use and psychotic ideation.

Adolescent↗

Knowledge and views on drug abuse of primary health care workers in Nigeria.

Primary health care (PHC) in Nigeria (as in many developing countries) relies heavily on paramedical personnel. Using a self-report structured questionnaire design, 207 PHC workers were assessed on their knowledge and views about drug and alcohol abuse. PHC workers with previous exposure to some form of drug abuse training were significantly more likely to be aware of the correct usage for the term 'drug abuse', although the whole range of drugs of abuse/dependence was much less well appreciated. Drugs reported by the PHC workers to be commonly abused in the study area were in keeping with previous findings on drug abuse in the country. However, 75.4% of the PHC workers perceived drug abuse as a low grade problem, in contrast to recent reports, of the increasing magnitude of drug abuse problems in the country. About one fifth of PHC workers were of the opinion that drug abusers should be punished. Only 35 (16.9%) of those who indicated the need for treatment mentioned that this could be carried out by PHC personnel. Many of the PHC workers showed limited knowledge of factors associated with drug abuse and on the scope of preventive strategies against drug abuse. Suggestions are made on the short and long term training needs of the PHC workers in order to ensure the successful incorporation of drug abuse treatment and prevention programmes into the PHC programme in Nigeria.

Adult↗

Family history of autoimmune diseases in psychosis.

The mothers of 101 psychotic patients and 116 normal controls were interviewed using a semi-structured questionnaire designed to determine the presence or absence of autoimmune disorders in first degree relatives of the probands. Thyrotoxicosis and insulin-dependent diabetes mellitus were significantly more common in the relatives of the psychotic patients than in the control relatives; in particular thyrotoxicosis was more frequent in the mothers of patients (11%) than the mothers of controls (2.6%). None of the examined characteristics of the patients, including RDC-diagnosis, family history of psychosis, age at onset of psychosis and winter birth, was predictive of thyrotoxicosis and insulin-dependent diabetes mellitus in relatives.

Adolescent↗

Do-not-resuscitate orders in the presurgical patient.

STUDY OBJECTIVE: To assess the policy and practice of anesthesiology departments in regard to their management of the presurgical do-not-resuscitate (DNR) patient. DESIGN: Questionnaire distributed to the program directors of 156 accredited residency programs in anesthesiology in the contiguous United States. SETTING: University hospital. MEASUREMENTS AND MAIN RESULTS: One hundred twelve of the 156 accredited U.S. programs responded to the questionnaire. The majority (81%) of programs that have a DNR policy for the presurgical patient suspend the order prior to surgery. However, only 50% of the institutions responding have standing policies, and of those that do not, only 40% plan to initiate such a policy. CONCLUSIONS: The need for a written policy for the DNR patient undergoing surgery is exemplified by the low percentage of institutions that have existing policies.

Anesthesia Department, Hospital↗

Bacterial endocarditis prophylaxis: what is recommended and what is practiced?

STUDY OBJECTIVE: To determine how often pediatric anesthesiologists follow the American Heart Association (AHA) recommendations for the administration of prophylactic antibiotics to prevent bacterial endocarditis (BE). DESIGN: Questionnaires mailed to all members of the Society for Pediatric Anesthesia regarding their use of antibiotics to prevent BE. SETTING: Anesthesia department at a university-affiliated children's hospital. MEASUREMENTS AND MAIN RESULTS: 898 questionnaires were mailed, and 465 questionnaires were returned, yielding a response rate of 52%. When anesthesiologists administer BE prophylaxis intravenously (IV), they perform an inhalation anesthetic 76% of the time prior to establishing IV access. Ninety percent of the respondents stated that if administration of antibiotics occurs after a mask induction, they do not delay incision or instrumentation for 30 minutes. Therefore, respondents do not follow AHA recommendations for BE prophylaxis 55% of the time. Of the 465 respondents, only 4 recalled pediatric patients who developed perioperative BE. CONCLUSIONS: The majority of anesthesiologists responding to this survey routinely do not follow the current AHA recommendations for BE prophylaxis when caring for children. Since there are no studies demonstrating that administering antibiotics 30 minutes prior to invasive procedures is more effective than administering antibiotics immediately prior to invasive procedures, it may be appropriate to follow a time sequence that is more comfortable and convenient for pediatric patients. We believe that a reconsideration of the current AHA recommendations for BE prophylaxis is warranted.

American Heart Association↗

Management of tracheobronchial and esophageal foreign bodies in children: a survey study.

STUDY OBJECTIVE: To assess the current anesthetic management for aspiration of a foreign body into the airway and esophagus of a young child. DESIGN: Questionnaire study. MEASUREMENTS AND MAIN RESULTS: A questionnaire regarding choice of induction technique in a variety of foreign body clinical scenarios was sent to 1,342 anesthesiologists, all members of the Society for Pediatric Anesthesia. The foreign body, either a coin (penny) or a safety pin (open), was positioned on radiography in a variety of anatomic locations. Depending on the foreign body location, the patient was either asymptomatic or exhibited symptoms. Participants indicated their choice of induction for each situation. Of the 1,342 questionnaires mailed, there were 838 respondents (62.4%). Coins and pins in the gastroesophageal tract were managed mostly by a rapid-sequence induction (p < 0.001). Coins and pins at all levels in the tracheobronchial tree were managed most often by a mask induction with no cricoid pressure (p < 0.001). Although 14.5% of respondents chose awake and sedated technique for a foreign body in the supraglottic area, few chose this technique for a foreign body in other locations. The type of object did not affect the choice of drugs for induction of anesthesia in most anatomic locations. Respondents with limited pediatric anesthesia experience used inhalation induction much less often than did those with more experience. Multiple-logistic regression analysis showed that both number of years in practice and type of practice (university, private, hybrid) were predictors for the induction. CONCLUSIONS: These data indicate that inhalation induction is favored most often for removal of foreign bodies in the airway, while intravenous induction is preferred for removal of foreign bodies in the gastroesophageal tract. In addition, practice type, greater percentage of time spent in pediatric anesthesia, and greater experience are related to a higher likelihood of inhalation induction.

Anesthesia↗

Factors that influence an anesthesiologist's decision to cancel elective surgery for the child with an upper respiratory tract infection.

STUDY OBJECTIVE: To examine factors that anesthesiologists consider when making decisions regarding elective surgery cancellation of the pediatric patient with an upper respiratory infection (URI). DESIGN: Questionnaire survey. SETTING: Anesthesiology departments and/or practices throughout the United States. PARTICIPANTS: 212 anesthesiologist members of the Society for Pediatric Anesthesia (SPA). MEASUREMENTS AND MAIN RESULTS: A total of 400 questionnaires were mailed to anesthesiologists randomly selected from the membership of the SPA. Of these questionnaires, 212 (54%) were completed and returned. Of these respondents, 71 (34.5%) reported that they seldom (1% to 25% of the time) cancelled cases due to an URI, and 43 (20.9%) stated that they usually (76% to 99% of the time) cancelled in the event of an URI. Two respondents (1%) reported never cancelling due to an URI, and six (2.9%) stated that they always cancelled. Frequency of cancellation was independent of type of practice. However, anesthesiologists who had been in practice for more than 10 years were significantly more likely to cancel than those who had been in practice for less than 10 years (p < 0.05). Factors that were considered most important in making decisions regarding cancellation included the urgency of the surgery and the presence of asthma. Other important considerations included fear of complications and the anesthesiologist's previous experience anesthetizing children with URIs. Factors related to the economics and inconvenience of cancellation did not influence the decision to cancel surgery. These factors included distance traveled, cost of cancellation, attitude of the parents, fear of litigation, and pressure to complete cases expediently. CONCLUSIONS: The results of this survey demonstrate a wide range of opinions and approaches to this enduring clinical dilemma. However, it appears that the practice of cancelling elective surgery for children with URIs may be changing over time, since younger anesthesiologists appear to cancel less often than their more experienced counterparts. It is hoped that this information will be useful to practioners in their evaluation and management of children with colds and will stimulate further investigation into this important clinical problem.

Anesthesia↗

Survey of knowledge, attitudes and practices for tuberculosis among general practitioners.

SETTING: Representative sample survey of knowledge, attitudes and practices (KAP) for tuberculosis among private general practitioners (GPs) in 1993 in Korea, OBJECTIVE: To investigate the KAP of general practitioners on the prevention and treatment of tuberculosis. DESIGN: Questionnaire surveys were performed for 923 private general practitioners through 29 health centres. RESULTS: 49% of GPs considered that the Korean tuberculosis situation is not serious. 54% were worried about infection from patients. 47% answered that BCG vaccination causes untoward reactions with no or limited effectiveness. 47% considered the National Tuberculosis Programme (NTP) unfavourably. Over 50% did not consider sputum examination essential in case finding/diagnosis, and 75% in monitoring of treatment response. For initial treatment of active tuberculosis, only 11% were prescribing the current Korean NTP's six-month standard regimen. 73% were giving currently non-recommendable regimens, and 16% unacceptably bad regimens. However, this situation could be improved, as 80% of GPs expressed the wish to acquire knowledge. CONCLUSION: Many misunderstandings were found in the field of transmission, BCG vaccination and the performance of the NTP; sputum examinations were considerably neglected in case finding/diagnosis and treatment monitoring. As for treatment, 89% were giving either non-recommendable regimens or bad regimens.

Adult↗

Pregnancy during the use of levonorgestrel intrauterine system.

OBJECTIVES: This study was undertaken to evaluate the pregnancy rate with the levonorgestrel intrauterine system (LNG IUS) and to analyze the outcome of pregnancies with the LNG IUS in situ in regular use. STUDY DESIGN: Questionnaires from 17,360 users of the LNG IUS were analyzed. With the consent of women reporting pregnancy during the use of the LNG IUS, related hospital records were reviewed concerning the pregnancies. RESULTS: Originally 132 pregnancies were reported. Medical records were reviewed from 108 of these women. In 64 pregnancies, conception occurred with the LNG IUS in situ. Thirty-three pregnancies were ectopic. The 5-year cumulative pregnancy rate per 100 users was 0.5 and the 5-year Pearl rate was 0.11. CONCLUSION: Pregnancy with the LNG IUS in situ is rare. Ectopic pregnancies constitute 53% of all pregnancies. Typical pregnancy symptoms occur during pregnancies with the LNG IUS. The importance to counsel about the risk of pregnancy before insertion is emphasized.

Contraceptive Agents, Female↗

Complications of laparoscopy: an inquiry about closed- versus open-entry technique.

OBJECTIVE: The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands. STUDY DESIGN: Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected. RESULTS: Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively (P<.001). Significantly more visceral lesions were found (P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively. CONCLUSION: Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.

Female↗

Heavier workload, less personal control: Impact of delivery on obstetrician/gynecologists' career satisfaction.

OBJECTIVE: Obstetrician/gynecologists' career satisfaction with certain work-related activities was examined among clinicians who perform deliveries and clinicians who do not. STUDY DESIGN: A questionnaire was sent to 1500 member-fellows of the American College of Obstetricians and Gynecologists; 842 members (56%) responded. The questionnaire was designed to distinguish between obstetrician/gynecologists who perform deliveries and clinicians who do not in the areas of satisfaction with specific aspects of career and work-related activities. Data were examined initially by multivariate analysis of variance and subsequently by univariate analysis of variance if the multivariate test was found to be significant. RESULTS: Workload and personal control were the primary factors for which there was a significant difference in satisfaction between clinicians who perform deliveries and clinicians who do not (P<.001). Obstetrician/gynecologists who do not perform deliveries reported working significantly fewer hours per week (P<.001) and had more satisfaction with their work activities than the delivery group overall. Despite lowered satisfaction with certain career aspects among the delivery Group, the highest positive disposition ratings that was given by respondents were for surgery, vaginal delivery, and planned cesarean delivery, with gender differences observed in the level of disposition for these particular activities. The most negative rating was reported for on-call/in-hospital time. CONCLUSION: Although positive disposition is associated with the activity of vaginal and cesarean delivery overall, 2 primary contributing factors of dissatisfaction that were identified among obstetrician/gynecologists who perform deliveries were increased workload and decreased personal control.

Delivery, Obstetric↗

Acoustic parameters of snoring sound to assess the effectiveness of the Müller Manoeuvre in predicting surgical outcome.

OBJECTIVE: To assess the effectiveness of the Müller Manoeuvre in predicting surgical outcome in non-apnoeic snorers. METHODS: Forty-one non-apnoeic snorers performed the Müller Manoeuvre, prior to palatal surgery for snoring. Pre-operatively and between 1.0 and 4.1 months (mean 2.5 months) post-operatively, patients were admitted overnight when their sleeping position and snoring sounds were recorded. At the time of the post-operative recordings, patients were required to complete a specifically designed questionnaire. Snore files comprising the inspiratory component of the first 100 snores whilst the patient was supine, were extracted. Snore duration (s), snore loudness (dBA), snore periodicity (%) and the energy ratios for the frequency bands 0-200, 0-250 and 0-400 Hz were calculated. Only patients who showed improvements in snore periodicity and all energy ratios were considered to be surgical successes. In addition, patients were also categorised as 'successes' or 'failures' depending on their responses to specific questionnaire questions. The effectiveness of the Müller Manoeuvre in predicting surgical outcome was then tested using these categories. RESULTS: The 41 patients included 35 men and 6 women. Mean age: 47 years (24-67 years). Mean PNIFR 145 (80-230). Median reported alcohol intake was 11-15 units/week (0 to 26-30 units/week). Mean BMI: 30.6 kg/m2 (24.3-47.2 kg/m2). Twenty-four patients underwent an uvulopalatal elevation palatoplasty and seventeen a traditional palatoplasty. Following the Müller Manoeuvre, patients were categorised as 'ideal', 'suboptimal, but acceptable' or 'unsuitable' for surgery. Using the acoustic parameters, 23/41 patients were considered a surgical success, whilst 18/41 were considered failures. Using the questionnaire responses, 14/40 patients were considered a surgical success, whilst 26/40 were considered failures. There was no correlation between the subjective and objective outcomes (rho=0.193; p=0.227). Neither pre-operative BMI, type of palatoplasty performed, patient gender, age, PNIFR or reported alcohol intake were confounders of surgical outcome. For patients considered 'ideal' and 'suboptimal, but acceptable', using acoustic outcomes, the Müller Manoeuvre had a specificity of 55.5% and a sensitivity of 30.4%, compared with a sensitivity of 57.7% and a specificity of 28.6% when questionnaire responses were used. If only patients considered 'ideal' were considered, the specificity was 66.7%, and the sensitivity 21.7% when using acoustic outcomes, compared with a sensitivity of 69.2% and a specificity of 78.6% when questionnaire responses were used. CONCLUSION: The Müller Manoeuvre appears to have no role in the pre-operative assessment of palatal surgery for non-apnoeic snorers.

Adult↗

Behavioral and mental health problems in low-income children with special health care needs.

This study examined caregiver perceptions of mental health problems and counseling needs in low-income children with special health care needs (CSHCN). Interviewers collected data from 257 caregivers of CSHCN (61% males; 60% African American; Mean age = 8.4 years) attending six Midwestern inner-city health clinics. Measures included the Child Behavior Checklist (CBCL) and an investigator-designed questionnaire. CBCL T-scores indicated that 38% of CSHCN had a behavioral or mental health problem, but only 26% of caregivers perceived the need for treatment or counseling. CSHCN should be assessed and referred appropriately for behavioral and mental health problems during routine health care visits.

Adolescent↗