Family practitioners' attitudes and knowledge about irritable bowel syndrome: effect of a trial of physician education

BACKGROUND

Primary physicians care for most patients with irritable bowel syndrome (IBS), but data on their attitudes and knowledge about the disorder are limited to research in the UK.

OBJECTIVE

The purpose of the present study was to assess US family practitioners' attitudes and knowledge about IBS and determine the effect of a single education class on these measures.

METHODS

In a large health maintenance organization (HMO), a baseline group of family practitioners twice completed a questionnaire on attitudes and knowledge about IBS, 3 months apart. A class group completed it pre-class, immediately post-class and 3 months post-class.

RESULT

Thirty-five physicians ranked IBS among five chronic, painful syndromes as highest in difficulty satisfying patients, tied with headache for highest in difficulty in practice strategy decision, second in time required, and fourth in diagnostic confidence and satisfaction in caring for patients. IBS and heartburn had widely separated rankings in all five attitudes. The correct answer rate on seven of 13 knowledge questions was <50%, and a majority did not identify the Rome II symptom criteria as typical and lacked other important knowledge. Of the 30 class physicians, the knowledge scores (mean +/- SD; maximum possible, 13) of 29 increased from 5.59 +/- 1.84 pre-class to 10.21 +/- 1.76 immediately post-class (P < 0.0001); 3 months later, the scores were lower (8.93 +/- 0.36) than post-class (P < 0.0001), but still higher than pre-class (P < 0.0001). Their attitude rankings were nearly identical pre-class and 3 months later (P > 0.05). In the 19 baseline physicians, IBS attitude rankings and knowledge scores did not change significantly over 3 months (P > 0.05).

CONCLUSION

These US family practitioners had attitudes about IBS patients and lacked knowledge that could interfere with patient care. A single class improved short-term knowledge but had little effect on attitudes about IBS.

The efficacy of silver-ion implanted catheters in reducing peritoneal dialysis-related infections

BACKGROUND

Dialysis-related infections are the commonest cause of catheter loss and transfer to hemodialysis. Surface modifications of the catheter that reduce infections are of major importance.

OBJECTIVE

The efficacy of silver-ion treated catheters in reducing dialysis-related infections was tested.

METHODS

The study design was a prospective, randomized controlled trial. Patients were implanted with either a silver-treated study catheter or a control catheter. Prospective collection of data included infectious complications and catheter survival.

RESULTS

The subject groups were comprised of 67 silver-treated catheters and 72 control catheters. Demographic characteristics of the study and control groups were equal. Exit-site infection rates for the study group and control group (0.52 and 0.45 episodes/patient-year of dialysis respectively) were not different by Poisson regression analysis (p > 0.4). Peritonitis rates were identical for the two groups (0.37 episodes/patient-year) and were not different by Poisson analysis (p > 0.9). Antibiotic-free intervals between infections for the study and control groups were not significantly different for exit-site infections (p = 0.58), peritonitis (p = 0.44), or both infections combined (p = 0.47). Actuarial analyses showed no differences between the groups in the probability of remaining free of exit-site infection (p > 0.2) or peritonitis (p > 0.7). Similarly, catheter survival was not significantly different between the groups (p > 0.6).

CONCLUSION

Surface modification of catheters with ion beam implantation of silver produced no clinical effect with respect to reducing dialysis-related infections.

Penicillin skin testing in advance of need: multiyear follow-up in 568 test result-negative subjects exposed to oral penicillins

BACKGROUND

There are few published data on adverse drug reactions and/or resensitization associated with oral penicillin use in penicillin allergy history-positive/penicillin skin test-negative individuals during routine clinical care with multiyear follow-up.

OBJECTIVES

We sought to provide long-term follow-up data on the type, severity, and frequency of adverse reactions associated with oral penicillin use in individuals who have histories of penicillin "allergy" yet also have negative results on penicillin skin tests done in advance of need. We also aimed to repeat testing on individuals with penicillin-associated adverse reactions.

METHODS

Medical records were reviewed for penicillin use and associated adverse reactions in all 568 penicillin skin test-negative individuals who had received at least 1 course of oral penicillin after testing but before December 31, 2001, during routine care. These individuals were drawn from a group of 1246 penicillin skin test-negative individuals seen initially between November 16, 1994, and August 13, 2001.

RESULTS

The mean length of follow-up was 4.26 +/- 1.64 years (range, 0.39-7.12 years). The mean penicillin exposure was 3.94 +/- 3.91 courses (range, 1-22 courses). Only 65 (11.4%) of 568 subjects had any penicillin-associated reactions, and 6 subjects had 2 reactions each. A reaction occurred in 27 subjects (4.8%) with their first penicillin reexposure. There were 71 (3.2%) reactions with 2236 total penicillin courses. There were no serious reactions. Repeated testing was done in 33 subjects older than age 18 years. Only 1 subject was positive on repeated penicillin skin testing.

CONCLUSION

Penicillin use after negative penicillin skin testing done in advance of need is safe, and resensitization is rare.

Comparison of arthroscopic findings with magnetic resonance imaging and arthrography in children with glenohumeral deformities secondary to brachial plexus birth palsy

BACKGROUND

Characterization of glenohumeral deformities secondary to brachial plexus birth palsy with plain radiography is difficult because the glenohumeral joint does not completely ossify until puberty. The purpose of this study was to compare the findings on magnetic resonance imaging and arthrography with those on arthroscopy to better understand the roles of these methods in the evaluation of glenohumeral development in this condition.

METHODS

Eighty-four children who ranged in age from seven months to thirteen years and six months had glenohumeral arthrography while they were under general anesthesia for operative treatment of an internal rotation contracture. Thirty-six children also received magnetic resonance imaging with use of cartilage-sensitive axial gradient-echo sequences. Thirty-seven children were evaluated arthroscopically.

RESULTS

Arthrography showed a concentric glenohumeral joint in thirty-three children, a flat glenoid in eight, a biconcave glenoid in seventeen, and a pseudoglenoid in twenty-six. Thus, 61% (fifty-one) of the eighty-four children with an internal rotation contracture had a substantial deformity. The severity of the contracture was associated with the existence and the type of the deformity (p = 0.001). Magnetic resonance imaging showed greater detail than arthrography did in defining the severity of the deformity in both the glenoid and the humeral head. The thirty-seven children who were examined arthroscopically showed a progression from those who had a concentric, conforming joint to those who had a markedly deformed joint with a bifurcated glenoid and a flattened, oval-shaped humeral head that articulated with the posterior aspect of the glenoid. Irregularities and cavitation of the anterior aspect of the glenoid were common. The subscapularis and rotator interval tissue were the primary sites of contracture.

CONCLUSIONS

Profound glenohumeral deformities secondary to brachial plexus birth palsy are commonly seen within the first two years of life. The information provided by imaging studies is helpful in defining the natural history of this condition and in determining the success of surgical intervention.

Oral antibiotic adverse reactions after penicillin skin testing: multi-year follow-up

BACKGROUND

Long-term follow-up data on adverse drug reactions after oral antibiotic use in penicillin allergy history positive individuals with penicillin skin test done in advance of need are rare.

METHODS

Oral antibiotic associated adverse drug reactions in 83 penicillin skin test positive individuals were compared to a sex, age, and length of follow-up matched sample of 166 penicillin skin test negative individuals, all of whom had at least one post penicillin skin test oral antibiotic. The mean post penicillin skin test follow-up interval was 34.5 +/- 16.6 months. There were 1655 total oral antibiotic exposures.

RESULTS

In penicillin skin test positive individuals, the adverse drug reaction rate was not significantly different with cephalosporin or non-beta-lactam use (P = 0.12). In penicillin skin test negative individuals the adverse drug reaction rate was significantly lower with cephalosporin vs. non-beta-lactam use (P = 0.005). Penicillin was safely used in penicillin skin test negative individuals. Overall cephalosporins caused fewer adverse drug reactions independent of penicillin skin test status (P = 0.005).

CONCLUSIONS

Penicillin skin testing was only able to predict penicillin associated adverse drug reactions in penicillin skin test positive individuals. Excluding accidental penicillin exposure in penicillin skin test positive individuals, non-beta-lactams were associated with adverse drug reactions more often than penicillins or cephalosporins, independent of the penicillin skin test result. Cephalosporins were used as or more safely than non-beta-lactams in both penicillin skin test positive and negative individuals.

The colposcopic impression. Is it influenced by the colposcopist's knowledge of the findings on the referral Papanicolaou smear?

OBJECTIVE

To determine whether the colposcopic impression is influenced by the colposcopist's knowledge of the referral Papanicolaou smear.

STUDY DESIGN

Using a community hospital database, the accuracy of the colposcopic impression (accuracy = proportion of women with histology greater than cervical intraepithelial neoplasia [CIN] 2 that have colposcopic impressions of greater than CIN 2) when referral smears were atypical squamous cells of uncertain significance (ASCUS), atypical glandular cells of uncertain significance (AGUS) or low grade squamous intraepithelial lesion (LSIL) was compared to that when smears showed high grade squamous intraepithelial lesion (HSIL) or cancer. The analysis was repeated with a screening study database in which colposcopic impression was assigned without knowledge of the Papanicolaou smear. Univariate and logistic regression analysis of the second database determined the relative importance of size and grade of lesion and Papanicolaou result to the accuracy of the colposcopic impression.

RESULTS

In the community database, colposcopic accuracy was 60/510 (12%) when smears were ASCUS, AGUS or LSIL and 77/132 (58%) when smears were HSIL or cancer (P < .001); in the second database, it was 2/19 (11%) when smears subsequently were reported as negative, ASCUS, AGUS or LSIL and 33/65 (54%) when smears were HSIL or cancer (P < .005). An accurate colposcopic impression was seen in 5/39 (13%) women with one-quadrant lesions, 8/18 (44%) with two-quadrant lesions and 23/27 (85%) with three- or four-quadrant lesions (P < .005). None of 19 women with smears reported as negative, ASCUS, AGUS or LSIL had lesions involving three or four quadrants of the cervix, while 27/65 (42%) women with smears reported as HSIL or cancer had such lesions (P < .005). With logistic regression, the more quadrants of the cervix involved, the more accurate the colposcopic impression. Once controlled for lesion size, there was no improvement when worst histologic grade or Papanicolaou smear result was considered.

CONCLUSION

Through lesions greater than CIN 2 were more often overlooked when referral smears were negative, ASCUS, AGUS or LSIL than when they were HSIL or cancer, the real reason that the lesions were not detected by colposcopy was that they were small.

Outcome and clinical implications of a surveillance and treatment program for Staphylococcus aureus nasal carriage in peritoneal dialysis patients

Staphylococcus aureus nasal carriage (SANC) is a risk factor for development of S. aureus dialysis-related infections. Reported here are results of a SANC surveillance and treatment program employed by our dialysis unit over a two-year period. Surveillance nasal cultures were performed at 3-month intervals in 129 peritoneal dialysis patients. Those with SANC applied mupirocin ointment intranasally 3 times daily for 5 consecutive days for 3 consecutive months. Treatment was repeated only when subsequent cultures showed SANC. Infection and catheter loss rates were compared to 63 historical controls, and between SANC and non SANC patients of the study group. Patients who were initially non carriers showed increasing probability for acquiring SANC throughout the study period. Following treatment, the probability for recurrence of SANC was 26%, 41%, 58%, and 62% at 1, 3, 6, and 12 months. The rates of S. aureus exit-site or tunnel infection (p = 0.36), peritonitis (p = 0.0002), and catheter loss (p = 0.01) were lower in the study group as compared to controls. Despite treatment, SANC patients demonstrated a twofold increase in exit-site/tunnel infection rate (p = 0.03) and a threefold increase in catheter loss rate (p = 0.1) as compared to non SANC patients. The high rate of SANC recurrence and the long interval between surveillance cultures may explain the failure of the current protocol to completely eliminate the risk for S. aureus infections. The results support a change in the treatment plan to that of continuing the monthly mupirocin regimen indefinitely once SANC has been identified.

Long-term inhalable particles and other air pollutants related to mortality in nonsmokers

Long-term ambient concentrations of inhalable particles less than 10 microm in diameter (PM10) (1973- 1992) and other air pollutants-total suspended sulfates, sulfur dioxide, ozone (O3), and nitrogen dioxide-were related to 1977-1992 mortality in a cohort of 6,338 nonsmoking California Seventh-day Adventists. In both sexes, PM10 showed a strong association with mortality for any mention of nonmalignant respiratory disease on the death certificate, adjusting for a wide range of potentially confounding factors, including occupational and indoor sources of air pollutants. The adjusted relative risk (RR) for this cause of death as associated with an interquartile range (IQR) difference of 43 d/yr when PM10 exceeded 100 microg/m3 was 1.18 (95% confidence interval [CI]: 1.02, 1.36). In males, PM10 showed a strong association with lung cancer deaths-RR for an IQR was 2.38 (95% CI: 1.42, 3.97). Ozone showed an even stronger association with lung cancer mortality for males with an RR of 4.19 (95% CI: 1.81, 9.69) for the IQR difference of 551 h/yr when O3 exceeded 100 parts per billion. Sulfur dioxide showed strong associations with lung cancer mortality for both sexes. Other pollutants showed weak or no association with mortality.

Long-term particulate and other air pollutants and lung function in nonsmokers

The associations between lung function measures (spirometry and peak expiratory flow lability) and estimated 20-yr ambient concentrations of respirable particles, suspended sulfates, sulfur dioxide, ozone, and indoor particles were studied in a sample of 1,391 nonsmokers followed since 1977. Differences in air pollutants across the population were associated with decrements of lung function. An increase of 54 d/yr when particles < 10 micro(m) in diameter (PM10) exceeded 100 microg/m3 was associated with a 7.2% decrement in FEV1, as percent of predicted, in males whose parents had asthma, bronchitis, emphysema, or hay fever and with increased peak expiratory flow lability of 0.8% for all females and 0.6% for all males. An increase in mean SO4 concentration of 1.6 microg/m3 was associated with a 1.5% decrement in FEV1, as percent of predicted, in all males. An increase of 23 ppb of ozone as an 8-h average was associated with a 6.3% decrement in FEV1, as percent of predicted, in males whose parents had asthma, bronchitis, emphysema, or hay fever.

Spirometric reference equations for older adults

The objective of this study was to develop spirometric reference equations for healthy, never-smoking, older adults. It was designed as a cross-sectional observational study consisting of 1510 Seventh Day Adventists, ages 43-79 years enrolled in a study of health effects of air pollutants. Individuals were excluded from the reference group (n = 565) for a history of current respiratory illness, smoking, or chronic respiratory disease, and for a number of 'non-respiratory' conditions which were observed in these data to be related to lower values of FEV1. Gender-specific reference equations were developed for the entire reference group and for a subset above 65 years of age (n = 312). Controlling for height and age, lung function was found to be positively related to the difference between armspan and height, and in males was found to be quadratically related to age. The predicted values for this population generally fell within the range of those of other population groups containing large numbers of adults over the age of 65 years. Individuals with lung function below the 5th percentile in this sample, however, could not be reliably identified by using the lower limits of normal predictions commonly used in North America and Europe.

Peak flow lability: association with asthma and spirometry in an older cohort

OBJECTIVE

To determine the success rate and correlates of ambulatory peak expiratory flow (PEF) monitoring in an epidemiologic study.

DESIGN

An observational survey.

SETTING

Several communities in California.

PARTICIPANTS

We studied 1,223 nonsmoking men and women (mean age, 66 years) from an established cohort.

OUTCOME MEASURES

A standard respiratory symptoms and diagnoses questionnaire, spirometry before and after bronchodilator, and a diary of PEF recorded four times per day for 7 days at home.

RESULTS

A physician diagnosis of asthma was reported in 8.6% of the women and 9.4% of the men. Of those who agreed to complete PEF diaries at home, 87% successfully provided a valid measure of PEF lability. The mean PEF lability from those with asthma was significantly higher than the others (12.0% vs 8.9% in women and 10.2% vs 8.1% in men). Independent correlates of higher PEF lability included asthma, wheezing symptoms, airways obstruction by spirometry, older age, and male gender.

CONCLUSIONS

Middle-aged and elderly persons are largely successful at providing a measure of PEF lability at home. In nonsmoking adults living in California, increased PEF lability is correlated with asthma, wheezing, airways obstruction, and older age, validating its use in epidemiology studies as an index of airways hyperreactivity.

Smoking characteristics of female veterans

Recent studies suggest that the prevalence of smoking among active duty military women is higher than that of active duty military men or civilians of either gender. No data have been published on cessation rates among female veterans. We wanted to report such rates in a group of female veterans at Pettis VAMC Preventive Medicine Clinic and to study predictive factors for smoking cessation and prevention. We identified female patients at Pettis VAMC Preventive Medicine Women's Clinic who had received services in the past 3 years or who enrolled as new patients during the study period; 529 received questionnaires by mail or at the clinic; 409 returned completed surveys. A high proportion (32.5%) of our sample of female veterans were current smokers, and 67% of female veteran smokers reported smoking at least one pack daily. More than one-third of ever-smokers began smoking during military service. Thirty-nine percent of the female veteran sample had CES-D scores of 16 or greater, and current smokers had significantly greater mean CES-D scores than former smokers. Twenty-three percent of current smokers had high nicotine dependence scores (> 7). The highest proportion of CES-D scores compatible with depressive symptoms (55%) was seen among current smokers who consumed a pack or more of cigarettes per day. Ever-smokers who screened as depressed were significantly less likely to have quit than those with lower CES-D scores; however, in multivariate models, CES-D scores were not significantly related to cessation. The prevalence of current, ever, and heavy smoking was high among this sample of female veterans attending a VAMC Preventive Medicine clinic. An unexpectedly high prevalence of screening scores compatible with depression was found among this sample, particularly among smokers. This warrants further investigation, particularly in light of the reported relationship between depression and smoking.

Chronic respiratory symptoms associated with estimated long-term ambient concentrations of fine particulates less than 2.5 microns in aerodynamic diameter (PM2.5) and other air pollutants

Seventh-Day Adventists (SDAs), nonsmokers who had resided since 1966 in the vicinity of nine airports throughout California (n = 1,868), completed a standardized respiratory symptoms questionnaire in 1977 and again in 1987. For each participant, cumulative ambient concentrations of fine particulates less than 2.5 microns (microns) in aerodynamic diameter (PM2.5) were estimated from airport visibility data. Long-term ambient concentrations of estimated PM2.5 in excess of 20 micrograms per cubic meter (micrograms/m3) were found to be associated with development of definite symptoms of chronic bronchitis between 1977 and 1987. Estimated mean concentrations of PM2.5 were associated with increasing severity of respiratory symptoms related to general airway obstructive disease, chronic bronchitis, and asthma. It was felt that the observed relationships, with the exception of the relationship between increasing severity of chronic bronchitis symptoms and PM2.5, could be due to surrogate relationships with other ambient pollutants.

Estimating fine particulates less than 2.5 microns in aerodynamic diameter (PM2.5) from airport visibility data in California

Methods were developed for estimating fine particulates less than 2.5 microns in aerodynamic diameter (PM2.5) from airport visibility data which detected seasonality and allowed for possible site- and season-specific regressions of PM2.5 on visibility. The methods were applied to nine airports in California in order to produce estimates of PM2.5 for the years 1966-1986 based on 1,767 paired PM2.5/visibility data points where PM2.5 had been measured at a monitoring station near the airport. General F-tests indicated that site- and season-specific regression equations resulted in a statistically significant reduction in residual error. The split halves correlation for estimating PM2.5 from visibility over all areas was 0.82. The methods were used to estimate long-term concentrations of ambient PM2.5 for an epidemiological cohort of 1,868 individuals.

Estimated long-term ambient concentrations of PM10 and development of respiratory symptoms in a nonsmoking population

Site- and season-specific regressions of particulates less than 10 mu in diameter (PM10) on total suspended particulates (TSPs) were formed throughout California during years when both were monitored. The regressions were then applied to monitored TSPs for the years 1973 to 1987, and indirect estimates of PM10 were formed. These estimates of PM10 were validated by interpolating them to other monitoring stations. The split-halves correlation between the estimated and monitored mean concentrations, obtained when both were first cumulated for a 2-y period, was .86. Indirect estimates of PM10 at monitoring stations were interpolated, by month, to zip code centroids of home and work location and were cumulated for a cohort of 3,914 California Seventh-day Adventist (SDA) nonsmokers. Multivariate analyses, adjusted for several covariates, showed statistically significant (p < .05), but small, positive associations between PM10 and development of (a) definite symptoms of overall airway obstructive disease, (b) chronic productive cough, and (c) increased severity of airway obstructive disease and asthma. The relative risk (RR) associated with 1,000 h/y (42 d) exposure to concentrations of PM10 that exceeded 100 micrograms/m3 for development of airway obstructive disease was 1.17 (95% confidence interval [CI]: 1.02, 1.33); for development of productive cough, the RR was 1.21 (CI 1.02, 1.44); and for development of asthma, the RR was 1.30 (CI, 0.97, 1.73). Stronger associations were observed for those who were exposed occupationally to dusts and fumes. The RR of developing airway obstructive disease as an adult for those who had airway obstructive disease as a child was 1.66 (CI 1.15, 2.33).

Asthma related to occupational and ambient air pollutants in nonsmokers

We attempted to determine the association between occupational and air pollutant exposure with the development of adult asthma through the analysis of a standardized respiratory questionnaire administered to a cohort of 3914 nonsmoking adults in 1977 and again in 1987. Ambient air pollution concentrations were estimated over a 20-year period using monthly interpolations from fixed-site monitoring stations applied to zip code locations by month of residence and work site. Second-hand smoke exposure was significantly associated with the development of asthma (related risk [RR] = 1.45, confidence interval [CI] = 1.21 to 1.75). Airways obstructive disease before age 16 was related to a marked increased risk (RR = 4.24, CI = 4.03 to 4.45). An increased risk of asthma was significantly associated with increased ambient concentrations of ozone exposure in men (RR = 3.12, CI = 1.61 to 5.85).