Effectiveness of Simeprevir Plus Sofosbuvir, With or Without Ribavirin, in Real-World Patients With HCV Genotype 1 Infection

BACKGROUND & AIMS

The interferon-free regimen of simeprevir plus sofosbuvir was recommended by professional guidelines for certain patients with hepatitis C virus (HCV) genotype 1 infection based on the findings of a phase 2 trial. We aimed to evaluate the safety and efficacy of this regimen in clinical practice settings in North America.

METHODS

We collected demographic, clinical, and virologic data, as well as reports of adverse outcomes, from sequential participants in HCV-TARGET--a prospective observational cohort study of patients undergoing HCV treatment in routine clinical care settings. From January through October 2014, there were 836 patients with HCV genotype 1 infection who began 12 weeks of treatment with simeprevir plus sofosbuvir (treatment duration of up to 16 weeks); 169 of these patients received ribavirin. Most patients were male (61%), Caucasian (76%), or black (13%); 59% had cirrhosis. Most patients had failed prior treatment with peginterferon and ribavirin without (46%) or with telaprevir or boceprevir (12%). The primary outcome was sustained virologic response (SVR), defined as the level of HCV RNA below quantification at least 64 days after the end of treatment (beginning of week 12 after treatment--a 2-week window). Logistic regression models with inverse probability weights were constructed to adjust for baseline covariates and potential selection bias.

RESULTS

The overall SVR rate was 84% (675 of 802 patients, 95% confidence interval, 81%-87%). Model-adjusted estimates indicate patients with cirrhosis, prior decompensation, and previous protease inhibitor treatments were less likely to achieve an SVR. The addition of ribavirin had no detectable effects on SVR. The most common adverse events were fatigue, headache, nausea, rash, and insomnia. Serious adverse events and treatment discontinuation occurred in only 5% and 3% of participants, respectively.

CONCLUSIONS

In a large prospective observational cohort study, a 12-week regimen of simeprevir plus sofosbuvir was associated with high rates of SVR and infrequent treatment discontinuation. ClinicalTrials.gov: NCT01474811.

Physician-led, hospital-linked, birth care centers can decrease cesarean section rates without increasing rates of adverse events

BACKGROUND

This study compares outcomes at a hospital-linked, physician-led, birthing center to a traditional hospital labor and delivery service.

METHODS

Using de-identified electronic medical records, a retrospective cohort design was employed to evaluate 32,174 singleton births during 1998-2005.

RESULTS

Compared with hospital service, birth care center delivery was associated with a lower rate of cesarean sections (adjusted Relative Risk = 0.73, 95% confidence interval 0.59-0.91; p < 0.001) without an increased rate of operative vaginal delivery (adjusted Relative Risk = 1.04, 95% confidence interval 0.97-1.13; p = 0.25) and a higher initiation of breastfeeding (adjusted Relative Risk = 1.28, 95% confidence interval 1.25-1.30; p ≤ 0.001). A maternal length of stay greater than 72 hours occurred less frequently in the birth care center (adjusted Relative Risk = 0.60, 95% confidence interval 0.55-0.66; p < 0.001). Comparing only women without major obstetrical risk factors, the differences in outcomes were reduced but not eliminated. Adverse maternal and infant outcomes were not increased at the birth care center.

CONCLUSION

A hospital-linked, physician-led, birth care center has the potential to lower rates of cesarean sections without increasing rates of operative vaginal delivery or other adverse maternal and infant outcomes.

Improving cancer survivorship care: oncology nurses' educational needs and preferred methods of learning

Oncology nurses are essential in all phases of cancer care; however, their role in survivorship care is unclear. To better understand the self-reported knowledge and educational needs on topics of survivorship care and oncology nurses' learning preferences, an online survey was conducted. Respondents self-reported knowledge level for 31 care topics, identified areas of most interest, topics needed to assist patients and address patient questions, and reported participation in continuing education and preferred learning methods. Knowledge was rated highest for topics of fatigue, anxiety, and fear of recurrence and lowest for issues related to finance, employment, and insurance. Nurses were most interested in late and long-term physical effects of cancer or treatment, managing emotional issues, cancer screening and surveillance, and complementary and alternative therapies. Study findings suggest that online learning methods would be feasible and well accepted by nurses to meet continuing education needs related to cancer survivorship.

Comparison of focus groups on cancer and employment conducted face to face or by telephone

Findings from telephone focus groups have not been compared previously to findings from face-to-face focus groups. We conducted four telephone focus groups and five face-to-face focus groups in which a single moderator used the same open-ended questions and discussion facilitation techniques. This comparison was part of a larger study to gain a better understanding of employment experiences after diagnosis of gynecologic cancer. Offering the telephone option made it easier to recruit women from rural areas and geographically distant cities. Interaction between participants occurred in both types of focus group. Content analysis revealed that similar elements of the employment experience after cancer diagnosis were described by telephone and face-to-face participants. Participants disclosed certain emotionally sensitive experiences only in the telephone focus groups. Telephone focus groups provide useful data and can reduce logistical barriers to research participation. Visual anonymity might help some participants feel more comfortable discussing certain personal issues.

Cancer-related tasks involving employment: opportunities for clinical assistance

Many cancer survivors experience unmet psychosocial needs related to their jobs, and women often fare worse than men in this regard. However, little research exists on ways to assist patients with cancer in preventing or managing common job problems. We conducted focus groups and a survey among 73 women who were employed at the time of presentation of a gynecologic cancer. We compared the findings with existing recommendations and professional standards for occupational rehabilitation. Participants described different cancer-related employment tasks in three time periods: just after diagnosis, during primary treatment, and after primary treatment is completed. The more difficult tasks included communicating with supervisors and coworkers, determining company policies, applying for employer-sponsored benefits, handling finances, managing symptoms on returning to work, finding effective solutions to cancer-related job problems, leaving the job with dignity if too sick or if the job ended, and making career plans. The cancer care team may be able to help meet the psychosocial needs of employed cancer survivors by screening for job concerns, providing information, formulating a return-to-work plan, treating symptoms, consulting with professionals who have employment-related expertise, and giving other forms of assistance.

Employment and quality of survivorship among women with cancer: domains not captured by quality of life instruments

BACKGROUND

Many quality of life instruments assess the amount of paid work in combination with role function at home in the same items and do not specifically assess social support in the workplace. The goal of this study was to obtain women's views on the relationship between employment and health-related quality of life.

METHODS

A focus group and questionnaire study was conducted among 73 women with gynecologic cancer who were employed at diagnosis and 25 people who provided them with psychosocial support.

RESULTS

The women held a variety of blue collar and white collar jobs at diagnosis. Employment provided a strong sense of accomplishment and a welcome distraction during treatment. The employment experience was described as distinct from role function at home. No one equated working more hours with better quality of life. Social support at work could be poor at the same time that support from family and friends grew stronger.

CONCLUSIONS

The contribution to their quality of life that cancer survivors feel they receive from employment may not be linearly related to the quantity of their role function in the workplace. Employment-related items could be useful as an adjunct to standard quality of life measures.

Use of a gestational carrier for a patient with recurrent adverse pregnancy outcomes from early onset severe pre-eclampsia

OBJECTIVE

To describe the first reported case of gestational carrier treatment to prevent severe early onset pre-eclampsia.

DESIGN

Case report.

SETTING

A university-based reproductive endocrinology and infertility clinic and a tertiary care hospital.

PATIENT(S)

A 29-year-old woman and her husband with three consecutive pregnancies complicated by early onset severe pre-eclampsia causing fetal demises at 22 and 24 weeks gestation; a neonatal death at 25 weeks gestation; and life-threatening maternal hemolysis, elevated liver enzymes, and low platelets.

INTERVENTION(S)

An IVF procedure in the patient using her husband's sperm with the transfer of two embryos to a friend who offered to be a gestational carrier.

MAIN OUTCOME MEASURE(S)

Successful IVF cycle in the patient and uncomplicated pregnancy and delivery in the gestational carrier.

RESULT(S)

The gestational carrier achieved a pregnancy and progressed without complications to delivery of a healthy, 3.2-kg infant at 39 weeks gestation.

CONCLUSION(S)

The use of a gestational carrier deserves consideration as a treatment option in patients with poor reproductive histories because of early onset severe pre-eclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. This experience also suggests that development of pre-eclampsia may be in large part maternally rather than embryologically or paternally driven.

Preconception care and treatment with assisted reproductive technologies

Couples with fertility problems seeking treatment with assisted reproductive technologies (ART) such as in vitro fertilization should receive preconception counseling on all factors that are provided when counseling patients without fertility problems. Additional counseling should address success rates and possible risks from ART therapies. Success rates from ART are improving, with the highest live birth rates averaging about 40% per cycle among women less than 35 years old. A woman's age lowers the chance of achieving a live birth, as do smoking, obesity, and infertility diagnoses such as hydrosalpinx, uterine leiomyoma, or male factor infertility. Singletons conceived with ART may have lower birth weights. Animal studies suggest that genetic imprinting disorders may be induced by certain embryo culture conditions. The major risk from ovarian stimulation is multiple gestation. About one-third of live-birth deliveries from ART have more than one infant, and twins represent 85% of these multiple-birth children. There are more complications in multiple gestation pregnancies, infants are more likely to be born preterm and with other health problems, and families caring for multiples experience more stress. Transferring fewer embryos per cycle reduces the multiple birth rate from ART, but the patient may have to pay for additional cycles of ART because of a lower likelihood of pregnancy.

Workgroup report: Implementing a national occupational reproductive research agenda--decade one and beyond

The initial goal of occupational reproductive health research is to effectively study the many toxicants, physical agents, and biomechanical and psychosocial stressors that may constitute reproductive hazards in the workplace. Although the main objective of occupational reproductive researchers and clinicians is to prevent recognized adverse reproductive outcomes, research has expanded to include a broader spectrum of chronic health outcomes potentially affected by reproductive toxicants. To aid in achieving these goals, the National Institute for Occupational Safety and Health, along with its university, federal, industry, and labor colleagues, formed the National Occupational Research Agenda (NORA) in 1996. NORA resulted in 21 research teams, including the Reproductive Health Research Team (RHRT). In this report, we describe progress made in the last decade by the RHRT and by others in this field, including prioritizing reproductive toxicants for further study; facilitating collaboration among epidemiologists, biologists, and toxicologists; promoting quality exposure assessment in field studies and surveillance; and encouraging the design and conduct of priority occupational reproductive studies. We also describe new tools for screening reproductive toxicants and for analyzing mode of action. We recommend considering outcomes such as menopause and latent adverse effects for further study, as well as including exposures such as shift work and nanomaterials. We describe a broad domain of scholarship activities where a cohesive system of organized and aligned work activities integrates 10 years of team efforts and provides guidance for future research.

Impact of 1996 Residency Review Committee Obstetrics-Gynecology primary care requirements on residency training and surgical procedures

OBJECTIVE

This study evaluated the impact of required primary care rotations in obstetrics-gynecology residency training after 1996.

STUDY DESIGN

A questionnaire was sent to the 1994 to 2003 graduates from 1 residency program, and records of surgical procedures completed during residency were analyzed.

RESULTS

Thirty-nine of 46 graduates participated in the study (response rate 85%). Required primary care training was associated with increased confidence in providing primary care (81.5% versus 54.5%, P = .12) but less agreement that obstetrics-gynecology is a primary care specialty (21.4% versus 45.5%, P = .23). Abdominal hysterectomies and vaginal hysterectomies per resident did not decrease (127 versus 113, P = 0.149, and 55 versus 48, P = .06, respectively). Adjusted for temporal trends, cesarean sections per resident decreased (366 versus 321, P = .009).

CONCLUSION

Residents maintained adequate rates of major inpatient surgical procedures after implementation of required primary care training. There was a tendency for residents who graduated after 1996 to have less favorable attitudes about primary care.

Occupational exposures and reproductive health: 2003 Teratology Society Meeting Symposium summary

Assuring reproductive health in the workplace challenges researchers, occupational safety and health practitioners, and clinicians. Most chemicals in the workplace have not been evaluated for reproductive toxicity. Although occupational exposure limits are established to protect 'nearly all' workers, there is little research that characterizes reproductive hazards. For researchers, improvements in epidemiologic design and exposure assessment methods are needed to conduct adequate reproductive studies. Occupational safety and health programs' qualitative and quantitative evaluations of the workplace for reproductive hazards may differ from standardized approaches used for other occupational hazards in that estimates of exposure intensity must be considered in the context of the time-dependent windows of reproductive susceptibility. Clinicians and counselors should place the risk estimate into context by emphasizing the limitations of the available knowledge and the qualitative nature of the exposure estimates, as well as what is known about other non-occupational risk factors for adverse outcomes. This will allow informed decision-making about the need for added protections or alternative duty assignment when a hazard cannot be eliminated. These policies should preserve a worker's income, benefits, and seniority. Applying hazard control technologies and hazard communication training can minimize a worker's risk. Chemical reproductive hazard training is required for workers by the Occupational Safety and Health Administration's Hazard Communication Standard. The National Institute for Occupational Safety and Health (NIOSH) has formed a National Occupational Research Agenda Team to promote communication and partnering among reproductive toxicologists, clinicians and epidemiologists, to improve reproductive hazard exposure assessment and management, and to encourage needed research.

Follicle-stimulating hormone and estradiol levels independently predict the success of assisted reproductive technology treatment

OBJECTIVE

To evaluate the relationship between early follicular phase levels of FSH and E(2) and outcomes of therapy with assisted reproductive technologies (ART).

DESIGN

Retrospective cohort study.

SETTING

ART centers in the United States.

PATIENT(S)

Women receiving 19,682 ART procedures performed in 135 clinics.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of clinical pregnancy, live birth delivery, and high ovarian response (>/=10 oocytes retrieved after stimulation).

RESULT(S)

The ratio of each FSH or E(2) value to the respective upper limit of normal value for the clinic was computed. Within each age group, rates of pregnancy, live birth, and high ovarian response decreased linearly as FSH levels increased. For example, among women 35 years of age and younger, pregnancy rates (PR) ranged from 41.1% (FSH ratio 0-0.5) to 18.5% (FSH ratio >2.0). The three outcomes exhibited a similar downward trend as E(2) ratios increased. When both hormone ratios were elevated, outcomes were least favorable. These relationships remained statistically significant after we adjusted for diagnosis, number of embryos transferred, previous births, previous ART therapy, and use of GIFT, zygote intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI), or assisted hatching.

CONCLUSION(S)

The FSH and E(2) ratios predict ART success independent of age and other clinical prognostic factors.

Kansas Office-Based Nurses' Evaluation of Patient Tobacco Cessation Activities

In this study, we examined the tobacco cessation efforts of nurses working in primary care settings. A 43-item questionnaire was mailed to 1,036 office-based nurses located throughout Kansas. With a response rate of 50.1%, 415 questionnaires were available for analysis. Although 89% of respondents encountered patients who smoked on a daily or weekly basis, only 51% reported documenting their patients' tobacco use, and 38% assessed patients' readiness to quit. Two thirds (66%) of nurses believed that tobacco management was part of their role but only 35% provided cessation advice, 23% recommended nicotine replacement therapy, and 14% provided coping techniques. Nurses cited barriers such as perceiving patients as disinterested or unmotivated to quit (65%) and having little time (55%), skills (32%), or knowledge (25%). Most (91%) agreed that they needed additional tobacco control education. Nurses who were advanced registered nurse practitioners or clinical nurse specialists were more likely to feel confident about their smoking cessation counseling skills compared to nurses with less education (66.7 vs. 31.2%, p =.010). Office-based nurses identified specific barriers that could be addressed through professional education about tobacco management.

Pregnancy during obstetrics and gynecology residency: effect on surgical experience

OBJECTIVE

This study explored residents' views about pregnancy during residency and the effect leaves of absence had on the quantity of surgical procedures performed.

STUDY DESIGN

Physicians who graduated from an obstetrics and gynecology residency between 1994 and 2002 were contacted by mail. Respondents completed a questionnaire and consented to use of the program's surgical database to obtain information regarding surgical procedures performed during their training.

RESULTS

Thirty-one of the 41 eligible resident physicians returned the questionnaire and consent form (response rate, 75.6%). Among the 14 responding men, 2 had taken a total of three nonvacation, noneducational leaves. Among the 17 women respondents, there were 16 leaves associated with deliveries, and the nonvacation, noneducational leave for women who were pregnant was statistically longer than for other residents (median of 6 weeks compared with 0 weeks, P<.001). Most pregnancies were planned (27/29, 93.1%) and were delivered in the third or fourth year of training (11/16, 68.8%). Former residents listed several ways that the program accommodated pregnancy and were satisfied with the program. The mean number of procedures for women with deliveries compared with other residents were as follows: cesarean section, 315 versus 281 cases (P=.20); abdominal hysterectomy, 116 versus 102 cases (P=.08); laparoscopy, 87 versus 92 cases (P=.72); vaginal hysterectomy, 51 versus. 45 cases (P=.11).

CONCLUSION

Pregnancy and delivery did not decrease surgical experience of four major procedures in this program, and pregnant physicians perceived appropriate support from their colleagues and the program administration.

Clinical outcomes among recipients of donated eggs: an analysis of the U.S. national experience, 1996-1998

OBJECTIVE

To evaluate the role of recipient age on the outcome of donor egg cycles.

DESIGN

Retrospective cohort study of aggregated national cycles of donor egg therapy that are collected by Society for Assisted Reproductive Technology and the Centers for Disease Control and Prevention.

SETTING

Assisted reproductive technology centers in the United States that report their results to the Centers for Disease Control and Prevention by way of the Society for Assisted Reproductive Technology.

PATIENT(S)

Recipients of embryos (17,339 cycles) derived from donated eggs between 1996 and 1998.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Rates of implantation, clinical intrauterine pregnancy, pregnancy loss, and delivery based on the age of the recipient.

RESULT(S)

Success of donor egg therapy was remarkably constant among recipients aged 25 years through those in their late forties. At higher ages, declining rates of implantation, clinical pregnancy, and delivery were seen, along with small increases of pregnancy loss. During the course of the 3 years studied, fewer embryos were transferred and higher rates of implantation were observed.

CONCLUSION(S)

The success of donor egg therapy is unaffected by recipient age up to the later 40s, after which they begin to decline. Although recipient age per se is likely to be the major cause of this effect, other factors may contribute to this observation.

Feasibility of maternity protection in early pregnancy

Many countries have maternity protection laws for women who need job modification or medical leave during pregnancy. This approach will prevent birth defects only if maternal job changes can be made before the critical period of organogenesis, which begins at three weeks' gestation. The authors studied the gestational ages at which pregnant women working with chemicals, radiation, and noise presented for occupational safety and health consultations. The work setting promoted early presentation because the consultation was free, convenient, mandatory, and would not result in job loss. Among the 213 pregnant women evaluated between 1996 and 2000, most (89.5%) had their occupational safety evaluations in the first trimester. Although this sounds ideal, the mean gestational age at presentation was 7.5 weeks, and only 3.3% of occupational health evaluations were initiated by three weeks' gestation. Environmental and biological monitoring showed that none of the women was exposed over occupational limits. These data suggest that a workplace free from reproductive hazards needs to be provided before conception.

Variability in physician management of employment during pregnancy

BACKGROUND AND OBJECTIVES

Successful employment outcomes for pregnant women result from a complex interplay between the woman, her employer, her prenatal care provider, laws and other influences.

METHODS

A mail survey about management of employment during pregnancy was sent to directors of US residency programs that train prenatal care providers. Each physician was randomly assigned one of 4 vignette patients whose job involved prolonged standing, rotating shifts and lifting 40 lbs. Half the vignette patients had risk factors for preterm birth and half would have financial difficulty if placed on an unpaid antenatal leave.

RESULTS

The 301 respondents estimated that they provide a written job restriction for 20% of their employed pregnant patients, although in 6 clinics the job restriction rate was 100%. For vignettes with preterm birth risk factors, 62.5% of physicians would always recommend a job restriction, 35.6% would do so sometimes, and 2.2% would rarely do so. When the vignette did not have risk factors for preterm birth, 21.5% of the physicians would always recommend a job restriction, 51.3% would do so sometimes, 25.9% would do so rarely and 1.3% would never do so. Economic factors were not associated with prescribing job restrictions. One in 5 of the residency programs provides no teaching on occupational health issues in pregnancy, and 65.1% provide 2 hours or less.

CONCLUSIONS

Variability in employment recommendations suggests that some women may not obtain the job modifications that they need, whereas others may be restricted unnecessarily. The limited curriculum time devoted to this topic may make it difficult to train physicians about complex employment issues during pregnancy.

Barriers to smoking cessation initiatives for Medicaid clients in managed care

In this paper, key barriers to providing smoking cessation services for low income individuals are illustrated using epidemiologic data from a population which was enrolled in a Medicaid managed care plan in Kansas during 1998. The Plan served 623 pregnant women who could potentially benefit from assistance in avoiding tobacco exposure. The prevalence of smoking among adult clients was 44.8%. twice the national average. Only 52.3% of adult smokers were advised by a provider to quit in the previous year. Most individuals in the client population (81.7% of the 10,733 members) were children, suggesting the importance of targeting environmental tobacco smoke exposure in order to reduce morbidity from asthma. The adult household member who needed smoking cessation services, however, was unlikely to qualify for health care benefits through Medicaid. The median length of enrollment was only 1.9 months, providing very little client contact time for tobacco control initiatives. The literature suggests that some providers may lack skills in treating tobacco as an addiction. It would be a major task for the managed care organization to train the 2,000 physicians in 68 of the 105 counties of Kansas who cared for this population. Potential solutions include improving reimbursement for smoking prevention and treatment, and developing cheaper smoking cessation services which are effective and acceptable among low-income individuals. The managed care organization could provide patient education materials and staff training for physicians and other members of the office staff.

Medically recommended cessation of employment among pregnant women in Georgia

OBJECTIVE

To ascertain the proportion of employed pregnant women who receive medical advice to stop working during pregnancy and to describe their characteristics.

METHODS

Data were analyzed from the Georgia Pregnancy Risk Assessment Monitoring System, a surveillance system that surveys new mothers about pregnancy risk factors, health behaviors, and birth-related outcomes. Employment during pregnancy was defined as work for pay for 10 hours or more per week.

RESULTS

We studied 1635 women who were employed during pregnancy. A physician or nurse had advised 27.7% (95% CI 24.5%, 30.9%) of them to stop working during pregnancy. Independent predictors of receiving this advice were hospitalization (RR 2.3, 95% CI 1.7, 2.8) and history of previous preterm birth (RR 1.6, 95% CI 1.1, 2.2). Low birth weight (under 2500 g) occurred in 5.8% of women not advised to stop work, in 6.9% of women advised to stop work because of swelling, fatigue, stress, or another reason, and in 13.4% of women advised to stop work because of labor, high blood pressure, or vaginal bleeding (P <.001). Among women advised to stop working in the first through seventh months of pregnancy, 91.7% (95% CI 88.8, 94.5) delivered at 36 or more weeks' gestation.

CONCLUSION

Work cessation during pregnancy was commonly recommended in this population and was associated with clinical risk factors and adverse birth outcomes. For some women it resulted in a long period of work absence before delivery.

Health information in material safety data sheets for a chemical which causes asthma

OBJECTIVE

To assess the quality of health information on material safety data sheets (MSDS) for a workplace chemical that is well known to cause or exacerbate asthma (toluene diisocyanate, TDI).

DESIGN

We reviewed a random sample of 61 MSDSs for TDI products produced by 30 manufacturers.

MEASUREMENTS AND MAIN RESULTS

Two physicians independently abstracted data from each MSDS onto a standardized audit form. One manufacturer provided no language about any respiratory effects of TDI exposure. Asthma was listed as a potential health effect by only 15 of the 30 manufacturers (50%). Listing asthma in the MSDS was associated with higher toluene diisocyanate concentrations in the product (P <.042). Allergic or sensitizing respiratory reactions were listed by 21 manufacturers (70%).

CONCLUSIONS

Many MSDSs for toluene diisocyanate do not communicate clearly that exposure can cause or exacerbate asthma. This suggests that physicians should not rely on the MSDS for information about health effects of this chemical.

Workplace reproductive problems

Occupational exposures can harm reproductive processes in men or women. Exposures may affect fertility, pregnancy outcomes or the child's health after delivery. The goal of patient management is to provide counseling at an appropriate level. Over-restricting the patient should be avoided while hazardous exposures should be identified and reduced. The occupational history can be used to estimate the magnitude of each exposure. If the exposure is a known reproductive hazard and the exposure level appears significant, there are several options for making the job safer. Modifications in work practices can be accomplished by advising the patient about changing work practices, writing formal work restrictions and talking with the employer. Temporary job transfers may be available. In some cases, a medical leave is needed. The primary care provider can play a key role in assisting patients to reduce reproductive risks.

Managing patients with concerns about workplace reproductive hazards

OBJECTIVES

To find out who uses an occupational reproductive consultation service, what proportion of patients have different types of workplace exposures, and what hypotheses can be generated about barriers to implementing medically necessary job modifications to promote reproductive health.

METHODS

A case series study was conducted by reviewing medical records at two occupational health clinics.

RESULTS

51 patients (1 man and 50 women) were seen, 10 of whom wished to discuss a future pregnancy and 41 of whom were pregnant. Pregnant women worked with a mean of 15.5 different chemicals, and patients were also concerned about ionizing radiation, biological hazards, electromagnetic fields, and ultraviolet light. Pregnant women made clinic visits at a mean gestational age of 10.9 weeks.

CONCLUSIONS

Only one man used the service, suggesting a lack of knowledge about possible paternal contributions to adverse reproductive outcomes. Many pregnant women visited the clinic too late to prevent harm from exposure to some teratogens, so preconception counseling may be of benefit. Cases are presented that illustrate ways in which the primary care provider can assist the patient who may be exposed to reproductive hazards.

Developing occupational and environmental medicine curricula for primary care residents: project EPOCH-Envi. Educating Physicians in OCupational Health and the Environment

To help primary care residency programs develop or improve residency curricula in occupational and environmental medicine, the National Institute for Occupational Safety and Health launched a train-the-trainer initiative. This project was called EPOCH-Envi (Educating Physicians in OCcupational Health and the Environment). From 1990 to 1996, 46 2-day curriculum development workshops were held. These featured (1) guidelines on how to plan, implement, and evaluate a curriculum, (2) continuing education on occupational illnesses and injuries, (3) a worksite or environmental site visit, and (4) information resources. A total of 435 faculty from 305 residency programs participated, representing 42.5% of the family practice residencies and 24.9% of the internal medicine residencies in the United States. A survey conducted among attendees (60.4% response rate) 17 months after their workshop revealed that 65.6% of respondents had added lectures on occupational and environmental topics to the residency curriculum. Other curriculum improvements were also made. Primary care physicians manage most patients with occupational and environmental health problems or concerns. Providing technical assistance specifically designed to support occupational and environmental health education in primary care residencies can have a positive impact on curriculum content.

Effect of over-the-counter cimetidine on phenytoin concentrations in patients with seizures

OBJECTIVE

To determine the effects of the maximum recommended over-the-counter (OTC) cimetidine dosage on phenytoin concentrations in ambulatory seizure patients on long-term phenytoin therapy.

METHODS

Adults with seizure disorders requiring phenytoin therapy were recruited. Trough total phenytoin concentrations were measured initially and once weekly for six weeks. All assays were performed using Biotrack patient-side cartridges. After a two-week baseline period, patients took cimetidine 200 mg twice daily for two weeks. Toxicity was monitored via weekly neurologic examinations and midweek telephone surveys. Patients were asked to return to clinic weekly during a two-week cimetidine washout period.

RESULTS

Nine patients entered and completed the study. All but two patients took other anticonvulsants known to interact with phenytoin (carbamazepine, n = 5; phenobarbital, n = 2). No adverse effects or changes in seizure frequency were reported. Paired Student's t-tests revealed no significant difference between serum phenytoin concentrations before (12.3+/-3.2 mg/L [mean +/- SD]) and after (12.8+/-4.0 mg/L) two weeks on the OTC cimetidine regimen. No differences were noted in estimated pharmacokinetic parameters (maximum metabolic rate, Michaelis-Menten constant) for the same time periods (paired Student's t-test, p > 0.05). The Biotrack assay had an r2 = 0.7311 (p < 0.001, two-sided) when compared with TDx.

CONCLUSIONS

It is possible that the lack of change in phenytoin concentrations was a result of the low daily dosage of cimetidine used or other factors related to the "real world" setting of the study. However, the potential for a serious drug interaction occurring in patients taking long-term oral phenytoin and OTC cimetidine appears to be small.

The unit of analysis error in studies about physicians' patient care behavior

OBJECTIVE

To estimate the frequency with which patients are incorrectly used as the unit of analysis among statistical calculations in published studies of physicians' patient care behavior.

DESIGN

Retrospective review of studies published during 1980-1990. ARTICLES: 54 articles retrieved by a computerized search using medical subject headings for physicians and study characteristics. Article selection criteria included the requirement that the physician should have been the correct unit of analysis.

INTERVENTION

Presence of the error was determined by consensus using published criteria.

MAIN RESULTS

The error was present in 38 articles (70%). The number of study physicians was reported in 35 articles (65%). The error was found in 57% of articles that reported the number of study physicians and in 95% of those that did not. The error rate was not lower among articles published more recently nor among those published in journals with higher rates of article citations in the medical literature.

CONCLUSION

The unit of analysis error occurs frequently and can generate artificially low p values. Failure to report the number of study physicians can be a clue that this type of error has been made.

Can physician education lower the cost of prescription drugs? A prospective, controlled trial

OBJECTIVE

To determine whether an educational program featuring a drug cost manual can assist physicians in reducing their patients' out-of-pocket prescription drug expenses.

DESIGN

Prospective controlled trial.

SETTING

A general internal medicine-teaching clinic in a university hospital.

PARTICIPANTS

Fifty-one medical interns.

INTERVENTION

Thirty-one interns received a manual of comparative drug prices annotated with prescribing advice, two feedback reports, and weekly cost-oriented prescribing reminders. A control group concurrently participated in a manual-based educational program on cholesterol management.

MEASUREMENTS

Copies of 3012 prescriptions written over 8 months were analyzed.

MAIN RESULTS

Intervention group physicians prescribed less expensive drugs within classes of drugs. The change in drug price score per prescription was -0.15 (95% Cl, -0.27 to -0.04; P = 0.01). A score of 3 was assigned to the most expensive, 2 was assigned to intermediate-priced, and 1 was assigned to the least expensive drug or drugs in the class. An increase of 0.74 months' (Cl, 0.49 to 0.98; P less than 0.001) supply of medication was dispensed per prescription, reducing dispensing fees. The program was well accepted by the physicians.

CONCLUSION

This relatively simple educational intervention can help physicians to reduce their patients' drug expenses and may serve as a model for incorporating cost information into the routine practice of medicine.

Teaching occupational and environmental medicine in primary care residency training programs: experience using three approaches during 1984-1991

There is a critical shortage of physicians trained to recognize and treat occupational and environmental health problems. We implemented several required teaching programs for internal medicine and family medicine residents that focus on providing primary care for these problems. Clinical experiences were developed using the university and medical center as an example of a workplace with chemical and physical hazards. On-site experiences were also provided at local industries, but when resident stipend support for this aspect was discontinued, that part of the program was suspended. Didactic programs were associated with a statistically significant improvement in house staff knowledge scores. These occupational and environmental health issues can be introduced during residency, resulting in increased expertise in this discipline.

Lengthy bed rest prescribed for acute low back pain: experience at three general medicine walk-in clinics

Early gradual ambulation is currently recommended for patients with acute low back pain if results of neurologic examination are normal. Bed rest for up to 2 days is considered optimal. To assess management practices, we retrospectively reviewed the medical records of individuals with acute back pain treated at three independent general medicine walk-in clinics. Patients having an acute flare-up of chronic back pain were excluded. Bed rest was recommended at the initial visit for 171 patients who had normal findings on neurologic examination. The duration of recommended bed rest was recorded in 76 of these 171 patients' medical records (44%). The median duration of recommended bed rest was 5.5 days (range 1 to 14 days). Most patients (60/76 [79%]) were advised to rest in bed longer than 2 days. Even if all patients in whom duration of bed rest was not recorded had been told to rest in bed for 2 days or less, bed rest prescriptions would still have been too lengthy in 60 of these 171 patients (35%). This practice may prolong the recovery of patients with acute low back pain.

Effect of daily charge feedback on inpatient charges and physician knowledge and behavior

Concurrent charge feedback has gained widespread acceptance as a method of minimizing hospitals' losses under the Medicare prospective payment system despite the fact that its effect on patient outcomes, physician behavior, or charges has not been studied in depth. In a controlled trial on two medical wards in an academic medical center, the effect of daily charge feedback on charges was studied. Sixty-eight house staff and 16 teaching attending physicians participated during a 35-week period, taking care of 1057 eligible patients. No significant differences in charges were seen when all patients were included. Since 45% of patients had planned protocol admissions (diagnostic workups or protocol treatment) on which the house staff had little change to impact, a subgroup analysis was performed, excluding these patients. In the remaining patients, a highly significant reduction in mean total charges (17%), length of stay (18%), room charges (18%), and diagnostic testing (20%) was found. In-hospital mortality and preventable readmission within 30 days were similar on the two wards. It was concluded that charge feedback alone is effective in a teaching hospital for decreasing charges.

Selective criteria may increase lumbosacral spine roentgenogram use in acute low-back pain

Eleven clinical criteria have been proposed to limit use of lumbosacral spine roentgenograms in patients with acute low-back pain who are at risk for vertebral cancer, osteomyelitis, acute fracture, or herniated disk. We retrospectively applied the criteria to 471 patients with acute low-back pain in three teaching hospital walk-in clinics. Roentgenograms were obtained at the initial visit in 99 patients (21.1%); the number would have increased to 217 (46.1%) if the criteria had been used. The following four patient characteristics were associated with actual roentgenogram use: older age, longer duration of symptoms, reflex asymmetry, and point vertebral tenderness. Adoption of the 11 criteria studied herein may inadvertently increase roentgenogram use, thereby raising health care costs and exposing more patients to gonadal irradiation. The standard of practice in these three clinics seemed to entail use of less broad roentgenogram selection criteria. Other published guidelines for roentgenograms emphasize clinical follow-up, reserving further evaluation for patients who fail to improve after a trial of bed rest and analgesics.

Need for insulin therapy in type II diabetes mellitus. A randomized trial

To identify patients with type II diabetes mellitus for whom insulin therapy is most beneficial, we conducted a randomized controlled trial in the general medicine clinic of a university hospital. Asymptomatic, obese, insulin-treated patients were given diet and diabetes education and, in half of these patients, insulin therapy was withdrawn. Over six months, patients developing hyperglycemic symptoms or acetonemia were counted as study failures. Failure criteria developed in 13 of 25 insulin-withdrawal patients, at a median of four weeks after withdrawal, compared with two of 24 control subjects. Elevated stimulated glucose levels predicted the need for insulin therapy. Hyperglycemia worsened in insulin-withdrawal patients who did not meet study failure criteria, but it improved in control patients. Study patients were insulin deficient as shown by low baseline C peptide values (0.43 +/- 0.05 nmol/L). The prompt metabolic decompensation precipitated by insulin withdrawal suggests that insulin-deficient patients may benefit from insulin therapy and may need it to prevent symptomatic hyperglycemia.

Characterization of aquatic bacteria and cloning of genes specifying partial degradation of 2,4-dichlorophenoxyacetic acid

Water samples from rivers, streams, ponds, and activated sewage were tested for the presence of bacteria which utilize 2,4-dichlorophenoxyacetic acid (2,4-D) as a sole source of carbon. Seventy percent of the attempted enrichments yielded pure cultures of 2,4-D-metabolizing bacteria. All but 1 of the 30 isolates were gram-negative rods, all but 2 were motile, and all were nonfermentative and oxidase and catalase positive. Nine isolates had DNA guanine-plus-cytosine values of 61.1 to 65 mol%. One isolate had a 67 mol% guanine-plus-cytosine value. The results suggest that these 2,4-D-metabolizing bacteria belong to the genus Alcaligenes. Fourteen of 23 isolates contained one or more detectable plasmids of about 20, 60, or 100 megadaltons. HindIII restriction fragment patterns showed these plasmids to be different from each other with one exception. Very similar restriction fragment patterns were revealed with a plasmid isolated from an Alcaligenes eutrophus strain obtained from Australia (pJMP397) and in an Alcaligenes sp. isolated in Oregon (pEML159). These two plasmids were about 56 megadaltons, had the same guanine-plus-cytosine value, were transmissable, and coded for 2,4-D metabolism and resistance to HgCl2. Hybridization of these two plasmids was demonstrated by using nick-translated 32P-labeled pJMP397. The vector pBR325 was used to clone HindIII fragments from pEML159. One cloned fragment of 14.8 megaldaltons expressed in Escherichia coli the ability to release 14CO2 from 2,4-D labeled in the acetate portion.