Bone density in haemophilia: a single institutional cross-sectional study

Haemophilia has been associated with low bone mineral density (BMD). However, prior clinical studies of this population have neither clearly elucidated risk factors for development of low BMD nor identified who may warrant screening for osteoporosis. The aim of the study was to evaluate the relationship between BMD and haemophilic arthropathy and other demographic and clinical variables. We undertook a cross-sectional study of BMD in adult men with haemophilia. Measures of predictor variables were collected by radiographic studies, physical examination, patient questionnaires and review of medical records. Among 88 enrolled subjects, the median age was 41 years (IQR: 20); median femoral neck BMD (n = 87) was 0.90 g cm(-2) (IQR: 0.24); and median radiographic joint score was 7.5 (IQR: 18). Among subjects <50 years (n = 62), after controlling for BMI, alcohol, HIV and White race, BMD decreased as radiographic joint score increased (est. β = -0.006 mg cm(-2) ; 95% CI -0.009, -0.003; partial R(2) = 0.23). Among subjects ≥50 years (n = 26), 38% had osteoporosis (T score less than or equal to -2.5) and there was no association between BMD and arthropathy. Risk factors for low BMD in men with haemophilia <50 years include haemophilic arthropathy, low or normal BMI and HIV. Men with haemophilia over age 50 years should have routine screening for detection of osteoporosis.

Physical activity and functional abilities in adult males with haemophilia: a cross-sectional survey from a single US haemophilia treatment centre

Physical activity and functional ability are important determinants of quality of life and these metrics are affected by both haemophilia and ageing. Outside haemophilic arthropathy, risk factors leading to reduced physical activity and function in people with haemophilia (PWH) are under-explored. The purpose of this analysis was to determine risk factors for reduced physical activity and functional limitations in PWH. A secondary analysis was conducted on data indexing physical activity and functioning of 88 PWH using data originally collected as part of a cross-sectional study at a single large haemophilia treatment centre. The Framingham Physical Activities Index (PAI), the Hemophilia Activities List (HAL) and the Timed Up-and-Go Test (TUG) were the outcome measures. The World Federation of Haemophilia (WFH) orthopaedic joint score was used as a measure of arthropathy. Multiple linear regression analysis was used to assess the relationship between the outcome measures and covariates. Worsening WFH joint score was independently associated with all three outcome measures (P < 0.05). Increasing age was associated with reduced PAI and increased TUG time (P < 0.05). The HAL summary score was decreased in patients with chronic liver disease (P = 0.006). The adjusted R(2) for each model was ≤ 0.35. This study provides evidence for the relationship between arthropathy and reduced physical functioning/activity, but also highlights that much of the variation in physical functioning/activity is not explained by haemophilia-related characteristics.

Medical students' self-reported typical counseling practices are similar to those assessed with standardized patients

CONTEXT/OBJECTIVES

We surveyed fourth-year medical students in the Class of 2003 at Emory University School of Medicine, Atlanta, Georgia, about various personal and clinical practices. We were especially interested in the frequency that these seniors reported of talking with patients about nutrition, weight, exercise, alcohol, and cigarette smoking. Because the validity of our findings about these counseling practices was limited by our having only self-reported data from seniors' questionnaires, we developed a standardized patient (SP) examination to test the relationship between what students reported on the questionnaires and how they actually performed with SPs.

DESIGN/SETTING/MAIN OUTCOME MEASURES

As part of a lengthy questionnaire, 88 senior medical students answered these 5 separated questions: "With a typical general medicine patient, how often do you actually talk to patients about: (1) nutrition; (2) exercise/physical activity; (3) weight; (4) smoking cessation (among smokers); and (5) alcohol? (never/rarely, sometimes, usually/always)." As part of their internal medicine subinternship final exam, students clinically assessed 4 SP cases with predetermined risk factors (poor diet, exercise, alcohol, and/or cigarette-smoking habits).

RESULTS

For every risk factor, the proportion of SPs actually counseled was higher for those students who self-reported discussing that risk factor more frequently with their patients. Additionally, the odds of counseling an SP for any risk factor were significantly higher (odds ratio = 1.76-2.80, P < .05) when students reported more frequent counseling.

CONCLUSION

Student self-reports regarding patient counseling may be useful when resources are limited, and the purpose is to grossly and anonymously distinguish between higher and lower performers.

Non-primary care physicians and smoking cessation counseling: Women Physicians' Health Study

OBJECTIVES

The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians in various specialties. In this study we describe the prevalence of self-reported counseling on smoking cessation among non-primary care women physicians and examine the association between their demographic, professional, and personal characteristics and such counseling on smoking cessation.

METHODS

Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians with 4,501 respondents representing all major specialties. Physicians in 9 specialty areas were grouped in 6 categories: (1) anesthesiology; (2) general surgery and surgical subspecialties; (3) emergency medicine; (4) medical subspecialties; (5) psychiatry; and (6) other. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year.

RESULTS

Overall, 45% of the physicians frequently counseled smokers to quit. Medical subspecialists (80%) were most likely and psychiatrists (29%) least likely to counsel frequently. Specialty, perceived relevance of counseling to the physician's practice, and self-confidence in counseling about smoking cessation were associated with frequent counseling.

CONCLUSION

Cessation counseling by non-primary care physicians can reduce tobacco-related morbidity and mortality. Increasing perceived relevance and self-confidence among this group of physicians, combined with implementation of system changes and the creation of physician accountability can facilitate the provision of such counseling.

Smoking cessation counseling by primary care women physicians: Women Physicians' Health Study

OBJECTIVES

The Women Physicians' Health Study (WPHS) offers a unique opportunity to examine the counseling and screening practices of women physicians. The objectives of this study were to: describe the prevalence of self-reported smoking cessation counseling among primary care women physicians and determine the association between physician demographic, professional, and personal characteristics and smoking cessation counseling.

METHODS

Conducted in 1993-1994, WPHS is a nationally representative cross-sectional mailed survey of U.S. women physicians and included 4,501 respondents representing all major specialties. Primary care physicians included 5 specialty areas and were grouped into 3 categories: (1) general primary care; (2) obstetrics/gynecology (ob/gyn); and (3) pediatrics. Frequent counseling was defined as having counseled patients who were known smokers at every visit or at least once a year.

RESULTS

Women physicians in general primary care (84%) and ob/gyn (83%) were more likely to frequently counsel their patients about cessation than were pediatricians (41%). Perceived relevance of counseling to a physician's practice was significantly associated with frequent counseling. Personal characteristics (current smoking status, personal or family history of a smoking-related disease, or living with a smoker as an adult or child) were not significantly correlated with counseling.

CONCLUSION

The majority (71%) of physicians reported frequently counseling their patients. However, there was significant variation by physician specialty. In addition, perceived relevance of counseling was strongly associated with counseling behavior. Physician counseling on cessation can reduce tobacco-related morbidity and mortality. Increasing perceived relevance, implementing system changes, and creating accountability can facilitate cessation counseling by physicians.

Diagnostic chelation challenge with DMSA: a biomarker of long-term mercury exposure?

Chelation challenge testing has been used to assess the body burden of various metals. The best-known example is EDTA challenge in lead-exposed individuals. This study assessed diagnostic chelation challenge with dimercaptosuccinic acid (DMSA) as a measure of mercury body burden among mercury-exposed workers. Former employees at a chloralkali plant, for whom detailed exposure histories were available (n = 119), and unexposed controls (n = 101) completed 24-hr urine collections before and after the administration of two doses of DMSA, 10 mg/kg. The urinary response to DMSA was measured as both the absolute change and the relative change in mercury excretion. The average 24-hr mercury excretion was 4.3 microg/24 hr before chelation, and 7.8 microg/24 hr after chelation. There was no association between past occupational mercury exposure and the urinary excretion of mercury either before or after DMSA administration. There was also no association between urinary mercury excretion and the number of dental amalgam surfaces, in contrast to recent published results. We believe the most likely reason that DMSA chelation challenge failed to reflect past mercury exposure was the elapsed time (several years) since the exposure had ended. These results provide normative values for urinary mercury excretion both before and after DMSA challenge, and suggest that DMSA chelation challenge is not useful as a biomarker of past mercury exposure.

Reconstruction of occupational mercury exposures at a chloralkali plant

OBJECTIVE

To reconstruct historical workplace exposure to mercury (Hg) from 1956 to 1994 at a large chloralkali factory for use in a current epidemiology study of the factory.

METHODS

All job activities of the employees were classified into one of 16 exposure categories, and the dates of changes in the processes were identified. Exposures to Hg for each job category, at each period of the plant's operation, were then reconstructed from several data sources. A job-time period-exposure matrix was created, and the individual exposures of former workers were calculated. Data on exposure to Hg in air were compared with modelled concentrations of Hg in air and data on urinary Hg of the employees.

RESULTS

Within an exposure category, concentrations of Hg in air were fairly constant for the first 20 years of the factory's operation, but began to increase in the late 1970s. Employees working in the cell room had the greatest exposures to Hg. The exposure estimates had significant correlations (p<0.001) with the urinary data and were well within the modelled range of concentrations of Hg in air.

CONCLUSIONS

The highest exposures occurred from 1987 until the plant closed in early 1994 with some exposure categories having time weighted average exposures to Hg greater than 140 microg/m(3).

Methodologic concerns in defining lesbian for health research

A recent report from the Institute of Medicine recommends more methodologic and substantive research on the health of lesbians. This study addresses one methodologic topic identified in the Institute of Medicine report and by a subsequent scientific workshop on lesbian health: the definition and assessment of sexual orientation among women. Data are from the Women Physicians' Health Study, a questionnaire-based U.S. probability sample survey (N = 4,501). The two items on sexual orientation (current self-identity and current sexual behavior) had a high response rate (96%), and cross-tabulation of responses indicated several combinations of identity and behavior. Three conceptually different definitions of "lesbian" are compared on the basis of (1) identity only, (2) sexual behavior only, and (3) both identity and sexual behavior. Suggestions and cautions are given to researchers who will add items on sexual orientation to new or ongoing research on women's health.

Health effects of long-term mercury exposure among chloralkali plant workers

BACKGROUND

Inorganic mercury is toxic to the nervous system, kidneys, and reproductive system. We studied the health effects of mercury exposure among former employees of a chloralkali plant that operated from 1955 to 1994 in Georgia.

METHODS

Former plant workers and unexposed workers from nearby employers were studied. Exposure was assessed with a job-exposure matrix based on historical measurements and personnel records. Health outcomes were assessed with interviews, physical examinations, neurological and neurobehavioral testing, renal function testing, and urinary porphyrin measurements. Exposure-disease associations were assessed with multivariate modeling.

RESULTS

Exposed workers reported more symptoms, and tended toward more physical examination abnormalities, than unexposed workers. Exposed workers performed worse than unexposed subjects on some quantitative tests of vibration sense, motor speed and coordination, and tremor, and on one test of cognitive function. Few findings remained significant when exposure was modeled as a continuous variable. Neither renal function nor porphyrin excretion was associated with mercury exposure.

CONCLUSIONS

Mercury-exposed chloralkali plant workers reported more symptoms than unexposed controls, but no strong associations were demonstrated with neurological or renal function or with porphyrin excretion.

U.S. Women Physicians' personal and clinical breast cancer screening practices

Little is known about predictors of physicians' personal or clinical compliance with breast cancer screening recommendations. We explored this in 4501 respondents to the Women Physicians' Health Study, a questionnaire-based study of a representative sample of U.S. women M. D.s. Overall, 21% of women physicians performed breast self-examination (BSE) at least monthly, about two thirds had received a clinical breast examination (CBE) within the last year, and 85% had received one within the last 2 years. Of those <40 years old, 14% had received a mammogram in the past year, as had 42% of those 40-49 and 59% of those 50-70 years old. Being a primary care practitioners or obstetrician/gynecologist was a significant predictor of counseling or screening for CBE and mammography. Only 46% of all women physicians reported discussing or performing mammograms at least once a year for those >/=50-</=75 years old, and 53% reported doing so for CBE. Also associated with performing CBE was examining one's own breasts at least once a year. Associated with mammography were having had a mammogram oneself in the past year and having a personal history of breast cancer. Other parameters, including age, ethnicity, region, practice type, practice site, control of work environment, work hours, amount of general continuing medical education (CME), career satisfaction, general health status, other breast disorders, personally having a recent CBE, or family histories of breast cancer or any other breast disorder, were not multivariately significantly associated with our counseling frequency outcomes. Women physicians may be especially efficient targets for breast cancer screening education.

Personal and clinical skin cancer prevention practices of US women physicians

OBJECTIVE

To document physician clinical and personal skin cancer prevention practices and associated characteristics.

DESIGN

A cross-sectional questionnaire survey of a representative sample of US women physicians.

SETTING

Mail survey.

SUBJECTS

Three thousand thirty-two nondermatologists and 95 dermatologists.

MAIN OUTCOME MEASURE

Personal and clinical practices.

RESULTS

Twenty-seven percent of nondermatologists counseled or screened their typical patients on skin cancer or sunscreen use at least once a year, while 49% did so less frequently, and 24% never counseled or screened at all. Of the 95 dermatologists, two thirds reported counseling or screening their typical patients at every visit. In bivariate analysis of nondermatologists, the distribution of counseling or screening was significantly (P<.05) associated with the following personal and professional characteristics: frequent sunscreen use, recent (within 2 years) skin examination, good health status, a primary care specialty, self-confidence in counseling or screening, extensive training in counseling or screening, high perceived relevance to the practice of the counseling or screening, nonurban practice site, and nonhospital-based or non-medical school-based practice. We found that 48% of all physicians always or nearly always used sunscreen, and 25% had received a clinical skin examination in the previous 2 years.

CONCLUSIONS

Although many primary care physicians report ever counseling or screening their typical patients about skin cancer and sunscreen use, increased professional education for primary care physicians could improve patient counseling about skin cancer prevention.

Physician disclosure of healthy personal behaviors improves credibility and ability to motivate

CONTEXT

While some studies have shown that physicians with healthy personal habits are especially likely to discuss prevention with their patients, to our knowledge no one has published information testing whether physician credibility and patient motivation to adopt healthier habits are enhanced by physician's disclosures of their own healthy behaviors.

DESIGN

Two brief health education videos about improving diet and exercise were produced and shown to subjects (n1 = 66, n2 = 65) in an Emory University general medical clinic waiting room in Atlanta, Ga. In one video, the physician revealed an additional half minute of information about her personal healthy dietary and exercise practices and had a bike helmet and an apple visible on her desk (physician-disclosure video). In the other video, discussion of personal practices and the apple and bike helmet were not included (control video).

RESULTS

Viewers of the physician-disclosure video considered the physician to be generally healthier, some-what more believable, and more motivating than did viewers of the control video. They also rated this physician to be specifically more believable and motivating regarding exercise and diet (P < or = .001).

CONCLUSION

Physicians' abilities to motivate patients to adopt healthy habits can be enhanced by conveying their own healthy habits. Educational institutions should consider encouraging health professionals-in-training to practice and demonstrate healthy personal lifestyles.

Family responsibilities and domestic activities of US women physicians

BACKGROUND

Women physicians may have a multiplicity of domestic roles (eg, cook, housekeeper, child care provider) that are of inherent interest and that may affect their professional lives, but are largely unstudied.

DESIGN, SETTING, PARTICIPANTS, AND MAIN OUTCOME MEASURES

We report data from respondents (N = 4501) to the Women Physicians' Health Study, a cross-sectional, questionnaire-based study of a stratified random sample of US women MDs.

RESULTS

Women physicians with children aged 0 to 17 years spent a median of 24.4 hours per week on child care. Women physicians typically spent half an hour per day cooking, and another half-hour per day on other housework. Little time was spent on gardening: a median of 0.05 hours (3 minutes) per week. Those performing more domestic tasks are likely to work fewer hours outside the home and to be on call less often. Women physicians who are married or widowed, have more children, have lower personal incomes, and have more highly educated and higher-earning spouses perform more domestic activities. We found no significant adverse relationship between time spent on any domestic activity and career satisfaction or mental or physical health.

CONCLUSIONS

Women physicians spend little time on domestic activities that can be done for them by others, including cooking, housework, and especially gardening. Women physicians spend somewhat less time on child care and substantially less time on housework than do other US women. Despite abundant editorializing about role conflicts of women physicians, our measures of career satisfaction and mental health were not adversely affected by time spent on domestic obligations.

Career satisfaction of US women physicians: results from the Women Physicians' Health Study. Society of General Internal Medicine Career Satisfaction Study Group

BACKGROUND

Despite major changes in health care, the prevalence and predictors of career satisfaction have not recently been comprehensively studied in either women or men physicians.

METHODS

The Women Physicians' Health Study surveyed a nationally representative random sample (n = 4501 respondents; response rate, 59%) of US women physicians. Using univariate and logistic regression analyses, we examined personal and professional characteristics that were correlated with 3 major outcomes: career satisfaction, desire to become a physician again, and desire to change one's specialty.

RESULTS

Women physicians were generally satisfied with their careers (84% usually, almost always, or always satisfied). However, 31% would maybe, probably, or definitely not choose to be a physician again, and 38% would maybe, probably, or definitely prefer to change their specialty. Physician's age, control of the work environment, work stress, and a history of harassment were independent predictors of all 3 outcomes, with younger physicians and those having least work control, most work stress, or having experienced severe harassment reporting the most dissatisfaction. The strongest association (odds ratio, 11.3; 95% confidence interval, 7.3-17.5; P<.001) was between work control and career satisfaction. Other significant predictors (P<.01) of outcomes included birthplace, ethnicity, sexual orientation, having children, stress at home, religious fervor, mental health, specialty, practice type, and workload.

CONCLUSIONS

Women physicians generally report career satisfaction, but many, if given the choice, would not become a physician again or would choose a different specialty. Correctable factors such as work stress, harassment, and poor control over work environment should be addressed to improve the recruitment and retention of women physicians.

Prevalences and correlates of ethnic harassment in the U.S. Women Physicians' Health Study

PURPOSE

To describe lifetime prevalences and correlates of ethnic harassment in U.S. women physicians.

METHOD

The authors analyzed responses to questions about ethnic harassment that appeared in the Women Physicians' Health Study, a 1993-94, nationally distributed survey of 4,501 female physicians.

RESULTS

Of the responding physicians, 62% of blacks reported having experienced ethnic harassment, twice the rate of Asians and "others," three times that of Hispanics, and ten times that of whites. Twenty-five percent of black physicians reported experiencing harassment in at least three phases of their careers (before medical school, during medical school, during training, in practice), compared with 6% of "others," 2% of Hispanics and Asians, and less than 0.5% of whites. U.S.-born and foreign-born doctors reported similar rates of harassment before and during medical school, while foreign-born doctors reported significantly more harassment during training and practice. Reports of harassment during medical school were higher for blacks under 50 than for those over 50 (38% vs 10%, p = .0101). In white physicians, harassment was significantly associated with religion. For certain ethnic groups, control of work environment, dissatisfaction with profession, and stress at work and home were associated with reported harassment.

CONCLUSIONS

The prevalences of ethnic harassment at various stages of medical training and practice are high, and not decreasing. This has serious potential ramifications for the medical profession's goal of a diverse physician workforce.