Archives of family medicine最新文献

Background: As the elderly population booms and the prevalence of dementia soars, it becomes imperative that primary care physicians recognize early dementia within their own practices. Early recognition and diagnosis of dementia will allow appropriate intervention and treatment to improve morbidity.

Objective: To examine the most common symptoms associated with early Alzheimer disease (AD), as presented by patients and their families, and to compare these with the recommendations of the "7-Minute Screen" by Solomon et al for the identification of AD and the recommendations of the Agency for Health Care Policy and Research (AHCPR) for the early recognition of dementia.

Methods: A retrospective medical record review was conducted in an outpatient referral population within 2 geriatric evaluation centers. Patient medical record selection was based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for AD, a Mini-Mental State Examination (MMSE) score of 23 or higher, a Geriatric Depression Scale score of less than 5, age above 60 years, and at least an eighth-grade level of education.

Results: From 1025 medical records reviewed, 50 patients were chosen who fulfilled all inclusion criteria. Forty patients (80%) missed at least 2, if not all 3, recall items on the MMSE. Thirty patients (60%) had difficulty managing finances and/or balancing a checkbook; 16 (32%) frequently repeated stories and statements; 15 (30%) became lost while driving; 10 (20%) frequently forgot the names of relatives; and 10 (20%) had poor judgment. These results demonstrated a high correlation with recall as a diagnostic factor in diagnosing early AD as found in the 7-Minute Screen. Moreover, these "clues" correlated well with the AHCPR's symptoms that indicate dementia. The symptoms specifically overlapped in the areas of learning and retaining new information (repetition), handling complex tasks (calculation), reasoning ability (judgment), and spatial ability and orientation (driving).

Conclusions: There may be a constellation of symptoms associated with early AD. This constellation includes missing recall items on the MMSE, difficulty in calculation, repetition, getting lost while driving, forgetting the names of relatives, and having poor judgment. Recall is the symptom most consistent with the findings of the 7-Minute Screen in diagnosing AD. However, repetition, calculation, judgment, and driving highly correlate with the AHCPR's dementia symptom checklist. Therefore, if primary care physicians keep this constellation of symptoms in mind while evaluating their geriatric population, they will have greater ability to suspect, diagnose, and treat AD at an early stage. Arch Fam Med. 2000;9:1066-1070

Background: Primary care patients often have certain expectations when visiting physicians, many of which may be undetected. These unmet expectations can affect outcomes such as satisfaction with care. We performed a formal literature review to examine the effect of fulfillment of patients' visit-specific expectations on their satisfaction as well as on health status and compliance.

Patients and methods: Included studies were conducted in primary care settings, systematically recruited patients, elicited previsit and/or postvisit expectations relative to specific visits, and measured patient-centered outcomes. Two reviewers abstracted information on study characteristics; types, timing, and method of expectation ascertainment; and outcomes. Disagreements were resolved by consensus.

Results: Twenty-three studies were reviewed including 7 trials, 4 cohort studies, and 12 cross-sectional studies. Patients frequently expected information rather than specific physician actions, but physicians often did not accurately perceive patients' visit-specific expectations. In 19 studies that assessed postvisit patient satisfaction, a positive association between meeting patient expectations and overall satisfaction was demonstrated in 11 studies, inconclusive in 3, and not established in 5. In 2 studies assessing physician satisfaction, physicians with access to patients' expectations were more satisfied than those without access. Other outcomes (symptom or disease improvement, health status, test ordering, health care costs, psychological symptoms) were measured in only a few studies, and the results were inconclusive.

Conclusions: Addressing patients' visit-specific expectations appears to affect satisfaction to a modest degree. Future studies should evaluate methods that efficiently elicit, prioritize, and provide patients' previsit expectations for physicians and should examine the longitudinal effect of expectation fulfillment on patient outcomes. Arch Fam Med. 2000;9:1148-1155

Objective: To determine the prevalence and nature of orofacial and dental problems in 2 family medicine practices.

Design: Prospective, cross-sectional analysis of consecutive patient visits.

Setting: Urban and rural family medicine practices.

Patients and participants: Four hundred seventy-two patients between age 10 and 86 years.

Interventions: None.

Main outcome measures: Prevalence and nature of patient visits to family medicine practices that were either initiated by problems in the region of the oral cavity or that involved questions raised by the patient concerning oral or perioral sites.

Results: Twenty-one patients (4.5%) of 472 met the inclusion criteria, 16 (76%) of whom had an oral problem as the primary or secondary reason for their visit. Perioral pain and mucosal ulcerations were the most common problems, and gingival tissue was the most common location. Almost two thirds of these patients had bacterial, fungal, or viral infections. Regarding treatment, 13 (62%) of these patients received advice, 10 (48%) received prescriptions, and 3 (15%) were referred to a dentist or another medical specialist.

Conclusions: Oral and perioral problems are common in the practice of family medicine, which suggests the desirability for specific oral medicine topics in the training and continuing education of primary care physicians. Arch Fam Med. 2000;9:1009-1012

Ascaris lumbricoides are among the medically important worms belonging to the phylum Nematoda (roundworms) that are parasites of the human gastrointestinal tract. Despite current sanitation and hygiene standards in the United States, infection due to intestinal roundworms is not uncommon in children and adults. A high index of suspicion is warranted as patients may present anywhere along a spectrum of illness from asymptomatic to acutely ill. The following is a case presentation and discussion of Ascaris lumbricoides, the common roundworm or intestinal longworm. Arch Fam Med. 2000;9:1193-1194

Background: Little data exist on the cause and treatment of subfacial pain and pressure and other discomfort attributed to the paranasal sinuses that develop early during the course of the common cold. The purpose of this study was to determine the efficacy of the combination of pseudoephedrine hydrochloride with acetaminophen for the treatment of early symptoms during colds, which are attributed by the patient to the sinuses.

Methods: Four hundred thirty subjects (216, pseudoephedrine and acetaminophen recipients; 214, placebo recipients) with cold symptoms of 48 hours or less who reported overall "sinus" symptoms of at least moderate severity were enrolled in this randomized double-blind placebo-controlled 2-dose study. Self-reported symptoms were scored (0 to 4, absent to severe) before and at 2 hours after the first and second doses. The 2 primary were measured 2 hours after the second dose were the overall sinus symptom assessment and a weighted composite assessment of sinus pressure, pain, and congestion (sinus symptoms).

Results: Compared with baseline, 2 hours after the second dose, the mean +/- SEM overall sinus symptom assessment score had decreased by 1.30 +/- 0. 06 in the pseudoephedrine and acetaminophen-treated subjects compared with 0.93 +/- 0.06 in the placebo-treated subjects (P< or = .029). The mean +/- SEM weighted average of sinus symptoms 2 hours after the second dose of study medication had decreased by 1.14 +/- 0.06 in the pseudoephedrine and acetaminophen-treated subjects compared with 0.84 +/- 0.06 in the placebo-treated subjects (P< or = .029). Reductions in similar magnitude were also observed for each of the individual sinus symptoms, and headache and rhinorrhea. Nervousness occurred in 4% of the pseudoephedrine and acetaminophen recipients compared with 0% of placebo recipients (P =.007).

Conclusion: Our results suggest that pseudoephedrine plus acetaminophen is effective for relief of symptoms attributable to the paranasal sinuses that may develop early in the course of a cold. Arch Fam Med. 2000;9:979-985

Objective and design: To evaluate a cohort of patients with major depression to examine the effect of competing demands on depression care during multiple visits over 6 months.

Participants and setting: Ninety-two patients with 5 or more symptoms of depression and no recent depression treatment were evaluated by 12 primary care physicians in 6 practices in the usual-care arm of an effectiveness trial of the Agency for Health Care Policy and Research Depression Guidelines.

Main outcome measure: Treatment was considered to be initiated if the patient reported starting a guideline-concordant antidepressant medication or making a visit for specialty counseling. Treatment completion was defined as either a 3-month course of guideline-concordant antidepressant use or completion of 8 or more specialty counseling visits.

Results: Among the 92 patients reporting no recent treatment at study enrollment, 57% reported starting and 17% reported completing a course of guideline-concordant antidepressant medication and or specialty counseling at the 6-month interview. The severity of physical problems among patients with high enthusiasm for depression treatment decreased the odds that patients would initiate depression therapy. Severity of physical problems had no observable effect on completing depression therapy in the group of patients who initiated treatment.

Conclusions: Physical problems compete with depression for attention over multiple visits in untreated patients who are enthusiastic about getting care for their emotional problems. Interventions are needed for this high-risk group, because depression treatment could potentially enhance patients' treatment of their physical problems. Arch Fam Med. 2000;9:1059-1064

Objective: To investigate the nature and frequency of adverse events that occur as a result of the practice of traditional Chinese medicine (acupuncture and Chinese herbal medicine) in Australia.

Methods: Data on adverse events were obtained as part of a comprehensive survey of all occupational health groups, government-registered and unregistered, who practiced traditional Chinese medicine or 1 of its main modalities.

Results: Practitioners reported numerous adverse events arising from the application of acupuncture (including fainting, nausea and vomiting, and increased pain), or the consumption of Chinese herbal medicines (including direct toxic effects and allergic reactions). Practitioners experienced an average of 1 adverse event every 8 to 9 months of full-time practice or 1 adverse event for every 633 consultations. The mean adverse event rate of nonmedical practitioners was less than half the mean adverse event rate of medical practitioners.

Conclusions: The practices of acupuncture and Chinese herbal medicine are not risk-free and fatalities have occurred. Variation in adverse event rates between medical and nonmedical practitioners may reflect differences in relevant education or different reporting behaviors. These data represent the first step in the evaluation of adverse event rates in traditional Chinese medicine. Arch Fam Med. 2000;9:1071-1078

Background: Physicians' health problems have been discussed mainly in relation to substance abuse and psychiatric disorders. In this study, the prevalence of common chronic diseases and their treatment were determined.

Objective: To find differences in self-reported health status, amount of sick leave, and the use of health services among physicians according to sex and specialty. Data were also compared with those of the total employed population.

Design and setting: Cross-sectional postal questionnaire survey in Finland.

Participants and methods: A random sample of licensed physicians younger than 66 years (n = 4477) was randomly selected from the register of the Finnish Medical Association. A total of 3313 physicians (74%) responded.

Main outcome measures: Perceived health, prevalence of diseases, self-treatment of diseases, amount of sick leave, and medical consultations.

Results: Female physicians assessed their health as being better than other female employees and had used health services and had been on sick leave more often than their male colleagues. Male physicians assessed their health as being equal to that of other men. Both female and male physicians had fewer sick leave than other employees. However, physicians-especially men-reported many common chronic illnesses as often or more often than other employees. Physicians had consulted other medical professionals less often than other employees, and they primarily self-treated their illnesses. Of the specialties, psychiatrists had used health services and had been on sick leave more often than other physicians.

Conclusion: This study indicates that the usual form of care of physicians' diseases is self-treatment and "working through" illnesses. Arch Fam Med. 2000;9:1079-1085

Context: Despite recommendations to screen prenatal care patients for partner violence, the prevalence of such screening is unknown.

Objectives: To estimate the statewide prevalence of partner violence screening during prenatal care among a representative sample of North Carolina women with newborns and to compare women screened for partner violence with women not screened.

Design, setting, and participants: This investigation examines data gathered through the North Carolina Pregnancy Risk Assessment Monitoring System, a random sample of more than 2600 recently postpartum women who were delivered of newborns between July 1997 and December 1998.

Main outcome measures: Self-reports of violence, health service factors, and sociodemographic characteristics.

Analysis: The prevalence of screening was computed, and odds ratios and 95% confidence intervals were used to examine bivariate and multivariable associations between being screened for partner violence and other factors.

Results: Thirty-seven percent of women reported being screened for partner violence during prenatal care. Logistic regression analysis found that women were more likely to be screened if they received prenatal care from (1) a public provider paid by a public source; (2) a private provider paid by a public source; or (3) a public provider paid by a private source.

Conclusions: These findings suggest that the majority of prenatal care patients in North Carolina are not screened for partner violence. Screening appears to be most highly associated with whether a woman is a patient in the public sector or the private sector, and with the source of payment for prenatal care. Arch Fam Med. 2000;9:1093-1099

Background: Studies in the past 25 years have suggested that physicians are not familiar with the costs of common prescription medications.

Objectives: To determine physician familiarity with the cost of common prescription medications and to determine the value physicians place on knowing information regarding the cost of medications.

Design: Survey.

Setting: Seven community-based family medicine residency teaching clinics in Iowa.

Participants: Two hundred five practicing resident and faculty physicians.

Interventions: From a series of $10 price intervals (range, $0.01-$80.00), physicians were asked to select the interval containing the cash price of the medication to an uninsured patient for 50 medications commonly prescribed in outpatient family medicine clinics. Physicians were also questioned about the value of medication cost information to their practice.

Main outcome measures: The percentage of correct responses and the mean pricing scores were calculated for each respondent and for all medications.

Results: One hundred seventy-eight physicians responded (86.8%). Only 22.9% of the responses correctly identified the cost of the medication. More than two thirds (68.3%) of the responses underestimated the correct price interval. Branded drugs were underestimated in 89.9% of responses, while generic drugs were overestimated in 90.2% of responses. Overall, 64.4% of physicians believed they did not receive sufficient information in their practices regarding prescription drug costs, and nearly all (93.6%) reported that regular information on prescription medication costs would help them prescribe more cost-effectively.

Conclusions: Physicians are unfamiliar with the costs of medications they commonly prescribe, and they report that regular access to information on prescription medication costs would help them prescribe more cost-effectively. Arch Fam Med. 2000;9:1002-1007