Archives of family medicine最新文献

Objective: This study evaluated physicians' self-reported management of acute low back problems in adults and adherence with published guidelines.

Design: Self-administered written survey based on the US Agency for Health Care Policy and Research (now the Agency for Healthcare Research and Quality) guideline on acute low back problems in adults.

Setting: A region of northern Illinois with a population around 250 000 and encompassing a medium-sized city.

Participants: One hundred eighty-two primary care physicians (nonpediatric) with medical staff appointments at area hospitals.

Main outcome measure: Adherence to published recommendations.

Results: Eighty-seven surveys were received for a 48% response rate. Overall, survey respondents recognized 5 of 7 red flags representing serious underlying abnormality 50% or less of the time. Forty percent (35/87) of physicians provided patients with written educational material, and only 25%(22/87) indicated they evaluated motor function of the fifth lumbar nerve, the most commonly affected level in intervertebral disk disease disease. About 25% (24/87) reported routine use of plain films; and 16% (14/87), routine use of computed tomography or magnetic resonance imaging. Most oral medication use was consistent with recommendations, but many also used drugs conditionally discouraged by the guideline (muscle relaxants, 91% [79/87]; opioids, 62% [54/87]) or cautioned against (oral steroids, 45% [39/87]; antidepressants, 23% [20/87]; injection therapy, 52% [45/87]). Only 22% (19/87) of respondents used or recommended manipulation.

Conclusions: The management of patients with acute low back problems by primary care physicians differs significantly from Agency for Health Care Policy and Research guideline recommendations in several key areas that include awareness of red flags, use of medication, use of radiographic studies, the need for patient education, and the use of physical modalities. Future research should focus on the impact of guideline compliance on patient outcomes and cost-effectiveness. Arch Fam Med. 2000;9:1015-1021

Objective: To assess effects of stepped collaborative care depression intervention on disability.

Design: Randomized controlled trial.

Setting: Four primary care clinics of a large health maintenance organization.

Patients: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication.

Intervention: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes.

Main outcome measures: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).

Results: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94).

Conclusions: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058

There has been an explosion of new antiepileptic drug availability for physicians to treat patients with recurrent seizures. Principal antiepileptic drugs consisted of 6 key agents for both generalized and partial epilepsy for nearly 8 decades. Since 1993, the availability of newer "second-generation" agents has nearly doubled the armamentarium available for the 2.5 million patients who have recurrent seizures. This new influx of medications has flooded the medical and lay community with choices never before appreciated. The promise of improved tolerability with different safety and efficacy profiles has been exciting for all involved in epilepsy management. While most of the newer agents have been approved for adjunctive use in medically refractory partial epilepsy with recurrent complex partial and secondarily generalized seizures, efficacy is expanding to include generalized epilepsy and children for some agents. Arch Fam Med. 2000;9:1135-1141

Every year, more than 1 million Americans die of different causes. Some die easily and comfortably. Others die with a great deal of suffering and distress. This article contrasts key aspects of the way Americans die with the way they say they would like to die. It will also highlight some of the barriers to providing high-quality end-of-life care. Arch Fam Med. 2000;9:1176-1180

Guidelines from the Centers for Disease Control and Prevention, Atlanta, Ga, recommend that all pregnant women be offered human immunodeficiency virus (HIV) testing to ensure that they have the opportunity to use currently available therapeutic interventions to reduce the risk infecting their offspring with HIV. These recommendations have resulted in an increased number of low-risk women being tested and a significant rise in the percentage of false-positive results from HIV antibody screening tests and ambiguous (indeterminate) findings from confirmatory tests. Women receiving such results are generally in emotional turmoil yet must make treatment choices if they prove to be infected. This article provides guidelines to help general medical practitioners to understand the nature of HIV testing, to assess a woman's infection status when initial tests are ambiguous, and to determine when treatment is appropriate.

Background: Many clinical guidelines (CGs) have been written during the past few years. Although family physicians (FPs) stand to benefit from many of these CGs, incorporating new CGs into daily practice seems to present a challenge.

Objective: To evaluate Israeli FPs' attitudes toward CGs.

Methods: We administered an anonymous questionnaire to general practitioners, residents, and board-certified FPs who participated in continuing medical education programs throughout Israel during May and June 1998. Our survey focused on physician attitudes and behaviors regarding CGs in general, and to CGs for treating the patient with diabetes mellitus (DM) in particular. The CGs for patients with DM have recently been promoted in the context of primary care quality improvement programs. Respondents also provided demographic and professional data.

Results: Of the 404 questionnaires distributed, 293 questionnaires were returned for a response rate of 83%. The average (+/-SD) age of respondents was 40.2 +/- 7.0 years, with a mean (+/-SD) of 13.3 +/- 8.0 years in practice. Overall, opinion regarding CGs was positive. About half of the respondents thought CGs improved patient compliance. Comparisons between the various physician groups highlighted several notable differences. Two thirds of the general practitioners believed CGs improved patient compliance, while this was true of only one third of the FPs (P<.001). Most FPs (62%) and senior residents (69%) felt CGs did not constrain their clinical freedom, while less than half of the general practitioners and junior residents felt this way (P =.045). Eighty-three percent of all respondents agreed that the CGs for the treatment of DM were able to be implemented, and 75% believed the CGs assisted them in the management of patients with DM. Whereas 39% expressed concern about being able to adapt generic CGs to individual patient needs, only 27% (P =.002) felt this way about the DM CGs. The vast majority (92%) were interested in understanding the scientific evidence supporting CGs as a prerequisite to adopting them. Most respondents preferred limiting CG length to a maximum of 5 pages.

Conclusions: We found support among Israeli FPs for the use of CGs. Clinical guidelines seem to be used in the field, in particular those developed for treating DM. In light of our findings, attention should be focused on optimally tailoring new CGs to meet scientific standards and crafting them to suit the preferences of local FPs.

Objective: To compare the efficacy and safety of valacyclovir hydrochloride and famciclovir for the treatment of herpes zoster.

Design: A double-blind, randomized, controlled, multicenter clinical trial in which patients received 7 days of treatment and were followed up for 24 weeks.

Settings: Patients reported directly to specialist centers or were referred from primary care centers.

Patients: There were 597 otherwise healthy immunocompetent outpatients, aged 50 years and older, who presented within 72 hours of onset of zoster rash.

Interventions: Treatment with valacyclovir hydrochloride (1 g 3 times daily) or famciclovir (500 mg 3 times daily) for 7 days.

Main outcome measures: Resolution of zoster-associated pain and postherpetic neuralgia, rash healing, and treatment safety.

Results: Intent-to-treat analysis did not detect statistically significant differences for valacyclovir vs famciclovir on resolution of zoster-associated pain (hazard ratio, 1. 02; 95% confidence interval, 0.84-1.23; P =.84). Furthermore, no differences were evident between treatments on rash healing rates and on a range of analyses of postherpetic neuralgia. Safety profiles for valacyclovir and famciclovir were similar, with headache and nausea being the more common adverse events.

Conclusions: Valacyclovir treatment is comparable to famciclovir treatment in speeding the resolution of zoster-associated pain and postherpetic neuralgia. Current wholesale prices indicate that valacyclovir is the more cost-effective treatment for herpes zoster ($83.90 vs $140.70 per course).