Archives of family medicine最新文献

Objective: To identify the perceived barriers to and benefits of leisure-time physical activity among older Mexican Americans (MA) and European Americans (EA).

Design: Cross-sectional survey using in-home interviews of subjects.

Setting: Subjects recruited from 10 family practice offices in South Texas that are part of a practice-based research network.

Participants: Two hundred ten MA and EA adults, aged 60 years and older, interviewed between April 1994 and April 1996.

Measurements: The perceived benefits and barriers summary score from the San Diego Health and Exercise Questionnaire, the Minnesota Leisure Time Physical Activity Questionnaire, body mass index, chronic diseases, depressive symptoms, and demographics.

Main results: Older MA reported greater perceived benefits to physical activity and fewer perceived barriers than older MA while having lower levels of habitual physical activity. Lower levels of education, male sex, higher body mass index, and older age were also associated with lower levels of habitual physical activity.

Conclusions: Although MA reported lower levels of physical activity, they perceived greater benefits and fewer barriers to physical activity. These attitudes about physical activity held by older MA may present an opportunity to encourage greater levels of physical activity throughout this population.

Background: Studies on alcohol abuse are frequently based on patients who meet minimum diagnostic criteria, thus ignoring patients with individual symptoms of harmful or hazardous use. Consequently, we are unable to characterize alcohol-abusing patients with sufficient clarity to effectively focus screening for primary prevention.

Objective: To determine the prevalence of harmful and hazardous use of alcohol, assess screening instruments for detecting alcohol abuse or dependence, and assess the impact of alcohol use on other diagnoses treated in outpatient settings.

Design: Survey (cross-sectional study).

Setting: Hospital-based outpatient clinic.

Participants: Three hundred randomly selected adults (aged 18 years and older).

Main outcome measure: Diagnosis of alcohol abuse or dependence based on the Diagnostic Interview Schedule (DIS).

Results: About 18% met DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) criteria of abuse or dependence while almost 50% had at least one symptom of harmful or hazardous use. The T-ACE questionnaire, a modified version of the CAGE questionnaire, was the most effective screening instrument for both men and women. Selected diagnoses, personal characteristics such as family history of alcohol abuse, and self-reported patterns of alcohol use could identify patients likely to meet diagnostic criteria.

Conclusions: Many symptoms of substance use disorders are not adequately addressed in outpatient practice. Little is known about how alcohol use in varying quantities affects health care utilization and treatment of conditions commonly seen in outpatient medicine. Consequently, we lack a full appreciation of the burden of disease borne by alcohol use and have yet to achieve a universally accepted method of approaching primary and secondary prevention of alcohol-related problems.

Background: Most research on the prevalence of mental disorders in primary care has been conducted in practices that serve middle- and upper-income patients.

Objective: To determine the prevalence of major mental disorders in a primary care practice that serves a predominantly low-income immigrant patient population.

Design: Cross-sectional survey; criterion standard.

Setting: Urban general medicine practice.

Participants: Systematic sample of consecutive adult patients with scheduled appointments. Of 1266 approached eligible patients, 1007 (80%) participated.

Main outcome measures: PRIME-MD Patient Health Questionnaire major depression, generalized anxiety disorder, panic disorder, alcohol use disorder, and suicidal ideation; drug use disorder; functional status; work loss; family distress; and mental health treatment.

Results: Major depression (18. 9%), generalized anxiety (14.8%), panic (8.3%), and substance use (7. 9%) disorders and suicidal ideation (7.1%) were highly prevalent. Many patients had more than 1 disorder (range, 36.3% [substance use disorder] to 76.9% [panic disorder]). In multivariate analyses, each disorder was significantly associated with an increase in impairment after controlling for demographic characteristics, perceived health, and the other disorders. A minority of patients with each disorder (range, 22.5% [substance use disorder] to 46.4% [panic disorder]) reported receiving mental health treatment in the last month.

Conclusions: Clinically significant depression, anxiety, substance use, and suicidal ideation are quite common in this practice and associated with significant functional impairment. Primary care practices that serve poor urban immigrant populations have a critical need to provide access to mental health services. Arch Fam Med. 2000;9:876-883

Survey responses were obtained from 113 family physicians in an exploratory investigation of bereavement care by family physicians. Respondents generally indicated that they believed that bereavement presented significant health risks to their patients and that the identification and treatment of bereaved patients was an important part of their role. However, physicians were highly variable in how they reported identifying and responding to bereaved patients in terms of counseling, addressing spiritual concerns, and medically treating symptoms. The "grief-responsive" physician is described based on these data. We document the interest and need for training in bereavement care.

Context: Little is known about older lesbian and bisexual women. Existing research rarely compares characteristics of these women with comparable heterosexual women.

Objective: To compare heterosexual and nonheterosexual women 50 to 79 years on specific demographic characteristics, psychosocial risk factors, screening practices, and other health-related behaviors associated with increased risk for developing particular diseases or disease outcomes.

Design: Analysis of data from 93,311 participants in the Women's Health Initiative (WHI) study of health in postmenopausal women, comparing characteristics of 5 groups: heterosexuals, bisexuals, lifetime lesbians, adult lesbians, and those who never had sex as an adult.

Setting: Subjects were recruited at 40 WHI study centers nationwide representing a range of geographic and ethnic diversity.

Participants: Postmenopausal women aged 50 to 79 years who met WHI eligibility criteria, signed an informed consent to participate in the WHI clinical trial(s) or observational study, and responded to the baseline questions on sexual orientation.

Main outcome measures: Demographic characteristics, psychosocial risk factors, recency of screening tests, and other health-related behaviors as assessed on the WHI baseline questionnaire.

Results: Although of higher socioeconomic status than the heterosexuals, the lesbian and bisexual women more often used alcohol and cigarettes, exhibited other risk factors for reproductive cancers and cardiovascular disease, and scored lower on measures of mental health and social support. Notable is the 35% of lesbians and 81% of bisexual women who have been pregnant. Women reporting that they never had sex as an adult had lower rates of Papanicolaou screening and hormone replacement therapy use than other groups.

Conclusions: This sample of older lesbian and bisexual women from WHI shows many of the same health behaviors, demographic, and psychosocial risk factors reported in the literature for their younger counterparts, despite their higher socioeconomic status and access to health care. The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women.

Hypertension is the most prevalent health problem among adult primary care patients, but its recognition and treatment are suboptimal. Although there is ample evidence from several large-scale randomized, controlled studies that treatment of hypertension reduces morbidity and mortality, current management of hypertension is characterized by underdiagnosis, misdiagnosis, undertreatment, overtreatment, and misuse of medications. As a result, roughly 75% of the estimated 50 million adults with hypertension in the United States are at increased risk for vascular complications. Optimal therapy requires careful attention to patients' age, sex, race, diet, exercise, tobacco use, comorbid conditions, choice of antihypertensive drug treatment, compliance with treatment, and achievement of blood pressure control. Other issues that deserve scrutiny are accuracy of the initial diagnosis, self-monitoring of blood pressure, and the advisability of attempting reduction of dosage or possible withdrawal from administration of antihypertensive drug treatment in patients whose blood pressures have been controlled for 1 year or more. Physicians' knowledge and use of the Sixth Joint National Committee on Prevention, Detection, and Treatment of High Blood Pressure report are deficient. Several responses to this current crisis in care of hypertensive patients are reviewed, including computer-aided management, medical chart audit, academic detailing, and a nurse case manager using prepared algorithms in consultation with the physician.

Background: The completion of annual screening mammography and other preventive health services among women aged 50 years and older remains an important quality of care indicator.

Methods: A biracial sample of 843 rural women (aged > or =50 years) from a population-based sample reported demographic and preventive health services utilization in the last year including the completion of screening mammography. Bivariate analysis and logistic regression were used to investigate the extent to which completion of other screening examinations, including Papanicolaou (Pap) smears and clinical breast examination, is associated with successful completion of mammography relative to demographic and health service variables.

Results: The completion of mammography was associated with age, race, education, health insurance, and the presence of a regular primary care physician, but the strongest predictors were the completion of a clinical breast examination and/or a Pap smear.

Conclusions: Women who receive a clinical breast examination and/or a Pap smear appear far more likely to receive screening mammography, suggesting a synergy in screening services. The relative efficacy of interventions to increase the completion of clinical breast examinations as well as other age-appropriate preventive services during routine office visits or during a single preventive services office visit should be further explored in primary care settings. Residency programs should provide training on the successful incorporation of such services into office practice patterns in an effort to continually improve quality of care.

Objective: To examine among immigrants and others seeking primary care: (1) the prevalence, types, and predictors of traumatic life events; and (2) the relations among traumatic life events, psychiatric disorders, and utilization of primary care services.

Design: Survey with structured diagnostic interview.

Setting: Community-based, university-affiliated primary care clinic in southern California.

Participants: Fourteen hundred fifty-six adult patients representing 4 ethnic groups (Mexican immigrants, Central American immigrants, US-born Latinos of Mexican descent, and US-born non-Latino whites).

Dependent measures: Rates of traumatic events measured with the Posttraumatic Stress Disorder section of the Diagnostic Interview Schedule; psychiatric disorders identified by the Composite International Diagnostic Interview using Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition criteria; physical functioning (Short Form Health Survey); and the number of medical clinic visits during a 6-month period.

Results: Nearly 10% of patients had experienced a traumatic event in the previous year, and 57% had experienced at least 1 during their lifetimes. The most common forms of trauma were interpersonal violence occurring outside the family (21%), acute losses or accidents (17%), witnessing death or violence (13%), and domestic violence (12%). When compared with the US-born non-Latino whites, Mexican immigrants were half as likely, and Central American immigrants were 76% more likely, to report having experienced a traumatic event. Married individuals were significantly less likely to report traumas. Traumatic experiences, female gender, and non-Latino ethnicity were associated with the presence of a psychiatric disorder. One-year and lifetime psychiatric disorders were associated with poorer physical functioning and an increased number of clinic visits during a 6-month period.

Conclusions: Traumatic life events are common and associated with psychiatric disorders other than posttraumatic stress disorder in an ethnically diverse sample of primary care patients. Psychiatric disorders, in turn, are strongly associated with poor physical functioning and higher rates of primary care utilization. Screening for traumatic experiences should accompany assessments of psychiatric disorders to ensure adequate treatment of patients seeking primary care services.

The American Cancer Society estimates that this year more than 180, 000 women in the United States will develop breast cancer and more than 40,000 women will die of the disease. According to a National Cancer Institute model, 5 years of preventive therapy with tamoxifen citrate reduced the risk of invasive breast cancer by 49% (P<.00001) in women at increased risk for breast cancer. The reduction in risk was greater in women with a history of lobular carcinoma in situ (LCIS; 56% relative risk reduction) or atypical hyperplasia (86% relative risk reduction). It should be noted, however, that no benefit was found in 2 European studies using notably different risk evaluation models and entry criteria. Because elevated risks of uterine cancer and thromboembolic disease have been associated with tamoxifen therapy, appropriate counseling should be given to any woman considering tamoxifen as a means of reducing breast cancer risk. Arch Fam Med. 2000;9:906-912