Clinic HIV-focused features and prevention of Pneumocystis carinii pneumonia

OBJECTIVE: To examine the association of clinic HIV-focused features and advanced HIV care experience with Pneumocystis carinii pneumonia (PCP) prophylaxis and development of PCP as the initial AIDS diagnosis. DESIGN: Nonconcurrent prospective study. SETTING: New York State Medicaid Program. PARTICIPANTS: Medicaid enrollees diagnosed with AIDS in 1990–1992. MEASUREMENTS AND MAIN RESULTS: We collected patient clinical and health care data from Medicaid files, conducted telephone interviews of directors of 125 clinics serving as the usual source of care for study patients, and measured AIDS experience as the cumulative number of AIDS patients treated by the study clinics since 1986. Pneumocystis carinii pneumonia prophylaxis in the 6 months before AIDS diagnosis and PCP at AIDS diagnosis were the main outcome measures. Bivariate and multivariate analyses adjusted for clustering of patients within clinics. Of 1,876 HIV-infected persons, 44% had PCP prophylaxis and 38% had primary PCP. Persons on prophylaxis had 20% lower adjusted odds of developing PCP (95% confidence interval [CI] 0.64, 0.99). The adjusted odds of receiving prophylaxis rose monotonically with the number of HIV-focused features offered by the clinic, with threefold higher odds (95% CI 1.6, 5.7) for six versus two or fewer such features. Patients in clinics with three HIV-focused features had 36% lower adjusted odds of PCP than those in clinics with one or none. Neither clinic experience nor specialty had a significant association with prophylaxis or PCP. CONCLUSIONS: PCP prevention in our study cohort appears to be more successful in clinics offering an array of HIV-focused features. Presented in part at the 19th Annual Meeting of the Society of General Internal Medicine, Washington, DC, May 1996, and the Eleventh International Conference on AIDS, Vancouver, BC, Canada, July 1996. Funded by the Agency for Health Care Policy and Research (RO1 HS06465-04).     

Clinical predictors of treatment reduction in hypertensive patients

Objective:To demonstrate that some hypertensive patients under good blood pressure (BP) control can reduce medications, and to identify predictors of successful reduction. Design:Observational study with 11-month follow-up. Setting:Outpatient hypertension clinic at the Seattle Veterans Administration Hospital. Patients:59 males (51% of those eligible) with diastolic BP<95 mm Hg for ≥6 months; 57 patients (97%) completed the study. Intervention:Gradual reduction of medications unless diastolic BP rose above 95 mm Hg. Measurements and main results:Intensity of treatment with BP medications was assessed using a scale of their comparative “vigors.” 35 patients (59%) reduced medications successfully. By the end of the study, systolic BP had risen by 8.2±12.3 mm Hg (mean±SD) in successful patients, while diastolic BP did not change significantly. Two predictors of treatment reduction were statistically significant in both univariate and multivariate analyses: successful patients had been treated more intensively (2.7±1.7 vs. 1.3±0.5 “vigor units,” p=0.0001), and they had been enrolled in the clinic longer (5.5±3.0 vs. 3.1±2.3 years, p=0.003). Lower systolic BP, higher urinary sodium excretion, lower compliance, and younger age were significant predictors of treatment reduction on univariate analysis only. Age≤65 years had the highest sensitivity (86%) for treatment reduction, while treatment with two or more “vigor units” had the highest specificity (79%) and likelihood ratio (3.3). Conclusions:Treatment reduction is feasible in many well-controlled hypertensives, though systolic BP rises. Patients with high intensity and long duration of treatment are most likely to reduce medications successfully. Presented in part at the annual meeting of the Society of General Internal Medicine, Arlington, Virginia, April 1988, and the annual meeting of the Robert Wood Johnson Clinical Scholars Program, Miami, Florida, October 1988. This study was conducted while Dr. Steiner was a Robert Wood Johnson Clinical Scholar at the University of Washington. Support was provided by the Northwest Health Services Research and Development Program of the Veterans Administration. The opinions, conclusions, and proposals in this paper are those of the authors, and do not necessarily represent the views of the Robert Wood Johnson Foundation or the Veterans Administration.     

Ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia

This study assesses the ability of primary care physicians to diagnose and managePneumocystis carinii pneumonia (PCP) in a standardized patient (SP) with unidentified HIV infection. One hundred thirty-four primary care physicians from five Northwest states saw an SP with unidentified HIV infection who presented with symptoms, chest radiograph, and arterial blood gas results classic for PCP. Seventy-seven percent of the physicians included PCP in their differential diagnoses and 71% identified the SP’s HIV risk. However, only a minority of the physicians indicated that they would initiate an appropriate diagnostic evaluation or appropriate therapy: 47% ordered a diagnostic test for PCP, 31% initiated an antibiotic appropriate for PCP, and 12% initiated an adequate dose of trimethoprim— sulfamethoxazole. Only 6% of the physicians initiated adjunctive prednisone therapy, even though prednisone was indicated because of the blood gas result. These findings suggest significant delay in diagnosis and treatment had these physicians been treating an actual patient with PCP. Presented at the International Conference on AIDS, Berlin, Germany, June 6 –11, 1993. Supported by grant number HS 06454-03 from the Agency for Health Care Policy and Research. Dr. Curtis is funded by the Robert Wood Johnson Clinical Scholars Program. The views expressed herein are those of the authors and are not necessarily the views of the Agency for Health Care Policy and Research or the Robert Wood Johnson Foundation.     

Visual impairment and cognitive dysfunction in Alzheimer’s disease

Objective:To determine whether impaired visual acuity is associated with dementia and cognitive dysfunction in older adults. Design:Paired case-control comparisons of the relative frequencies of visual impairment in demented cases and nondemented controls. Cohort analyses of correlation between visual acuity and cognitive functioning in demented cases. Setting:Internal medicine clinics at two academically affiliated medical centers. Participants:Eighty-seven consecutively selected patients ≥65 years of age with mild-to-moderate, clinically diagnosed Alzheimer’s disease (cases) and 87 nondemented controls matched to the cases by age, sex, and education. Measurements and main results:The prevalence of visual impairment was higher in cases than in controls [unadjusted odds ratio for near-vision impairment =2.7 (95% CI=1.4, 5.2); unadjusted odds ratio for far-vision impairment =2.1 (95% CI=1.02, 4.3); odds ratios adjusted for family history of dementia, depression, number of medications, and hearing loss were 2.5 (95% CI=1.1, 10.5) for near-vision impairment and 1.9 (95% CI=0.8, 4.6) for far-vision impairment]. When further stratified by quartiles of visual acuity, no statistically significant “dose-response” relationship between vision impairment and dementia risk was observed. Among cases, the degree of visual impairment was significantly correlated with the severity of cognitive dysfunction for both near and far vision (adjusted ps<0.001). Conclusions:Visual impairment is associated with both an increased risk and an increased clinical severity of Alzheimer’s disease, but the increased risk may not be consistent with a progressive dose-response relationship. Further studies are needed to determine whether visual impairment unmasks and exacerbates the symptoms of dementia or is a marker of disease severity. Supported by the Robert Wood Johnson Foundation Research and Development Program to Improve Patient Functional Status, the University of Washington Alzheimer’s Disease Research Center (National Institutes of Health grant No. AG 05136) and Alzheimer’s Disease Patient Registry (National Institutes of Health grant No. AG 06781), and National Institute on Aging Academic Award No. K08 AG00265 (Dr. Uhlmann). The views expressed here are not necessarily those of the Robert Wood Johnson Foundation.     

Differences in end-of-life decision making among black and white ambulatory cancer patients

OBJECTIVE: African-American (black) and white individuals have been shown to differ in their desire for life-sustaining treatments and their use of living wills for end-of-life care, but the reasons for these differences are unclear. This study-was designed to test the hypothesis that these ethnic differences exist because black patients trust the health care system less, fear inadequate medical treatment more, and feel less confident that living wills can give them more control over their terminal care. DESIGN: Cross-sectional, in-person survey conducted from November 1993 to June 1994. SETTING: Two medical oncology clinics with 40% to 50% black patient representation. PARTICIPANTS: Ambulatory cancer patients, 92 black and 114 white, who were awaiting their physician visits and agreed to participate (76% of those eligible). Patients were excluded if they were under age 40 or if they had nonmelanoma skin cancer only. MEASUREMENTS AND MAIN RESULTS: Black ambulatory cancer patients wanted more life-sustaining treatments (odds ratio [OR] 2.8; 95% confidence interval [CI] 1.4–5.3), and were less likely to want to complete a living will at some time in the future (OR 0.36; 95% CI 0.17–0.75) than were white patients after controlling for socioeconomic variables. However, these differences were not related to lack of trust or fear of inadequate medical treatment in this study population. Both groups of patients trusted the health care system and felt that physicians treated patients equally well. Neither group feared inadequate or excessive medical care, and the majority of both groups agreed that living wills would help them keep control over their terminal care. CONCLUSIONS: Black and white cancer patients make different end-of-life choices, even after adjusting for likely explanatory variables. The other factors that influence decision making remain unclear and need to be further explored if physicians are to understand and help their patients make choices for end-of-life care. Abstract presented at the Robert Wood Johnson Clinical Scholars Program National Meeting, November 1994. Funded by Robert Wood Johnson Clinical Scholars Program while Dr. McKinley was a Clinical Scholar (July 1992–June 1994).     

Gender differences in the management of acute chest pain

OBJECTIVE: To determine whether evaluation and management of males and females differ after presentation to the emergency department with acute chest pain. DESIGN: Prospective cohort study with follow-up at 1 month. SETTING: Urban teaching hospital. PATIENTS: The study population included 1,411 patients who were 30 years of age or older who visited the emergency department with acute chest pain from October 1990 through May 1992. These 1,411 patients represent 69% of the 2,056 patients approached for consent. The utilization of exercise stress testing as outpatients was measured for a subset of 954 patients who were interviewed at 1 month after their presentation. MEASUREMENTS/MAIN RESULTS: After controlling for clinical and nonclinical predictors, women were less likely to be admitted to the hospital (adjusted odds ratio [OR] 0.68; 95% confidence interval [CI] 0.47, 0.99). Among the 954 patients with 1-month follow-up, women were less likely than men to undergo an exercise stress test during the first month after presentation, with borderline statistical significance after adjusting for the interaction between gender and admission to the hospital (adjusted OR 0.30; 95% CI 0.09, 1.0). Among the patients who were admitted to the hospital, women were as likely as men to undergo exercise stress testing (adjusted OR 0.81; 95% CI 0.57, 1.2) but were less likely to undergo cardiac catheterization (adjusted OR 0.44; 95% CI 0.25, 0.80). CONCLUSIONS: Gender-based differences in management may occur at several stages in the evaluation of patients with acute chest pain. Observed differences in use of invasive procedures between men and women may be due in part to lower rates of exercise test use and admission to the hospital for evaluation of acute chest pain. From the Section for Clinical Epidemiology, the Division of General Medicine, and the Cardiovascular Division, Department of Medicine, and the Department of Emergency Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts. Supported in part by a grant from the Agency for Health Care Policy and Research (RO1-HS06452). Dr. Paula Johnson was the recipient of a Clinician-Scientist Award (91004160) at the time of this study and is now the recipient of a Minority Faculty Development Award from the Robert Wood Johnson Foundation. Dr. Thomas Lee was the recipient of an Established Investigator Award (900119) from the American Heart Association. Presented at the national meeting of the American Federation for Clinical Research, May 3, 1993, Washington, DC.     

Professional satisfaction experienced when caring for substance-abusing patients

This survey aimed to describe and compare resident and faculty physician satisfaction, attitudes, and practices regarding patients with addictions. Of 144 primary care physicians, 40% used formal screening tools; 24% asked patients’ family history. Physicians were less likely (P<.05) to experience at least a moderate amount of professional satisfaction caring for patients with alcohol (32% of residents, 49% of faculty) or drug (residents 30%, faculty 31%) problems than when managing hypertension (residents 76%, faculty 79%). Interpersonal experience with addictions was common (85% of faculty, 72% of residents) but not associated with attitudes, practices, or satisfaction. Positive attitudes toward addiction treatment (adjusted odds ratio [AOR], 4.60; 95% confidence interval [95% CI], 1.59 to 13.29), confidence in assessment and intervention (AOR, 2.49; 95% CI, 1.09 to 5.69), and perceived responsibility for addressing substance problems (AOR, 5.59; CI, 2.07 to 15.12) were associated with greater satisfaction. Professional satisfaction caring for patients with substance problems is lower than that for other illnesses. Addressing physician satisfaction may improve care for patients with addictions. This work was presented in part at the annual meeting of the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program, Tucson, Ariz, December 4, 1998, the annual meeting of the Society of General Internal Medicine, San Francisco, Calif, April 29, 1999, and at the annual meeting of the Association of Medical Education and Research on Substance Abuse, Alexandria, Va, November 5, 1999. Deceased. Dr. Saitz received support from the Robert Wood Johnson Foundation as a Generalist Physician Faculty Scholar (Grant No. 031489) for this work. He and Dr. Samet were also supported in this work by the Center for Substance Abuse Prevention (Faculty Development Grant T26-SP08355). Drs. Samet, Saitz, and Sullivan, and Mr. Winter and Ms. Lloyd-travaglini receive support from the National Institute on Alcohol Abuse and Alcoholism (R01-AA10870). Dr. Friedmann was supported by a Mentored Clinical Scientist Career Development Award (K08-DA 00320).     

Delivery of primary care to women

OBJECTIVE: Women’s health centers have been increasing in number but remain relatively unstudied. We examined patient expectations and quality of care at a hospital-based women’s health center compared with those at a general medicine clinic. DESIGN: Cross-sectional survey. SETTING: University hospital-affiliated women’s health and general internal medicine clinics. PARTICIPANTS: An age-stratified random sample of 2,000 women over 18 years of age with at least two visits to either clinic in the prior 24 months. We confined the analysis to 706 women respondents who identified themselves as primary care patients of either clinic. MEASUREMENTS AND MAIN RESULTS: Personal characteristics, health care utilization, preferences and expectations for care, receipt of preventive services, and satisfaction with provider and clinic were assessed for all respondents. Patients obtaining care at the general internal medicine clinic were older and had more chronic diseases and functional limitations than patients receiving care at the women’s health center. Women’s health center users (n=357) were more likely than general medicine clinic users (n=349) to prefer a female provider (57% vs 32%, p=.0001) and to have sought care at the clinic because of its focus on women’s health (49% vs 17%, p=.0001). After adjusting for age and self-assessed health status, women’s health center users were significantly more likely to report having had mammography (odds ratio [OR] 4.0, 95% confidence interval [CI] 1.1, 15.2) and cholesterol screening (OR 1.6, 95% CI 1.0, 2,6) but significantly less likely to report having undergone flexible sigmoidoscopy (OR 0.5, 95% CI 0.3, 0.9). There were no significant differences between the clinics on receipt of counseling about hormone replacement therapy or receipt of Pap smear, or in satisfaction. CONCLUSIONS: These results suggest that, at least in this setting, women’s health centers provide care to younger women and those with fewer chronic medical conditions and may meet a market demand. While the quality of gender-specific preventive care may be modestly better in women’s health centers, the quality of general preventive care may be better in general medical clinics. Dr. Phelan was a Robert Wood Johnson Clinical Scholar at the University of Washington. The views, opinions, and conclusions in this article are those of the authors and not necessarily those of the Robert Wood Johnson Foundation.     

The use of formal prior directives among patients with HIV-related diseases

Objective:To examine the knowledge of, counseling about, and use of prior directives among patients with HIV-related disease. Design:Cross-sectional survey with personal interviews that was part of the evaluation of a multi-site AIDS Health Services Program. Setting:Outpatient clinics and AIDS community-based organizations. Patients/participants:To be eligible for the survey, subjects had to be at least 18 years of age and enrolled in the AIDS Health Services Program for at least one month. 1,031 clients were interviewed in nine communities. Measurements and main results:Of those surveyed, 61% had thought a moderate or great amount about naming a proxy for health care decisions. The majority (68%) of the patients knew about prior directives, yet only 35% had been counseled and only 28% had a prior directive. Of those counseled, physicians had counseled only 11% (38/359). Gay/bisexual men were more likely to have been counseled and to have executed a prior directive than were others. Counseling was associated with having obtained a prior directive. Counseled subjects were 3.5 times more likely to have obtained a prior directive than were those not counseled. Conclusions:A gap exists between subjects’ knowledge and implementation of prior directives. To help bridge this gap, the authors recommend that physicians not only attend to the technical aspects of patient care, but also determine patient values concerning life-sustaining therapy and counsel patients on prior directives. Supported by National Institute of Aging Post Doctoral Health Care Research Training Grant AG00160 (JT) and supported in part by a grant from the Robert Wood Johnson Foundation.     

Long-term care preferences of hospitalized persons with AIDS

Objective:To determine in a cohort of hospitalized persons with AIDS: 1) their preferences for various postdischarge long-term care settings, 2) the postdischarge settings recommended by primary care providers (doctors, nurses, and social workers), and 3) the impact of these views on the resulting discharge dispositions. Design:Prospective cohort study. Setting:Medical wards of five Seattle tertiary care hospitals. Participants:120 consecutive hospitalized persons with AIDS and their primary care providers. Measurements and main results:Although 70 (58%) of the patients found care in an AIDS long-term care facility acceptable, 87 (73%) preferred home care. Thirty-eight (32%) of the cohort were appropriate for long-term care after hospitalization, according to primary care providers. Eleven of the 38 patients deemed appropriate for long-term care were discharged to long-term care settings; among these, three had preferred home care. Likelihood of discharge to long-term care settings increased if patients found it acceptable (OR=7.1; 95% CI=3.2, 15.5), if they did not prefer home care (OR=7.7; 95% CI=4.7, 13.5), and if providers judged them to be appropriate for long-term care (OR=29; 95% CI=13, 64). In unstructured interviews, availability of emotional and medical support and privacy emerged as important factors to persons with AIDS considering long-term care. Conclusions:Hospitalized persons with AIDS willingly express their desires for various postdischarge care settings. A majority find long-term care in AIDS facilities acceptable, although they generally prefer home care. Discharge disposition is associated with acceptability, preference, and appropriateness for long-term care. Presented in part at the Vth International Conference on AIDS, Montreal, Quebec, Canada, June 5, 1989. Also presented in part at the 14th annual meeting of the Society of General Internal Medicine, Seattle, Washington, May 1–3, 1991. Supported in part by the Northwest Health Services Research and Development Field Program (Seattle VA Medical Center) and the Seattle/King County Department of Public Health, AIDS Prevention Project. Dr. McCormick was a fellow in the Robert Wood Johnson Clinical Scholars Program during this project. The opinions stated herein are those of the authors and may not represent the views of the Robert Wood Johnson Foundation or the Department of Veterans Affairs.     

Oral contraceptives and rheumatoid arthritis: Results from a primary care-based incident case-control study

Objective:

The possibility that oral contraceptives offer a protective effectagainst the development of rheumatoid arthritis is still contentious. Of the 17 studies investigating this association, 11 have found a protective effect, and 6 have not. These differences are probably attributable to either selection or information biases in a subset of studies, although the exact reason is unknown. To overcome the methodological problems inherent in the design of previous studies, we have conducted a population-based case-control study.

Methods:

Women who were incident cases of inflammatory polyarthritis,defined as swelling of at least two joint areas lasting at least 4 weeks, were recruited directly from primary care and compared with age-matched women from the same population.

Results:

Cases and controls reported a similar level of “ever use” of oral contraceptives, adjusted odds ratio = 0.88 (95% confidence interval, 0.47, 1.64). The cases were, however, less likely to report using oral contraceptives at the time of onset, adjusted odds ratio = 0.22 (95% confidence interval, 0.06, 0.85). Similar results were observed for cases who satisfied the criteria for rheumatoid arthritis and cases who did not.

Conclusion:

These results indicate that only current oral contraceptive useprotects against the development of inflammatory polyarthritis.     

Helicobacter pylori is not a risk factor for hepatic encephalopathy

Background. Helicobacter pylori infection has been described as a risk factor for hepatic encephalopathy in patients with chronic liver disease although the topic remains controversial.Aims. To determine whether Helicobacter pylori infection is an independent predictive factor for encephalopathy in patients with liver cirrhosis.Methods. Clinical, epidemiological, analytical and nutritional parameters of 205 patients were collected. Helicobacter pylori infection was determined by serology. Encephalopathy (grade 11 or higher) was clinically assessed during follow-up. The relationship between each parameter and encephalopathy was analysed by Kaplan-Meier curves and the Log rank test. The most significant parameters underwent multivariate analysis by Cox regression.Results. Twenty-five variables were related to encephalopathy in the bivariate analysis. Multivariate analysis selected five independent factors: previous bouts of encephalopathy (Odds ratio 3.79; 95% confidence interval 1.94–7.38), albumin (Odds ratio 0.86; 95% confidence interval 0.80–0.92), tricipital skin fold (Odds ratio 0.79; 95% confidence interval 0.66–0.95] chronic pulmonary disease (Odds ratio 2.78, 95% confidence interval; 1.31–5.92), and on-going alcoholism (Odds ratio 2.62; 95% confidence interval 1.16-5.88].Conclusions. Helicobacter pylori is not an independent risk factor for hepatic encephalopathy.     

Hospital ownership and preventable adverse events

OBJECTIVE: To determine if type of hospital ownership is associated with preventable adverse events. DESIGN: Medical record review of a random sample of 15,000 nonpsychiatric, non-Veterans Administration hospital discharges in Utah and Colorado in 1992. MEASUREMENTS AND MAIN RESULTS: A two-stage record review process using nurse and physician reviewers was used to detect adverse events. Preventability was then judged by 2 study investigators who were blinded to hospital characteristics. The association among preventable adverse events and hospital ownership was evaluated using logistic regression with nonprofit hospitals as the reference group while controlling for other patient and hospital characteristics. We analyzed 4 hospital ownership categories: nonprofit, for-profit, major teaching government (e.g., county or state ownership), and minor or nonteaching government. RESULTS: When compared with patients in nonprofit hospitals, multivariate analyses adjusting for other patient and hospital characteristics found that patients in minor or nonteaching government hospitals were more likely to suffer a preventable adverse event of any type (odds ratio [OR] 2.46; 95% confidence interval [CI], 1.45 to 4.20); preventable operative adverse events (OR, 4.85; 95% CI, 2.44 to 9.62); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.27; 95% CI, 1.48 to 12.31). Patients in forprofit hospitals were also more likely to suffer preventable adverse events of any type (OR, 1.57; 95% CI, 1.03 to 2.38); preventable operative adverse events (OR, 2.63; 95% CI, 1.42 to 4.87); and preventable adverse events due to delayed diagnoses and therapies (OR, 4.15; 95% CI, 1.84 to 9.34). Patients in major teaching government hospitals were less likely to suffer preventable adverse drug events (OR, 0.38; 95% CI, 0.16 to 0.89). CONCLUSIONS: Patients in for-profit and minor teaching or nonteaching government-owned hospitals were more likely to suffer several types of preventable adverse events. Further research is needed to determine how these events could be prevented. Presented in part at The Enhancing Patient Safety and Reducing Errors in Health Care Conference, Rancho Mirage, Calif, November 8–10, 1998. Funding for this work was provided by the Robert Wood Johnson Foundation.     

Remove airway ultraflex stents by flexible bronchoscope

IntroductionDespite removal of airway metallic stents by rigid bronchoscope was presented, there are few reports describing such removal by flexible bronchoscope.Methods36 patients who had airway Ultraflex stents removed by flexible bronchoscope from 2002 to 2009 were reviewed. Factors contributing to removal method and complications during and after removal were analyzed by multinomial logistic regression.ResultsAmong 36 patients with stent extraction; 17 stents (47.2%) were removed by a single procedure and 19 (52.8%) by multiple procedures. There was no mortality or severe morbidity during or after stent removal. There were 21 complications after stent removal, including retained stent pieces (n = 9), mucosal tear with bleeding (n = 5), and re-obstruction requiring silicone stent placement (n = 7). Stent indwelling time > 10 months (adjusted odds ratio: 9.5; 95% confidence interval: 7.9–11.1, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 5.2; 95% confidence interval: 2.2–8.6, P=0.01), and stent fracture before removal (adjusted odds ratio: 3.5; 95% confidence interval: 1.8–15.4, P=0.04) were independent predictors of the need for multiple procedures for stent removal. Stent indwelling time > 10 months (adjusted odds ratio: 4.2; 95% confidence interval: 2.1–8.9, P=0.01), obstructive granulation tissue formation before stent removal (adjusted odds ratio: 16.5; 95% confidence interval, 1.8–49.6, P=0.01), and multiple procedures required for removal (adjusted odds ratio: 6.9; 95% confidence interval, 1.1–43.5, P=0.04) were independent predictors of removal complications.ConclusionsA flexible bronchoscope can be used to remove stents in patients with central airway obstruction and stent-related complications. This procedure should be performed in centers with experienced multidisciplinary teams.     

Serum selenium and colonic neoplastic risk

BACKGROUND: Selenium deficiency has been associated with cancer risk in several organs. This association was investigated in neoplasia of the colorectum. DESIGN: A case-control study is reported with two patient series, colorectal cancer and colorectal adenomatous polyps, and a control group found to be free of colorectal neoplasia. Diagnosis was determined by colonoscopy and histologic review of suspected neoplasms. Serum drawn at the time of colonoscopy was subsequently assayed for selenium content, and quartiles based on selenium were defined. Crude and adjusted odds ratios with 95 percent confidence intervals for adenoma related to selenium were calculated, controlling for known or suspected risk factors including gender, age, race, body mass index, family history, tobacco use, alcohol consumption, serum beta carotene, serum alpha tocopherol, and serum ferritin. RESULTS: There were 138 controls who had no neoplastic disease, 139 adenoma patients, and 25 cancer patients. For adenoma,comparing higher quartiles of selenium to the first (lowest selenium), the adjusted odds ratio for the second quartile was 1.7 (95 percent confidence interval, 0.8–3.7), the third quartile was 1.4 (0.7–3.2), and the fourth (highest selenium) quartile was 1.8 (0.9–4). The odds ratios for cancer patients were 0.8 for the second quartile, 1 for the third quartile, and 1.7 for the fourth quartile. CONCLUSION: No trend could be detected toward a protective effect of higher levels of serum selenium for colonic benign or malignant tumors.Supported by grants from The American Society of Colon and Rectal Surgeons Research Foundation, the Department of Clinical Investigation of Walter Reed Army Medical Center, and Public Health Service Grant CA 36978.Address reprint requests to Dr. Nelson: 1740 West Taylor, Room 2204, M/C 957, Chicago, Illinois 60612.     

High Rates of Prostate-specific Antigen Testing in Men with Evidence of Benign Prostatic Hyperplasia

Purpose: Benign prostatic hyperplasia is common among men who may be candidates for prostate cancer screening using prostate-specific antigen (PSA) testing. Patterns of PSA testing among men with evidence of benign prostatic hyperplasia have not been studied.Methods: We examined the prevalence and correlates of a self-reported history of PSA testing. In 1994, 33,028 US health professionals without prostate cancer aged 47 to 85 years provided information on prior PSA testing, lower urinary tract symptoms characteristic of benign prostatic hyperplasia, history of prostatectomy, and prostate cancer risk factors. In 1995, a subset of 7,070 men provided additional information on diagnosis and treatment of benign prostatic hyperplasia.Results: From 39% of men in their 50s to 53% of men in their 80s reported PSA testing in the prior year (P <0.0001 for trend with age). Men were more likely to report PSA testing if they had lower urinary tract symptoms characteristic of benign prostatic hyperplasia (age-adjusted odds ratio for severe symptoms 2.2, 95% confidence interval 1.8 to 2.6), a prior history of prostatectomy (age-adjusted odds ratio 1.1, 95% confidence interval 1.02 to 1.2), or a physician diagnosis of benign prostatic hyperplasia (odds ratio 1.9, 95% confidence interval 1.7 to 2.2; adjusted for age, signs or symptoms of benign prostatic hyperplasia, and prostate cancer risk factors).Conclusions: These US health professionals reported preferential use of PSA testing among men least likely to benefit from early cancer detection (older men) and among men most likely to have a false-positive PSA result (men with benign prostatic hyperplasia). Physician and patient education are needed to promote more rational and selective use of this screening test.     

Increased mortality in Type II diabetic patients using sulphonylurea and metformin in combination: a population-based observational study

Aims/hypothesis. This study analysed cause-specific mortality in Type II (non-insulin-dependent) diabetic patients using either sulphonylurea alone or in combination with metformin. Methods. Patients were followed from the first day they were taking either the combination or sulphonylurea alone. Odds ratios by Cox regression analyses were adjusted for age, sex, duration of diabetes, study area, year of inclusion and fasting blood glucose at inclusion. Results. We included 169 patients taking sulphonylurea and metformin in combination and 741 patients taking only sulphonylurea. Mean (range) follow-up time was 6.1 (0.1–13.0) years. The adjusted odds ratio for overall mortality was 1.63 (95 % confidence interval 1.27–2.09) in patients taking sulphonylurea and metformin combination vs those using sulphonylurea alone. For mortality from ischaemic heart disease and stroke the adjusted odds ratios were 1.73 (95 % confidence interval 1.17–2.55) and 2.33 (95 % confidence interval 1.17–4.63), respectively. Conclusion/interpretation. There was a higher cardiovascular mortality in Type II diabetic patients taking sulphonylurea and metformin in combination than in those taking only sulphonylurea. Hence, it cannot be excluded that this kind of combination therapy possibly increases cardiovascular mortality. It is feasible that the increased mortality was secondary to a more aggressive type of diabetes in the patients using sulphonylurea and metformin in combination. Combination therapy is known to promote additional blood glucose reduction but there is as yet no evidence that a sulphonylurea and metformin combination is more beneficial on micro- or macrovascular disease than sulphonylurea or metformin alone. [Diabetologia (2000) 43: 558–560] Received: 6 December 1999 and in revised form: 7 February 2000     

Early participation in an HIV cohort study slows disease progression and improves survival

Battegay M, Wirz M, Steuerwald MH, Egger M, Swiss HIV Cohort Study (University Hospital of Basel, Basel, University of Berne, Berne, and University of Lausanne, Lausanne, Switzerland; and University of Bristol, Bristol, UK). Early participation in an HIV cohort study slows disease progression and improves survival. J Intern Med 1998; 244 : 479–87. Background Different levels of experience of physicians caring for patients with HIV infection have been found to be associated with differences in survival amongst their patients. We examined whether early participation in the Swiss HIV Cohort Study (SHCS), an ongoing prospective study with regular follow-up visits at specialized clinics, improved survival of HIV-infected patients. Methods We studied 3553 HIV-infected individuals who joined the Swiss HIV Cohort Study (SHCS) with different levels of immunosuppression: mild (CD4 count above 500 × 10⁶ cells L^?1; n × 2038); severe (100–199 cells; n = 960); and very severe (50–99 cells; n = 555). Characteristics at different CD4 cell levels were compared and Cox proportional hazards regression was used to examine the mortality experience during a total of 16 201 person-years of follow-up. Results Participants joining the cohort early with mild immunodeficiency were younger, more likely to be female, and more likely to have a history of intravenous drug use. At CD4 cell counts below 200 × 10⁶ cells L^?1, they were less likely to have a history of Pneumocystis carinii pneumonia or AIDS, more likely to be on prophylaxis against P. carinii and more likely to be on antiretroviral therapy than those joining with severe or very severe immunodeficiency. For example, at the time of the first CD4 cell count in the range of 50–99 × 10⁶ cells L^?1, 8.9, 15.0 and 21.6% of participants who joined with mild, severe and very severe immunodeficiency had suffered an episode of P. carinii pneumonia. In Cox models adjusted for CD4 cell count at entry and other relevant baseline differences, mortality was increased amongst participants who joined with severe and very severe immunodeficiency. Hazard ratios (95% confidence intervals (CI)) were 1.71 (1.21–2.42) for participants with severe immunodeficiency at entry and 2.61 (1.70–4.01) for those with very severe immunodeficiency, compared with 1.0 for those with mild immunodeficiency at entry. Conclusions Individuals who were seen regularly at specialized HIV units from early stages of the infection onwards were, at comparable levels of immunodeficiency, less likely to progress to AIDS, and mortality during subsequent follow-up was reduced. This is likely to be explained by better access to prophylactic regimens and antiretroviral therapy.     

The identification of psychiatric illness by primary care physicians

Objective:This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians. Design:Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental bealth problems was abstracted from the medical records. Setting:The study was conducted at a multispecialty group practice in a semirural area of Wisconsin. Patients:Study participants consisted of a stratified probability sample of 247 patients seeking primary care. Results:Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates. Supported in part by a contract (DBE-77-0071) and grant from the National Institute of Mental Health (MH-33940) and a grant from the Robert Wood Johnson Foundation.     

Helicobacter pylori Infection and Gender: A Meta-Analysis of Population-Based Prevalence Surveys

Although most of Helicobacter pylori–related diseases are associated with male gender, the role of gender as a risk factor for H. pylori infection is still debated. To assess the true association between H. pylori and gender, we conducted a meta-analysis of large, population-based studies where the measure of association had been adjusted at least for age and socioeconomic status, and obtained primary data from authors when information on gender associations were not presented. In 18 adult populations, the test of heterogeneity was not significant and male gender was significantly associated with H. pylori infection (summary odds ratio [OR] 1.16 [95% confidence interval (CI) 1.11, 1.22]). In 10 pediatric populations, the test of heterogeneity was of borderline significance, and the summary OR computed using a random effect model was close to 1 (summary OR 1.03 [95% CI 0.91, 1.17]). This study confirms the male predominance of H. pylori infection in adults as a global and homogeneous phenomenon; such predominance is not apparent in children. Differential antibiotic exposure or differential protective immunity between genders may explain the different results observed between children and adult studies.