Prayer for health concerns: results of a national survey on prevalence and patterns of use

BACKGROUND: Prayer is a common practice in the United States, yet little is known about the prevalence and patterns of use of prayer for health concerns. OBJECTIVE: To determine the prevalence and patterns of use of prayer for health concerns. METHODS: We conducted a national survey in 1998 (N = 2055, 60% weighted response rate) on use of prayer. Data were also collected on sociodemographics, use of conventional medicine, and use of complementary and alternative medical therapies. Factors associated with the use of prayer were analyzed using multivariable logistic regression. RESULTS: We found that 35% of respondents used prayer for health concerns; 75% of these prayed for wellness, and 22% prayed for specific medical conditions. Of those praying for specific medical conditions, 69% found prayer very helpful. Factors independently associated with increased use of prayer (P<.05) included age older than 33 years (age 34-53 years: odds ratio [OR], 1.6 [95% confidence interval (CI), 1.3-2.1]; age > or =54 years: OR, 1.5 [95% CI, 1.1-2.0]); female sex (OR, 1.4 [95% CI, 1.1-1.7]); education beyond high school (OR, 1.5 [95% CI, 1.2-1.8]); and having depression, chronic headaches, back and/or neck pain, digestive problems, or allergies. Only 11% of respondents using prayer discussed it with their physicians. CONCLUSIONS: An estimated one third of adults used prayer for health concerns in 1998. Most respondents did not discuss prayer with their physicians. Prayer was used frequently for common medical conditions, and users reported high levels of perceived helpfulness.     

The dawning of a new sedative: propofol in gastrointestinal endoscopy

BACKGROUND: Using gentler endoscopes and improved sedation, great strides have been made in enhancing patients' comfort and acceptance of endoscopic procedures. Because morbidity and mortality have been associated with benzodiazepines in endoscopic sedation, safer alternatives were sought. Propofol (2,6-diisopropylphenol), a rapid and short-acting anesthetic, initially used in the 1980's for general anesthesia induction and maintenance, is a promising candidate. METHODS: This review article examines experiences and literature references of propofol's use in endoscopic procedures. Three critical questions are posed: What are the major advantages and potential risks of propofol? When should propofol be used? Who should administer propofol, how should it be administered, and what type of monitoring is required? RESULTS: With considerable inter-patient variability, the propofol dose must be carefully titrated according to the individual patient's response. Factors influencing dosage include age, ASA class, patient's height and procedure duration. Propofol's primary risk is its narrow therapeutic range which necessitates careful patient monitoring. CONCLUSIONS: Propofol's advantages over benzodiazepines and narcotics include a more rapid onset of action, full relief of discomfort and rapid recovery to alertness without residual sedative effects or anterograde amnesia, thereby making this drug a cost-effective and, with proper monitoring, safe choice.     

Attitudes to early rheumatoid arthritis: changing patterns. Results of a survey

OBJECTIVE: To determine if rheumatologists have changed their views on diagnosis and treatment of early rheumatoid arthritis (RA). METHODS: Three consecutive questionnaires were sent out to international rheumatologists in 1997, 2000, and 2003. The following aspects of early RA were covered: definition; patient referral time; diagnostic means; follow up intervals; and treatment strategies. All initial participants who responded to at least one of the follow up surveys were included in the analysis. RESULTS: RA is now defined by a smaller number of affected joints (monarthritis: 9.8% respondents in 1997 v 17.4% in 2003), and shorter symptom duration (<3 months: 65.5% in 1997 v 85.8% in 2003). Early referrals (<6 weeks) increased (8.9% in 1997 v 17.4% in 2003). Serological test for diagnosis was mostly rheumatoid factor (100% in 2003), but anti-CCP was already used by 17.4% in 2003. Follow up of patients with early RA intensified (every 2 weeks: 16.1% in 1997 v 30.4% in 2003; every month: 47.8% in 2003 v 64.3% in 1997). Treatment with disease modifying antirheumatic drugs (DMARDs) mainly comprised methotrexate, sulfasalazine, and antimalarial drugs. Leflunomide was among the two favourite DMARDs of 10.9% in 2003, whereas no biological agent was so. In 2003, 46.7% respondents started treatment with DMARDs if RA was suspected (30.9% in 1997); no one waited for erosions to occur (7.3% in 1997). CONCLUSION: The data obtained in this study suggest that the concept of diagnosing and treating RA early is accepted by a large proportion of the rheumatological community.     

The changing use of esophageal manometry in clinical practice

Objective: Clinical practice guidelines now advise against the use of esophageal manometry in the early evaluation of unexplained chest pain. We examined data from patients referred for manometric evaluation over a 10-yr period (1987–1996) to see if clinicians were changing practice patterns and whether manometric diagnoses were affected by the changes.
Methods: Principal indications for the procedure and manometric findings were extracted from a review of 1162 subjects referred to a single clinical laboratory. The tracings were analyzed using a standardized classification method and categorized according to a pathophysiology-based scheme. Referral indications and manometric diagnoses were compared for the first and second 5-yr periods of study.
Results: Chest pain as a referral indication declined from the first to the second half of the study period (odds ratio, 0.44;   p < 0.0001  ), whereas dysphagia and preoperative evaluations became more common (odds ratio, 1.3;   p < 0.05  ; odds ratio, 13.7;   p < 0.0001  , respectively). Similarly, hypermotility disorders decreased in frequency (odds ratio, 0.63;   p = 0.0001  ), whereas hypomotility disorders increased (odds ratio, 1.6;   p < 0.01  ). The decrease in hypermotility disorders was solely related to a decrease in nonspecific spastic disorders, including nutcracker esophagus (odds ratio, 0.58;   p < 0.0001  ); the proportion of diagnoses of achalasia and diffuse esophageal spasm remained stable.
Conclusion: These data show that practice patterns are already following current guidelines. They also reflect the disillusionment of clinicians with the poor specificity of manometry in chest pain management, the increasing popularity of antireflux surgery, yet the ongoing observation that nonspecific spastic disorders are closely associated with unexplained chest pain and may have a still-undefined pathogenetic role.     

Stroke management in a general internal medicine department: results of a survey regarding practice

PURPOSE: The incidence of strokes in the general population and the insufficient numbers of centers specialized in their management has led to the increased hospitalization of patients in general, internal medicine departments. The prognosis for patients is related to the relevance of the initial diagnostic and therapeutic measures. To optimize management of stroke patients outside of specialized units, a survey concerning practice was conducted in internal medicine departments in western France, and a meeting was held to define guidelines. METHODS: Data sheets were mailed to practitioners in internal medicine departments prior to the survey. The following data were recorded for each patient hospitalized during the two-week study: age, sex, clinical characteristics of stroke, risk factors, investigations performed, and initial and subsequent medical management. On the basis of the results, management guidelines were considered and defined. RESULTS: Patients hospitalized for a stroke in internal medicine departments have a similar profile to those hospitalized in neurology departments. CT-scan and EKG recordings were performed in most patients whereas other investigations (cervical ultrasound, echocardiography, MRI) were used less frequently. The use of rehabilitation and therapeutic strategies for secondary stroke prevention were not always performed according to current guidelines. CONCLUSION: Internal medicine departments are frequently involved in the care of stroke patients. The present study of clinical practice may help to improve stroke management in these non-specialized departments.     

The digital rectal examination: a multicenter survey of physicians' and students' perceptions and practice patterns

Objectives:The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs among a variety of providers and explored factors affecting its performance and utilization.Methods:A total of 652 faculty, fellows, medical residents, and final-year medical students completed a questionnaire about their use of DREs.Results:On average, 41 DREs per year were performed. The yearly number of examinations was associated with years of experience and specialty type. Patient refusal rates were lowest among gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were negatively correlated with comfort level of the physician in performing a DRE. More gastroenterologists used sophisticated methods to detect anorectal conditions, and gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis with a DRE was strongly associated with the number of DREs performed annually.Conclusions:The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic confidence, and training adequacy were directly related to level of experience with the examination. Training in DRE technique has diminished and may be lost. The DRE's role in medical school and advanced training curricula needs to be re-established.     

A national survey of practice patterns of gastroenterologists with comparison to the past two decades

Previous surveys on the practice of gastroenterology collected limited data on practice demographics. Gastroenterology practices may have changed over the past decade as a result of changes in health care delivery. The authors sought to describe the practice composition and demographics of today's gastroenterologist, and also to make comparisons to prior studies to determine whether changes have occurred. A nationwide cross-sectional survey was performed in 1997 of 900 American Gastroenterological Association (AGA) members selected randomly from the AGA directory. A total of 767 AGA members were eligible for the study, and 376 responded (response rate, 49%). The mean age was 46 years old and the mean year training was completed was 1982. The majority of gastroenterologists were in solo or group practice (57%) and in an urban setting (55%). Respondents were fairly equally represented from different regions of the country. The most common diagnosis seen was irritable bowel syndrome ([IBS] 19%), followed by esophageal reflux (17%) and inflammatory bowel disease (14%). Functional disorders as a group (IBS, nonulcer dyspepsia, and other functional disorders) were, by far, the most common disorders (35%), which is similar to findings in prior studies of gastrointestinal practices. Only 3% of gastroenterologists believed that managed care has made it easier to deliver quality health care to patients with IBS. Despite changes that have occurred in health care over the past decade, the types of diagnoses seen in gastroenterology practices has remained the same. Most gastroenterologists feel that managed care has not made it easier to deliver quality health care.     

Prevention of venous thrombosis after electrophysiology procedures: a survey of national practice

Purpose

Femoral venous access is required for most electrophysiology procedures. Limited data are available regarding post-procedure venous thromboembolism (VTE), specifically deep vein thrombosis (DVT) and pulmonary embolism (PE). Potential preventative strategies are unclear. We aimed to survey Canadian centers regarding incidence of VTE and strategies for prevention of VTE after procedures that do not require post-procedure anticoagulation.

Methods

An online survey was distributed to electrophysiologists representing major Canadian EP centers. Participants responded regarding procedural volume, incidence of VTE post-procedure, and their practice regarding pharmacological and non-pharmacological peri-procedural VTE prophylaxis.

Results

The survey included 17 centers that performed a total of 6062 procedures in 2016. Ten patients (0.16%) had VTE (including 9 DVTs and 6 PEs) after diagnostic electrophysiology studies and right-sided ablation procedures excluding atrial flutter. Five centers (41.6%) administered systemic intravenous heparin during both diagnostic electrophysiology studies and right-sided ablation procedures. For patients taking oral anticoagulants, 10 centers (58.8%) suspend therapy prior to the procedure. Two centers (11.8%) routinely prescribed post-procedure pharmacologic prophylaxis for VTE. Four centers (23.5%) used compression dressings post-procedure and all prescribed bed rest for a maximum of 6 h. Of the variables collected in the survey, none were found to be predictive of VTE.

Conclusions

VTE is not a common complication of EP procedures. There is significant variability in the strategies used to prevent VTE events. Future research is required to evaluate strategies to reduce the risk of VTE that may be incorporated into EP practice guidelines.

     

Knowledge and attitudes regarding preventative HIV vaccine clinical trials in Italy: results of a national survey

We carried out a telephone survey to assess willingness to participate in HIV vaccine trials. The survey was conducted by interviewing randomly selected callers to the Italian National AIDS Help line. The questionnaire consisted of four sections: demographic information, knowledge about HIV vaccines and vaccines in general, factors related to participation in HIV vaccine trials, and acceptability of a future HIV vaccine. Over 50% of the sample had adequate knowledge about HIV and vaccines. Among the individuals interviewed, 37% would volunteer for a vaccine trial; those reporting high-risk behaviours were more likely to volunteer. Of the participants, 83% would agree to be vaccinated with a highly effective vaccine, and 92% would pay for the vaccine. Although the limits of telephone surveys should not be neglected, the results of this survey are encouraging.     

Autopsy consent practice at US teaching hospitals: results of a national survey

BACKGROUND: Autopsy rates continue to fall despite the enduring benefit of the procedure to families and medical science, yet there are few data about the consent process itself. OBJECTIVE: To evaluate the current practice of obtaining autopsy consent, by assessing the consent forms currently in use, the knowledge and attitudes of chief residents on the procedure, and the expert opinion of pathologists in those institutions. DESIGN: Cross-sectional survey. SETTINGS AND PARTICIPANTS: One hundred twenty-seven US teaching hospitals. RESULTS: Of all autopsy consent forms we surveyed, 84.7% contained 7 of 10 elements recommended by the College of American Pathologists. Only 7.1% of institutions supplied educational materials for the physician, as recommended by the College of American Pathologists. Overall, 50.1% of chief residents reported deficiencies in their knowledge of the autopsy procedure. Correspondingly, greater than 74.5% felt that educational materials would be beneficial for physicians and the family. Finally, 93.3% of chief residents believed that a limited autopsy should be offered to families, while 68 (90%) of 76 pathologists at these institutions believed that limited autopsies are an unsatisfactory alternative to the complete procedure. CONCLUSIONS: Chief residents at US teaching hospitals reported substantial deficiencies in their knowledge about autopsy and desire more training on the consent process. Autopsy consent forms are often lacking information that might help physicians and families in making an educated choice about autopsy. Teaching institutions need to reevaluate the training for the autopsy consent practice.     

Treatment of anal fissures: Results from a national survey on French practice

BackgroundTreatment of an anal fissure (AF) is based on medical treatment (nonoperative therapies) and surgical procedures. However, the choice of treatment and its role in therapeutic strategy vary from one country to another, and to date, no standard French recommendation is currently available. Our aim was to assess French practices in the treatment of AFs.MethodsA national survey of members of the French National Society of Colo-Proctology (SNFCP) was carried out using an online questionnaire (1) to evaluate French practice and (2) to compare them with guidelines of other societies.ResultsTwo hundred responses were obtained among the 300 registered members, representing a participation rate of 67%. Members of the SNFCP agree with all scientific societies on the importance of first-line medical treatment, with surgery proposed as a second-line treatment in the case of the failure of well-conducted medical treatment. However, calcium channel blockers and topical nitrates as first-line treatment are rarely prescribed in France. Priority is therefore given to “simple” topical healing products and oral analgesics on demand. Similarly, surgical management differs since LIS is the “gold standard” in most guidelines, whereas in France, despite the data in the literature, fissurectomy is the first-line treatment.ConclusionsOur study indicated the fissure treatment discrepancies of France with other countries concerning the usage of topical treatments and the choice of first-line surgical treatments that is currently considered a “French exception".     

General practice management of illicit drug users in Scotland: a national survey

Aims To describe the level of involvement of general practitioners (GPs) in the management of illicit drug dependency; nature of current practice in the management of illicit drug dependency; influence of guidelines on practice; GP training experience and needs; and to consider the policy implications of the findings. Design A cross‐sectional postal questionnaire survey. Setting General practice in Scotland. Participants A 1 : 4 randomized sample (n = 926) of general practice principals, stratified according to age, gender and number of practice partners. Measurements A structured postal questionnaire. Findings A 63% response rate was achieved after two reminders (n = 583). Sixty per cent of respondents treated drug users, 51.5% provided methadone maintenance but only 58% used doses in the recommended range. Maintenance prescribing of dihydrocodeine and benzodiazepines was provided by 24% and 44.8% of respondents, respectively. While 79.3% had received the national clinical guidelines only 22.5% believed this had influenced their practice. Only a third of respondents had received drug dependency training. Beliefs about whether prescribing for drug misusers is part of a GPs professional remit was split. Conclusions There was relatively high involvement with drug users, with methadone maintenance being the most common treatment provided. Maintenance prescribing of dihydrocodeine and benzodiazepines were common despite a lack of clinical evidence supporting the effectiveness of these treatments. This may reflect the nature of the presenting drug problems and highlights the difficulties some GPs may face in managing multiple drug dependencies within current guidelines. Further local training to implement guidelines along with trials of alternative treatments currently outwith guidelines should be considered.     

Infection control practitioners' perceptions and educational needs regarding bioterrorism: results from a national needs assessment survey

BACKGROUND: The perceived threat that biological weapons will be used in an act of terror against the United States has escalated sharply since the discovery of anthrax-tainted letters after the terrorist attacks of September 11, 2001. These events underscore the critical nature of health care and public health preparedness and the need to augment infection control practitioner education and training. METHODS: Between October 2000 and August 2001 a national needs assessment was conducted by use of a 35-question survey. The survey measured infection control practitioners' (ICPs') perception of the risk for bioterrorism in the United States and in their community, the proportion of ICPs with prior training in bioterrorism preparedness, and preferences for delivery media of future bioterrorism education. RESULTS: The assessment of the perceived threat of bioterrorism in the United States during the next 5 years (P =.022) and in the ICPs' work community (P <.001) revealed significant regional differences. Only half (56%) of the respondents reported prior training in bioterrorism preparedness. Respondents reported that the 2 most common barriers to receiving training were lack of training opportunities (70.2%) or no dedicated work time for training (19.4%). CONCLUSIONS: The results of this study indicate an urgent need for more resources and opportunities for clinical education in bioterrorism preparedness that will provide continuing education credit. Successful bioterrorism education will require a variety of instructional designs and media delivery methods to address ICPs' preferences and needs.     

The use of disease modifying antirheumatic drugs in women with rheumatoid arthritis of childbearing age: a survey of practice patterns and pregnancy outcomes

OBJECTIVE: To describe the practices of rheumatologists when prescribing the disease modifying antirheumatic drugs (DMARD) methotrexate (MTX), leflunomide (LF), etanercept (ET), and infliximab (IN) to women of childbearing age with rheumatoid arthritis (RA) and the pregnancy outcomes of patients who become pregnant while taking these medications. METHODS: A questionnaire was mailed to 600 members of the American College of Rheumatology inquiring about their perception of fetal risk, their recommendations regarding the use of birth control in women of childbearing age taking DMARD, and the pregnancy outcomes of women with DMARD exposure. RESULTS: One hundred seventy-five rheumatologists (29%) returned completed surveys. Respondents were more likely to agree that pregnancy is contraindicated in women taking MTX (95%) or LF (92.7%) than for women taking ET (38.6%) or IN (46.5%). Accordingly, most required birth control for women taking MTX (95.7%) and LF (97.3%), and fewer for women taking ET (75.4%) or IN (73.4%). A total of 65 pregnancies exposed to these DMARD were reported (MTX 38, LF 10, ET 14, IN 2, MTX and ET 1). Only 3 congenital malformations, all in the MTX group, were reported among the 52 pregnancies with known outcomes. CONCLUSION: Rheumatologists agree that there is a risk of teratogenicity with MTX and LF and usually require the use of reliable methods of birth control in women taking these medications. There is no consensus about ET and IN; however, physicians still tend to discuss reliable birth control methods with their female patients. We have confirmed there is a risk of congenital malformations with in utero exposure to MTX. No malformations were reported in infants exposed to LF, ET, or IN, but the number of reported pregnancy outcomes was small.     

Management of Barrett's esophagus: a national study of practice patterns and their cost implications

OBJECTIVE: The optimal management of Barrett's esophagus (BE) is controversial. Little is known about current practice patterns or associated direct medical costs. METHODS: In a national cross-sectional survey, we asked a random sample of gastroenterologists how they would manage patients with BE and various degrees of dysplasia. We used logistic regression to identify factors associated with so-called "frequent" (at least every 12 months) surveillance. We calculated direct medical costs using Medicare payments and population-based estimates of the number of BE patients under surveillance. RESULTS: Approximately 50% of 555 gastroenterologists responded. More than 96% of respondents recommended endoscopic surveillance for BE. For BE without dysplasia, 30% would perform frequent surveillance; this was the case particularly gastroenterologists older than age 45 yr (odds ratio = 1.91, p = 0.038) or those receiving primarily fee-for-service reimbursement (odds ratio = 2.57, p = 0.004). For BE with low-grade dysplasia, the frequency of endoscopy was highly variable (range, 1-24 months). For BE with high-grade dysplasia, 73% of gastroenterologists recommended esophagectomy and the remainder recommended endoscopic surveillance. Approximately 95% of the gastroenterologists who recommended surveillance for high-grade dysplasia, however, were not in agreement with recommended protocols. We estimated the national annual expenditure for surveillance endoscopy every 24 months for BE without dysplasia to be at least $22 million. Increase in surveillance intensity from low frequency (every 36 months) to high frequency (every 12 months) strategies would escalate costs by $29 million annually. CONCLUSIONS: Physician age and reimbursement influence BE surveillance practice, suggesting the influence of nonclinical factors on clinical decision making. The majority of clinicians who would recommend surveillance for high-grade dysplasia may not be using an appropriately aggressive strategy. Variations in surveillance strategies can have large cost implications.     

Evaluating agreement regarding the resectability of colorectal liver metastases: a national case-based survey of hepatic surgeons

Background

The resectability of colorectal liver metastases is in part largely based on the surgeon''s assessment of cross-sectional imaging. This process, while guided by principles, is subjective. The objective of the present study was to assess agreement between hepatic surgeons regarding the resectability of colorectal liver metastases.

Methods

Forty-six hepatic surgeons across Canada were invited. A patient with biologically favourable disease was presented after having received neoadjuvant chemotherapy. The scenario was matched with 10 different scrollable abdominal CT scans representing a maximum response after six cycles of chemotherapy. Surgeons were asked to offer an opinion on resectability of liver metastases, and whether they would use adjunct modalities to hepatic resection.

Results

Twenty-six surgeons participated. Twenty responses were complete. The median number of scenarios deemed resectable was 6/10 (range 3–8). Two control scenarios demonstrated perfect agreement. Agreement on resectability was poor for 4/8 test scenarios, of which one scenario demonstrated complete disagreement. Among resectable cases, the pattern of use of adjunct modalities was variable. A median ratio of 0.87 adjunct modality per resectable scenario per surgeon was used (range 0.25–1.75).

Conclusion

A significant lack of agreement was identified among surgeons on the resectability and use of adjunct modalities in the treatment of colorectal liver metastases.     

Office-based unsedated small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett's esophagus: a randomized and blinded comparison

OBJECTIVES: A major limitation to screening and surveillance of Barrett's esophagus is the complexity, expense, and risk associated with sedation for upper endoscopy. This study examines the feasibility, accuracy, and patient acceptability of office-based unsedated endoscopy as an alternative. METHODS: Of 274 eligible adults scheduled for endoscopic screening for gastroesophageal reflux symptoms or surveillance of Barrett's esophagus at a tertiary care center, 121 underwent unsedated small-caliber endoscopy and conventional endoscopy in a randomized crossover study. The two procedures were compared with regard to histological detection of Barrett's esophagus and dysplasia and biopsy size. Patients answered questionnaires assessing the tolerability of the procedures. RESULTS: The prevalence of Barrett's esophagus was 26% using conventional endoscopy and 30% using unsedated endoscopy (P= 0.503). The level of agreement between the two approaches was "moderate" (kappa= 0.591). Each modality detected four cases of low-grade dysplasia with concordance on one case. The tissue samples collected with unsedated endoscopy were smaller than with conventional endoscopy (P < 0.001). The majority of subjects rated their experience with both procedures as being well tolerated with minimal or no difficulty. When asked which procedure they would prefer in the future, 71% (81/114) chose unsedated small-caliber endoscopy. CONCLUSIONS: Office-based unsedated small-caliber endoscopy is technically feasible, well tolerated, and accurate in screening for Barrett's esophagus, despite yielding a smaller biopsy specimen. This approach bears the potential to eliminate the infrastructure and cost required for intravenous sedation in this application.