Do physicians spend more time with non-English-speaking patients? (57/7400)

OBJECTIVE: To determine whether physicians at a general internal medicine clinic spend more time with non-English-speaking patients. DESIGN: A time-motion study comparing physician time spent with non-English-speaking patients and time spent with English-speaking patients during 5 months of observation. We also tested physicians' perceptions of their time use with a questionnaire. SETTING: Primary care internal medicine clinic at a county hospital. PATIENTS/PARTICIPANTS: One hundred sixty-six established clinic patients, of whom 57 were non-English speaking and 109 were English speaking, and 15 attending physicians and 8 third-year resident physicians. MEASUREMENTS AND MAIN RESULTS: Outcome measures included total patient time in clinic, wait for first nurse or physician contact, time in contact with the nurse or physician, physician time spent on the visit, and physician perceptions of time use with non-English-speaking patients. After adjustment for demographic and comorbidity variables, non-English-speaking and English-speaking patients did not differ on any time-motion variables, including physician time spent on the visit (26.0 vs 25.8 minutes). A significant number of clinic physicians believed that they spent more time during a visit with non-English-speaking patients (85.7%) and needed more time to address important issues during a visit (90. 4%), (both p <.01). Physicians did not perceive differences in the amount they accomplished during a visit with non-English-speaking patients. CONCLUSIONS: There were no differences in the time these physicians spent providing care to non-English-speaking patients and English-speaking patients. An important limitation of this study is that we were unable to measure quality of care provided or patients' satisfaction with their care. Physicians may believe that they are spending more time with non-English-speaking patients because of the challenges of language and cultural barriers.  (+info)

Nonoccupational risk factors for carpal tunnel syndrome. (58/7400)

OBJECTIVE: To examine the relation between selected nonoccupational risk factors and surgery for carpal tunnel syndrome. DESIGN: Case-control study using an administrative database. PARTICIPANTS: Enrollees of New Jersey Medicare or Medicaid programs during 1989 to 1991. MEASUREMENTS: The outcome of interest was open or endoscopic carpal tunnel release. We examined the relation between carpal tunnel release and diabetes mellitus, thyroid disease, inflammatory arthritis, hemodialysis, pregnancy, use of corticosteroids, and hormone replacement therapy. MAIN RESULTS: In multivariate models, inflammatory arthritis was strongly associated with carpal tunnel release (odds ratio [OR] 2.9; 95% confidence interval [CI] 2.2, 3.8). However, corticosteroid use also appeared to be associated with a greater likelihood of undergoing carpal tunnel release, even in the absence of inflammatory arthritis (OR 1.6; 95% CI 1.2, 2.1). Diabetes had a weak but significant association with carpal tunnel release (OR 1.4; 95% CI 1.2, 1.8), as did hypothyroidism (OR 1.7; 95% CI 1.1, 2.8), although patients with hyperthyroidism did not have any change in risk. Women who underwent carpal tunnel release were almost twice as likely to be users of estrogen replacement therapy as controls (OR 1.8; 95% CI 1.0, 3.2). CONCLUSIONS: Although inflammatory arthritis is the most important nonoccupational risk factor for carpal tunnel release, these data substantiate the increase in risk associated with diabetes and untreated hypothyroidism. Further investigation in detailed clinical studies will be necessary to confirm whether changes in corticosteroid use and hormone replacement therapy offer additional means of risk reduction for this common condition.  (+info)

Prolonged neoadjuvant chemotherapy with GM-CSF in locally advanced breast cancer. (59/7400)

BACKGROUND: Neoadjuvant chemotherapy improves survival in patients with locally advanced breast cancer (LABC). Usually three to four cycles of conventional-dose neoadjuvant chemotherapy are administered prior to local therapy, and another three cycles thereafter. In an attempt to improve results, we increased the dosages and applied GM-CSF, which, besides being a hematopoietic growth factor, has become increasingly known for its immunostimulatory effects, which might enhance the antitumor effect. METHODS: Forty-two patients with stage IIIA or IIIB breast cancer were treated with doxorubicin (A) (90 mg/m2) and cyclophosphamide (C) (1,000 mg/m2) at three-weekly intervals. In the second and fourth cycle a 10% dose reduction of both agents was applied. On the second day GM-CSF 250 micrograms/m2/day was started and given for 10 days. Initially, some patients were treated with < or = four cycles, but as the study progressed and toxicity appeared tolerable, six cycles were given whenever possible. After the chemotherapy, patients underwent surgery and postoperative radiotherapy. RESULTS: The response rate for the whole group to AC was 98% (95% confidence interval 94%-100%), with a clinical complete response rate of 50% (95% confidence interval 35%-65%). Six patients had a pathological complete response. Median follow-up from the start of chemotherapy is 49 months (range 10-100). The disease-free survival (DFS) at three years is 57% and the overall survival (OS) at three years is 79%. There is a significant trend for improved DFS (p = 0.0000) and OS (p = 0.0002) with increasing number of cycles. CONCLUSION: The results of the present study with neoadjuvant dose-intensive AC chemotherapy and GM-CSF compare favorably with previous studies in patients with LABC. This is most apparent in patients who received six cycles of neoadjuvant chemotherapy. We hypothesize that these encouraging results are probably related to the prolonged presence of the primary tumor, and to the long-term administration of GM-CSF with the primary tumor and axillary lymph nodes in situ. Therefore, a randomized study is warranted. We already initiated an international randomized trial in patients with LABC in order to answer two questions. First, does prolonged neoadjuvant chemotherapy result in an improved DFS and OS in comparison with the conventional approach, and secondly, what is the effect of GM-CSF in this approach in comparison with G-CSF?  (+info)

Inflammatory status as a main determinant of outcome in patients with unstable angina, independent of coagulation activation and endothelial cell function. (60/7400)

AIMS: Inflammation, endothelial cell function and the coagulation system have been demonstrated to be involved in the onset and course of unstable angina. Whether a proinflammatory state independently determines outcome is unknown and has not been determined yet in a clinically well defined study population of consecutive patients admitted with unstable angina. METHODS AND RESULTS: Markers of inflammation, coagulation activation and endothelial cell function were determined on admission in blood of 211 consecutive patients with severe unstable angina and were related to the in-hospital course. Refractory unstable angina occurred in 76 patients (36%) during their hospital stay. In a univariate analysis, C-reactive protein (P = 0.03), fibrinogen (P < 0.001) and erythrocyte sedimentation rate (P = 0.001) levels were significantly higher in patients with refractory unstable angina, when compared with patients who had an uneventful clinical course. The odds ratios (95% CI) adjusted for age, sex, body mass index, smoking behaviour and cholesterol levels of the occurrence of refractory unstable angina for patients in the highest quartile compared with patients in the lowest quartile of inflammatory markers were 2.19 (0.94-5.11) for C-reactive protein, 2.83 (1.13-7.10) for fibrinogen and 4.72 (1.70-13.09) for the erythrocyte sedimentation rate. The findings were not affected by the presence or absence of myocardial necrosis or the interval between onset of angina and blood collection. No association was found between markers of coagulation activation or markers of endothelial cell function, and in-hospital outcome. CONCLUSION: We found that in a clinically well-defined study population of patients with severe unstable angina, a proinflammatory state is an important and independent determinant of short-term outcome. The data strengthen the importance of inflammation in this syndrome.  (+info)

Nuchal translucency in fetuses affected by homozygous alpha-thalassemia-1 at 12-13 weeks of gestation. (61/7400)

OBJECTIVE: Fetuses affected by homozygous alpha-thalassemia-1 are anemic in the first trimester. We studied their nuchal translucency (NT) measurements at 12-13 weeks of gestation. METHODS: Nuchal translucency was measured prospectively in fetuses at risk of homozygous alpha-thalassemia-1. Measurements of those fetuses subsequently confirmed to be affected by homozygous alpha-thalassemia-1 but with a normal karyotype were compared to those of 440 controls. The controls were from the general obstetric population who had NT measurements at 12 or 13 weeks with known normal outcome. All the NT measurements were expressed as multiples of the median (MoM) for the gestational day. RESULTS: Between 1996 and 1998, 94 at-risk pregnancies were studied. Of these, 32 were subsequently confirmed to be affected by homozygous alpha-thalassemia-1. Chromosome study was not carried out in three cases and these were excluded from the analysis. Nuchal translucency MoMs for cases and controls were found to fit a log Gaussian distribution. The log means (standard deviation) for case and control NT MoM were 0.075 (0.156) and -0.0019 (0.091), respectively. The median NT MoM (95% CI) for cases was 1.19 (1.08-1.62) and was significantly higher than that of the controls (p < 0.001). However, there was extensive overlap of NT between cases and controls. CONCLUSION: Overall, there was a 19% increase in NT MoM in fetuses affected by homozygous alpha-thalassemia-1. This represents a difference of only 0.3-0.4 mm, which is clinically insignificant. This finding indirectly suggests that the increased NT in trisomic fetuses cannot be explained by fetal anemia. Conversely, the presence of increased NT in a fetus at risk of homozygous alpha-thalassemia-1 should alert one to the possibility of chromosomal abnormality rather than being attributed to fetal anemia.  (+info)

Hepatitis B carriage explains the excess rate of hepatocellular carcinoma for Maori, Pacific Island and Asian people compared to Europeans in New Zealand. (62/7400)

BACKGROUND: The aim of this research was to determine the hepatitis B surface antigen (HBsAg) carrier prevalence among cases of hepatocellular carcinoma (HCC), and the population attributable risk of HBsAg carriage for HCC, by ethnicity in New Zealand. METHODS: The hospital notes of HCC cases registered with the New Zealand Cancer Registry, for the years 1987-1994 inclusive, were viewed to determine the HBsAg status. Results The HBsAg status was determined for 193 cases of HCC. The HBsAg carrier prevalence for non-Europeans with HCC was markedly higher than that for Europeans, being 76.7% for Maori, 80.0% for Pacific Island people, and 88.5% for Asians, compared to 6.0% for Europeans. In addition to the effect of ethnicity, HCC cases aged <60 years were more likely to be HBsAg carriers than those aged > or = 60 years. The estimated population attributable risk of HBsAg for HCC, within each ethnic group, was only marginally less than the HBsAg prevalence due to the high relative risk of HBsAg carriage for HCC. The standardized incidence rate ratios of HCC for Maori, Pacific Island people and Asians compared to Europeans were 9.6, 20.4, and 22.3, respectively. Hepatocellular carcinoma attributable to HBsAg carriage explained 79%, 83%, and 92% of the excess standardized rate of HCC, compared to Europeans, for Maori, Pacific Island people, and Asians, respectively. Conclusions The HBsAg carrier prevalence in non-European cases of HCC in New Zealand is between 75% and 90%. HBsAg carriage explains the majority of the excess rate of HCC in non-Europeans compared to Europeans in New Zealand.  (+info)

Incidence of myocardial infarction in the Danish MONICA population 1982-1991. (63/7400)

BACKGROUND: Cardiovascular mortality has been declining in Denmark over the past 20 years. Trends in incidence of myocardial infarction (MI) over the period 1982-1991 are described within the framework of the World Health Organization MONICA Project. METHODS: The DAN-MONICA heart register included all cases of MI in 25-74-year-old men and women living in 11 municipalities around Glostrup County Hospital evolving over a period of 10 years. They were identified retrospectively based mainly on relevant ICD diagnoses in death certificates and hospital discharge reports. Cases meeting WHO-MONICA criteria for definite or possible MI, recurrent as well as first-ever MI, were registered. Subsequent tracing of cases through national registers on deaths and hospitalizations by means of the patient's civil registration number ensured the completeness of the registration. RESULTS: A total of 6025 cases of MI occurred in the period, 4532 among men and 1493 among women. A total of 2923 men and 1047 women had a first-ever MI in the period. The age-standardized rates show a definite decline over the registration period for men and a less distinct decline for women. CONCLUSIONS: The DAN-MONICA heart register meets the requirements for completeness and uniformity throughout the registration period. Causes and magnitude of bias are well described. Even when possible sources of bias are taken into account, the incidence of MI decreased significantly over the 10-year-period 1982-1991 by an average of 5.0% per year for men and 3.5% per year for women.  (+info)

A Markov chain model to assess the efficacy of screening for non-insulin dependent diabetes mellitus (NIDDM). (64/7400)

BACKGROUND: The high prevalence and severe consequences of non-insulin dependent diabetes mellitus (NIDDM) in Taiwan calls for urgent measures to detect this disease in the asymptomatic phase. However, the efficacy of early detection of NIDDM is highly dependent on its natural history from the disease-free state, through the asymptomatic to the symptomatic phase and death from NIDDM or other causes. METHODS: In order to project the above progression, a five-state illness-and-death Markov chain model was proposed to estimate these transition parameters using data from two rounds of a blood sugar screening programme for NIDDM in Puli, in central Taiwan. RESULTS: Results showed that the annual incidence for asymptomatic NIDDM was 10.67 per 1000 (95% CI: 8.26-13.79) and the average duration between the asymptomatic and symptomatic phases (the sojourn time) was 8 years (95%CI: 5.74-11.29). The 10-year survival rate for asymptomatic NIDDM (79.35%) was better than that for symptomatic NIDDM (69.45%). Prediction of deaths from NIDDM was performed to assess how the efficacy of screening for NIDDM varied by different screening frequencies (annual, biennial, 4-yearly and the control group). Results indicated there is no substantial difference in mortality reduction from NIDDM among the annual, biennial and 4-yearly screening regimens. However, a 4-yearly screening regimen significantly reduced deaths from NIDDM by 40% (95% CI: 26-51%). CONCLUSIONS: A long sojourn time and the substantial reduction in mortality suggest that a 4-yearly screening regime for NIDDM would be most effective and feasible in Taiwan. The proposed five-state Markov chain model can be applied to other similar NIDDM screening projects.  (+info)