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Summary. Chronic infection with the hepatitis C virus (HCV) is more prevalent than human immunodeficiency virus (HIV) infection, but more public health resources are allocated to HIV than to HCV. Given shared risk factors and epidemiology, we compared accuracy of health beliefs about HIV and HCV in an at-risk community. Between 2002 and 2003, we surveyed a random patient sample at a primary care clinic in New York. The survey was organized as domains of Common Sense Model of Self-Regulation: causes ('sharing needles'), timeline/consequences ('remains in body for life', 'causes cancer') and controllability ('I can avoid this illness', 'medications may cure this illness'). We compared differences in accuracy of beliefs about HIV and HCV and used multivariable linear regression to identify factors associated with relative accuracy of beliefs. One hundred and twenty-two subjects completed the survey (response rate 42%). Mean overall health belief accuracy was 12/15 questions (80%) for HIV vs 9/15 (60%) for HCV ( P < 0.001). Belief accuracy was significantly different across all domains. Within the causes domain, 60% accurately believed sharing needles a risk factor for HCV compared to 92% for HIV ( P < 0.001). Within the timeline/consequences domain, 42% accurately believed HCV results in lifelong infection compared to 89% for HIV ( P < 0.001). Within the controllability domain, 25% accurately believed that there is a potential cure for HCV. Multivariable linear regression revealed female gender as significantly associated with greater health belief accuracy for HIV. Thus, study participants had significantly less accurate health beliefs about HCV than about HIV. Targeting inaccuracies might improve public health interventions to foster healthier behaviours and better hepatitis C outcomes. [ABSTRACT FROM AUTHOR]

Adult literacy programmes, particularly literacy-for-health programmes that integrate health material in their curricula, are gaining momentum as a means to improve women's and children's health and increase women's empowerment. However, the relationship between literacy skills and these benefits remains unclear. This paper presents results from a study on the Reproductive Health Literacy (RHL) Project among Sierra Leonean and Liberian women in refugee camps in Guinea. Literacy classes met for 2 hours twice per week for 6 months, with content focused on safe motherhood, family planning, STIs/HIV/AIDS and gender-based violence. A closed-ended interview and a written test of literacy skills were administered to 549 former RHL students to understand the programme's effects. Results indicate that participants had a high level of reproductive health knowledge after participation, and reported an increase in literacy skills. Respondents' current use of modern contraception was 48%, of which 23% reported using a condom at last sex. Findings suggest an increase from reported pre-RHL behaviour. Participants also reported a dramatic increase in ‘boldness’, the phrase used to describe empowerment. While only a third (32%) of respondents considered themselves ‘more bold’ than other women before RHL, a clear majority (82%) so considered themselves after RHL. A comparison of schooled and unschooled women indicates that those who had had previous schooling did better in RHL than their non-schooled colleagues, but both groups had good knowledge retention, positive behaviour levels and felt more bold after RHL participation. [ABSTRACT FROM AUTHOR]

PURPOSE: To review the accuracy of the history and physical examination, clinical assessment, and noninvasive diagnostic tests for the diagnosis of deep vein thrombosis (DVT).BACKGROUND: Each year, over 250,000 patients are hospitalized in the United States for the treatment of acute DVT, and many more are diagnosed while hospitalized for surgical procedures or medical illness or while residing in long-term care facilities. Prompt diagnosis and treatment are essential to prevent the short-term sequelae of pulmonary embolism and death and the long-term complications of recurrent venous thromboembolism and the postthrombotic syndrome. Knowledge of the accuracy of elements of the history and physical examination helps clinicians assess the probability of DVT before ordering confirmatory diagnostic studies or instituting therapy.Several studies have found that the incidence of venous thrombosis increases with age.The important contribution of age was demonstrated in a study of Swedish men that found the cumulative probability for venous thromboembolism to be relatively low (0.5%) by the age of 50 but substantial (10.7%) by the age of 80. The case-fatality rate also increases with age; mortality increases exponentially beginning at the age of 40. Given the advancing age of the population of the United States, clinicians can expect to be assessing patients, and particularly older patients, for suspected DVT with increasing frequency. The authors have reviewed the literature to describe the accuracy of various elements of the history and physical examination, the combination of these findings, and noninvasive tests in the diagnosis of DVT.DATA SOURCES: A structured Medline search was performed (limited to English-language studies from 1966 to 1997) to identify studies examining the clinical assessment of patients with suspected DVT. Bibliographies of the retrieved articles were reviewed for additional relevant studies.STUDY SELECTION CRITERIA: Studies examining the accuracy of the physical examination, clinical assessment, or diagnostic tests for the diagnosis of DVT were selected for complete review.DATA EXTRACTION: Of 115 articles retrieved, 68 were considered relevant for analysis and were completely reviewed. The selected studies were graded based on the quality of their methods using a scoring system described by Sackett et al.Data for individual trials are presented separately. Meta-analyses were not performed. The prevalences of symptoms and signs of DVT are reported for patients with and without DVT. Data are presented as odds ratios (ORs) for risk factors and as sensitivity, specificity, and likelihood ratios (LRs) for the clinical assessment of DVT. The derivation and validation of a clinical decision rule is described in detail. The results for the clinical decision rule are reported as positive predictive values and LRs. ORs, LRs, sensitivities, and specificities are reported with 95% confidence intervals (CIs). [ABSTRACT FROM AUTHOR]

An abstract of the article "A simplified version of the Walsh clinical prediction rule was accurate for detecting streptococcal pharyngitis" is presented.

Objective: This study aimed to characterize seniors' beliefs about generic drugs, and examine potential correlates of these beliefs, including socioeconomic and health status variables, health literacy, and physician communication skills.Methods: Older adults (> or = 65 years) were interviewed in two primary care practices of an inner-city, tertiary care hospital (n = 311). Beliefs about generics were measured using a scale that compared generic and brand name drugs across four domains. Beliefs were modeled with multivariable linear regression.Results: Negative beliefs about generics were associated with non-white race (p < 0.0001), lower education (p = 0.008) and income (p = 0.001), and having Medicaid coverage (p = 0.001). Individuals with low health literacy and who reported that their physicians had poor communication skills were more likely to hold negative views (p < 0.0001 and p = 0.003, respectively). In multivariable analysis, black race (beta = -2.30, p = 0.006) and inadequate health literacy (beta = -2.17, p = 0.0004) remained strongly associated with negative views about generic drugs. Poor physician communication skills also predicted negative beliefs about generics but the association was not significant for all levels of communication skill.Conclusion: Many low-income seniors mistrust generic medications, especially African-Americans and seniors with low health literacy.Practice Implications: Educational efforts to promote generic medications should account for patients' health literacy and cultural backgrounds. [ABSTRACT FROM AUTHOR]

Sierra Leone suffered from 11 years of civil war (1991-2002) resulting in tens of thousands of deaths and mutilations and massive population displacement. In 2001, ARC International, Sierra Leone, conducted a baseline survey of 244 female youth and 293 male youth on knowledge, attitudes, and behaviours around HIV/AIDS and STIs in Port Loko. In 2003, following 2 years of HIV prevention activities, a comparable post-intervention survey of 250 female and 299 male youth was performed. Comparison of baseline and post-intervention results showed that HIV/AIDS knowledge increased dramatically among both groups, with those able to name three effective means of avoiding AIDS increasing from 4% to 36% among female youth, and 4% to 45% among male youth. Reported condom use at last sex increased among female youth from 16% to 46% and among male youth from 16% to 37%. These results demonstrate that, despite the challenges inherent in a post-conflict country, good quality AIDS prevention programmes can be successful. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study is to determine the rates of CT pulmonary angiography (CTPA) interpreted as limited and severely limited in pregnant patients suspected for pulmonary embolism (PE), and to evaluate factors that influence these rates.Methods: This is a retrospective study with CTPA for evaluation of PE in pregnancy across a large health system from 2006 to 2017. CTPA was classified as limited from the radiology report with a subset of those studies classified as severely limited. Bivariate and multivariate analysis was performed for limited and severely limited rates with maternal age and patient size as a continuous variable and race, trimester, patient location study priority status, and result of chest radiograph before CTPA as categorical variables.Results: 874 patients with 33% of studies limited and 4% of studies severely limited. Multivariate logistic regression of CTPA studies revealed decreasing patient age (OR 0.967, p = 0.0129) and increasing patient size (OR 1.013, p < 0.0001). Studies performed in the second trimester (OR 1.869, p = 0.0242) and third trimester (OR 2.314, p = 0.0021) were more likely to be reported as limited (each p < 0.05). Increasing patient size (OR 1.017, p = 0.0046) was the only significant predictor of severely limited versus non-severely limited studies.Conclusion: CTPA interpreted as limited in pregnancy are common and may be associated with younger age, larger patient size, and second and third trimesters. However, severely limited interpretations are much less common, with patient size the only significant predictor. [ABSTRACT FROM AUTHOR]

Continued political and civil unrest in low-resource countries underscores the ongoing need for specialised reproductive health services for displaced people. Displaced women particularly face high maternal mortality, unmet need for family planning, complications following unsafe abortion, and gender-based violence, as well as sexually transmitted diseases, including HIV. Relief and development agencies and UN bodies have developed technical materials, made positive policy changes specific to crisis settings and are working to provide better reproductive health care. Substantial gaps remain, however. The collaboration within the field of reproductive health in crises is notable, with many agencies working in one or more networks. The five-year RAISE Initiative brings together major UN and NGO agencies from the fields of relief and development, and builds on their experience to support reproductive health service delivery, advocacy, clinical training and research. The readiness to use common guidance documents, develop priorities jointly and share resources has led to smoother operations and less overlap than if each agency worked independently. Trends in the field, including greater focus on internally displaced persons and those living in non-camp settings, as well as refugees in camps, the protracted nature of emergencies, and an increasing need for empirical evidence, will influence future progress. [ABSTRACT FROM AUTHOR]

BACKGROUND: Pelvic examination is an important component of the primary care of women by internists, but training beyond medical school is rare. DESCRIPTION: We created an internist-run educational program for 1st-year medical residents in pelvic examination. The program consisted of 4 weekly patient-care sessions with 2 to 3 patients seen by each resident each session. Internists supervised each exam and gave real-time feedback and utilized a skills-assessment checklist during the first and last exams of the program to give comprehensive, formative feedback. EVALUATION: We evaluated the program using a self-assessment questionnaire concerning pelvic examination competency and attitudes, which utilized a 5-point Likert scale and was administered prior to, and 3 months after, the program. A total of 37 participants completed the program and reported improvements in competency and a trend toward an increased likelihood of performing exams. CONCLUSIONS: This program, in which internists trained medical residents in pelvic examination, utilized real patients, improved participants self-assessed competency, and may increase the likelihood of residents performing pelvic examination in primary care. [ABSTRACT FROM AUTHOR]

OBJECTIVES: To determine the proportion of patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) who are adequately assessed for human immunodeficiency virus (HIV) and to identify variables associated with absence of HIV testing. PATIENTS AND METHODS: We retrospectively reviewed the medical records of patients who had positive serologic test results for reactive HBV and/or HCV between January 1999 and December 1999 and were followed up at a general internal medicine clinic in East Harlem, NY. Data were collected on patient demographics, HIV risk factors, and other variables that might influence the physician's decision to test the patient for HIV. Primary outcomes were HIV tests performed and documented discussions of at-risk HIV behavior. RESULTS: The HIV tests were performed in 40% (95% confidence interval [CI], 32%-49%) of the 141 patients with reactive HBV and/or HCV serologic test results. Predictors of HIV testing on multivariate logistic regression were age younger than 50 years (odds ratio [OR], 25; 95% CI, 13-3.8), male sex (OR, 1.6; 95% CI, 1.1-2.2), and having an established primary care provider (OR, 2.3; 95% CI, 1.2-3.9). Injection drug use was not significantly associated with HIV testing. CONCLUSIONS: Although HBV and HCV have clear epidemiological links with HIV, this study shows that a high percentage of these patients are not being tested. Although some of the factors associated with lack of testing were identified, further studies on the barriers to HIV testing are needed to reveal potential approaches to increase rates of HIV testing in this high-risk population. [ABSTRACT FROM AUTHOR]

BACKGROUND: Domestic violence (DV) is prevalent but often unrecognized, and it is a challenge to teach. This article presents an evidence-based DV education program for medical residents and incorporates it into a women's medicine curriculum. DESCRIPTION: An initial 3-hr seminar included video and case discussion, literature review, and role play. Participants then actively screened patients for 2 weeks and returned for a follow-up discussion session. The program was well received. EVALUATION: Six to 12 months after the intervention, key features questions were utilized to measure ability to correctly suspect DV in patient situations. Residents who had not attended the program served as controls. Three of the 8 questions were suspicious for abuse. Fifty-four percent of respondents in the intervention group correctly suspected DV in at least 2 out of 3 questions compared with 20% of controls (p = .02). CONCLUSIONS: An evidence-based DV education program was well received and helped correctly suspect DV. [ABSTRACT FROM AUTHOR]

BACKGROUND: Evidence-based medicine (EBM) is a framework for critically appraising medical literature and applying it to the care of individual patients. Lack of faculty skilled in practicing and teaching EBM limits the ability to train residents in this area. DESCRIPTION: A 31/2-day interactive course, called Teaching Evidence-Based Medicine, was given in 1996, 1998, and 1999. The goal of the course was to create a cadre of faculty within New York State's internal medicine residency programs educated in EBM knowledge and skills who could integrate EBM into their training program. Thirty (58.8%) of 51 metropolitan New York internal medicine residency programs and three of 12 upstate programs sent participants. EVALUATION: The postcourse ratings showed increased self-rated knowledge and a willingness to apply the teaching methods at their home institutions. CONCLUSIONS: There is a high demand for the opportunity to learn EBM skills and in turn to implement EBM at home institutions [ABSTRACT FROM AUTHOR]

Clinical experience provides clinicians with an intuitive sense of which findings on history, physical examination, and investigation are critical in making an accurate diagnosis, or an accurate assessment of a patient's fate. A clinical decision rule (CDR) is a clinical tool that quantifies the individual contributions that various components of the history, physical examination, and basic laboratory results make toward the diagnosis, prognosis, or likely response to treatment in a patient. Clinical decision rules attempt to formally test, simplify, and increase the accuracy of clinicians' diagnostic and prognostic assessments. Existing CDRs guide clinicians, establish pretest probability, provide screening tests for common problems, and estimate risk. Three steps are involved in the development and testing of a CDR: creation of the rule, testing or validating the rule, and assessing the impact of the rule on clinical behavior. Clinicians evaluating CDRs for possible clinical use should assess the following components: the method of derivation; the validation of the CDR to ensure that its repeated use leads to the same results; and its predictive power. We consider CDRs that have been validated in a new clinical setting to be level 1 CDRs and most appropriate for implementation. Level 1 CDRs have the potential to inform clinical judgment, to change clinical behavior, and to reduce unnecessary costs, while maintaining quality of care and patient satisfaction. JAMA. 2000;284:79-84 [ABSTRACT FROM AUTHOR]

OBJECTIVE: To assess the impact of a decision aid on perceived risk of heart attacks and medication adherence among urban primary care patients with diabetes. METHODS: We randomly allocated 150 patients with diabetes to participate in a usual primary care visit either with or without the Statin Choice tool. Participants completed a questionnaire at baseline and telephone follow-up at 3 and 6 months. RESULTS: Intervention patients were more likely to accurately perceive their underlying risk for a heart attack without taking a statin (OR: 1.9, CI: 1.0-3.8) and with taking a statin (OR: 1.4, CI: 0.7-2.8); a decline in risk overestimation among patients receiving the decision aid accounts for this finding. There was no difference in statin adherence at 3 or 6 months. CONCLUSION: A decision aid about using statins to reduce coronary risk among patients with diabetes improved risk communication, beliefs, and decisional conflict, but did not improve adherence to statins. PRACTICE IMPLICATIONS: Decision aid enhanced communication about the risks and benefits of statins improved patient risk perceptions but did not alter adherence among patients with diabetes. [ABSTRACT FROM AUTHOR]