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These practice guidelines are a modular update of the “Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures.” The guidance focuses on topics not addressed in the previous guideline: ingestion of carbohydrate-containing clear liquids with or without protein, chewing gum, and pediatric fasting duration.

These practice guidelines provide evidence-based recommendations on the management of neuromuscular monitoring and antagonism of neuromuscular blocking agents during and after general anesthesia. The guidance focuses primarily on the type and site of monitoring and the process of antagonizing neuromuscular blockade to reduce residual neuromuscular blockade.

Objective: Poor speech intelligibility adversely affects quality of life self-assessment in long term survivors of head and neck cancer treatment. Study Design: Observational case series including both objective clinical speech testing and subjective quality of life questionnaire administration. Methods: Five-year head and neck cancer survivors were recruited to study the association between speech intelligibility and quality of life. Survivors were analyzed as an entire group, and also subdivided into laryngectomees and non-laryngectomees. Objective testing included sentence and word intelligibility. Subjective testing included quality of life questionnaires (UWQOL, FACT, FACT-head and neck, and PSS-HN) and a locally prepared “cancer concern” question. Associations were sought between intelligibility, quality of life and demographics. Results: Sixty-two survivors underwent testing. Lower sentence intelligibility and word intelligibility scores were associated with diminished self-perceived UWQOL Speech (P = .0001 and P = .0001, respectively) and PSS-HN Understandability of Speech (P = .009 and P = .005). Decreased word intelligibility was additionally associated with decreased UWQOL Chewing (P = .003), UWQOL Swallowing (P = .02), UWQOL Recreation (P = .05), PSS-HN Willingness to Eat in Public (P = .03), and PSS-HN Normalcy of Diet (P = .0001). The associations continued even after patients who had undergone laryngectomy were excluded. Conclusions: Long-term survivors of head and neck cancer continue to have both objective and subjective deficits in speech parameters five years after treatment. Objective deficits are associated with subjective concerns about speech, eating, and recreation. Understanding how communication deficits affect quality of life in long-term head and neck cancer survivors may allow more effective therapies to modulate these concerns in the recovery period.

Objectives/Hypothesis: A cohort of 3-year survivors of head and neck cancer was evaluated for persistent quality of life (QOL) concerns and long-term treatment effects. Study Design: Mailed questionnaire. Methods: The questionnaire with the University of Washington Quality of Life (UWQOL) scale, the Performance Status Scale for Head and Neck Cancer (PSS-HN), the Functional Assessment of Cancer Therapy (FACT) scale, and the Functional Assessment of Cancer Therapy Head and Neck (FACT-HN) scale and locally prepared questions was sent to 111 3-year disease-free survivors. Analysis was performed to statistically evaluate the effect of stage, site, treatment type, surgery, and cancer concern on QOL. Current smoking information was gathered. Results: Seventy-two survivors completed the questionnaire. Advanced stage was correlated with lower QOL scores in the domains of disfigurement, chewing ability, speech, and eating in public. QOL scores did not vary by initial tumor site. Patients treated with irradiation alone had statistically better QOL scores than those treated with combined surgery/radiation therapy in the pain, disfigurement, chewing, and speech domains. Laryngectomy and composite resection survivors reported lower QOL scores than patients treated with irradiation alone. A low level of cancer concern persisted in about half of the long-term survivors. Cancer concern was associated with continued pain, disfigurement, and limitations on eating in public. Three-quarters of the tobacco users had quit by the time of the questionnaire. Nevertheless, the patients were not thoroughly convinced that tobacco had caused their cancer. Conclusions: Long-term survivors of head and neck cancer experience QOL effects well after completion of treatment. Effects are most pronounced in survivors who required combined surgery/radiation therapy. Continuing low levels of cancer concern persist in about half of the survivors. Many cancer survivors successfully quit smoking.

Telephone interviews were conducted on a random sample of 164 dairy farmers knowledge and beliefs about pesticide hazards, intentions to use precautions, perceptions of pesticide safety peer norms, perceived self-efficacy to prevent personal exposure, and use of protective equipment. Self-efficacy and risk perception appear less relevant to safety behavior than other variables. Future research should focus prospectively and on national samples. Language: en

Purpose: The purpose of this study was to evaluate an intervention to improve patient-surrogate agreement on end-of-life resuscitation preferences. Materials and Methods: Seven hundred seventeen patients with a 50% 6-month survival rate and their surrogate decision-makers were recruited for a randomized clinical trial from five teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Intervention patients (n = 386) were assigned specially trained nurses who spent extra time with patients and families explaining prognoses and treatments. Control patients (n = 331) received usual care. Patient preferences and surrogate's perception of those preferences at pre- and post-intervention interviews were compared. Results: Agreement between patients and surrogates was 75.0% at the day 3 interview and 79.6% at the month 2 interview, increasing 4.6% (95% CI: 0.1%, 9.1%). Improvements in agreement from day 3 to month 2 were seen equally in both study groups. A multivariable analysis verified that the intervention did not have an effect on agreement and indicated a decrease in agreement among older patients and among surrogates not in the immediate family. Conclusions: The SUPPORT intervention was not successful in increasing agreement between patients and surrogates. Because of the complex issues involved in end-of-life decision-making, a more agressive intervention may be needed. Other findings suggest that improvements in communication are particularly needed when patients are older and when the surrogate is not a patient's immediate relative.

Article-at-a-Glance Background As primary care physicians develop ongoing relationships with their patients, each contact provides another opportunity for primary, secondary, or tertiary prevention activities. In 1991 an interdisciplinary prevention project team using continuous quality improvement (CQI) principles was established to improve family practice residents' provision of such services. Diagnostic journey For a random sample of 60 patient charts, abstractors looked for documentation of 23 clinical preventive services, including nursing screens, physician on-site and off-site implemented services, lifestyle education (diet, tobacco use), and self-screening education. After the chart review, the physicians, nurses, residents, and clinical staff used a fishbone analysis to identify physician-, clinic system–, and patient-centered factors contributing to the lack of conformance with clinical prevention guidelines. Remedial journey The residency program began a series of didactic sessions on clinical prevention and instituted a procedures rotation to teach prevention procedure skills such as flexible sigmoidoscopy, stress testing, and colposcopy. On the CQI team's recommendation, a checklist developed by physicians and staff which itemized age- and gender-specific clinical prevention services was placed at the front of all patient charts. Clinic-system and patient factors were also addressed. Holding the gains—monitoring performance The 1993 postintervention chart review showed significant improvements for 17 (81%) of the 21 targeted services. Discussion Providing educational sessions on prevention, permitting residents to select the areas of prevention on which to focus, and giving feedback on resident and staff performance through ongoing, nonpunitive monitoring resulted in increased provision of clinical prevention services in a family practice residency training center.

Objective To determine risk factors of medical injury, defined as untoward injury from diagnostic or therapeutic healthcare interventions. Identifying risk factors for medical injuries could inform the development of preventive interventions. Methods A hospital-based case–control study. Cases and controls were selected among patients discharged from a large Midwestern teaching hospital between 1 January 2003 and 31 December 2004. Cases (n=268) were selected in a three-step process. First, medical injuries in the discharge database were identified using the Wisconsin Medical Injury Prevention Programme Surveillance Criteria. Second, provisional cases were randomly chosen from patients flagged with a medical injury. Provisional controls were randomly selected from patients not flagged with a medical injury, matching for Diagnosis Related Group of the provisional cases. Third, a chart review determined ultimate case–control status. Severity of illness and risk of mortality were calculated using the All Patients Refined–Diagnosis Related Groups system. Zahn's comorbidity score was calculated. Conditional logistic regressions were run with injury status as the dependent variable. Results Among the 268 cases, 47.8% were procedure-related injuries and 44.8% were medication-related injuries. Conditional logistic regressions found higher severity of illness and higher risks of mortality were related to risk of medical injury (OR 3.29 (95% CI 1.05 to 10.31) and OR 5.16 (95% CI 1.42 to 18.79), respectively). Additional regressions showed the Zahn comorbidity score related to the risk of medical injury (OR 1.63, 95% CI 1.31 to 2.02). Conclusions Patients with higher severity of illness, higher risk of inpatient mortality and multiple comorbidities are at increased risk for a medical injury.

BACKGROUND: The purpose of this project is to improve the health of blood donors by educating and motivating them to seek medical attention for anemia. The National Anemia Action Council, BloodCenter of Wisconsin, and the Medical College of Wisconsin formed a partnership to engage volunteer blood donors and develop an educational intervention to motivate donors with anemia to seek appropriate medical care. STUDY DESIGN AND METHODS: Partners developed an educational pamphlet and conducted two focus groups with volunteer blood donors for feedback. Participants were recruited from volunteer donors at BloodCenter of Wisconsin found to have anemia (men age, 18 years and older with a hematocrit [Hct] level of

Electronic Medical Records (EMRs) are quickly becoming a standard component of medical practices.We longitudinally studied the impact of EMR implementation on physician perceptions of quality of care, documentation, and work hours, as well as on measured physician productivity.Physicians were surveyed at 3-month intervals regarding perceived impact of the EMR on quality of care, documentation, and productivity. Relative Value Units (RVUs) per clinic hours were used to measure productivity. Paired t-tests were used to compare the mean RVUs per clinic hour in the pre-EMR with the immediate post-EMR time period and the long-term post-EMR time period.RVUs per hour increased significantly from the pre-EMR time period to the immediate post-EMR time period (means 1.49 and 1.82, respectively, P = 0.0007). The long-term post-EMR time period also showed a significant increase over the pre-EMR period (mean 1.79, P = 0.007). Sixty-six percent of physicians perceived that EMR implementation increased their work amount a little or much more.Not only did physician production rise immediately, it stayed at the increased level for the duration of our study period. This may be due to improved documentation supporting more appropriate billing. However, physicians also perceived the EMR as taking up more of their time.

Introduction/context Torture is widely practiced throughout the world and, yet, the ways by which torture is perpetrated, its regional similarities and differences, is not well understood. Our goal for this cases series was to elucidate the methods of torture practiced within different countries to both add to and expand upon previous research. This knowledge is important since it can buttress efforts to assist with torture survivors’ recovery—medically, psychologically, and legally. Methods Fifty-eight survivors of torture who presented to a single interviewer over a 15-year period (1990–2005) for purposes of assisting with their claim for political asylum in the U.S. were enrolled into the study. The survivors’ legal affidavits were examined and both quantitative and qualitative data were extracted for analysis. This data included the following: (1) duration, condition, and frequency of imprisonment, (2) abductors’ affiliation and dress, (3) torture type, method, and frequency (both physical and mental), and (4) qualitative description of above items. Results Twenty-three countries were represented in the sample covering six major world regions. Women appear to be at greater risk for sexual torture than men. Sub-Saharan Africans tend to have more abuse compared to other world regions. Furthermore, the length of confinement also appears to trend towards longer duration in those survivors from Sub-Saharan African countries. Certain types of torture were almost universal in their application such as threats of death and beatings, but the manner by which survivors were beaten varied considerably, with hitting/kicking and beating with a stick/baton being the most common. There was no correlation between types of torturous acts and religion. Conclusion This case series confirms some earlier findings about regional similarities and differences in torture methodology. Study results built upon previous studies as well as uncovered new findings suggesting that more work needs to be done. Further, our results will help survivors of torture with their recovery both through improved patient care outcomes and by impacting upon the way asylum cases are adjudicated.

This study investigates the Wisconsin adolescent self-poisoning problem, using state discharge data on medication-related self-inflicted injuries, focusing on medications used and risk factors.Wisconsin inpatient discharge files for 3 years (January 1, 2000-December 31, 2002) were evaluated. Medication-related injuries were analyzed for intentionality, medications used, discharge status, and risk factors such as mental illness, eating disorders, and alcohol abuse or dependence.There were nearly 3000 medication-related injury hospitalizations--1150 of them self-poisoning hospitalizations--among Wisconsin 12-17 year olds during 2000-2002. Females 12-17 years had twice as many medication-related injuries as males. Sixty percent of medication-related injuries occurred in patients with a mental disorder diagnosis. Non-narcotic analgesics were most commonly used and had one of the highest rates of intentionality (65%). A large proportion of intentional/suicidal medication-related injuries were discharged to another facility (35%), compared to 14% among all medical injuries. Males with medication-related injuries were twice (95% CI: 1.60, 2.75) as likely and females 1.4 (95% CI: 1.2, 1.6) times as likely to have intentional/suicidal injuries if they also abused or depended on alcohol.Given that a nonfatal suicide attempt is the strongest predictor of eventual suicide, the hundreds of self-poisoning discharges per year in Wisconsin 12-17 year olds is a serious public health concern. Both the medical community and public health community should heed the warnings of these nonfatal suicide attempts and implement educational programs addressing this issue.

Few studies using biologic markers to examine nonpersistent pesticide exposure among pesticide applicators were conducted in field settings. This study compares self-reported dermal, inhalation, and ingestion exposures with urinalysis results after one-time application of the commonly used herbicide atrazine to field crops. It was hypothesized that: i) applicator reports of exposure would be associated positively with detection of urinary atrazine metabolites, and ii) applicator reports of personal-protective-equipment (PPE) use would be associated negatively with detection of urinary atrazine metabolites.Wisconsin dairy farmers were randomly selected to participate in 1997 to 1998 and were instructed to collect a urine sample 8 hours after the first pesticide application of the season. Farmers then were interviewed within 1 week of their first application to report on application practices. Eighty-six urine samples were analyzed for deethylatrazine, a major atrazine metabolite.Comparing urinalysis results with self-reported dermal, inhalation, and ingestion exposure showed poor agreement between self-reported exposure and urinary deethylatrazine detections (all kappa0.40). Multivariate linear regression modeling with deethylatrazine level as the outcome showed that self-reported practices did not significantly predict atrazine metabolite levels.Possible explanations for the discrepancies between urinalysis results and self-reported data include: i) inaccuracies in self-reported data and ii) substantial interpersonal variation in atrazine metabolism, resulting in major differences in body burden for similar exposures. Either explanation poses challenges for epidemiologic studies of the health effects of pesticides, which rely solely on self-reported measures of exposure. Additional evaluation of determinants of accuracy in self-assessed occupational and environmental exposures is needed.

Objectives To analyze how the dental status of long-term head and neck cancer survivors affects their subjective quality of life. Study design Observational case series. Methods A convenience sample of 5-year head and neck cancer survivors underwent the following battery of tests: 1) targeted head and neck examination, 2) updated medical history, 3) dental evaluation, 4) standardized quality of life questionnaires. Results Eighty-six survivors were included in the study. The following associations were identified: 1) those who became edentulous secondary to cancer treatment and those without occlusion at time of the study demonstrated worse Pain, Activity, Recreation/Entertainment, Chewing, Swallowing, Speech, Eating in Public, Normalcy of Diet, Physical Well-Being, Social/Family Well-Being, Functional Well-Being, and Additional Concerns scores; 2) higher Decayed/Missing/Filled scores were associated with worse Pain, Disfigurement, Activity, Recreation/Entertainment, Employment, Chewing, Swallowing, Speech, Eating in Public, Understandability of Speech, Normalcy of Diet, Physical Well-Being, Additional Concerns scores, and weight loss; 3) decreased oral opening measurements were associated with worse Chewing, Swallowing, Eating in Public, Normalcy of Diet, Additional Concerns scores, and weight loss; 4) edentulous survivors who did not use dentures had worse Pain, Activity, Recreation/Entertainment, Understandability of Speech, and Eating in Public scores. Conclusions Although previous studies have shown that many of the effects of cancer treatment disappear between 1 and 3 years, this study shows that the dental status has a persistent impact on subjective quality of life.

To identify and rate the importance of several psychosocial and physiologic influences on quality of life (QOL) among a cohort of 5-year head and neck cancer survivors, we conducted a cross-sectional study of a convenience sample that used both questionnaires and physiologic evaluations.QOL was assessed by the Functional Assessment of Cancer Therapy (FACT) and the FACT Head and Neck additional concerns (FACT-HN) questionnaires. Psychosocial characteristics (or risk factors) potentially influencing QOL were measured by the Millon Behavioral Health Inventory (MBHI) and the Social Support Questionnaire (SSQSR). Physiologic risk factors were measured in examinations that included shoulder and neck range of motion, whole and stimulated saliva measurements, and oropharyngeal swallowing efficiency. We evaluated the association of selected QOL measures with three groups of potential risk factors: psychosocial factors, consisting of selected MBHI and SSQSR scales; physiologic factors, consisting of selected physical ability measures; and a combination of psychosocial/physiologic factors.The entire study population of 105 subjects completed the FACT and FACT-HN questionnaires; 86 of these completed the physiologic tests as well. Combined psychosocial/physiologic models best predicted all QOL measures considered. Psychosocial models alone, compared with physiologic models alone, better predicted FACT physical and social/family well-being measures. Physiologic models alone, compared with psychosocial models alone, better predicted FACT-HN additional concerns measures. Premorbid pessimism (MBHI) was consistently the best predictor of QOL measures.Both psychosocial and physiologic factors influence QOL in patients with head and neck cancer, but many QOL measures are most strongly influenced by psychosocial considerations. Physicians and surgeons caring for long-term head and neck cancer survivors should be cognizant of the importance of psychosocial risk factors in the QOL of their patients.

To describe the nature and extent of workplace environmental tobacco smoke exposures in Wisconsin.Descriptive data and confidence intervals from the Current Population Survey tobacco supplements of 1995-1996 and 1998-1999 are presented.The percent of indoor workers working under a smoke-free policy increased slightly, from 62% in 1995-1996 to 65% in 1998-1999. Respondents with a college degree were more likely to work under a smoke-free policy than those with a high school education or less. Among respondents with a work policy in 1998-1999, a complete ban on smoking reduced any workplace exposure in the past 2 weeks (4%) compared to a partial ban (26%) or an unrestricted policy (30%).Wisconsin has seen a small increase in workplace policies that ban smoking in the workplace. These policies are more likely to protect workers of higher socioeconomic status and may increase health disparities in tobacco-related diseases in the future.

Objective To determine associations between objective assessments (swallowing function and weight change) and subjective quality-of-life (QOL) measures. Design Observational case series using clinical testing and questionnaires. Setting University hospital-based tertiary clinical practice. Patients Convenience sample of 5-year survivors of head and neck cancer (62 nonlaryngectomy survivors were studied). Interventions Objective testing included examination, weight history, videofluoroscopic swallow studies (VFSS), and oropharyngeal swallowing efficiency (OPSE). Subjective testing included QOL questionnaires (University of Washington Quality-of-Life [UWQOL] Scale, Performance Status Scale for Head and Neck Cancer Patients [PSS-HN], Functional Assessment of Cancer Treatment–General [FACT-G] Scales, and Functional Assessment of Cancer Therapy–Head and Neck [FACT-H&N] Scale). Main Outcome Measures Aspiration (identified by VFSS), weight change, and QOL measures. Results Aspiration was associated with the decreased QOL scores in chewing, swallowing, normalcy of diet, and additional concerns of the FACT-H&N Scale. No association was found between aspiration and willingness to eat in public, subjective understandability, or any of the FACT-G scales. Of the nonlaryngectomy survivors, 27 (44%) demonstrated some degree of aspiration during VFSS. Associations were found between aspiration, primary tumor T stage, weight change, and OPSE. Aspirators lost a mean of 10.0 kg from precancer treatment weight, while nonaspirators gained a mean of 2.3 kg (P Conclusions Almost half of long-term nonlaryngectomy head and neck cancer survivors demonstrated at least some degree of aspiration. The presence of aspiration is associated with substantial weight loss, advanced initial tumor stage, diminished oropharyngeal swallowing efficiency, and lower scores on a variety of QOL scales.

Problem: Few studies have evaluated the degree of xerostomia in long-term cancer survivors or its impact on quality of life (QOL). The purpose of this study was to objectively measure the degree of xerostomia and to determine the effect of xerostomia on the subjective quality of life of long-term survivors of head and neck cancer treated with external beam irradiation. Methods: A convenience sample of 5-year head and neck cancer survivors underwent the following battery of tests: (1) targeted head and neck exam, (2) OPSE (swallow evaluation), (3) measurements of stimulated and unstimulated saliva, and (4) standardized QOL questionnaires. Results: Eighty-six survivors were included in the study. The following associations were identified: (1) unstimulated weights were influenced by site (P = 0.0096) and stage of cancer (and P = 0.047); (2) stimulated saliva weights were influenced by stage (P = 0.0018); site (P = 0.0002), particularly the larynx (P = 0.0001); and treatment (P = 0.0071); (3) unstimulated weight only correlated with one QOL measure (mouth is dry); (4) decreased stimulated saliva weight correlated with impaired swallowing (P = 0.0043) and negatively impacted all but three QOL measures; and (5) subjective xerostomia correlated with impaired swallowing (P = 0.046) as well as worse scores on about half of the QOL measures. Conclusion: This study shows that objective (stimulated saliva weight) and subjective (standardized QOL questionnaires) xerostomia persists in long-term head and neck cancer survivors. The xerostomia impairs swallowing and has a negative influence on many QOL measures. Laryngeal irradiation has little or no impact on subsequent xerostomia. Significance: Though many of the effects of radiation therapy resolve in the first 3 years, xerostomia may persist. This study demonstrates that subjective and objective indicators of xerostomia are present 5 years after treatment. The presence of chronic xerostomia continues to affect many areas of QOL in long-term head and neck cancer survivors, including though not limited to those related to the oral cavity. Support: None reported.

Problem: To evaluate the impact of dizziness on the quality of life (QOL) in Meniere’s disease (MD) patients in and out of crisis and to verify a possible relationship between the QOL impairment and the clinical data. Methods: Fifty patients with diagnosis of definite MD were included in the study. The impact of dizziness on the QOL was assessed by the Dizziness Handicap Inventory (DHI), administered to the patients in and out of crisis. The DHI scores were correlated to the clinical data. Tinnitus, aural fullness, imbalance, and functional disabilities were evaluated according to the Inner Ear Profile (IEP), in and out of crisis. Vertigo was assessed by Vertigogram. Hearing was assessed by CHE AAO-HNS staging. Vestibular function was evaluated by computerized vectonystagmography. All patients were also analyzed regarding disease duration and unilateral or bilateral labyrinth involvement. Statistical analysis was performed by using Anova and the test of equality of 2 proportions. Results: The sample consisted of 39 females and 11 males, with a mean age of 50.8 years. The DHI, during the crisis period, showed physical, functional, and emotional aspects scores statistically higher (P Conclusion: Definite MD patients present QOL impairment due to dizziness in and out of crisis. The impairment is worst in crisis when compared to the out-of-crisis period. The QOL impairment is greater in patients with bilateral labyrinth involvement out of crisis, than in patients with unilateral labyrinth involvement in the same period. Significance: Definite MD patients do have dizziness-related QOL impairment, independent of all clinical studied data. Support: None reported.

Physicians advising their patients to quit smoking has been recognized as an effective component of smoking cessation treatment, yet evidence suggests that physicians are not consistently providing this type of counseling.Data from both the Current Population Survey's (CPS) Tobacco Use Supplements administered September 1998, January 1999, and May 1999 and from the 2000 Behavioral Risk Factor Survey System (BRFSS) were analyzed and compared. The weighted proportions and 95% confidence intervals of Wisconsin and US smokers who had seen a physician in the past year and reported receiving advice from them to quit smoking were calculated. Proportions were analyzed for the total population as well as for subgroups of gender, age, race, educational level, and income level.CPS data showed that Wisconsin smokers who had seen a physician in the past year were significantly more likely to receive smoking cessation advice from their physician (64%) compared to US smokers (59%). Though not significant, a similar trend was seen in the BRFSS data. There were no consistent significant differences in rates analyzed by gender, age, race, educational level, or income level.Data from the CPS and BRFSS show that less than two thirds of Wisconsin smokers are receiving smoking cessation advice from their physicians. Increasing physician counseling of patients who smoke continues to be a priority public health goal for decreasing morbidity and mortality from tobacco-related illnesses.

Epidemiological studies of radium dial painters have found an association between exposure to high-dose radium and bone cancers. However, only limited data exist on the relationship between low doses of radium, as are found in some drinking water sources, and osteosarcoma. The authors conducted a population-based case-control study to examine the association between exposure to radium in drinking water and the occurrence of osteosarcoma. Estimates of radium exposure and covariates used were based on subjects' residential ZIP codes. The median radium level was not significantly associated with osteosarcoma (odds ratio = .98; 95% confidence interval = .93,1.04; p = .56). The authors found no evidence that radium, at current levels in Wisconsin drinking water, resulted in excess cases of osteosarcoma.

To examine academic rankings and educational backgrounds of underrepresented minority (URM) family medicine faculty and compare their academic ranks with national trends. The authors also determined the extent to which international and historically black educational institutions contributed URM faculty to family medicine.In 1999 questionnaires were sent to 129 family medicine departments asking for academic ranks and educational institutions attended by their URM faculty. Comparisons were made between URM faculty's academic ranks and all family medicine faculty, medical school minority faculty, and medical school faculty.A total of 80% of URM faculty were assistant professors or instructors, and 4.4% were professors. URM family medicine faculty had significantly lower rankings compared with medical school minority faculty and all family medicine faculty. URM family medicine faculty at historically black medical schools were more likely to have received their degrees from historically black undergraduate institutions and medical schools than were URM family medicine faculty at non-historically-black medical schools.URM family medicine faculty appear to experience a double disadvantage: being minority and working for family medicine departments. Their academic ranks remain far below those of both minority medical school faculty and family medicine faculty, a discouraging finding considering the current shortage of URM faculty in family medicine departments. Historically black medical schools cannot address the shortage alone, so non-historically-black medical schools need to both recruit URM faculty and follow up with appropriate mentoring of those faculty.

BACKGROUND: This study measured compliance with pesticide-specific protective gear use requirements practiced by farmers applying pesticides to field crops. MATERIALS AND METHODS: Two hundred and twenty randomly selected dairy farmers were interviewed 1 week after pesticide application to determine use of personal protective equipment while applying at least 1 of 15 possible restricted use pesticides (response rate = 82.4%). RESULTS: Among the three most common pesticides used (dicamba, atrazine, and cyanazine), the proportions of farmers fully complying with gear use requirements were 8.8, 8.6, and 2.5%, respectively. For those same pesticides, the proportions (and 95% CI) using none of the required gear were 56.9% (47.3-66.5%), 38.6% (27.2-50.0%), and 47.5%(32.0-63.0%), respectively. CONCLUSIONS: Both full and partial compliance with required personal protective equipment was low for each of the 15 chemicals applied by the applicators in this sample.

A study was conducted in 1994 to determine the need for faculty in family medicine. This paper reports a comparative follow-up study in 1999.This follow-up study determined faculty positions filled in the last 5 years, new faculty positions currently available, replacement faculty positions currently available, and new faculty positions anticipated to be available in the next 3 years. In addition, comparisons were made with the previous study regarding time available for clinical, educational, and research activities.In the 1994 survey, respondents reported 496 open faculty positions and anticipated that 677 would become available during the subsequent 3 years, for a total of 1,173 positions. The 1999 survey data indicated that the actual number of positions filled or still open since 1994 was 1,072. In contrast, new positions open in 1999 or anticipated to be open in the subsequent 3 years were 604. For both residencies and departments, most positions in both surveys were for clinicians.Despite a decrease in the number of available positions for family medicine faculty reported between the 1994 original survey and 1999 follow-up survey, there are still more than 600 faculty positions currently available, and additional new positions are anticipated over the next 3 years.

Objectives. This study examined recent trends in age- and race-specific patterns of breast cancer mortality. Methods. We analyzed breast cancer mortality data for 1979 through 1996. Results. From 1993 to 1996, White women of all age groups experienced average annual decreases in breast cancer mortality. Throughout the study, young Black women had higher rates of breast cancer mortality than young White women. Older Black women had lower mortality rates than older White women in the earlier years of the study but experienced higher rates in the later years (1993‐1996). Conclusions. Trends in risk factors and early detection do not provide an adequate explanation for this recent substantial increase in breast cancer mortality among older Black women. (Am J Public Health. 2001;91:118‐121) In 1980, Gray and colleagues calculated the breast cancer mortality ratios for Black women and White women. They found that although Black women younger than 45 years had consistently higher rates than comparably aged White women, among those 55 and older the rate for Black women was about 10% lower than that for White women. 1 Sondik reported the same pattern for 1973 to 1989: among those younger than 50 years, Black women had higher breast cancer mortality rates than White women, and among those older than 50 years, Black women had lower rates than White women. 2 More recent analyses of age- and race-specific breast cancer mortality data through 1992 reported the same trend among Black and White pre- and postmenopausal women. 3,4

Although a number of health hazards associated with pesticide exposure have been well documented, relatively little is known about the knowledge and health beliefs that may influence pesticide handling. This study measured knowledge levels concerning pesticide safety and precautionary handling among applicators and examined relationships between knowledge scores and intentions to use handling precautions, perceptions of pesticide safety peer norms, and perceived self-efficacy to prevent personal exposure. Telephone interviews were conducted with a randomly selected sample of 164 dairy farmers who were pesticide applicators residing in Wisconsin (response rate = 77.4%). The percentage of correct responses to 18 knowledge items ranged from 100% to 45.7%. Knowledge levels were positively related to intentions, beliefs, and self-efficacy regarding use of personal protective gear but were not significantly related to risk perceptions and peer norms concerning pesticide safety.

The purpose of this study was to evaluate an intervention to improve patient-surrogate agreement on end-of-life resuscitation preferences.Seven hundred seventeen patients with a 50% 6-month survival rate and their surrogate decision-makers were recruited for a randomized clinical trial from five teaching hospitals participating in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). Intervention patients (n=386) were assigned specially trained nurses who spent extra time with patients and families explaining prognoses and treatments. Control patients (n=331) received usual care. Patient preferences and surrogate's perception of those preferences at pre- and post-intervention interviews were compared.Agreement between patients and surrogates was 75.0% at the day 3 interview and 79.6% at the month 2 interview, increasing 4.6% (95% CI: 0.1%, 9.1%). Improvements in agreement from day 3 to month 2 were seen equally in both study groups. A multivariable analysis verified that the intervention did not have an effect on agreement and indicated a decrease in agreement among older patients and among surrogates not in the immediate family.The SUPPORT intervention was not successful in increasing agreement between patients and surrogates. Because of the complex issues involved in end-of-life decision-making, a more aggressive intervention may be needed. Other findings suggest that improvements in communication are particularly needed when patients are older and when the surrogate is not a patient's immediate relative.

To gain an understanding of the prevalence, utilization patterns, and practice implications of the use of Native American healers together with the use of physicians, we conducted semistructured interviews at an urban Indian Health Service clinic in Milwaukee, Wisc, of a convenience sample of 150 patients at least 18 years old. The mean age of patients was 40 years, and the sex distribution was 68.7% women and 31.3% men. Thirty tribal affiliations were represented, the largest groups being Ojibwa (20.7%), Oneida (20.0%), Chippewa (11.3%), and Menominee (8.0%). We measured the number of patients seeing healers and gathered information on the types of healers, the ceremonies used for healing, the reasons for seeing healers, and whether patients discuss with their physicians their use of healers. We found that 38.0% of the patients see a healer, and of those who do not, 86.0% would consider seeing one in the future. Most patients report seeing a healer for spiritual reasons. The most frequently visited healers were herbalists, spiritual healers, and medicine men. Sweat lodge ceremonies, spiritual healing, and herbal remedies were the most common treatments. More than a third of the patients seeing healers received different advice from their physicians and healers. The patients rate their healer's advice higher than their physician's advice 61.4% of the time. Only 14.8% of the patients seeing healers tell their physician about their use. We conclude that physicians should be aware that their Native American patients may be using alternative forms of treatment, and they should open a respectful and culturally sensitive dialogue about this use with their patients.

Practice guidelines were developed to improve medical outcomes and cost-effectiveness. The experiences of family physicians, who may need to use multiple guidelines in their practices, are crucial for effective development and implementation of practice guidelines. We surveyed a national sample of US family physicians about factors that affect their adoption and use of practice guidelines.We mailed a structured survey to a national random sample of 400 family physician members of the American Academy of Family Physicians.The response rate was 51%. Most respondents (69%) reported a positive attitude about practice guidelines, but only 44% reported using any guidelines. More younger physicians thought that guidelines could be useful tools. Most preferred guidelines that could be modified (87%) and that were no longer than two pages. Only 27% of respondents knew where to locate a guideline on a particular topic. Forty-three percent of respondents reported that it would be useful if guidelines were a component of an electronic medical record.If guidelines are to be used by practicing family physicians, a generalist perspective needs to be considered in future guideline development and implementation. Younger physicians had more positive attitudes toward guidelines.

Objective. To evaluate trends in length of hospital stay, hospital charges, and readmission rates of Wisconsin newborns from 1989 through 1994 in light of recent policies requiring earlier discharges after delivery of newborns.Methodology. Two data sources were used: 1) 1989–1994 Hospital Inpatient Discharge Data from the Wisconsin Office of Health Care Information, and 2) 1994 birth certificate and matched infant mortality data from the Wisconsin Center for Health Statistics. Average lengths of stay and average hospital (delivery and readmission) charges were calculated, and readmission rates were estimated for full-term, premature, and sick newborns.Results. There were 368 955 full-term and 26 668 premature newborns in Wisconsin from 1989 through 1994. The average length of stay decreased by 24% in full-term newborns from 1989 through 1994, while average hospital (delivery and readmission) charges rose over 40% during the same period. Average length of stay for premature infants increased by 24% while their hospital delivery charges increased 214% during the study period. Readmission rates halved, yet charges per readmission doubled for full-term infants. More than twice as many full-term newborns were classified as sick in 1994 (43%) compared with 1989 (19%).Conclusions. Managed care efforts to control costs of neonatal care through earlier newborn discharge policies may have limited impact. Physicians or hospitals may be compensating for these policies by classifying more newborns as sick, thereby allowing for longer hospital stays to be reimbursed by the insurance carriers. Premature infants

When patients are active participants in discussions, comprehension and compliance are likely to improve. This study examines the use of two interventions to aid patients in initiating such discussions in the area of health maintenance.The study was a randomized controlled trial of adult patients. The first intervention used two cards that listed seven core health maintenance concerns. The second intervention used a brief session with a nurse to help patients identify their health risks and develop a plan for seeking any desired information about these risks. An exit questionnaire and a telephone interview 4 to 6 weeks later assessed the extent to which (1) information seeking by patients was stimulated; (2) patients recalled the information obtained; (3) patients used the information to effect lifestyle changes; and (4) patients felt they participated in the decision to discuss health maintenance.Both interventions stimulated patients to request health maintenance information (both P.05); the second intervention significantly increased patient recall (P = .018). Neither intervention, however, had a significant impact on lifestyle change or sense of participation in the decision to initiate discussion. Analysis of the second intervention did show that both increasing patients' recall of information (P = .008) and sense of involvement in the decision to discuss health maintenance (P = .003) significantly increases the likelihood of lifestyle change.Two interventions have been developed that are relatively simple and inexpensive methods to stimulate patients to seek health maintenance, and quite probably other health-related information. The blunted impact of these two interventions, however, raises the question of whether such simple and relatively inexpensive interventions are strong enough to stimulate patients to use this information to initiate change when one seeks to address a wide range of risks.

This research studied the desire and attempts of cigarette smokers in Wisconsin to quit smoking. Data were based on the 1993 Wisconsin Division of Health's Behavioral Risk Factor Surveillance System (BRFSS). Among the 23% of respondents who were current smokers, 79% said they wanted to quit smoking and 60% said they had quit smoking for a day or more in the preceding year. High rates of wanting to quit and having tried to quit were found in all demographic subgroups of smokers studied. Compared to lighter smokers, heavy cigarette smokers (20 or more cigarettes per day) were less likely to have tried quitting in the past year, but were almost as likely to want to quit. These results demonstrate the great demand for smoking cessation services among smokers in Wisconsin and support for efforts to increase the use and effectiveness of these interventions.

Although numerous anecdotal reports are being offered about the growing number of unfilled faculty positions in US family medicine departments, virtually no literature exists on faculty recruitment. The objective of this study was to define the scope and nature of current faculty recruitment needs in family medicine.A national survey was sent to all family medicine department chairs and family practice residency program directors concerning faculty positions unfilled at their sites and positions for which recruitment would occur within the next 5 years. The survey asked for information on currently available positions; academic title of position; percentage of time to be devoted to clinical, educational, administrative, and research activities; primary focus of the position; date when the position became available; and the length of time the position has been unfilled. Similar information was collected on positions anticipated to be available within the next 5 years.A total of 364 surveys were returned, for an overall response rate of 70%. Information from the survey revealed a current, substantial demand for family medicine faculty throughout the country, with an even greater demand anticipated for the near future. Respondents reported 496 currently unfilled positions for family medicine faculty and another 677 positions anticipated to be available within the next 19.5 months on average. A total of 89.7% of those anticipated positions were reported as either "certain" or "somewhat certain," in terms of likelihood of availability.The demand for family medicine faculty is increasing, and much of the demand is financially motivated. Clinical expectations appear to be higher among departments than for residencies. Finally, it was revealed that most positions had minimal allotments for research time. Family medicine must recommit itself to the development of a scholarly agenda as it recruits new faculty.