Newborn hepatitis B immunization rates in primary care practices.

OBJECTIVES: To assess the hepatitis B immunization rate and to identify the reasons for an incomplete immunization series in newborns and infants seen in primary care practices. DESIGN: An inception cohort study enrolling newborns and infants and assessing their hepatitis B immunization status at 9 and 18 months of age. SETTING: Six primary care offices, most in rural environments. PATIENTS: All newborns and infants seen at 1 of 6 offices. INTERVENTION: Infants born between January 1, 1993, and September 30, 1994, were followed up through June 30, 1995. Hepatitis B immunization status and the reasons for an incomplete status were recorded at each visit. MAIN OUTCOME MEASURES: Hepatitis B immunization rates at 9 and 18 months of age, and the reasons for immunization failure. RESULTS: The immunization rates of infants aged 9 and 18 months were 60% and 77%, respectively. The most common reasons for inadequate immunization of the 247 infants followed up through age 18 months were patient transfer (7%), failing to return for a scheduled visit (4%), and guardians refusing the immunization (4%). Failure to return for a scheduled visit was the reason for the incomplete immunization in 13% of the 9-month-old infants. Immunization of these patients was the most important factor in the higher immunization rate at 18 months of age. By the age of 18 months, 95% of all infants had received at least 2 doses of the hepatitis B immunization. CONCLUSIONS: A hepatitis B newborn immunization rate of 77% by age 18 months was achieved in a primary care office setting. Barriers to complete immunization by the age of 18 months include patient transfer, patient failure to return, and parental refusal of immunization.

Relationships between endosonographic appearan e and clinical or manometric features in patients with achalasia.

BACKGROUND: The existence of endosonographic abnormalities of the oesophagus in achalasia is discussed. The place of endoscopic ultrasonography (EUS) needs to be clarified. PATIENTS: Thirty five untreated patients suffering from achalasia and 28 controls without oesophageal disease were prospectively enrolled since 1993. Pseudoachalasia was diagnosed in two patients. METHODS: EUS measurements were performed at two opposite sites at the level of the cardia, and 5 cm and 10 cm proximally, avoiding compression by the water filled balloon. RESULTS: The oesophageal wall and the fourth hypoechoic layer were significantly thicker at the level of the cardia and 5 cm above, with mean differences between patients and controls of 0.37/0.42 mm and 0.16/0.23 mm respectively. No statistically significant correlation could be demonstrated between the thickness of the oesophageal wall or of the fourth hypoechoic layer and weight loss, or the average pressure of the lower oesophageal sphincter. However, a significant inverse relationship was demonstrated between the duration of symptoms and the thickness of the fourth hypoechoic layer. The thickness of the fourth hypoechoic layer was also increased in patients who required only one pneumatic dilatation (P < 0.01). CONCLUSION: The thickness of the oesophageal wall and of the fourth hypoechoic layer appeared to be significantly increased in achalasia patients. However, the slight increase of the mean size (< 0.5 mm) of the muscularis propria suggests that EUS is not helpful in the diagnosis of achalasia. The physiopathological basis of advanced achalasia has to be reconsidered as we demonstrated an inverse relationship between the duration of symptoms and the thickness of the muscularis propria.

Physician extenders: who is using them?

BACKGROUND: Nurse practitioners and physician assistants (physician extenders) are playing an increased role in medical care. The purpose of this research was to determine the proportion of adults who have received health care from physician extenders. METHODS: This study used the subject population of the 1990 Kentucky Health Survey, a probability survey of all households in Kentucky. Study personnel contacted subjects using random digit telephone dialing. Subjects were then interviewed to ascertain whether subjects had received health care from physician extenders and whether they were satisfied with that care. RESULTS: Of 687 participating subjects, 25% had received care from physician extenders during the previous two years, primarily for minor problems and routine checkups. More than 90% of these subjects reported satisfaction with the care they received. Users of physician extenders did not differ from nonusers with respect to income, education, insurance status, self-assessment of health status, or rural versus urban location. Men used physician extenders more frequently than women. CONCLUSIONS: A substantial proportion of the population has used physician extenders. Patient satisfaction with physician extenders is high. Use of physician extenders may be an effective strategy for improving delivery of primary care.

Inflammation on the cervical Papanicolaou smear: the predictive value for infection in asymptomatic women.

BACKGROUND: The clinical significance of inflammation on the cervical Papanicolaou (Pap) smear of asymptomatic women is unknown. This study assessed the possible association between inflammation on Pap smears with the presence of cervical/vaginal pathogens. METHODS: A questionnaire was given to 290 asymptomatic women seen for routine gynecologic examination, including Pap smear, in a primary care setting. The women were tested for the presence of Candida species, Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonnorrhoeae, and Chlamydia trachomatis. RESULTS: Recovery of Chlamydia and Trichomonas was more frequent in women with inflammation on Pap smear than in women without inflammation, but the positive predictive value of inflammation was only 7% for Chlamydia and 14% for Trichomonas. Seventy-one percent of the women with inflammation had no evidence of any of the organisms. After a 6-month follow-up period, women with inflammation on Pap smear were no more likely than their matched counterparts without inflammation to return for a clinic visit with symptoms of vaginitis. CONCLUSIONS: In this study, inflammation on Pap smear had a relatively low predictive value for the presence of vaginal pathogens in asymptomatic women.

[Endoscopic retrograde cholangiopancreatography in children and adolescents]. / Cholangio-pancréatographie rétrograde endoscopique chez l'enfant et l'adolescent.

Nineteen children and adolescents, mean age 9.6 +/- 1.2 years, underwent endoscopic retrograde cholangiopancreatography (ERCP). Indications for ERCP were cholestasis in 11 cases, suspected pancreatic disease or trauma in 8 cases. Equipment and technique used for papilla catheterisation were similar to those routinely used in adults. Bile duct or pancreatic opacification were successfully obtained in all cases. Transient acute pancreatitis following the procedure was observed in one patient, and resolved spontaneously. ERCP confirmed diagnosis suspected after ultrasound study and abdominal CT scan in 9 patients. In the remaining 10 cases, diagnosis was only made by ERCP. Twelve patients were operated based on ERCP results. We conclude that ERCP is rarely performed in children, but remains as useful as in adults in biliary and pancreatic examination.

[Palliative treatment of esophageal neoplastic stenosis using bipolar electrocoagulation probe]. / Traitement palliatif des sténoses néoplasiques oesophagiennes par sonde d'électrocoagulation bipolaire (BICAP).

OBJECTIVE, PATIENTS AND METHODS: The objective of this study was to evaluate the results of palliative bipolar electrocoagulation probe (BICAP) treatment in 26 patients with non surgical, obstructive esophageal cancer. The mean tumor length was 7.2 cm. The strictures were located as follows: 3 in the cervical esophagus, 8 in the thoracic esophagus, 13 in the distal third of the esophagus and 2 involved both the cervical and thoracic esophagus. Most lesions were circumferential (73% versus 27% non circumferential) and exophytic (78% versus 22% sub mucosal). Coagulation was carried out under direct endoscopic control in the forward direction. The success of treatment was evaluated on the basis of the degree of reopening achieved (easy passage of an endoscope 12 mm in diameter) and good functional results (improvement of dysphagia, scored from 0 to 4 using a standard grading scale, for more than 15 days). RESULTS: Twenty-six patients underwent a total of 45 BICAP treatments (31 initial sessions, 14 repeated sessions). Reopening was achieved in 92% of cases and good functional results were obtained in 85% (mean dysphagia score: 3.2 before treatment versus 1.1 after treatment). The improvement of dysphagia resulted in a significant improvement of general performance status and stabilization or weight improvement in 21 patients. The mean number of sessions necessary for good initial results was 1.2 +/- 0.4. After the initial treatment by BICAP, radiotherapy or radiochemotherapy were respectively associated in 4 and 10 patients. The median duration of improvement was significantly longer in patients who underwent radiochemotherapy as compared with patients treated by BICAP alone (22 weeks versus 4 weeks). During the follow-up, 9 patients required several BICAP treatments and at the end of their disease, 12 patients underwent other palliative procedures. Major complications occurred in 4 cases (2 esotracheal fistulas, 1 hemorrhage, and 1 aspiration pneumonia) and mortality related to the procedure was 8%. CONCLUSIONS: Palliative BICAP treatment of obstructing esophageal and cardial cancer provide quick relief of dysphagia but repeated treatment sessions are necessary to maintain initial improvement. The procedure requires a short hospitalization stay and can be easily accomplished in all cases regardless of the tumor features.

Common chronic disease in Vietnam-era veterans and nonveterans.

Little research has been conducted investigating the general experience of military service during Vietnam and its long-term relation to common nonpsychiatric problems. The relationship between Vietnam-era veteran status and common chronic disease was examined using data from the 1987 National Health Interview Survey. Compared to a cohort of nonveterans, Vietnam-era veterans were not more likely to have common chronic disease. Moreover, veterans were not significantly more likely than nonveterans to have limitations in activity. The findings indicate that military service during the Vietnam conflict does not place veterans at greater risk for common chronic disease.

Carbamazepine. What physicians should know about its hematologic effects.

Transient leukopenia and, less commonly, neutropenia may occur with carbamazepine therapy. Discontinuation of therapy is usually not indicated unless symptoms are severe, persistent, or accompanied by infection. Patients with a low leukocyte or neutrophil count before treatment may be at increased risk for carbamazepine-induced leukopenia or neutropenia. Careful monitoring of blood counts, particularly during the first month of therapy, is essential. The frequency of monitoring can be determined on an individual basis. If a hematologic abnormality develops, the frequency of monitoring should be increased, especially if carbamazepine is not discontinued. Only when the neutrophil count falls below 500/mm3 does a severe risk of infection exist.

[Watermelon stomach: a rare cause of iron deficiency anemia, surgically treatable; a new case with review of the literature]. / L'estomac pastèque : une cause rare d'anémie ferriprive, de traitement chirurgical; un nouveau cas et revue de la littérature.

The authors report a new case of water-melon stomach, without portal hypertension, and responsible for a iron deficiency anemia cured by antrectomy. Water-melon stomach is a particular form of gastric antral vascular ectasia, characterized by a specific and striking endoscopic aspect. The diagnostic, histologic, pathogenic and therapeutic aspects are reviewed.

Diabetic ketoacidosis and pregnancy.

This paper describes the clinical course of a young diabetic primigravida who presented to her physician with vomiting and abdominal pain. Despite the conventional doses of intravenous fluid and insulin that were used to treat her suspected diabetic ketoacidosis, she remained severely acidotic and developed increasing abdominal pain. Two hundred twenty units of regular insulin over a 5-hour period were required to reverse the lipolysis, acidemia, and abdominal pain, which characterized her severe episode of diabetic ketoacidosis. This discussion emphasizes the importance of insulin in the reversal of the hyperglycemia and acidosis that accompany a diabetic crisis. The roles of bicarbonate, phosphorous, magnesium, insulin, potassium, and fluids are discussed along with conditions such as pregnancy, infection, pancreatitis, and abdominal pain, which can complicate the management of diabetic ketoacidosis.

Enoxaparin in the prevention of deep venous thrombosis.

Enoxaparin, a low-molecular-weigth heparin, has recently been approved for use in the prevention of deep venous thrombosis following elective hip replacement surgery. Clinical trials have demonstrated enoxaparin to be superior to placebo, dextran and unfractionated heparin in deep venous thrombosis prophylaxis. However, no published studies have compared the efficacy of enoxaparin with that of warfarin in the prevention of deep venous thrombosis. Advantages of enoxaparin include less frequent dosing, reduced need for laboratory monitoring and a lower incidence of adverse effects, including hemorrhage. Although enoxaparin is more expensive than unfractionated heparin, its potential benefits may offset its higher cost.

Patient and physician characteristics associated with perceived quality of care.

This study was undertaken to describe patient and physician sociodemographic characteristics that might be associated with the patient's perception of the quality of care rendered by his or her physician. A random telephone survey of 685 adult Kentucky residents showed that self-health assessment correlated positively, while patient education correlated negatively, with perceived quality of care. Perceived physician origin was related to the respondent's perceptions of quality of care, with native-born physicians perceived as supplying higher quality of care than their foreign-born counterparts. Cultural and communication issues might explain differences in perceived quality of care.

Pediatric admissions by family physicians and pediatricians in a semirural environment: implications for residency training.

BACKGROUND: The 3-year family practice residency curriculum includes longitudinal care of children in the family health center and a 4-month experience dedicated to the care of children. This study was designed to compare the diseases of hospitalized children cared for by family physicians and pediatricians and to examine the use of pediatricians as consultants by family physicians. METHODS: The study included all patients younger than 18 years who were discharged by a family physician or a pediatrician from this semirural hospital during a 3-year period. The primary discharge diagnosis, physician, consultations, and transfer status were recorded. RESULTS: Family physicians cared for 37 percent of the 4169 pediatric patients discharged during the study. Infectious diseases and their complications were the most common conditions for patients who were discharged beyond the newborn period. The 15 most frequent discharge diagnoses were identical for family physicians and pediatricians, accounting for about 86 percent of all discharge diagnoses. Pediatricians, however, cared for 86 percent of the newborns with major complications and were responsible for 80 percent of the infants and children who were transferred. The overall inpatient consultation rate of pediatricians by family physicians was 8 percent, whereas the consultation rate for nonneonatal-related discharges was 20 percent. CONCLUSION: In this semirural environment, family physicians and pediatricians care for a very similar mix of hospitalized pediatric patients. Pediatricians, however, care for a greater proportion of newborns with major complications.

Clinically significant drug interactions.

A large number of drugs are introduced every year, and new interactions between medications are increasingly reported. Consequently, it is no longer practical for physicians to rely on memory alone to avoid potential drug interactions. Multiple drug regimens carry the risk of adverse interactions. Precipitant drugs modify the object drug's absorption, distribution, metabolism, excretion or actual clinical effect. Nonsteroidal anti-inflammatory drugs, antibiotics and, in particular, rifampin are common precipitant drugs prescribed in primary care practice. Drugs with a narrow therapeutic range or low therapeutic index are more likely to be the objects for serious drug interactions. Object drugs in common use include warfarin, fluoroquinolones, antiepileptic drugs, oral contraceptives, cisapride and 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. Many other drugs, act as precipitants or objects, and a number of drugs act as both. Regularly updated manuals of drug interactions and CD-ROM-formatted programs are useful office references.

Chlormezanone-induced fulminant hepatitis in a pregnant woman: successful delivery and liver transplantation.

The case of a 29 year old woman affected by fulminant hepatitis during the third trimester of pregnancy, after a 3 week administration of chlormezanone is reported. Following induced Caesarean delivery, the patient underwent an orthotopic liver transplantation. The mother and her baby were in good condition 26 months after liver transplantation. In this case, chlormezanone was probably responsible for the fulminant hepatitis.