Family physician attitudes about HIV screening.

This study examined why and for whom family physicians are likely to require HIV screening according to general policies or procedures, based on a national survey of 2,660 family practice physicians. Of those contacted, 1,678 responded, yielding a response rate of 63.7%. The study also examined whether attitudes toward screening differed for physicians in different types of practices, of varying educational backgrounds, and with differing opinions regarding treating persons with AIDS (PWAs). The results showed that required screening was most strongly endorsed for pregnant women who had other risk factors and for i.v. drug users. Those physicians who most favored mandatory screening were also most likely to favor the mandatory reporting of AIDS cases to public health officials. They also had the least formal medical training (were not residency trained or board certified) and expressed the greatest apprehension regarding their own and their staff's preparedness and willingness to treat PWAs. A major implication of the findings is that family physicians and others who do mandatory testing should be provided opportunities, through residency training, board-certification preparation, or continuing medical education, to learn how to care for those patients they test who turn out to be seropositive.

The patient with gonococcal infection.

Despite the availability of effective antimicrobial therapy since the middle of the twentieth century, gonococcal disease remains a common and expensive public health problem. The patient who presents to the primary care office with gonococcal disease, or one who is found to be infected after screening, still faces significant emotional and economic barriers to effective treatment and control of the spread of the disease. Along with the emergence of resistant strains and the previously existing problems of asymptomatic carriers and reluctance to seek treatment, physicians are charged with the problems of identifying patients at risk for the disease, providing effective treatment for those infected, and preventing further spread of infection. Simple, effective, and inexpensive therapies that also treat the frequently present coinfections with other sexually transmitted diseases are not yet available. Antibiotic therapy must still be chosen with regard to the patient's history and circumstances. The approach to counseling the patient about avoidance of complications, prevention of reinfection, and prevention of transmission of infection must be mastered by the primary care physician if progress is to be made toward the eradication of gonococcal disease.

The globus syndrome: value of flexible endoscopy of the upper gastrointestinal tract.

Flexible endoscopy of the upper gastrointestinal tract usually does not form part of the primary diagnostic evaluation of the globus syndrome. In a prospective trial, a flexible endoscopy was performed in 51 globus patients with normal results of the laryngologic and radiographic examination. Pathologic findings requiring therapy were diagnosed in 70.6 per cent of cases. The most frequent findings were reflux oesophagitis (n = 24; 47 per cent) and hiatal hernia (n = 25; 49 per cent). In 16 cases (31.4 per cent) these were accompanied by other pathologic lesions. A total of 32 patients (62.7 per cent) suffered from oesophageal diseases as sole aetiologic factors of the globus syndrome, which led us to postulate a causative relationship in these cases. Flexible endoscopy therefore can contribute significantly to the differential diagnosis of the globus syndrome. It must be kept in mind, however, that there is a 'blind zone' for endoscopic assessment in a region of the hypopharynx, thus some indications may require rigid endoscopy.

Senile dementia of the Binswanger's type.

Senile dementia of the Binswanger's type is a term used to describe a dementia syndrome characterized by onset in the sixth or seventh decade of life, subcortical neurologic deficits, psychiatric disorders and evidence of hypertension or systemic vascular disease. The status of senile dementia of the Binswanger's type as a distinct entity is a matter of some controversy. The array of neuroimaging abnormalities and clinical findings attributed to this condition overlap with a number of other neuropathologies. Leukoaraiosis, or attenuation of subcortical white matter, seen on computed tomographic scans or magnetic resonance imaging of the brain, is a hallmark of senile dementia of the Binswanger's type. The clinical findings associated with Binswanger's disease are varied but typically include a progressive dementia, depression and "subcortical" dysfunction such as gait abnormalities, rigidity and neurogenic bladder. Treatment is largely supportive and includes a discussion about advanced directives, social support and antidepressant therapy. Control of hypertension and aspirin prophylaxis may help prevent further progression of white matter disease.

Managing pain in the dying patient.

End-of-life care can be a challenge requiring the full range of a family physician's skills. Significant pain is common but is often undertreated despite available medications and technology. Starting with an appropriate assessment and following recommended guidelines on the use of analgesics, family physicians can achieve successful pain relief in nearly 90 percent of dying patients. Physicians must overcome their own fears about using narcotics and allay similar fears in patients, families and communities. Drugs such as corticosteroids, antidepressants and anticonvulsants can also help to alleviate pain. Anticonvulsants can be especially useful in relieving neuropathic pain. Side effects of pain medications should be anticipated and treated promptly, but good pain control should be maintained. The physical, psychologic, social and spiritual needs of dying patients are best managed with a team approach. Home visits can provide comfort and facilitate the doctor-patient relationship at the end of life.

Management of dyslipidemia in adults.

The importance of treating dyslipidemias based on cardiovascular risk factors is highlighted by the National Cholesterol Education Program guidelines. The first step in evaluation is to exclude secondary causes of hyperlipidemia. Assessment of the patient's risk for coronary heart disease helps determine which treatment should be initiated and how often lipid analysis should be performed. For primary prevention of coronary heart disease, the treatment goal is to achieve a low-density lipoprotein (LDL) cholesterol level of less than 160 mg per dL (4.15 mmol per L) in patients with only one risk factor. The target LDL level in patients with two or more risk factors is 130 mg per dL (3.35 mmol per L) or less. For patients with documented coronary heart disease, the LDL cholesterol level should be reduced to less than 100 mg per dL (2.60 mmol per L). A step II diet, in which the total fat content is less than 30 percent of total calories and saturated fat is 8 to 10 percent of total calories, may help reduce LDL cholesterol levels to the target range in some patients. A high-fiber diet is also therapeutic. The most commonly used options for pharmacologic treatment of dyslipidemia include bile acid-binding resins, HMG-CoA reductase inhibitors, nicotinic acid and fibric acid derivatives. Other possibilities in selected cases are estrogen replacement therapy, plasmapheresis and even surgery in severe, refractory cases.

To report or not to report. Physicians' attitudes toward discipline and child abuse.

Interviews were conducted with 58 physicians to ascertain what factors influenced their reporting of child abuse. When physicians were presented with sample cases of injured children, factors that influenced their decision to report suspected abuse included their attitudes toward physical discipline, seriousness of the injury, presence of other injuries, their familiarity with the family, appropriate parental concern, compatibility of the history and physical examination findings, and the child's behavior. Results indicated that inappropriate discipline was usually not equated with reportable child abuse. Physicians believed that abuse is not often reported because of its low incidence in the private practice setting, the fear of losing patients, the need for certainty, and the lack of confidence in community agencies. These beliefs may conflict with the welfare of young patients.