Legacy and current pesticide residues in Syr Darya, Kazakhstan: Contamination status, seasonal variation and preliminary ecological risk assessment.

The Syr Darya is one of two major rivers in Central Asia supplying critical fresh water to the Aral Sea. In spite of the river's importance and agriculturally-intensive history, few studies have provided a modern evaluation of and the occurrence of pesticide residues potential effects to aquatic life. The primary goal of this investigation was to determine seasonal variations in ambient concentrations of modern and legacy pesticides in bottom sediment and water of the Syr Darya in Kazakhstan (KZ) downstream from an agriculturally-intensive watershed in Uzbekistan. Grab samples and passive samplers were used at five remote sampling stations during June 2015 to provide a baseline for ecotoxicological evaluation. Results were compared with samples collected during and after the agricultural growing season. Polar organic chemical integrative samplers (POCIS) were used in June and calibrated for time-weighted average concentrations of current use pesticides. Among legacy chlorinated pesticides measured in grab samples from the river, lindane (γ-HCH) was detected most frequently with the highest concentrations occurring during June. For all the sampling events, residues of lindane (γ-HCH) ranged from 0.014 to 0.24 µg/L detected in water samples, are among the highest concentrations reported for rivers globally. Concentrations of γ-HCH, p,p'-DDE and dieldrin were highest in October when dieldrin concentrations approached 0.4 µg/L. Sources of legacy pesticides may be either illicit upstream use or evidence of previous atmospheric contamination of glacial meltwater. Chronic exposure to these residues may lead to ecological risk to lower order organisms in both the sediment and water column.

Inpatient resource utilization, disease severity, mortality and insurance coverage for patients hospitalized for hepatitis C virus in the United States.

Although the incidence of new hepatitis C virus (HCV) infection has fallen, HCV-related complications are on the rise. Our aim was to assess and describe the 2005-2009 national inpatient mortality and resource utilization trends for patients with HCV. Data from the National Inpatient Sample (NIS) and the National Hospital Discharge Survey (NHDS) between 2005 and 2009 were analyzed. Included were all adult hospital discharges with HCV-related ICD-9 codes. Incremental hospital charge, in-hospital mortality and length of stay (LOS) were estimated using n = 1000 bootstrap replicates clustered by unique hospital identifier. A total of 123 939 (0.38%) discharges were related to HCV (primary or secondary diagnosis). In-hospital mortality increased from 1.7% (2005) to 2.6% (2009) (P < 0.001). Inflation-adjusted charges increased 2% annually from 2005 ($16 455 ± $570) to 2009 ($17 532 ± $1007, P = 0.029). This increase occurred despite the average LOS (5 days) and hospital costs ($6500) remaining stable while at the same time, hospital-to-hospital transfer admissions and disposition to home health care increased. HCV-related hepatocellular carcinoma predicted longer hospital stay and death; older age predicted death; and receiving more procedures predicted higher hospital costs. The percentage of patients with private insurance significantly decreased (4.7%), while government-sponsored insurance and uninsured increased by 2.5% and 2.1%, respectively (P < 0.05). Uninsured patients had a 49%-72% greater chance of dying during hospitalization than those with government-sponsored insurance. HCV-related inpatient mortality and resource utilization have increased. HCC was the largest predictor for mortality and resource utilization. These data are consistent with the rising clinical and societal burden of chronic hepatitis C in the United States.

Patients' preferences and health utility assessment with SF-6D and EQ-5D in patients with chronic hepatitis C treated with sofosbuvir regimens.

BACKGROUND: Health utilities measure patients' preferences for a health state. AIM: To assess health utilities for sofosbuvir-containing therapy for chronic hepatitis C. METHODS: The SF-6D utility scores were derived from the SF-36 instrument administered at baseline, during and post-treatment to participants of the previously reported clinical trials of sofosbuvir. EQ-5D utility scores were also approximated from the SF-36 using a regression model. RESULTS: Nine hundred and ninety-four patients were enrolled. Baseline SF-6D and EQ-5D scores were 0.66 ± 0.13 and 0.71 ± 0.22, respectively (the POSITRON trial), 0.71 ± 0.16 and 0.76 ± 0.23 (FISSION), 0.70 ± 0.14 and 0.75 ± 0.22 (FUSION), 0.72 ± 0.15 and 0.79 ± 0.22 (NEUTRINO). In all studies, SF-6D and EQ-5D scores were highly correlated with each other. (r = 0.83-0.87, P < 0.0001). After 12 weeks, patients receiving sofosbuvir + ribavirin (POSITRON) had similar utility scores to placebo (P > 0.05). Patients receiving 12 and 16 weeks of sofosbuvir + ribavirin (FUSION) had similar utility scores (P > 0.05). In FISSION, patients receiving sofosbuvir + ribavirin had significantly better utilities compared to patients receiving interferon + ribavirin (P < 0.001). Patients receiving sofosbuvir + ribavirin + interferon (NEUTRINO) had a decrease in utilities during treatment (SF-6D: from 0.72 to 0.62, EQ-5D: 0.79 to 0.65; P < 0.0001) similar to that observed in patients receiving pegylated interferon + ribavirin for 24 weeks in FISSION (0.72 to 0.62 and 0.77 to 0.65, respectively, P < 0.0001). After 12 weeks post-treatment, patients with SVR (FUSION) had improvement in SF-6D (+0.026 from baseline, P = 0.013) and EQ-5D (+0.043, P = 0.013). In multivariate analyses, baseline depression, anxiety, fatigue, insomnia and treatment-related anaemia were the most consistent predictors of utilities. CONCLUSIONS: Patients' health utilities are minimally impacted by sofosbuvir + ribavirin treatment, as compared to interferon-based, therapy regardless of treatment duration. Clinical trials' numbers: NCT01542788 (POSITRON), NCT01497366 (FISSION), NCT01604850 (FUSION), NCT01641640 (NEUTRINO).

The impact of chronic hepatitis C on resource utilisation and in-patient mortality for Medicare beneficiaries between 2005 and 2010.

BACKGROUND: As baby boomers age, chronic hepatitis C (CHC) will become increasingly important in Medicare eligible group. AIM: To evaluate trends in Medicare resource utilisation for CHC. METHODS: We analysed the Medicare in-patient and out-patient data from 2005 to 2010. For each patient, all claims with CHC as a principal diagnosis were added up and yearly CHC-related spending was calculated. RESULTS: A total of 48,880 out-patient claims for 21,655 CHC patients and 4884 hospital admission claims for 3092 patients were included. The number of in-patient (1.5-1.6/year) or out-patient (2.2-2.3/year) visits per patient did not change over time, nor did the demographic characteristics of the CHC population. The majority of this population was eligible for Medicare based on disability and the average number of diagnoses per in-patient claim (from 8.11 in 2005 to 8.60 in 2010) and per out-patient claim (from 2.18 in 2005 to 2.71 in 2010) increased (both P < 0.0001). The average total yearly spending per patient increased in the out-patient setting from $488 in 2005 to $584 in 2010 (P = 0.0132) and did not change in the in-patient setting (from $22,245 in 2005 to $23,383 in 2010, P = 0.14). In the multivariate analysis, the number of diagnoses and conditions per claim and the number of in-patient or out-patient procedures per year were the important independent predictors of increased resource utilisation. CONCLUSIONS: Most Medicare beneficiaries with chronic hepatitis C who sought in-patient or out-patient care in 2005-2010 had received Medicare for disability. Although the total resource utilisation did not change, the proportion of patient's responsibility increased.

The effect of socioeconomic status on treatment and pregnancy outcomes in women with epilepsy in Scotland.

Compared to the background population, people with epilepsy tend to have lower rates of education and employment, lower rates of marriage and childbearing, and lower overall socioeconomic status (SES). Disparities in epilepsy care based on sociodemographic factors have been observed in the literature, but it is not known whether any such disparities exist in the UK. The UK Epilepsy and Pregnancy Register is a prospective, observational, registration and follow-up study that was set up to determine the relative safety of all AEDs taken in pregnancy. Here, we report outcomes of registered pregnancies to women with epilepsy living in Scotland from December 1996 to June 2012, based on the degree of socioeconomic deprivation of their postcode area. The Scottish Index of Multiple Deprivation (SIMD) quintile scores from 2006 were used to determine degree of socioeconomic deprivation, and group 1 (most deprived) and group 5 (least deprived) were compared. There were 1526 pregnancies with complete outcome data to women living in Scotland. Of these, 1453 (95.1%) resulted in a live birth and 68 (4.7%) had a major congenital malformation (MCM). Postcodes could not be reliably identified or verified for an additional three women, who have been excluded from SIMD group analysis. Of all women included in this study, 32.4% were in group 1 and 13.2% in group 5. No difference in MCM rate was observed between the two groups (4.4% in group 1 compared to 4.7% in group 5, p=0.84). Women in group 5 were more likely to take preconceptual folic acid (56.8% compared to 14.0%, relative risk: 4.1; 95% CI: 3.1-5.2) and less likely to have generalized tonic-clonic seizures in pregnancy (13.0% compared to 29.2%, relative risk: 0.4; 95% CI: 0.3-0.7) than those in group 1. Women in group 5 were more likely to be on monotherapy regimens (80.2% compared to 65.9%, relative risk: 1.2; 95% CI: 1.1-1.3), less likely to be on valproate (19.5% compared to 28.0%, p=0.05), and more likely to be on lower doses of the drug (825.9mg/day compared to 1012.0mg/day, p=0.05) compared to those in group 1. Although no change in MCM rate was seen based on SES, differences in treatment between socioeconomic groups do exist, particularly for preconceptual folic acid consumption, AED regimen, and seizure frequency. Greater emphasis on the importance of preconceptual counseling, both to discuss AED choice and folic acid intake, would be of benefit, particularly to those living in areas of high socioeconomic deprivation, to improve equity of healthcare delivery for women with epilepsy in Scotland.

Results of the Cox-Maze III/IV procedure in patients over 75 years old who present for cardiac surgery with a history of atrial fibrillation.

AIM: Elderly patients with atrial fibrillation (AF) present a special challenge. Despite the documented advantage in ablating AF, the addition of the procedure may add complexity and potentially impact patient outcome. This study explored the impact of the Cox-Maze III/IV procedure on elderly patients experiencing AF who present for cardiac surgery. METHODS: Forty-four patients aged ≥ 75 with concomitant surgery underwent the Cox-Maze III/IV procedure for AF. These patients were followed using our extensive longitudinally designed registry to include health related quality of life (HRQL). Late death was captured by the Social Security Index and the National Death Index. RESULTS: The mean age for this sample was 79.5 ± 3 years and mean additive euroSCORE was 9 ± 2.1 (high risk). The majority of patients with the Cox-Maze procedure underwent concomitant valve surgery (N. = 41, 93%). There was a low incidence of STS measured perioperative outcomes in this group. NSR rates at six months were 90% (26/29) and 85% (23/27) at 12 months for the ablation group. There were no embolic strokes and major bleeding events occurred in only two patients. By Kaplan-Meier analysis, two-year cumulative survival was 89.6% and there was only one operative mortality in this group (2.3%). CONCLUSION: Addition of the Cox-Maze III/IV procedure in patients ≥ 75 years may add to the complexity of the surgical procedure, but does not increase the operative risk. Age should not be the only discriminating factor when considering the Cox-Maze III/IV procedure for patients aged ≥ 75 years who present for cardiac surgery while experiencing atrial fibrillation.

The definition of chronic lung disease in patients undergoing cardiac surgery: a comparison between the Society of Thoracic Surgeons and the American Thoracic Society/European Respiratory Society Classifications.

AIM: Early and late outcomes following cardiac surgery may be adversely affected in patients with chronic lung disease (CLD) and the presence of CLD is definition dependent. The purpose of this study was to compare the Society of Thoracic Surgeons (STS) definitions for CLD to the modified American Thoracic Society (ATS)/European Respiratory Society (ERS) definitions in diagnosing and classifying CLD among a cohort of cardiac surgery patients. METHODS: A prospectively-designed study whereby high risk patients for CLD presenting for non-emergent cardiac surgery and had a history of asthma, a 10 or more pack year history of smoking or a persistent cough were included. All patients underwent spirometry testing within two weeks of surgery. The presence and severity of CLD was coded two times: 1) STS definitions with spirometry; 2) ATS/ERS guidelines. The rate of misclassification was determined using concordance and discordance rates. Sensitivity analysis of the STS spirometry definitions was calculated against the ATS/ERS definitions and respective classifications. RESULTS: The discordant rate for the STS spirometry driven definitions versus the ATS/ERS definitions was 21%. Forty patients (21%) classified as no CLD by the STS spirometry definition were found to have CLD by the ATS/ERS definition. The STS classification had 68% sensitivity (84/124) when identifying any CLD and only 26% sensitivity (14/54) when identifying moderate CLD. CONCLUSION: The current STS spirometry driven definitions for CLD did not perform as well as the ATS/ERS definitions in diagnosing and classifying the degree of CLD. Consideration should be given to using the ATS/ERS definitions.

Current application of National Institute for Health and Clinical Excellence (NICE) guidance in the management of patients with severe psoriasis: a clinical audit against NICE guidance in seven National Health Service specialist dermatology units in England.

BACKGROUND: Psoriasis affects 1-2% of the U.K. population, with 20-30% of those affected having severe psoriasis managed with systemic therapies. Biological agents are a useful option when other systemic therapies have failed. The National Institute for Health and Clinical Excellence (NICE) in the U.K. has published three sets of guidance relating to the use of biological agents. AIM: To establish whether biological agents were being used in line with NICE guidance. METHODS: The study was conducted in seven specialist dermatology units, and involved the retrospective collection of data from patients treated with biological agents since the introduction of the NICE guidance. RESULTS: In total, 176 patients with 212 episodes of treatment were included in the study. Biologics were started for appropriately severe disease in 85% of cases (n = 180) and only after failure, intolerance or contraindication to standard systemic therapies in 97% of cases (n = 206). Etanercept was discontinued appropriately in responders before week 24 in only 12% (five of 60 responders). Across all agents, 40% (72 of 178 with continuity status) were continued on treatment despite not achieving an adequate response according to NICE criteria. CONCLUSIONS: In the seven sites audited, compliance with national guidance was entirely appropriate in terms of therapy initiation; however, the requirement to discontinue etanercept in responders was rarely followed. Similarly, discontinuation of biologicals in nonresponders was not routine practice. This may indicate a reluctance of both patients and clinicians to withdraw an at least partly effective therapy from these refractory patients.

Salary equity among male and female internists in Pennsylvania.

BACKGROUND: Women constitute an increasing proportion of physicians in the United States. Historically, inequities have existed between male and female physicians in professional advancement, but evidence has suggested that disparities in salary are resolving. OBJECTIVE: To examine the current state of salary equity among male and female internists. DESIGN: Population-based survey mailed to all Board-certified female internists and a matched group of male internists who had graduated from medical school 10 to 30 years ago and were currently practicing. SETTING: Pennsylvania. PARTICIPANTS: 232 male and 213 female internists for whom data were complete. MEASUREMENTS: Respondents answered questions about demographic characteristics, training, practice type and setting, status within the practice, family life, and salary. RESULTS: Women were more likely to be involved in the least lucrative practice arrangements. They were more likely to be in low-paying specialties, to not be a partner in the practice, and to be salaried employees; they also spent fewer hours per week seeing patients. Even after adjustment for these differences, hourly earnings were significantly higher (14%) among men than among their female colleagues. Men's earnings significantly exceeded women's earnings among physicians with no academic affiliation, those in high-earning specialties, and those in general internal medicine. CONCLUSIONS: Significant salary differentials exist between male and female internists overall and in various medical practice settings.

No evidence of linkage between the very-low-density lipoprotein receptor gene and fasting serum insulin or homeostasis model assessment insulin resistance index: the National Heart, Lung, and Blood Institute Family Heart Study.

A major gene effect on the fasting insulin level and insulin resistance has been suggested in previous studies. Several candidate genes for insulin resistance in rare syndromes have been proposed. However, there has been limited success in finding genes for common forms of insulin resistance. There is accumulating evidence of a relationship between insulin resistance and a disturbance of free fatty acid (FFA) metabolism. The very-low-density lipoprotein (VLDL) receptor, which is associated with FFA metabolism, could serve as a possible candidate gene for insulin resistance. We performed linkage analyses between the VLDL receptor gene and fasting insulin and the homeostasis model assessment (HOMA) insulin resistance index (fasting insulin x fasting glucose/22.5) in 1,050 sibpairs participating in the phase II physical examination of the National Heart, Lung, and Blood Institute Family Heart Study (FHS). Data analyses were completed using the SIBPAL component of the SAGE software package (SAGE, Statistical Analysis for Genetic Epidemiology, Version 3.1; Computer program package available from the Department of Epidemiology and Biostatistics, Case Western Reserve University, Cleveland, OH, 1997). We did not find evidence for linkage of the fasting insulin or the HOMA insulin resistance index with a polymorphic marker at the VLDL locus (P = .316 and .402, respectively). Adjustment of fasting insulin and the HOMA insulin resistance index for the body mass index (BMI) did not change the results (P = .319 and .472, respectively). In conclusion, no evidence was found for a linkage between a locus controlling the fasting insulin level or HOMA insulin resistance index and a VLDL polymorphism in the present study. Additional adjustment of fasting insulin or the HOMA insulin resistance index for the BMI did not change the linkage results significantly.

Current status of cardiac transplantation.

Cardiac transplantation, first introduced 30 years ago, has become a widely used and increasingly important procedure for treatment of truly end-stage heart disease. Current use is limited strictly by donor supply, making selection of appropriate recipients an important ethical and societal issue. Survival rates after transplantation rose in the 1980s with the use of cyclosporine and have remained relatively consistent since then, although recipients older than 65 years or younger than 1 year have lower survival rates than recipients of other ages. Although immunosuppressive drugs have helped establish cardiac transplantation as a successful procedure, risks of opportunistic infection and rejection, as well as coronary arteriopathy, have led to development of new immunosuppressive agents currently under study. Future alternatives to the current technology of cardiac allotransplantation may include xenotransplantation and/or nonbiological replacement of the heart with mechanical devices.

The problem of quality of life in medicine.

The use of the term "quality of life" to encompass the values and perceptions of patients has created doubt, confusion, and misunderstanding among practitioners, researchers, policymakers, and patients. The principal reason for this state of affairs is that a clear conceptual basis for quality-of-life measures is lacking. In this article, the current rationale for quality-of-life measurement in the health field is examined, and the drawbacks of the various models being used are outlined. Our suggestion is that quality of life as an outcome could be explored more clearly (ie, defined) if quality of life were replaced with a more easily handled notion such as that of "subjective health status." However, the idea that the patient's perspective is as valid as that of the clinician when it comes to evaluating outcomes has a great deal of legitimacy and should certainly not be abandoned.

Women's vital voices. The costs of exclusion in Eastern Europe.

PIP: In the newly independent states of Eastern Europe, the low status of women is hindering economic development and the transition to democracy. The transition from communism to capitalism has caused women to suffer from diminished labor market access, increased vulnerability to crime (including trafficking in women), loss of family-oriented social benefits, and exceedingly low representation in parliaments. These factors have combined to produce the striking feminization of poverty evident in many countries. Many countries also have not yet established laws and mechanisms to protect women from sexual harassment in employment, rape, or domestic violence. All of this ignores the fact that women create the essential social elements of political stability and fuel economies because they are reliable employees and innovative entrepreneurs. In response, women have formed new alliances, (including some that reached across enemy lines in Bosnia) and scores of nongovernmental organizations. The US has responded by taking actions that focus on women's economic enterprises, such as directing management training to women farmers in Albania and Russia and advocating the creation of microcredit schemes for women. The US is also supporting efforts to harmonize national and international policies and legislation to stop trafficking in women and is taking steps to support and develop women leaders in the region. It is in the best interest of the US to magnify the voices of women who are echoing US values in postcommunist Europe.^ieng

Marketing midwifery education: findings from a survey.

OBJECTIVE: to collect information from a sample of identified customers (midwives and midwifery managers employed by health authorities and trusts) in order to develop a marketing strategy for a Department of Nursing, Midwifery and Health Care. DESIGN: two descriptive and analytical surveys using questionnaires. SETTING: mid- and west Wales, UK. SUBJECTS: randomly selected sample of 75 midwives and census sample of eight midwifery managers working within the National Health Service. MEASUREMENTS AND FINDINGS: quantitative and qualitative data collection methods. KEY CONCLUSIONS: organisations have to define, and listen carefully, to their customers and offer courses which are appropriate, related to clinical midwifery practice and have titles that accurately reflect the content. Midwives are enthusiastically committed to continuing education despite the current difficulties. Word of mouth and personal recommendation remains the most effective form of advertising. University departments of nursing and midwifery can easily become removed from clinical practice. Education assists practitioners in changing and adapting to a new order; it is also crucial in developing skills in critical thinking and analysis. New skills are needed if practice is to improve. IMPLICATIONS FOR PRACTICE: academic departments can easily become remote and out of touch with the needs of clinicians and midwifery managers. Departments must take steps to define the customer, listen carefully to what they want and make every effort to provide continuing education for midwives that is relevant, responsive, accessible and attainable. The benefits of education also must be marketed.

Housing conditions and mental health in a disadvantaged area in Scotland.

OBJECTIVE: To examine the mental health impact of different aspects of poor housing. DESIGN: This was a post hoc analysis of data from a household interview survey. SETTING: A public sector housing estate on the outskirts of Glasgow. SUBJECTS: These comprised 114 men and 333 women aged between 17 and 65 from 451 households. MEASURES: Dependent variable: scoring > or = 5 on the 30 item general health questionnaire (GHQ30). INDEPENDENT VARIABLES: self reported data on household composition, whether ill health was a factor in the move to the current dwelling, length of time at address, household income, whether the respondent was employed, chronic illness, and 6 problems with the dwelling. RESULTS: Reporting a problem with dampness was significantly and independently associated with scores of > or = 5 on the GHQ30 after controlling for possible confounding variables. CONCLUSION: Initiatives to tackle housing dampness may be important in developing a strategy to improve mental health for the study area. More research on the mental health impact of different aspects of poor housing is required.

Risk adjustment: the missing piece of market competition.

This DataWatch describes the process adopted by The Health Insurance Plan of California (The HIPC) for assessing and adjusting for health risk differences among participating health plans. We also report on the results of the 1996 risk assessment/adjustment calculations. A risk assessment value is calculated for each health plan based on the plan's enrollee mix as compared with the mix of enrollees in The HIPC as a whole. The results indicated that approximately 1 percent of total premium dollars needs to be transferred to bring all health plan scores within the acceptable level (+/- 5 percent) of risk distribution.

Heart retransplantation: the 25-year experience at a single institution.

BACKGROUND: The current critical shortage of cardiac allograft donors means that the decision to offer a patient repeat heart transplantation must be carefully considered. Since 1968, a total of 66 heart retransplantation procedures (63 first-time and three second-time) have been performed in 63 patients at Stanford. METHODS: There were 52 male and 11 female patients, ranging in age from 3 to 62 years with a mean age of 41 years. Indications for retransplantation were primary allograft failure in nine patients, acute rejection in 17, graft atherosclerosis in 37, and constrictive disease in three. Six of the seventeen patients (35%) who underwent retransplantation before 1981 died in the hospital, and none are currently alive. Of the 46 patients who underwent retransplantation since 1981 treated with cyclosporine-based immunosuppression, 11 (24%) died in the hospital. Actuarial survival estimates for the whole retransplantation group at 1, 5, and 10 years were 55% +/- 8%, 33% +/- 8%, and 22% +/- 7%, respectively. RESULTS: This survival was significantly worse (p < 0.05) than that in patients undergoing primary heart transplantation (81% +/- 2%, 62% +/- 2%, 44% +/- 13% at 1, 5, and 10 years). Those patients who underwent retransplantation for graft atherosclerosis since 1981 had a significantly better 1-year survival (p < 0.05) than those who underwent retransplantation for allograft rejection (69% +/- 10% versus 33% +/- 16%), but the 5-year survival was similar in both groups (34% +/- 11% versus 33% +/- 16%). Since 1981, actuarial freedoms from infection and rejection were 22% +/- 8% and 41% +/- 9%, respectively, at 1 year, and 7% +/- 7% and 36% +/- 9% at 5 years. Patients with cyclosporine-induced renal dysfunction (serum creatinine level of greater than 2.0 mg/dl) had a high probability of requiring postoperative dialysis and also of death after retransplantation. Three patients with significant cyclosporine-induced renal dysfunction underwent simultaneous kidney transplantation and heart retransplantation, and all were alive and well at the time this article was written. Sixteen patients were also currently alive at a mean follow-up of 44 months, and 15 were in New York Heart Association functional class I. CONCLUSIONS: We continue to list carefully selected candidates with good rehabilitation potential for heart retransplantation.

Information needs of health care professionals in an AIDS outpatient clinic as determined by chart review.

OBJECTIVE: To examine the information needs of health care professionals in HIV-related clinical encounters, and to determine the suitability of existing information sources to address those needs. SETTING: HIV outpatient clinic. PARTICIPANTS: Seven health care professionals with diverse training and patient care involvement. METHODS: Based on patient charts describing 120 patient encounters, participants generated 266 clinical questions. Printed and on-line information sources were used to answer questions in two phases: using commonly available sources and using all available medical library sources. MEASUREMENTS: The questions were divided into 16 categories by subject. The number of questions answered, their categories, the information source(s) providing answers, and the time required to answer questions were recorded for each phase. RESULTS: Each participant generated an average of 3.8 clinical questions per chart. Five categories accounted for almost 75% of all questions; the treatment protocols/regimens category was most frequent (24%). A total of 245 questions (92%) were answered, requiring an average of 15 minutes per question. Most (87%) of the questions were answered via electronic sources, even though paper sources were consulted first. CONCLUSIONS: The participating professionals showed considerable information needs. A combination of on-line and paper sources was necessary to provide the answers. The study suggests that present-day information sources are not entirely satisfactory for answering clinical questions generated by examining charts of HIV-infected patients.