An assessment of mood in males attending an infertility clinic.

This study was undertaken to assess the mood profile in men seeking treatment for infertility and also to investigate if aetiological factors of infertility have any impact on mood. This was a prospective questionnaire study and the setting was the Human Assisted Reproduction Ireland (H.A.R.I.) unit in the Rotunda Hospital. Fifty men participated in the study and were required to complete the Hospital Anxiety and Depression Scale (HADS) questionnaire. The results were analysed using an ordered logit regression analysis on the statistical software package DATA DESK 5.0.1. There were no cases of depression in the study population. However, detectable anxiety levels were displayed in 31.9% of men. Those with severe oligospermia had a higher mean anxiety score (8.5) compared with other patient subgroups. Clinically significant anxiety was found in 8.5%; all of these men had a male-factor problem. The study population was relatively small but some interesting trends were observed. A larger trial is warranted to assess if genuine at-risk groups exist.

Using hydrofluoroether solvents to replace HCFC-141b, Part II.

The use of hydrochlorofluocarbon (HFC) solvents is banned from the end of 2001. Part of this article assessed the merits of using hydrofluoroethers as replacement solvents. Alternatives to HFCs are more expensive. Part II looks at how to reduce the cost of conversion.

Does HIV reporting by name deter testing? MESH Study Group.

OBJECTIVE: Name-based HIV reporting is controversial in the United States because of concerns that it may deter high-risk persons from being tested. We sought to determine whether persons at risk of HIV infection knew their state's HIV reporting policy and whether they had delayed or avoided testing because of it. DESIGN: A cross-sectional anonymous survey. METHODS: We interviewed 2404 participants in one of three high-risk groups: men who have sex with men (MSM), heterosexuals attending a sexually transmitted disease (STD) clinic, and street-recruited injection drug users (IDU). Participants were asked standardized questions about their knowledge of reporting policies and reasons for having delayed or avoided testing. We recruited in eight US states: four with name-based reporting and four without; all offered anonymous testing at certain sites. RESULTS: Fewer than 25% correctly identified their state's HIV reporting policy. Over 50% stated they did not know whether their state used name-based reporting. Of the total, 480 participants (20%) had never been tested. Of these, 17% from states with name-based reporting selected concern about reporting as a reason for not testing compared with 14% from states without name-based reporting (P = 0.5). Comparing previously tested participants from states with name-based reporting to those from states without, concern about HIV reporting was given as a reason for delaying testing by 26% compared with 13% of IDU (P < 0.001), and for 26% compared with 19% of MSM (P = 0.06). CONCLUSION: Most participants did not know their state's HIV reporting policy. Name-based reporting policies were not associated with avoiding HIV testing because of worry about reporting, although they may have contributed to delays in testing among some IDU.

Multistate evaluation of anonymous HIV testing and access to medical care. Multistate Evaluation of Surveillance of HIV (MESH) Study Group.

CONTEXT: Infection with the human immunodeficiency virus (HIV) is the only infectious disease for which anonymous testing is publicly funded, an exception that has been controversial. OBJECTIVE: To assess whether anonymous HIV testing was associated with earlier HIV testing and HIV-related medical care than confidential HIV testing. DESIGN: Retrospective cohort. SETTING: Arizona, Colorado, Missouri, New Mexico, North Carolina, Oregon, and Texas. PARTICIPANTS: Probability sample of 835 new acquired immunodeficiency syndrome (AIDS) cases reported to the state health department's HIV/AIDS Reporting System from May 1995 through December 1996. All had responded to the AIDS Patient Survey; 643 had been tested confidentially for HIV, and 192 had been tested anonymously. MAIN OUTCOME MEASURES: First CD4+ cell count; number of days from HIV-positive test result to first HIV-related medical care, from first HIV-related medical care to AIDS, and from first HIV-positive test result to AIDS. RESULTS: Persons tested anonymously sought testing and medical care earlier in the course of HIV disease than did persons tested confidentially. Mean first CD4+ cell count was 0.427x 10(9)/L in persons tested anonymously vs 0.267x 10(9)/L in persons tested confidentially. Persons tested anonymously experienced an average of 918 days in HIV-related medical care before an AIDS diagnosis vs 531 days for persons tested confidentially. The mean time from learning they were HIV positive to the diagnosis of AIDS was 1246 days for persons tested anonymously vs 718 days for persons tested confidentially. After adjustment for the subject's age, sex, race/ethnicity, education, income, insurance status, HIV exposure group, whether the respondent had a regular source of care or symptoms at the time of the HIV test, and state residence, anonymous testing remained significantly associated with earlier entry into medical care (P<.001). CONCLUSION: Anonymous testing contributes to early HIV testing and medical care.

Assessment of left ventricular outflow in hypertrophic cardiomyopathy using anyplane and paraplane analysis of three-dimensional echocardiography.

This study analyzes the alterations in size and geometry of the left ventricular (LV) outflow tract that occur in hypertrophic cardiomyopathy (HC) using transthoracic 3-dimensional echocardiography. Transthoracic 3-dimensional echocardiography was performed in 17 patients with HC (4 after myectomy) and in 10 normal subjects. Images were acquired with the rotational approach, with electrocardiographic and respiratory gating. From the 3-dimensional datasets, short-axis parallel slicing of the LV outflow tract at a 1mm distance was performed at the onset of systole. For each slice, cross-sectional area and maximal and minimal diameter were calculated. Reconstruction of the LV outflow tract could be displayed in 3 dimensions in all patients, allowing orientation and clear definition of the irregular geometry. In patients with HC, the minimal LV outflow tract cross-sectional area was smaller than in normal subjects (2.3 +/- 1.0 vs 5.0 +/- 0.9 cm(2), p < 0.0001). The ratio between maximal and minimal cross-sectional areas was higher in patients with HC than in normal subjects (2.6 +/- 0.9 vs 1.4 +/- 0.2, p <0.0001). The ratio between maximal and minimal diameter of the smallest cross section of the LV outflow tract was also significantly higher in patients with HC than in normal subjects (1.6 +/- 0.3 vs, 1.2 +/- 0. 1, p <0.001); a value of 1.36 separated normal subjects from HC patients without previous myectomy. In conclusion, precordial 3-dimensional echocardiography allows detailed qualitative and quantitative information on the LV outflow tract. Patients with HC are characterized by a highly eccentric and asymmetric shape of the LV outflow tract, and by a smaller minimal cross-sectional area than that seen in normal subjects.

The role of black and Hispanic physicians in providing health care for underserved populations.

BACKGROUND: Patients who are members of minority groups may be more likely than others to consult physicians of the same race or ethnic group, but little is known about the relation between patients' race or ethnic group and the supply of physicians or the likelihood that minority-group physicians will care for poor or black and Hispanic patients. METHODS: We analyzed data on physicians' practice locations and the racial and ethnic makeup and socioeconomic status of communities in California in 1990. We also surveyed 718 primary care physicians from 51 California communities in 1993 to examine the relation between the physicians' race or ethnic group and the characteristics of the patients they served. RESULTS: Communities with high proportions of black and Hispanic residents were four times as likely as others to have a shortage of physicians, regardless of community income. Black physicians practiced in areas where the percentage of black residents was nearly five times as high, on average, as in areas where other physicians practiced. Hispanic physicians practiced in areas where the percentage of Hispanic residents was twice as high as in areas where other physicians practiced. After we controlled for the racial and ethnic makeup of the community, black physicians cared for significantly more black patients (absolute difference, 25 percentage points; P < 0.001) and Hispanic physicians for significantly more Hispanic patients (absolute difference, 21 percentage points; P < 0.001) than did other physicians. Black physicians cared for more patients covered by Medicaid (P = 0.001) and Hispanic physicians for more uninsured patients (P = 0.03) than did other physicians. CONCLUSIONS: Black and Hispanic physicians have a unique and important role in caring for poor, black, and Hispanic patients in California. Dismantling affirmative-action programs as is currently proposed, may threaten health care for both poor people and members of minority groups.

A combined urodynamic and continence unit--a review of the first 19 years.

We have completed a 19-year audit of all patients referred to the urodynamic/continence unit since its inception in 1972 and their subsequent clinical management; a total of 20,437 patients were referred, increasing from 51 in the first year to 1564 in 1990. Although the annual number of referrals has remained constant for the last 8 years, the need for more complex urodynamic assessment such as video-cystourethrography has increased from 5% (56/1164) in 1981 to 25% (385/1564) in 1990. The number of out-patient attendances to medical, physiotherapy and continence clinics has also increased over that period. We conclude that the number of referrals represents increasing recognition of the value of urodynamic assessment. Accurate diagnosis leads to more effective treatment, whether surgical, medical or conservative. Some methods of diagnosis are complex and suitable only for a tertiary referral centre.

Collecting data to evaluate the effect of health policies on vulnerable populations.

Public health policies often have disproportionate effects on the poor and other vulnerable groups. Standard survey techniques are often difficult to apply to these vulnerable populations, and many data bases systematically omit such individuals. The purpose of this paper is to review our experience in collecting primary survey data from public hospital, mentally ill, HIV-infected, and non-English-speaking patients. Important issues in conducting research on these populations include proper selection of subjects and comparison groups and difficulties involved in recruitment and enrollment of subjects. Maintaining longitudinal data on these populations is difficult and often requires tracking, secondary contacts, home visits and community outreach, and the use of organizations, institutions, and networks. Investigators must also pay careful attention to ethical issues involved in conducting research on vulnerable populations.

Prophylactic antibiotics at caesarean section do not reduce costs.

A prospective audit of 200 patients was undertaken to determine the effectiveness of prophylactic antibiotics at caesarean section in reducing the cost of postnatal care. The main outcome measures were the cost-effectiveness of this treatment in reducing the cost of care and incidence of infection. The results show that the routine administration of prophylactic antibiotics had no significant effect on infection rates, the prescribing of puerperal antibiotics or the duration of stay in the postnatal period. The total cost of antibiotics in the prophylaxis group was over four times that in the non-prophylaxis group. The results of this study suggest that routine administration of antibiotics at caesarean section does not reduce the costs of care in the puerperium.

CD4 lymphocyte count as an indicator of delay in seeking human immunodeficiency virus-related treatment.

BACKGROUND: As many as half of patients infected with the human immunodeficiency virus who are medically eligible for Pneumocystis prophylaxis and zidovudine treatment have not received these treatments. We used the CD4 lymphocyte count as an indicator of delay in seeking treatment among patients infected with human immunodeficiency virus and assessed whether insurance status was associated with the stage of illness when care is initiated. METHODS: Data from 96 patients who initiated medical care at a university acquired immunodeficiency syndrome clinic from August 1989 to January 1991 were retrospectively reviewed. RESULTS: Patients initiated care at a relatively late stage of illness (mean CD4 lymphocyte count, 0.37 x 10(9)/L [369/mm3]), and 29% were below the threshold for Pneumocystis prophylaxis. Patients with private insurance had significantly lower CD4 counts (mean, 0.27 x 10(9)/L) than did individuals with public insurance (mean, 0.46 x 10(9)/L). CD4 counts did not increase during the 18-month study period. CONCLUSIONS: The majority of patients infected with human immunodeficiency virus are eligible for medical therapy and could benefit by initiating care sooner. Private insurance was not associated with initiating early care, supporting anecdotal reports that some privately insured individuals may be reluctant to seek care for a human immunodeficiency virus-related condition.

Consequences of queuing for care at a public hospital emergency department.

OBJECTIVE: To determine whether the length of a queue at a public hospital emergency department was associated with increased likelihood of patients' leaving without being seen by a physician and whether leaving adversely affected patients' health or affected their subsequent use of health care services. DESIGN: Observational cohort. Patients were surveyed during 1 week in July 1990 and received a follow-up survey 7 to 14 days later. The responses of patients who left without being seen by a physician were compared with those who were seen by a physician. SETTING: Emergency department at San Francisco (Calif) General Hospital. PATIENTS: All English-, Spanish-, and Cantonese-speaking adults waiting for emergency care were eligible. Of 882 eligible individuals, 700 agreed to participate; 85% of enrolled subjects saw a physician and 15% left without being seen. Demographic characteristics of patients who were and who were not seen were not significantly different. MAIN OUTCOME MEASURES: Emergency department waiting time and changes in patients' self-reported health. RESULTS: Patients were more likely to leave as waiting times increased. At follow-up, patients who left without being seen were twice as likely as those who were seen to report that their pain or the seriousness of their problem was worse. Only 4% of patients who left required subsequent hospitalization, but 27% returned to an emergency department. CONCLUSION: Many patients can appropriately decide whether their problem is truly urgent and make alternative plans in the face of long waits, but the health of some patients may be jeopardized by long queues for emergency care.

Measuring health changes among severely ill patients. The floor phenomenon.

The interest in measuring health status with survey instruments has not been matched with an analysis of their performance characteristics in the field. We used the Medical Outcome Study Short Form (MOS-20) to assess health outcomes among patients who were hospitalized in one of two public hospitals. We mailed the MOS-20 and a series of transition questions, which asked about changes in health, to patients admitted in the previous year. We received 414 completed surveys from 480 patients at baseline and follow-up data on 90% of these patients six months later. Baseline MOS-20 scores for study patients were significantly lower, corresponding to worse health, than previously reported outpatient and general population cohorts. While the direction of change on serial applications of the MOS-20 paralleled the patients' perception of change reported on transition questions, many patients who reported their health had become worse also recorded the lowest possible score on the MOS-20 at baseline. These low baseline MOS-20 scores prohibited the recognition of larger declines in function during the follow-up period. This floor in the response range creates an instrument bias against documenting a decline in health among severely ill patients, the group in which it may be most important to detect such a change.

Correlates of certification in family medicine in the billing patterns of Ontario general practitioners.

There is conflicting evidence as to whether physicians who are certified in family medicine practise differently from their noncertified colleagues and what those differences are. We examined the extent to which certification in family medicine is associated with differences in the practice patterns of primary care physicians as reflected in their billing patterns. Billing data for 1986 were obtained from the Ontario Health Insurance Plan for 269 certified physicians and 375 noncertified physicians who had graduated from Ontario medical schools between 1972 and 1983 and who practised as general practitioners or family physicians in Ontario. As a group, certificants provided fewer services per patient and billed less per patient seen per month. They were more likely than noncertificants to include counselling, psychotherapy, prenatal and obstetric care, nonemergency hospital visits, surgical services and visits to chronic care facilities in their service mix and to bill in more service categories. Certificants billed more for prenatal and obstetric care, intermediate assessments, chronic care and nonemergency hospital visits and less for psychotherapy and after-hours services than noncertificants. Many of the differences detected suggest a practice style consistent with the objectives for training and certification in family medicine. However, whether the differences observed in our study and in previous studies are related more to self-selection of physicians for certification or to the types of educational experiences cannot be directly assessed.