End-of-life decisions in HIV-positive patients: the role of spiritual beliefs.

OBJECTIVE: To describe the role of spiritual beliefs in HIV-positive patients' end-of-life decisions. DESIGN: Inperson, cross-sectional survey. SETTING: An HIV/AIDS floor of an urban, university teaching hospital. PATIENTS: Ninety hospitalized HIV-positive patients. MAIN OUTCOME MEASURES: Prior discussions about advance directives, possession of a living will (written advance directive), fear of death, professions of hope and purpose in life, religious beliefs and practices, guilt about HIV infection, and perception of HIV as punishment. RESULTS: Of 104 eligible patients, 90 agreed to be interviewed. Twenty-four per cent of patients had discussed their resuscitation status with a physician and 17% possessed a living will; 44% of patients felt guilty about their HIV infection, 32% expressed fear of death, and 26% felt their disease was some form of punishment. Prior discussions about resuscitation status were less likely in those who perceived HIV as punishment (P=0.009) and more likely in those who believed in God's forgiveness (P=0.043). A living will was more common in those who prayed daily (P=0.025) and in those whose belief in God helped them when thinking about death (P=0.065). Fear of death was more likely in those who perceived HIV as punishment (P=0.01) or felt guilty about having HIV (P=0.039), and less likely in those who read the Bible frequently (P=0.01) or attended church regularly (P=0.015). Outcome measures did not vary significantly according sex, race, HIV risk factors, or education level. CONCLUSIONS: In this HIV-positive population, spiritual beliefs and religious practices appeared to play a role in end-of-life decisions. Discussions about end-of-life decisions may be facilitated by a patient's belief in a forgiving God and impeded by a patient's interpretation of HIV infection as punishment. Health-care providers need to recognize patients' spiritual beliefs and incorporate them into discussions about terminal care.

Comparison of acute-phase reactants in pediatric patients with fever.

We compared WBC count greater than or equal to 15,000/cu mm (high WBC count). Wintrobe ESR greater than or equal to 30 mm/hr (high ESR), temperature greater than or equal to 40 degrees C, and positive slide tests for C-reactive protein (CRP) at a serum dilution of 1:50 in febrile, ambulatory children. The CRP test was performed with and without heat inactivation of serum. An excellent correlation was found between noninactivated and inactivated CRP test results. Since the noninactivated CRP test can be done quickly, its results would be readily available in an outpatient setting. High ESR demonstrated the best balance of specificity and sensitivity for bacteremia, pneumonia, and other possible or proved bacterial illnesses. A positive CRP test was highly specific for these diagnoses but less sensitive than an ERS greater than or equal to 30 mm/hr. Three combinations of acute-phase reactants, high WBC count and/or high ESR, high ESR and/or positive CRP test, and high WBC count and/or high ESR and/or positive CRP test performed as well as high ESR alone. Each was less specific but more sensitive than high ESR for possible or proved bacterial illnesses. The evaluation of an ambulatory, febrile child with acute-phase reactants should include at least determination of ESR.

Temperature greater than or equal to 40 C in children less than 24 months of age: a prospective study.

In a prospective study, 330 consecutive children less than 24 months old coming to the emergency room of Yale-New Haven Hospital with a temperature greater than or equal to 40 C were evaluated. Nearly all patients had a white blood cell (WBC) count, erythrocyte sedimentation rate (ESR) (Wintrobe), blood culture, and chest roentgenogram. Eighty-eight percent were evaluated 24 to 48 hours later. The mean WBC count and ESR were significantly elevated in children with positive blood cultures or pneumonia. The risk of bacteremia was increased threefold and the risk of pneumonia was increased twofold in children with a WBC count greater than or equal to 15,000/cu mm or an ESR greater than or equal to 30 mm/hr compared to children without leukocytosis or elevated ESR. Sixty-one percent of children with bacteremia or pneumonia. 63% of children in whom these diagnoses were not apparent on physical examination, and 86% of children with otitis media complicated by pneumonia or bacteremia had either a WBC count greater than or equal to 15,000/cu mm or an ESR greater than or equal to 30 mm/hr. A WBC count greater than or equal to 15,000/cu mm and an ESR greater than or equal to 30 mm/hr were more effective than a polymorphonuclear leukocyte count greater than or equal to 10,000/cu mm and/or a band count greater than or equal to 500/cu mm in screening young children with high fever for bacteremia, pneumonia, or complicated otitis media.

History and observation variables in assessing febrile children.

Attending pediatricians listed five history and eight observation variables on which they base their "instinctive" judgment (prior to performing a physical examination) of overall degree of illness of febrile children. Attending pediatricians and house staff observer pairs independently scored these variables in an overall assessment on 219 young, febrile children. The observation variable playfulness had the strongest correlation with overall assessment. Observer agreement in scoring the variables and overall assessment, while statistically significant, was only fair. When an attending pediatrician judged a child as moderately or severely ill on overall assessment, serious illnesses were four times as likely as when such a judgment was not made. When a house officer judged a child as moderately or severely ill, serious illnesses were less than twice as likely as when such a judgment was not made. However, only 57% of children with serious illnesses were judged by the attending pediatrician as moderately or severely ill on overall assessment. These data demonstrate the importance and limitations of "instinctive" clinical judgments about young, febrile children; the association between observation of complex behavioral patterns, especially playfulness, and overall assessment; and the need for further study of these complex behavioral patterns in order to define a reliable clinical approach to febrile children.

School-age mothers: predictors of long-term educational and economic outcomes.

The long-term effects of school-age pregnancy were investigated in a 20-year follow-up of a cohort of women who were pregnant adolescents in the late 1960s. Of the 149 living young black primiparas in the original cohort, 121 (81%) were located and interviewed. At follow-up the study population ranged in age from 32 to 38 years, 68% were unmarried, 71% had finished high school, 82% were completely self-supporting, and 27% reported living in public housing. Long-term success, defined as currently employed or supported by a spouse and a high school education (62%) or its equivalent, was associated with six features: having completed more school prior to becoming pregnant (odds ratio [OR] = 18; 95% confidence interval [CI] 2.3, 139.5); participating more actively in a program intervention offered to these pregnant teenagers 20 years ago (OR = 11.11; 95% CI 1.54, 79.87); being in school with no subsequent pregnancy at 26 months postpartum (OR = 10.1; 95% CI 1.64, 62.07); feeling in control of one's life (OR = 5.4; 95% CI 1.36, 21.54) and little social isolation (OR = 8.24; 95% CI 1.56, 43.50) at 26 months postpartum; and lifetime fertility control defined as one or two children after the index child (OR = 14.19; 95% CI 3.28, 61.29). It is concluded that most former teenage mothers complete a reasonable amount of education and are economically self-sufficient.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship between infant feeding and infectious illness: a prospective study of infants during the first year of life.

Prior studies investigating the relationship between infant feeding and infectious illnesses in developed countries have provided conflicting data about whether breast-feeding protects against common infectious illnesses early in life. These conflicts may in part be due to the failure to consider the following methodologic issues: (1) collecting data prospectively at frequent intervals for active surveillance of the detection of infections and of feeding practices, (2) specifying what is meant by infectious illnesses and breast-feeding, (3) controlling for confounding variables such as social class or presence of siblings in the household, and (4) applying appropriate analytical strategies to a population in which both feeding and exposure to illness change over time. A total of 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, were studied prospectively for the first 12 months of life by means of a detailed, monthly, mailed questionnaire that focused on feeding practices and illnesses (overall response rate, 73%). The percentage of infants who were completely or mostly breast-fed decreased from 88% at 1 month to 20% at 12 months of age. After adjustment for major covariates, no statistically significant relationship was found between the type of infant feeding and the incidence of four categories of infectious illnesses: gastroenteritis, upper respiratory illness, otitis media, and lower respiratory illness. The adjusted incidence density ratio for gastroenteritis was 1.067 (95% confidence interval = 0.982, 1.226) and for upper respiratory illnesses 0.984 (95% confidence interval = 0.883, 1.096).(ABSTRACT TRUNCATED AT 250 WORDS)

Further definition of history and observation variables in assessing febrile children.

The experienced clinician makes a judgment (hereafter called overall assessment [OA]) about the degree of illness of a febrile child prior to physical examination. In order to define the history and observation variables on which OA is based, 262 febrile children less than or equal to 24 months of age were evaluated simultaneously by multiple observers including attending pediatricians, practicing pediatricians, pediatric house officers, and nurses. The observer listed history and observation variables he/she thought most important in making an OA on a blank, lined form and then scored those variables and OA as normal, or mildly, moderately, or severely impaired. Scoring for observation rather than history variables was better correlated with scoring for OA and serious illness. The observation variables most frequently mentioned by all observers were the child's "looking at the observer" and "looking around the room." There were 20 observation variables frequently mentioned, the scoring of which significantly correlated with scoring for OA; four of these 20 variables related to eye function. The child's response to a stimulus was noted in 105/186 different observation variables listed; both the attending pediatrician and the house officer scored these stimulus-response variables significantly different in children with, vs those without, serious illnesses. For attending pediatricians, house officers, and nurses, serious illness was five to seven times as likely if an OA of moderate or severe impairment was made than if it were not made. OA is a key skill in evaluating febrile children; these data identify variables on which OA is based, document the importance of assessing eye function in young, febrile children, and demonstrate that eye function is one key type of stimulus-response behavior on which the pediatrician as clinician and developmentalist relies to make judgments about febrile children.

Comparison of frequencies of atrial fibrillation after coronary artery bypass grafting with and without the use of cardiopulmonary bypass.

This study compared the incidence of postoperative atrial fibrillation in a group of 34 patients undergoing coronary artery bypass graft surgery without the use of cardiopulmonary bypass and cardioplegia with a control group of 747 patients undergoing coronary artery bypass graft surgery using cardiopulmonary bypass and standard cardioplegia. A trend toward a lower incidence of postoperative atrial fibrillation was found in the group that underwent coronary artery bypass graft surgery without the use of cardiopulmonary bypass (n = 0.06).

Rainbow reviews. VII: Recent publications of the National Center for Health Statistics.

In this article, selected recent publications of the National Center for Health Statistics (NCHS) are reviewed. In particular, data from a recent NCHS report on hearing loss were found to be consistent with a prediction made in a preview article in this series that there would be an increase in high-tone hearing loss among persons who were exposed to loud music as teenagers and young adults, beginning in the late 1960s, although the data were not specific enough to be considered proof. In addition, the article discusses: (1) recent data on home health care, (2) new insights on how people remember and report on preventive examinations and tests, (3) a comparison of vital statistics in the United States and the Russian Federation, and (4) trends in births to unmarried women.

"Rainbow reviews." IV: Recent publications of the National Center for Health Statistics.

I am always impressed at the wealth of interesting and useful information available from the NCHS, if one knows where to look. The Center tries to adapt to the changing needs of the potential users of their data, including health planners and policy analysts, and academicians. This is illustrated by the increasing emphasis on medical care utilization, especially in long term care, on disease prevention and health promotion issues and on international comparisons. Clinical investigators should be familiar with the NCHS reports, if only to avoid duplication of effort. But beyond that, the information they present can be used to develop hypotheses, estimate variances for sample size determinations, and provide useful model instruments and methods. Beyond that, the NCHS does not analyze and report exhaustively on these data, if only because of lack of resources, so that it makes most of these data available for further research at a nominal charge. Many doctoral dissertations have been based on these tapes as the primary data source for detailed content analysis and/or for methodologic innovation.

The value and hazards of standardization in clinical epidemiologic research.

The statistical standardization of rates produces a single summary value that converts crude rates of occurrence into "standardized" rates that are adjusted for differences in the composition of compared populations. Although the process is well described in the epidemiologic literature and is regularly applied in comparisons of large populations, many investigators are not familiar with three important hazards that are magnified for the smaller groups studied in clinical epidemiologic research. This report contains a new "symmetrical" outline of the direct and indirect standardization processes, and an illustration of three pragmatic hazards: (1) Because the direct standardizing factor uses the observed stratum-specific rates, and because any stratum-specific rates that depend on small denominators may be misleading or unstable, the indirect method is preferred when the observed strata have small denominators. (2) Both the direct and indirect standardizing methods are highly vulnerable both to the choice of reference population and to the boundaries chosen when strata are demarcated or consolidated. The standardized rates can be altered dramatically according to differences in the stratum proportions of the reference population, or to distinctions produced when standardizing strata are consolidated. (3) If the stratum-specific rates and stratum proportions have different patterns of variation across the strata of the compared groups, the use of a single summary value--no matter what method of standardization is applied--may obscure cogent patterns of variation and significant differences in the stratum-specific rates. These hazards can be overcome if the studied group and the reference population are carefully compared for inconsistent variations in the stratum-specific rates and proportions before any standardizing procedure is applied. In many instances, the best approach may be to compare the unaltered stratum-specific rates, without standardization.

Infant feeding patterns during the first year of life in Denmark: factors associated with the discontinuation of breast-feeding.

We prospectively studied 500 infants born consecutively in a university-affiliated community hospital in Copenhagen, Denmark, over the first 12 months of life using a detailed monthly mailed questionnaire (overall response rate = 73%) which focused on feeding practices and illnesses. Seventy-seven percent of respondents breast-fed their infants at 1 month of life compared to 19% at 12 months of life. Analysis of breast-feeding behavior using survival analysis showed that 50% of the mothers who breast-fed since the first month of their infant's life were still breast-feeding at 7 months of life. Also, there was a greater than two-fold increase in the rate of discontinuation of breast-feeding for infants in daycare compared to infants not attending daycare (RR = 2.08, 95% CI = 1.43, 3.01). Discontinuation of breast-feeding was not significantly associated with the number of children in the family or with social class. These results give insight into infant feeding patterns in a developed country and suggest that: (1) breast-feeding is the dominant method of feeding during the infant's first year of life, and (2) the rate of discontinuation of breast-feeding is increased by the entry of these infants into daycare.

Influenza outbreaks in nursing homes: how effective is influenza vaccine in the institutionalized elderly?

During the 1984-1985 influenza season, outbreaks of influenza A (H3N2) occurred in three Connecticut nursing homes. Influenza vaccination rates were 67% (96 out of 144), 35% (30 out of 85) and 69% (332 out of 483), respectively. The relative risk of illness for vaccinated compared to unvaccinated residents was 1.8 (95% confidence interval, 0.6, 5.9), 1.6 (95% confidence interval, 0.8, 3.0) and 1.1 (95% confidence interval, 0.8, 1.7) for each of the three nursing homes, respectively. In the third outbreak, 22 vaccinated residents without clinical illness had a geometric mean titer of hemagglutination-inhibition (HI) antibody of 20. Although low, this titer was significantly higher than that of nine unvaccinated residents without clinical illness (12, p less than .05); only three (14%) vaccinated residents had HI titers of greater than or equal to 40. These results suggest that levels of HI antibody in vaccinated residents were not protective at the time of the third outbreak, four to five months after vaccination. In general, the study of vaccine effectiveness in nursing homes is limited by sample size and statistical power. Despite these limits, the retrospective investigation of influenza outbreaks in nursing homes is often the only practical way to evaluate influenza vaccine effectiveness in the elderly on a yearly basis.

Infection control practices in Connecticut's skilled nursing facilities.

Questionnaires were sent to all skilled nursing homes in Connecticut as part of a larger study of nosocomial infections, infection risks, and infection control programs. This article describes surveillance practices, isolation practices, control measures, and employee health activities of skilled nursing homes in Connecticut. The overwhelming majority of skilled nursing homes used written criteria to determine nosocomial infections, and all undertook surveillance; the majority did surveillance at least weekly and 21% did on a daily basis. The most frequent source of information for reporting infections were microbiology reports and information from the charge nurse. Three fourths of the skilled nursing homes stated that the responsibility of reporting communicable disease is that of the infection control practitioner. Two thirds of the skilled nursing homes stated that they had policies on the reporting of isolation practices, including the refusal or acceptance of patients with infections; 38% had residents under isolation precautions. Of all the patient care control measures, only that of changing urinary catheters on a routine basis was associated with facility size. More than 90% of facilities reported having an employee health program, but the benefit was limited.

Infection control practitioners and committees in skilled nursing facilities in Connecticut.

All skilled nursing facilities (SNFs) in Connecticut were surveyed and more than 71% responded to a Centers for Disease Control-funded project, a component of which is reported herein. The study describes the infection control practitioner (ICP), assistance provided ICPs from external sources, and infection control committees. Almost all ICPs received some training in infection control and worked in the field for an average of 3 1/2 years. Both the number of hours devoted to infection control and the percentage of time spent by the ICP on infection control activities increased with the size of the facility. More than one half of the ICPs in SNFs have relationships with hospital ICPs. The majority of SNF infection control committees met quarterly. The chairperson most often was a physician, although ICPs held this office in almost one third of the reporting SNFs. We conclude that ICPs in Connecticut SNFs have increased in number and that they devote more time and effort to infection control than in previous years.

Health risk behaviors and health perceptions in the Peruvian Amazon.

Behavioral health risk factor and health belief data for the indigenous population of the Peruvian Amazon are unavailable. Therefore, we conducted structured interviews of adults living in 5 towns in the remote Amazon region of Peru. Respondents (n = 179) were 67% women with a mean age of 35.4 years. The average household size was 6.7 people. A majority (72%) were unable to see a doctor when needed because of lack of money and distance. Only 6% reported excellent health, and nearly half (49%) reported fair health. Forty-eight percent drank alcohol and 73% smoked. Only 34% thought mosquitoes cause malaria, but 98% were using mosquito nets. In conclusion, our findings indicate the indigenous population of the Peruvian Amazon has limited access to basic health care. Although most of those surveyed use mosquito netting, few know that mosquitoes transmit malaria. Tobacco and alcohol use are major behavioral health risk factors.

An integrated residency in internal and preventive medicine.

The importance of preventive and population-based principles in clinical practice is widely acknowledged. The challenge of imparting these principles in either undergraduate or postgraduate medical education has, however, not been fully met. The necessary skills are provided comprehensively by preventive medicine residency programs, but at the expense of clinical training. Sequential residencies in primary care and preventive medicine, the currently available means of obtaining thorough preparation in both clinical and population-based principles, represent an inefficient, generally unappealing, and non-integrated approach. In response to these concerns, and in an effort to make preventive medicine training appeal to a wider audience, the authors developed and implemented a residency program fully integrating internal and preventive medicine. The program meets, and generally exceeds, the requirements of both specialty boards over a four-year period. The program provides extensive training in clinical, preventive, and public health skills, along with case management and cost-effective care, conferring the MPH degree and leading to dual board eligibility. The model is ideally wed to the demands of the modern health care environment in the United States, is extremely attractive to applicants, and may warrant replication both to train academic and administrative leaders and to raise the standards of preventive and public health practice in primary care.

Depression in former school-age mothers and community comparison subjects.

This paper examines the lifetime prevalence and correlates of major depressive disorder in a cohort of former school-age mothers and compares the prevalence and correlates to those found in women of the same age, ethnicity, and geographical location as the school-age mothers. The sociodemographic characteristics show some striking differences. The former young mothers were less likely to be on public assistance (19% vs 42%), but were more likely to be working (78% vs. 55%), to have completed high school or college and to meet the DSM-III criteria for depression (10.7% vs. 4.9%) than the sample of community women. The only factor related to depression in the former school-age mothers was a diagnosis of drug/alcohol abuse or dependence.

Dietary fat consumption in a cohort of American adults, 1985-1991: covariates, secular trends, and compliance with guidelines.

PURPOSE: To examine compliance with the guideline for dietary fat (i.e., 30% of total daily colonies) and covariates of fat intake in a cohort of adults using both 24-hour recall and food frequency questionnaire (FFQ). DESIGN: Prospective, observational cohort study over 5 years. SETTING: Community-based sample in Reno, Nevada. SUBJECTS: Equal numbers of male and female, lean and overweight adults (n = 508), recruited from 1985 to 1986, of whom 348 completed all relevant surveys. MEASURES: Subjects underwent repeated anthropometric measures and completed extensive surveys on diet, weight cycling, lifestyle, and physical activity. RESULTS: Mean fat intake by 24-hour recall declined from 36.9% to 33.6% of calories between years 1 and 5 (p < .001), while calorie intake increased (p = .2). As measured by FFQ at year 2, mean fat intake was 39.1% of calories, and only 11.8% of subjects were in compliance with the guideline for dietary fat intake. Fat intake by FFQ at year 2 was statistically higher than by 24-hour recall in year 1 for lean women (p = .02) and lean men (p = .02), but not for the overweight of either gender, and was significantly higher than the year 5 24-hour recall for all categories of gender and weight (p < .001). Calorie intake, gender, and body mass index were significant in regression models that explained less than 10% of total variability in fat intake (r2 = .08; p < .01). CONCLUSIONS: Compliance with the nationally recommended level of dietary fat intake was poor in this cohort, especially as measured by FFQ. Variability in fat intake was largely unexplained by host characteristics, including education. Further study is required to corroborate secular trends in population fat intake, elucidate the determinants of such intake, and identify cost-effective strategies for reducing the consumption of dietary fat.