Occupational Characteristics and Patterns as Risk Factors for Parkinson's Disease: A Case Control Study.

BACKGROUND: Associations have been reported between the risk of Parkinson's disease (PD) and employment in certain fields. Most studies have focused on toxic exposures as potential causal explanations. However, PD also has been associated with personality characteristics that may influence occupational choices and patterns. OBJECTIVE: This study evaluates the role of personality as indicated by occupational choices and employment patterns in the risk for PD. METHODS: In-person interviews were conducted to assess occupational histories and early-adult personality indicators among 89 PD patients and 99 controls. RESULTS: PD cases had fewer lifetime jobs than controls (mean for cases = 4.38 ± 2.20; mean for controls = 5.00 ± 2.26; p = 0.03). Among women, PD was positively associated with more complex work with people (OR = 1.45, 95% CI 1.12-1.89), representing a 95% increased risk for PD comparing women with the greatest complexity of work with those requiring the least complexity of work with people. Women PD cases also performed less complex work with things compared with controls (OR = 0.69 (95% CI 0.53-0.90)), translating into a 13-fold increased risk for PD among women whose work involved the least complex work with things compared with the most. The numbers of jobs and job types were associated with taking more activity risks as a young-adult (r = 0.19, p = 0.02; r = 0.26, p = 0.001, respectively). CONCLUSIONS: Cases with PD held fewer lifetime jobs compared with controls. Occupational complexity was associated with the risk for PD among women, but not men. Further consideration of the possible influence of personality on occupational choices is warranted.

Compliance with recommendations for lipid management among patients with type 2 diabetes in an academic family practice.

BACKGROUND: Lipid abnormalities are twice as common in patients with type 2 diabetes, and this contributes substantially to their increased risk of cardiac disease. The American Diabetic Association (ADA) has defined treatment goals for high-density lipoprotein (HDL) cholesterol (>45 mg/dL), triglyceride (<200 mg/dL), and low-density lipoprotein (LDL) cholesterol (<100 mg/dL). It is unknown, however, how frequently patients with diabetes managed in primary care settings are able to attain these treatment goals. METHODS: We randomly selected 239 patients with type 2 diabetes and conducted a chart review to determine whether patients had attained ADA lipid goals. We examined clinical predictors of goal attainment using logistic regression. RESULTS: The number and percentage of patients who had attained ADA lipid goals was as follows: HDL cholesterol, 87 of 207 (42.0%); LDL cholesterol, 93 of 208 (47.0%); and triglyceride, 142 of 206 (70.0%). Only 30 of 206 (14.6%) patients had achieved all 3 lipid goals. Three groups of patients with diabetes had greater odds of achieving the LDL treatment goal: men, patients taking a lipid-lowering drug, and patients with hypertension. Patients with diabetes had greater odds of achieving the HDL goal if they were female, were black, or if they had lower values for body mass index and triglyceride. The odds of achieving the triglyceride goal were greater for men, for patients having Medicare insurance supplemented by private insurance, and for those with increasing values of HDL. CONCLUSION: We found that the majority of patients with diabetes failed to attain lipid goals set forth by the American Diabetes Association. Further study is needed in larger populations to confirm these findings, and if confirmed, to determine the reasons that patients fail to achieve lipid goals.

Prevalence of patients with type 2 diabetes mellitus reaching the American Diabetes Association's target guidelines in a university primary care setting.

BACKGROUND: The success with which primary care physicians are able to meet American Diabetes Association (ADA) clinical goals is unknown. METHODS: Charts of 218 randomly sampled type 2 diabetic patients were abstracted to assess the attainment of six ADA treatment goals and receipt of four ADA-recommended health services. RESULTS: The mean number of ADA goals attained was 4.9 (SD, 1.6). Only one patient had attained all 10 goals. Most patients had attained ADA goals for triglycerides, diastolic blood pressure, hemoglobin A1c, low-density lipoprotein cholesterol, and diabetic education. Most patients had not received an annual eye examination or urine microalbuminuria screening, most were not taking daily aspirin, and most had not attained treatment goals for high-density lipoprotein or systolic blood pressure. CONCLUSION: ADA treatment goals may be quite difficult to attain in the primary care setting. Further studies are needed to understand the barriers to diabetes control.

Evidence of gender bias in patients undergoing flexible sigmoidoscopy.

Some studies have revealed gender bias against women in various aspects of medical care. There is no substantial evidence of gender bias in patients undergoing cancer evaluations, specifically colorectal cancer screening and diagnosis of colorectal complaints. This study was designed to examine the role of gender bias related to patients undergoing flexible sigmoidoscopy. At the University of South Florida, we conducted a retrospective study of 1910 patients at three distinct flexible sigmoidoscopy clinics over several years, through 1992. The proportions of male and female patients who underwent the procedure for indications of either screening for colorectal cancer or the diagnosis of colorectal complaints were determined. These proportions were compared with the respective male and female patient proportion from the total number of currently active patients at each site who were eligible to have the procedure for an appropriate indication. At all three sites, a significantly smaller proportion of women (p < 0.01) underwent the procedure than expected. This was true for both screening and diagnostic indications. Conversely, at all sites significantly more men (p < 0.01) underwent the procedure for both indications. The results of this study suggest gender bias against women for patients undergoing flexible sigmoidoscopy for both screening and diagnosis. This bias may adversely affect the lethality of colorectal cancer in women. It is important to determine if such biases are influenced by the physician's recommendation or mainly due to patient attitudes.

Treatment options for early Parkinson's disease.

Proper treatment of tremor in any clinical setting depends on correct diagnosis. Essential, or familial, tremor is symptomatic with movement and involves the limbs, head and voice. Parkinson's disease tremor occurs at rest, involves the jaw and limbs and is associated with bradykinesia, rigidity and falling. Parkinson's disease is treated with a number of medications, but levodopa, a dopamine precursor, is considered most effective. Other therapies in the early stages of Parkinson's disease may include neuroprotective agents, dopamine agonists, dopamine reuptake inhibitors, anticholinergics and/or amantadine. Polypharmacy is often necessary to minimize or avoid drug side effects.

The disclosure of the diagnosis of cancer.

Before significant efforts relative to patient education and subsequent informed decision making can occur, it is essential to assess the patient's perceptions and emotional responses to the diagnosis. The direction and depth of this exploration are likely to be determined by such factors as quality of the previous relationship with the patient, the patient's belief and support system, and the patient's previous experience with trauma. Other determining factors are the sense of urgency with which medical decisions need to be made and the interpersonal skills of the physician. It is important at the time of diagnosis to understand and respond to the patient's cognitive and emotional responses to the diagnosis. The sensitive physician allows time to acknowledge and legitimate those responses. It is often important to allow the ventilation of those reactions before further education and decision making can occur. By accepting and acknowledging the patient's reactions, the physician can reduce the patient's feelings of isolation and helplessness. The quality of such a relationship then becomes the foundation on which the patient and family and physician can begin to attend to the issues before them.

Barriers to screening among participants of a media-promoted breast cancer screening project.

Breast cancer detection and awareness projects have been implemented nationwide in an attempt to increase compliance with screening mammography. Previous studies, however, showed that the elderly, minorities, and women of lower socioeconomic status fail to respond in representative numbers. A cross-sectional analysis of 6640 participants of a Breast Cancer Detection and Awareness Project in Tampa, FL, was conducted to determine if barriers and motivations to screening differed among targeted (the elderly, minorities, women of lower socioeconomic status) and nontargeted groups. Targeted demographic groups reported far more barriers to screening and fewer motivating factors in their decision to participate in screening. This was true for the elderly, minorities, and women of lower socioeconomic status. Women in greater need of screening mammography report fewer motivations, and must overcome greater barriers to participate in media-promoted breast screening projects. Changes in the design and promotion of these screening projects must occur to prevent reverse targeting.

Reverse targeting in a media-promoted breast cancer screening project.

BACKGROUND: The American Cancer Society has sponsored community-based, low-cost, Breast Cancer Detection Awareness Projects throughout the United States. The authors hypothesized that these projects tend to exclude minorities and women of lower socioeconomic status--groups with a higher incidence of late-stage disease. METHODS: A cross-sectional survey was performed of participants in the 1990 Breast Screening Project in Tampa, Florida. The demographic profile of participants was compared with that predicted by 1990 census data. RESULTS: There were 13,920 women who called phone banks for additional information. Of these, 13,215 were deemed eligible and 6640 completed mammographic screening. Forty percent of participants were having mammography for the first time. Comparisons with census data indicated that elderly people, members of minority groups, and women of lower educational levels were underrepresented. CONCLUSIONS: The results of this study support the concept that "reverse targeting" occurs with these breast cancer screening projects, and recommendations for recruiting underrepresented groups are given.

Compliance with screening mammography. Survey of primary care physicians.

A survey of primary care physicians in the greater Tampa Bay metropolitan area was conducted to determine compliance with screening mammography and associated physician characteristics. Information requested included their age, sex, specialty, and board certification status, and the ages and frequencies that they recommend screening mammography for their patients. A total of 565 physicians responded. Even though 88% indicated they follow American Cancer Society recommendations when advising screening mammography, only 62% were actually in full compliance. A significantly greater percentage of obstetricians/gynecologists were compliant (74%) compared to other specialties (family practice, 57%, p = .006; internal medicine, 56%, p = .007; general practice, 53%, p = .003). Women physicians were more likely to be compliant than men (83% versus 58%, p less than .001), and younger physicians more likely than older physicians (72% versus 49%, p less than .001). There was no significant difference in compliance rates between board certified and noncertified physicians.

Family practitioner's guide to patient self-treatment of acute diarrhea.

The majority of cases of acute, nonspecific diarrhea are of short duration, can be treated symptomatically with nonprescription medications and adequate hydration, and do not require a visit to the physician's office. If the family practitioner can determine via telephone that the patient, or the caller's child, is not experiencing certain signs and symptoms often associated with diarrheal illness that may indicate a more severe condition (e.g., high fever, vomiting, persistent diarrhea, or diarrhea accompanied by blood or severe abdominal or rectal pain), self-treatment may be allowed without an office visit. In addition, if the physician determines that the patient is not suffering from diarrheal dehydration, indicated by dry mouth, excessive thirst (or for children, inadequate fluid intake), wrinkled skin, little or no urination, dizziness, or lightheadedness, the physician may also allow the patient to be treated without an office visit. If, however, the patient is experiencing any of these symptoms, an office visit is required to facilitate further evaluation by the physician.

Venomous snakebites in the United States.

Venomous snakebite treatment is controversial. Venomous snakebites are known to occur in all but a few states. Approximately 10 to 15 individuals die from snakebites each year, with bites from diamondback rattlesnakes accounting for 95 percent of fatalities. The identification of the two endogenous classes of venomous snakes are discussed in detail to aid in determining the proper treatment for each class. Approximately 25 percent of all pit viper bites are "dry" and result in no envenomation. The best first aid is a set of car keys to get the victim to a facility where antivenin is obtainable. Incision and suction should be limited to very special situations; cryotherapy and use of tourniquets applied by laymen should be avoided. Proper medical management at a health care facility requires establishing whether envenomation has occurred and to what extent, followed by appropriate dosing of antivenin. The use of corticosteroids and antibiotics is controversial. Tetanus immunization should be updated, if necessary. Although research in developing a more purified antivenin is under way, the best treatment for snakebite is prevention.

Graduate follow-up in the US Air Force family practice residency programs.

Between June 30, 1973, and June 30, 1982, 216 family physicians completed residency training in family practice residencies sponsored by the US Air Force. The primary purpose of this study was to measure the adequacy of the graduates' residency training program. One hundred seventy-nine (83 percent) of the graduates responded to an extensive eight-page survey. The study assessed all Air Force program graduates as a whole as well as each program separately. Seventy-four percent of the respondents are still in the Air Force. All but one are board certified, and 19 have been recertified. Of the 179 respondents, 37.0 percent are involved in teaching medical students of family practice residents, only 5.0 percent are dissatisfied with their present hospital privileges, 43.5 percent felt that their residency training was superior to that provided by civilian family practice residency, 53.7 percent felt the training was equal, and 2.8 percent felt the training was inferior. Practice satisfaction and continuing medical education needs were also addressed in the study.

Vasectomy.

Bilateral vasectomy is a common method of achieving elective sterilization in men. Knowledge of male genital anatomy is important in the performance of this procedure as well as in screening patients with anatomical contraindications. Careful counseling techniques will help avoid medicolegal problems. There are several operative techniques used to perform a vasectomy. Postoperative evaluation and semen analysis should be accomplished to recognize and allay complications. Major complications are rare; minor complications are relatively frequent, with early diagnosis and treatment important in hastening recovery. Psychological consequences are rare. Thus, vasectomy is a relatively safe, inexpensive, and dependable contraceptive procedure.