Can recovering alcoholics help hospitalized patients with alcohol problems?

OBJECTIVE: The researchers evaluated the relative effectiveness of 2 interventions for patients with alcohol problems. STUDY DESIGN: A nonrandomized intervention study was used to compare usual care (control) with a 5- to 15-minute physician-delivered message (brief intervention) and with the physician message plus a 30- to 60-minute visit by a recovering alcoholic (peer intervention). Telephone follow-up was obtained up to 12 months after hospital discharge that focused on patient behaviors during the first 6 months following discharge. POPULATION: The study included 314 patients with alcohol-related injuries admitted to an urban teaching hospital. OUTCOMES MEASURED: Researchers measured complete abstinence from alcohol during the entire 6 months following hospital discharge, abstinence from alcohol during the sixth month following hospital discharge, and initiation of alcohol treatment or self-help within 6 months of hospital discharge. RESULTS: Valid responses were obtained from 140 patients (45%). Observed success rates were: 34%, 44%, and 59% (P=.012) for abstinence from alcohol since discharge in the usual care group, the brief intervention group, and the peer intervention group, respectively; 36%, 51%, and 64% (P=.006) for abstinence at the sixth month following hospital discharge; and 9%, 15%, and 49% (P &it.001) for initiation of treatment/self-help. During the telephone follow-up interview, several patients in the peer intervention group expressed gratitude for the help they received with their drinking problems while in the hospital. A few patients dramatically changed their lives. They went from being unemployed and homeless to full-time employment and having a permanent residence. They credited the peer intervention as being the most important factor that motivated them to seek help for their alcohol use disorder. One of these individuals serves as a volunteer, visiting hospitalized patients with drinking problems. CONCLUSIONS: Among trauma victims with injuries severe enough to require hospital admission, brief advice from a physician followed by a visit with a recovering alcoholic appears to be an effective intervention. Although further study is needed to confirm these findings, in the meantime physicians can request that members of Alcoholics Anonymous (AA) visit their hospitalized patients who have alcohol use disorders. Interventions by recovering alcoholics are part of their twelfth-step work (an essential part of the AA program) and are simple, practical, involve no costs, and pose little patient risk. They can be arranged from the patient's bedside telephone. Some patients will show a dramatic response to these peer visits.

Disorders of puberty.

Normal puberty begins between eight and 14 years of age in girls and between nine and 14 years of age in boys. Pubic hair distribution is used to stage puberty, along with breast size and contour in girls and testicular volume in boys. Some children experience constitutional sexual precocity, but precocity is likely to be pathologic if it occurs in very young children, if there is contrasexual development or if the sequence of normal pubertal milestones is disrupted. Delayed puberty may be constitutional, but pathologic causes should be considered. The etiology of a pubertal disorder can often be determined with the use of a focused medical history, a directed physical examination and appropriate diagnostic tests. Treatment for disorders of puberty is determined by the underlying cause.

Which medical school applicants will become generalists or rural-based physicians?

The hypotheses that data, available at the time when a medical school admission decision is made, can be used to predict generalist specialty choice and rural practice location were tested. Applicant data, available to admissions committee members at the University of Louisville in 1986 and 1987 about the classes of 1990 and 1991 respectively, were correlated with specialty choice and practice location in a retrospective cohort study. Data collected from 1994 to 1996 about the 1990 and 1991 graduates were used to develop a mathematical model to predict specialty choice and practice location using stepwise logistic regression. These models were more accurate in predicting which applicants would not select a generalist career (negative predictive value = 80.7%) than those who would (positive predictive value = 42.7%) and in predicting those who would not practice in a rural location (negative predictive value = 91.9%) than those who would (positive predictive value = 37.8%). We conclude that applicant data, available at the time admission decisions are made, are of limited value for identifying those who will eventually become generalist physicians or practice in a rural area. However, the data are useful for identifying those who will not.

The practicality of using the SMAST and AUDIT to screen for alcoholism among adolescents in an urban private family practice.

We assessed the practicality of using the Short Michigan Alcoholism Screening Test (SMAST) and the Alcohol Use Disorders Identification Test (AUDIT) in screening adolescents for alcoholism in a primary care setting. In addition, we sought to determine the prevalence of alcohol use among adolescents, 16-21 years of age, presenting to a private Family Medicine practice for medical care. A consecutive sample of 67 subjects presenting for medical care were asked to complete the SMAST and AUDIT questionnaires. Overall, 52 (78%) of the questionnaires were returned with complete data. Of the 52 patients, 25 (48%) admitted to drinking. Using a "positive" score on either the SMAST or AUDIT as a positive test for alcohol use yielded a sensitivity of 40% and a predictive value positive of 100%. Using a "negative" score on both the SMAST and AUDIT as a negative test for alcohol use yielded a specificity of 100% and a predictive value negative of 64%. Although alcohol use was relatively common considering the age group, using the SMAST and AUDIT to screen for alcoholism is labor intensive and is not practical in this situation. Because patients appeared to misinterpret some questions and were often accompanied to the office by their parents, their answers may not be valid. History of alcoholism taken upon typical office examination and relevant advice appears to be a better alternative to the use of questionnaires in determining the prevalence of alcohol use in this age group.

Alcoholism. Taking a preventive, public health approach.

Alcoholism is a common, chronic, often progressive disorder that has negative effects on a patient's health and severe consequences for society as well. A positive, public health approach that integrates medical, psychological, and social therapies can lead to improved outcomes for patients who abuse alcohol. Physicians can play an important role by educating patients to prevent alcohol abuse from starting, being alert to the risk factors, recognizing the signs of alcoholism (especially during its early stages), and initiating interventions designed to halt progression of this disease. Doctors should maintain a therapeutic stance with patients who have continued to abuse alcohol, even after frequent relapses. Consultation with alcoholism experts may be helpful when treatment is difficult or there is the possibility of a dual diagnosis.

Influence of curricular changes in health promotion and disease prevention on residents' behaviors over a five-year period.

BACKGROUND: Residents' compliance with guidelines for health promotion and disease prevention (HPDP) often fall short of the ideal. METHOD: After a year in which faculty developed clinical practice HPDP guidelines, an intervention consisting of curricular changes and chart modifications was planned and pilot-tested in 1985-86 at an ambulatory care clinic of the Family Practice Residency Program, University of Louisville School of Medicine. Approximately 24 residents per year (eight at each level of training) worked in the clinic throughout the study years. The HPDP curriculum required residents to attend 48 one-hour conferences conducted over a three-year period. Four retrospective chart audits were used to measure residents' compliance with the HPDP guidelines during (1) the year before the pilot test (104 charts), (2) the pilot year (113 charts), (3) the year after the pilot test--the first year of full implementation (100 charts), and (4) five years after the pilot test (100 charts). Data from the chart audits were analyzed by using a permutation test for decreasing trend. RESULTS: Although there was an increase in the residents' compliance with the HPDP guidelines during the pilot year, the residents' HPDP activities tended to return to baseline levels in the following years, despite the ongoing curriculum. CONCLUSION: The authors conclude that because the frequency of the residents' HPDP activities tended to return to baseline levels, clinical education alone is not enough to sustain residents' compliance with HPDP guidelines.

The results of 20 years of family practice residency training at the University of Louisville.

In response to shortages of generalist physicians, especially in rural areas, family practice residency programs were established at both of Kentucky's medical schools. In 1972 a family practice residency program became operational at the University of Louisville. A study was conducted to determine the effectiveness of this program. We were especially interested in those factors that were associated with a physician's choice to practice in rural or urban medically underserved areas. The records of the 100 program graduates were reviewed to determine the physician's gender, ethnic background, hometown, and current practice location. A questionnaire was mailed to program graduates to obtain additional information about factors that influence physician practice location. For the purpose of this study, "rural" was defined as a community of less than 25,000. Sixty-eight of the program's 100 graduates currently practice in Kentucky. Forty-nine graduates serve patients in rural or medically underserved urban areas, and of those, 31 are located in Kentucky. Whites and those from rural hometowns were more likely to practice in rural communities than minorities or those from urban hometowns. However, minorities were more likely than whites to practice in medically underserved urban areas. No association was found between gender and practice location. Initial interest in rural practice and participation in financial aid programs requiring service in a rural area were associated with rural practice location, but participation in rural rotations at the predoctoral or residency training level were not. We conclude that the family practice training program at the University of Louisville has been successful in training generalist physicians to serve rural and medically underserved urban populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Impaired physicians.

The prevalence of chemical dependency among physicians in the United States is probably the same as for the general population, about 8% to 12%. Organized medicine has responded to this problem by establishing programs to help these impaired physicians. Chemically impaired physicians can be treated and followed by structured programs with favorable results. To prevent the tragic outcomes of untreated physician impairment due to chemical dependency, nonimpaired physicians must learn about this problem and take the appropriate actions. Impaired physicians need not fear treatment, for it can help them return to a productive career. To further lessen the tragic effects of substance abuse among physicians, proactive strategies of prevention should be adopted by medical schools, residency programs, hospital staffs, and similar physician organizations.

Impaired physicians: the Kentucky experience.

Since 1976 the Committee on Impaired Physicians of the Kentucky Medical Association has become involved with 134 physicians. Most were referred because of possible substance abuse. These physicians represent a wide range of ages and specialties. The Committee typically follows approximately 35 physicians at any given time. Many recover from their problem and are able to return to practice. However, the Committee is aware of only a minority of the impaired physicians that might exist in Kentucky. To be more effective and to reach more impaired physicians, the Committee will need to expand its mission and obtain more resources.

Hypopituitarism.

The pituitary regulates the body's endocrine system, including the thyroid gland, adrenal cortex, ovaries and testes, through the release of numerous hormones. Pituitary function, in turn, is regulated through complex feedback loops involving the hypothalamus and the target endocrine glands. Hypopituitarism may result from multiple causes, including primary and metastatic cancer, ischemic and granulomatous disease, infection, developmental abnormalities and trauma, which may affect the gland itself (primary hypopituitarism) or the hypothalamus (secondary hypopituitarism). Depending on the anatomic lesion, patients with hypopituitarism may present with signs or symptoms of multiple endocrine abnormalities, such as hypothyroidism, adrenal insufficiency, diabetes insipidus, hypoglycemia, sexual dysfunction and growth retardation. A thorough clinical history, detailed examination, laboratory evaluation of endocrine function and radiographic views of the pituitary and sella turcica can suggest the diagnosis and etiology. Treatment, usually lifelong, may include hormone replacement and medical or surgical correction of the underlying disease.

Parasites of the skin and hair.

Because scratching is nature's treatment for ectoparasites, they should be considered in the differential diagnosis of any pruritic rash. Usually, the diagnosis is not difficult to make if the clinician suspects an ectoparasitic cause and is familiar with the symptoms and signs of these disorders. The diagnosis is confirmed using a few instruments and basic office supplies. The clinician must treat not only the individual patient but must also consider the source of the infection because others may require treatment. Family and community education about removal of the parasites from the patient's environment is one of the clinician's responsibilities.

Rural health, family practice, and area health education centers: a national study.

The National Area Health Education Center (AHEC) Program and the family practice specialty were both created around 1970, in part to help meet the health care needs of medically underserved populations. Because these two entities share the common goal of alleviating physician shortages in rural areas, a study was conducted to determine the nature and extent of their interaction. Questionnaires were mailed to all AHEC projects and all nonmilitary family practice residency programs. Response rates were 100% and 79%, respectively. Elective rural rotations (usually preceptorships) are offered by 135 (49%) residencies, but only 84 (31%) require them. Fourteen (64%) AHEC projects interact with family practice residencies; however, only 9% (15/167) of the programs in those states utilize AHEC resources. The authors conclude that additional rural rotations could be offered to family practice residents by taking advantage of under-utilized resources of the National AHEC Program.