Hepatitis B immunization in a university student population.

In the United States, hepatitis B virus infection occurs predominantly among adolescents and young adults, despite the availability of an effective vaccine. Immunization status and hepatitis B virus (HBV) vaccine acceptance among 505 students visiting the student health services of a large southern university were investigated. Only 58 students had received HBV vaccine. The cost of the vaccine was paid by the students personally (35.5%) or by their parents (34.5%) or employers (31.0%). Nearly half of the students (45.7%) did not know their vaccination status. Lower immunization percentages were found among Hispanics, men, persons of lower education levels, and students aged 25 years and under. Being immunized was related to the perception that the vaccine was affordable, although most students (95.7%) said that the cost of HBV vaccine was excessive. Health professionals' emphasis on the need for HBV vaccination and a reduction in the price of the vaccine could improve HBV immunization rates among university students.

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.

Bilateral testicular cancer.

Although the case we described is not common, the incidence of testicular cancer, as well as bilateral testicular cancer, is rising. The primary care physician can help reduce morbidity in these patients by encouraging monthly self-examinations of the testicles and by paying attention to high-risk subgroups, such as those with a family history of testicular cancer, a personal history of cryptorchidism, infertility, or a contralateral testicular volume less than 12 mL. The primary care physician should, in at least these cases, discuss the option of a testicular biopsy to rule out CIS in the contralateral testicle. Treatment and follow-up options can then be explored to reduce further sequelae from this disease.

Does early clinical exposure enhance performance during third-year clerkship?

This study was undertaken to assess the effects of early clinical exposure in an indigent care free clinic on third-year clerkship mini-board scores (clinical knowledge), faculty evaluation (especially rapport with colleagues and patients), and final rotation grades. After completion of third-year clerkships, a sample of participants was compared with nonparticipants. Comparative statistics, repeated measure analysis, and analyses of variance were performed on the entire group as well as by sex and by individual rotation. No statistically significant differences were found in the mainframe, but subgroup findings indicate further study is warranted. Negative findings might be explained in part by small sample size and the fact that the clinic is exclusively outpatient, while the third-year clerkship experience is inpatient. Data collection is being continued, and studies are ongoing to look at the long-term effect of the program on participants.

Seasonality of Chlamydia trachomatis genital infections in university women.

Previous studies have shown seasonal fluctuations in the incidence of most sexually transmitted diseases, with a peak in the third quarter, but none have specifically evaluated Chlamydia trachomatis genital infections. From 1989 to 1991, 8,234 women presenting to the student health centers of Florida's two largest universities for routine gynecologic care and diagnosis of sexually transmitted diseases were tested for Chlamydia trachomatis genital infections. The bimonthly variation in incidence was statistically significant, with a significant peak in the months of August and September of 10.70%, compared with the yearly average of 8.74%. Because the pattern of incidence of chlamydia in university women is seasonal, those concerned with healthcare should increase their efforts during the third quarter to identify infected individuals and to provide preventive programs.

Methanol intoxication. Case report.

A 46-year-old male presented to the emergency room seven hours after consuming a large container of sterno. He could not see and complained of abdominal and back pain. He was tachypneic, tachycardic, hypertensive and hypothermic. Laboratory results were significant for a severe metabolic acidosis, a serum osmolality of 465 and serum methanol level of 493 mg/dl. Aggressive treatment included ethanol drip, bicarbonate and hemodialysis. He survived and regained his eyesight in spite of this degree of elevation of the serum methanol level. The literature does not reveal a similar report.

Methanol intoxication. How to help patients who have been exposed to toxic solvents.

Methanol intoxication can be a challenge, in part because it is relatively uncommon but also because of the pharmacokinetics involved. A patient may not experience symptoms and thus may not present for treatment for several hours, or even a day or two, after exposure to the toxic substance. Yet, the interval between ingestion and treatment is one of the most important factors in determining patient outcome. Typical symptoms of methanol intoxication include lethargy, vertigo, vomiting, blurred vision, and decreased visual acuity. Treatment focuses on prevention of methanol conversion to its toxic metabolites, correction of metabolic acidosis, and elimination of the toxic substances from the system. Ethanol and bicarbonate administration and hemodialysis have been effective.

Influence of longitudinal primary care training on medical students' specialty choices.

BACKGROUND: At the University of South Florida College of Medicine, a program designed to give students four years of primary care training began in 1983. As of 1992, six classes that included program participants had graduated. The present study examined the effect of the program on the participants' choices of specialty by comparing their choices with those of other graduates. METHOD: Each year program volunteers were solicited from a class size of about 96 freshmen. Of the 201 volunteers from the classes of 1987-1992, 93 were randomly selected to participate in the program. The participants received primary care education one half-day per week in a community-based clinical setting. The specialty choices of the 543 graduates from 1987-1992 were determined from the National Resident Matching Program and were divided into primary care (family practice, internal medicine, pediatrics); surgery, obstetrics-gynecology, and psychiatry; and other (high-technology specialties). Comparisons were made (1) between volunteers and nonvolunteers and (2) between volunteers who were participants and those who were not. The Z-test was used, with alpha set at .01. RESULTS: Significantly more volunteers--with no difference between participants and nonparticipants--matched with primary care specialties, and more volunteers were women. Significantly more nonvolunteers matched with high-technology specialties--again, no difference between participants and nonparticipants. CONCLUSION: The program did not seem to influence the students' specialty choices, because students interested in participating--regardless of whether they actually participated--were more likely to match with primary care specialties and were more likely to be women.

Comparison of the cytology brush with the Dacron swab for detecting Chlamydia trachomatis by enzyme immunoassay in female university students.

Previous studies comparing the cytology brush (Cytobrush) with swabs for the detection of Chlamydia trachomatis from the uterine cervix have yielded divided results. The authors carried out a retrospective analysis at the University of South Florida Student Health Service to evaluate the effect of a change in specimen collection technique on C trachomatis prevalence estimates in female university students. Samples were collected from 1,003 women in 1989, using a small Dacron swab, and 1,229 women in 1990, using a brush; the samples were tested by means of the Pathfinder Enzyme Immunoassay (EIA) detection kit. Positive test results were 5.88% for 1989 and 11.66% for 1990. Actual C trachomatis prevalence for 1989 and 1990 was stable, as determined by three control groups. The results suggest that the cytology brush is more effective than the Dacron swab for the detection of C trachomatis in the uterine cervix when it is used with the Pathfinder EIA test kit.

Effect of undocumented and excluded vaccinations on measles immunity in a university population.

Epidemic measles has occurred even in highly vaccinated university and college populations because vaccine efficacy is only 90-95% and some student bodies do not have 100% vaccine coverage. Some institutions have not adopted or enforced a one-dose, preregistration immunization requirement because of the increased administrative burden, although in 1990 a documented two-dose schedule was recommended to increase herd immunity to a critical 93.5-96.0%. Perhaps one documented immunization for all students coupled with an undocumented or excluded pre-1968 one that some students are reporting will result in adequate herd immunity. At the University of South Florida 149 students (group I), after documenting receipt of one immunization, attempted to prove immunity by having an antibody test. They were compared with 181 students who documented two doses (group II) for factors which might influence differences of immunity between the groups after one dose. Undocumented immunizations were estimated by determining the percent of students reporting recent immunizations after allowing for the expected unimmunized percent. Excluded vaccinations were calculated for students born before 1967. Group I had a 98% (95% C.I. 94.2-99.6) immunity. One-third to one-half of both groups had undocumented and excluded immunizations. Some differences identified were not important enough to prevent extrapolation of this high immunity from group I to group II students. One documented live measles vaccination for all students combined with an undocumented or excluded one for some of them may provide adequate herd immunity to prevent measles epidemics on university and college campuses.

Validity of immunization documentation presented to a student health program.

BACKGROUND: Unavoidable exposure to disease and to patients susceptible and vulnerable to disease warrants that students entering medical school be immunized against many of the illnesses for which vaccines are available. The validity of immunization records presented at the time of registration, however, is largely dependent on the provision of accurate and reliable documentation by the student. METHODS: We evaluated for authenticity the immunization and tuberculin testing records of 85 students entering medical school in 1990. Five levels of valid documentation were defined, and the information on each record was reviewed accordingly. RESULTS: Only 43% of the records were original documents or laboratory reports of antibody titers, and 7.5% were not date-specific. We found that 8% to 20% of the forms were missing physician and/or student signatures, and 12% to 19% of the forms did not have health care provider addresses. CONCLUSIONS: Even though medical student preventive health programs may have strict requirements, there may be substantial deficiencies in the quality of the documentation provided by the students. Such deficiencies undermine the purpose of these programs.

Cancer screening. Knowledge, recommendations, and practices of physicians.

BACKGROUND: Americans visit their primary care physicians several times a year. These visits provide physicians with many opportunities to reduce cancer risk in their patients by recommending periodic cancer screening. There is evidence of noncompliance among primary care physicians and their patients with regard to periodic cancer screening. Barriers to screening may be perceived by physicians and patients. RESULTS: The authors found that when physicians recommended cancer screening tests, the compliance among patients was relatively high. CONCLUSION: Primary care physicians can take the opportunity to recommend cancer screening tests during routine patient visits, and this strategy may well increase cancer screening rates in the population.

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.

Cancer survivors.

Cancer survivorship is becoming a newly defined entity. Cancer therapies can produce many late physical effects by adversely affecting every organ system. Psychosocial issues that have been studied include: psychiatric, self-concept, school performance, and behavioral adjustment, employment and insurance discrimination, and marital status. Quality-of-life assessments in adult survivors is comparable to controls but is diminished for children with disease or treatments that affect the CNS. The greatest fear for cancer survivors is the 10 to 20 times greater risk of SMN as compared with persons with no history of cancer. Infertility and sexual dysfunction are real concerns for survivors that usually go unexpressed. Some cancers have a familial predisposition; however, treatments do not appear to increase the risk of birth defects or childhood cancers in the offspring. Lower socioeconomic status adversely affects cancer survival because of lost opportunities for cancer screening, other diseases, and untreated cancer. The primary care physician can competently care for cancer survivors and should emphasize health promotion and risk prevention behaviors, topics especially applicable for this patient population.

The dieffenbachia plant. Case history.

When ingested, the common house plant dieffenbachia can lead to significant toxicity and possibly death if timely medical attention is not forthcoming following initial exposure. The deleterious effects should not be overlooked especially when children are involved who, naturally curious, may bite into this innocuous looking plant. Although the patient in this case was a type II diabetic on insulin, neither hypo- nor hyperglycemia developed. There was no other significant electrolyte imbalance despite the acute stressor placed on him.

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.

Prostate cancer screening.

No screening test has been proven to reduce prostate cancer mortality. DRE has been the traditional method of screening, and it is often used to detect other diseases in addition to prostate cancer. Newer modalities, such as TRUS and PSA, can identify patients with nonpalpable prostate cancer, but the use of these tests will also result in many false-positives. In addition, it is not known whether the use of these tests will reduce prostate cancer mortality, or instead cause harm to those patients screened. Given the potential for harm, and the extraordinary expense, routine screening of asymptomatic men with newer modalities should be considered experimental.

Matriculants' compliance with a required preventive health program.

Several organizations have made recommendations about medical students' health. To determine the University of South Florida College of Medicine's concurrence with published guidelines, a prospective analytic study of the 1990 entering class was carried out, using the 1989 class as a control. Enforcement measures not present in 1989 were initiated in 1990. The requirements for the 1990 matriculants were a history and physical examination; tuberculin testing; immunizations to rubella, rubeola, tetanus-diphtheria, and hepatitis B; status of immunity to chickenpox; and proof of health insurance. The results showed that in 1990 expensive requirements had the lowest rates of compliance, and inexpensive ones, the highest rates of compliance. Comparing 1990 with 1989 showed that the enforcement measures significantly improved compliance for expensive requirements, and for requirements that obligated a student to incur a fee because they needed to be updated. The authors conclude that cost is a major deterrent to compliance and that, in order to improve compliance, medical schools must either implement effective enforcement measures or transfer the cost from the student to the institution.

The influence on students' specialty selections of faculty evaluations and mini-board scores during third-year clerkships.

The authors investigated whether graduating students' specialty choices were influenced by favorable faculty evaluations and mini-Board scores during their third-year clerkships, and if so, whether the influences were gender-specific. Data were collected from a total of 53 students in two classes, 1988-89 and 1988-90. Univariate and multivariate tests were performed, and the results were analyzed between each class group and between genders in both groups. These results also were compared with information about the students gathered before they matriculated. In general, the results showed a gender-specific correlation: for each rotation where the women's faculty evaluations were significantly higher than the men's, the women subsequently outnumbered the men in choosing that rotation's specialty. Conversely, for each rotation where the men's mini-Board scores were significantly higher than the women's, the men outnumbered the women in choosing that rotation's specialty. The most notable difference was in pediatrics: 8% of the women had indicated an interest in that specialty on the prematriculation questionnaire, while almost one-third of the women in the classes of 1990 and 1991 chose pediatrics residencies. These findings suggest that the favorable scores and evaluations may be one of the influences for students' specialty choices, and that their influence may be gender-specific.