Interpretation of the American Board of Family Practice In-training Examination.

The American Board of Family Practice (ABFP) In-training Examination (ITE) is the most frequently used method of evaluation among accredited family practice programs. Despite its common use, there are still misunderstandings regarding the proper interpretation of the ABFP ITE results. The ABFP ITE is a norm-referenced test that allows for comparison of a resident's performance relative to other residents in the same year of training; it does not measure absolute performance. There is a paucity of evidence supporting the validity of the ABFP ITE. The eight specialty areas and clinical set problems lack sufficient reliability to be interpreted per individual resident. The composite score of the ABFP ITE has sufficient reliability to be used as part of a formal and comprehensive evaluation system. Group comparisons using the 10 ABFP ITE measures are appropriate.

Prayer in medicine: a survey of primary care physicians.

Prayer and spirituality have been shown to have a significant impact on several health variables. Additionally, studies have shown that patients think prayer is important to their health. Very little research, however, has been done to determine primary care physicians' opinions regarding prayer and spirituality as it pertains to healthcare. We surveyed primary care physicians in Mississippi to assess their use of prayer in medical practice. Ninety-one percent of respondents considered prayer an important treatment modality, but 50.6% rarely or never discussed prayer with patients. Most who excluded prayer from clinical practice did so to avoid imposing their beliefs upon patients. A majority of primary care physicians in Mississippi recognize prayer as an important psychosocial variable in assessing and treating patients, but many are hesitant to incorporate this variable into the doctor-patient encounter.

Fine-needle aspiration: survey of clinical utility.

OBJECTIVES: The goal was to determine the features of clinical usage of fine-needle aspiration (FNA) in this country in terms of utilization, indications, and practice and demographic characteristics of those who use FNA. STUDY DESIGN: A survey was mailed to otolaryngologist-head and neck surgeons (OTO-HNSs) in the United States. The results were totaled and analyzed for indications for FNA performance, practice setting, age, and geographic location of practitioners. RESULTS: The most common indications for use of FNA were in the diagnoses of neck, thyroid, salivary, and other masses in the head and neck. In the survey group the average number of FNAs performed per month was 4.7 per respondent practitioner. FNA was statistically related to age (older physicians performed it less) and region of the country. FNAs are performed at a lower rate in the West. CONCLUSIONS: FNA is a commonly performed procedure. Certain groups of OTO-HNSs (older, located in western states) do not perform FNA as commonly as other OTO-HNSs. Further education regarding the merits of FNA is needed.

Use of subjective global assessment to identify nutrition-associated complications and death in geriatric long-term care facility residents.

OBJECTIVE: The primary objective of this study was to assess the use of Subjective Global Assessment to identify nutrition-associated complications and death in a geriatric population. A secondary objective was to evaluate the ability of Subjective Global Assessment to identify geriatric residents of long-term care facilities who were undernourished or at risk for developing undernutrition. METHODS: Fifty-three consecutive residents who were > or = 65 years of age and had been residing in a long-term care facility for < 2 weeks were enrolled in the study. The Subjective Global Assessment Classification technique was performed according to the procedure outlined by Detsky and colleagues. Residents were classified as well-nourished (A), mild/moderately undernourished (B) or severely undernourished (C). In addition, a Subjective Global Assessment Composite Score was derived. Subjective Global Assessment measures were compared with two traditional objective measurements of nutritional status: serum albumin and serum total cholesterol. Outcome measurements of nutrition-associated complications were determined over a 3-month period by recording the incidence of major infections, decubitus ulcers, nutrition-related hospital readmissions, and mortality. RESULTS: Sixteen residents (30.2%) were categorized as Subjective Global Assessment class A, 28 residents (52.8%) were class B, and 9 residents (17%) were class C. A significant association was found between nutritional status as determined by Subjective Global Assessment Composite Score and nutrition-associated complications (p<0.05). Subjective Global Assessment Classification was related to death (p<0.05) with severely undernourished residents having the highest mortality rate. Hypoalbuminemia only demonstrated a significant relationship with nutrition-associated complications (p<0.05), whereas hypocholesterolemia was associated with death (p<0.05). CONCLUSIONS: Subjective Global Assessment of nutritional status appears to be a simple, noninvasive and cost-effective tool for assessing nutritional status of geriatric residents in long-term care facilities. This assessment tool is also beneficial for identifying patients with increased risk of nutrition-associated complications as well as death.

Onychomycosis: improved cure rates with itraconazole and terbinafine.

Onychomycosis is a disease that is important to our patients. Based on the current literature, recent developments of newer antifungal agents have improved cure rates of onychomycosis in the past few years (Table 3). No significant differences in safety and tolerability between itraconazole and terbinafine exist. Terbinafine does appear to have a preferable drug interaction profile. Daily therapy with either agent at standard doses has been shown to be effective when compared with placebo. When studies have directly compared daily administration of terbinafine and itraconazole, both medications have shown similar efficacy. Daily terbinafine therapy, however, appears to be more effective than pulse therapy with itraconazole. In addition, one small study showed a trend in favor of continuous rather than intermittent terbinafine therapy and similar efficacy of intermittent itraconazole and intermittent terbinafine therapy. Furthermore, terbinafine is more cost-effective than itraconazole. Finally, as quality-of-life data suggest, onychomycosis is important to our patients and affects both physical and psychosocial components of our patients' lives.

Endoscopic-assisted adenoidectomy.

Adenoidectomy is a commonly performed procedure. The advent of endoscopic sinus surgery has popularized the use of endoscopes. Endoscopic-assisted adenoidectomy (EAA) is a natural progression of this technology to allow a more complete adenoidectomy. Two hundred thirty-six patients undergoing adenoidectomy were evaluated with an endoscopic technique. A routine transoral adenoidectomy was performed first. Then a 4-mm 0 degrees telescope was used transnasally, and residual adenoid tissue was removed from the anterior superior nasopharynx. Invariably, residual adenoid tissue was found after transoral adenoidectomy. The EAA technique is minimally invasive, adds less than 5 minutes to the procedure, and is not associated with excessive bleeding. Readily available telescope and endoscopic equipment is used. The EAA technique is advocated for use as an adjunct to a more complete adenoidectomy.

Halitosis.

Although halitosis is generally thought of as a social handicap related to poor oral hygiene or disease of the oral cavity, it may also indicate a serious systemic illness that requires diagnosis and treatment. Halitosis can be the result of pathologic or nonpathologic factors, both local systemic. A complete physical examination, with laboratory and radiographic studies as indicated by the history and physical examination, will generally identify a treatable cause for halitosis. Treatment is directed at the underlying cause. Simple measures, including careful oral hygiene, may be employed to lessen breath odor.

Efficacy of sliding-scale insulin therapy: a comparison with prospective regimens.

OBJECTIVE: To compare the efficacy of retroactive sliding-scale insulin therapy, proactive therapy, and a combination of the two methods in establishing glycemic control in hospitalized diabetic patients. METHODS: Medical records of 47 diabetic ketoacidosis inpatients were reviewed retrospectively. RESULTS: The sliding-scale insulin therapy group's glucose deviation score (167.4) was significantly higher than the deviation for the proactive (112.9) and combination (121.3) groups. The sliding-scale insulin therapy group also had a significantly higher median glucose value (262.5) than the proactive (199.9) and combination (221.2) groups as well as a significantly higher number of nursing shifts (0.70) in which a glucose of 250 mg/dl or greater was recorded than in the proactive (0.37) and combination (0.40) groups. The proactive group was on their treatment regimen significantly less time than the combination group (5.5 vs 10.4 nursing shifts, respectively). The proactive group was hospitalized significantly fewer days (4.4) than the combination (6.3) and sliding-scale insulin therapy (6.3) groups. CONCLUSIONS: The present study lends support to previous concerns that sliding-scale insulin therapy is less effective than preventive therapy in the management of hospitalized diabetic patients.

Clinical evaluation for colonic polyps: usefulness of signs and symptoms in diagnosis.

This article reports a prospective cross-sectional study of the relationship between various signs and symptoms commonly ascribed to colorectal cancer and the presence or absence of colonic polyps found by colonoscopic examination. Of the 166 patients who participated in the study, 96 were positive for colonic polyps and 70 were negative. There was a significant increase in risk for adenomas polyps as age increased among males. For females, the step-wise logistic regression indicated that an absence of abdominal pain/cramping (p < .01), a change in stool shape (p < .01), and a history of colorectal polyps (undifferentiated) in first-degree relatives (p < .05) were associated with adenomatous polyps.

Fatigue: a new approach to an old problem.

Previous research regarding the fatigued patient has dealt primarily with the diagnostic labels applied by physicians, rather than specific presenting symptoms of the fatigued patient. The purpose of the present study was to identify, based on presenting symptoms, gender, marital status, and race, relatively homogeneous sub-groups within a sample of fatigued patients that would aid in the diagnosis and treatment of the underlying disorder(s). Results of cluster analysis suggested the presence of an Organic, Anxiety, Depression, and Mixed Anxiety/Depression group within the sample of 197 fatigued patients. Significant differences among these four groups were found on 13 of the 15 symptoms included in the cluster analysis. The proportion of males, married patients, and white patients in the Organic Group was significantly greater than in the other three inorganic clusters as a whole. Positive or negative responses to these 13 symptoms can facilitate the diagnosis and treatment of the fatigued patient.

An assessment of obstetric services in Mississippi.

Seven hundred and six (80.6% response rate) obstetricians, family physicians, and general practitioners responded to a survey designed to elicit information regarding their obstetric practice. Results of the study were compared to a similar survey conducted in 1985. The proportion of obstetricians offering obstetric care has remained relatively constant since 1985. Among family physicians and general practitioners, however, there was a significant decrease in the proportion who practice obstetrics (p < .01), and a significant increase in the proportion who have discontinued obstetric practice in the last five years (p < .01) and who plan to discontinue obstetric care in the next five years (p < .05). Consistent with the 1985 data, cost of malpractice insurance, threat of litigation, and time demand were the three most frequently reasons for discontinuing obstetric care. Without changes in the current system, the provision of obstetric care in rural areas will continue its current dramatic decline.

Practice and attitudes of primary care physicians in a rural southern state concerning HIV/AIDS patients.

In preparing for the development of a plan of care for persons with AIDS and other HIV related conditions, the HIV Services Planning Program, a joint effort of the Department of Family Medicine of the University of Mississippi Medical Center and the Bureau of Preventive Health of the Mississippi State Department of Health, conducted a survey of all primary care physicians throughout the state of Mississippi. The purpose of the survey was to determine health care services provided to persons with HIV/AIDS. Specific areas of interest included: (a) type of medical specialty; (b) location of primary practice; (c) services provided for persons with HIV/AIDS; and (d) utilization of universal blood and body fluid precautions, i.e., barrier techniques. Descriptive statistics were utilized in analyzing responses.

The Cytobrush effect on Pap smear adequacy.

One hundred twenty-four Papanicolaou smears were studied to compare the yield of endocervical cells obtained with the Cytobrush/Ayre spatula method to that of the cotton-tipped applicator/Ayre spatula method. Forty-nine of the 62 Pap smears (79%) obtained with the combination Cytobrush/Ayre spatula method contained endocervical cells, compared to 22 of the 62 smears (35%) obtained with the cotton swab/Ayre spatula method (chi 2 = 24.02, P less than 0.0001). The Cytobrush/Ayre spatula method obtained endocervical cells in 14 of 17 (82.4%) of the patients with stenotic ora, compared to 0 of 12 (0%) patients for the cotton swab/Ayre spatula method (P less than 0.001). The Cytobrush/Ayre spatula method obtained endocervical cells in 8 of 11 (72.7%) postmenopausal patients, compared to 4 of 14 (28.6%) patients for the cotton swab/Ayre spatula method (P = 0.05). Using the cervical Cytobrush for Pap smears increases the recovery rate of endocervical cells, which may improve the detection of cervical dysplasia in the patient population as a whole, in postmenopausal women, and in women with stenotic cervical ora.

Chaperone use in primary care.

Two recently published surveys showed that a significant number of male adolescent medicine specialists performed unchaperoned pelvic examinations. Since this is a surprising finding, primary care physicians in Mississippi were surveyed to assess their use of chaperones during patient examinations. The survey found that male physicians typically did use chaperones for pelvic examinations. The frequency of chaperone use among male physicians when performing pelvic examinations did not vary by physician specialty. There was considerable variability in chaperone use by female physicians for both male and female patients.