Relapse in sexual behavior among homosexual men: a 2-year follow-up from the Chicago MACS/CCS.

Serial biannual cross-sectional assessments of HIV sexual risk indicated a consistent increase in safer sexual practices among homosexual men participating in the Chicago-Multicenter AIDS Cohort Study (MACS)/Coping and Change Study (CCS) in 1986-1988. Safer sexual practices were achieved by avoidance of anal sex and less often by consistent use of condoms. Longitudinal patterns of variability in individual behavior were also assessed. After 1 year of follow-up, 53% of the participants maintained safer practices in receptive anal sex, 6% maintained unsafe practices, while 31% relapsed at least once. After 2 years, 45% maintained safer practices, 3% maintained unsafe practices and 47% relapsed at least once. Similar trends were observed in insertive anal sex.

Pediatric Milliman and Robertson length-of-stay criteria: are they realistic?

OBJECTIVE: Guidelines for inpatient length of stay (LOS) have been developed by several groups; among the most widely applied are those published by Milliman and Robertson (M&R). Few published reports have examined the relationship of actual practice to such guidelines, none in pediatric populations. This study was designed to compare pediatric practice in a large and defined population to M&R LOS criteria. METHODS: Administrative data from New York State in 1995 were used to examine LOS for discharges corresponding to 16 selected pediatric diagnoses for which M&R publishes guidelines. Outliers, defined as the 2% of discharges with the longest LOS, were eliminated. The distribution of LOS for each diagnosis was compared with M&R LOS guidelines. RESULTS: In New York State during 1995, pediatric LOS was markedly divergent from M&R guidelines. In general, the percentage of discharges in excess of the criterion LOS was less for nonmandatory admissions (croup: 23%, gastroenteritis: 44%, and pneumonia: 48%) than for those requiring surgery (uncomplicated appendectomy: 67%, pyloromyotomy: 62%, and major but noncritical burns: 64%) or prolonged treatment with antibiotics (bacterial meningitis: 91% and osteomyelitis: 86%). CONCLUSIONS: In New York State during 1995, LOS for selected pediatric conditions was generally in excess of published M&R guidelines. This raises concern about the potential effects of such guidelines on both patients and the hospitals caring for them. While endorsing the need for cost-effective practice, we call attention to the methods used to develop and validate guidelines.length of stay, pediatrics, managed health care, administrative data, practice guidelines.

Gallium-67 scanning for carcinoma of the lung.

Gallium-67 citrate scanning was prospectively evaluated in 55 patients who had lung lesions suspected to be primary carcinoma on chest x-ray films and in whom subsequent histologic diagnosis was obtained. Of 47 patients with histologically proved carcinoma of the lung, 44 (94 per cent) had a positive 67Ga scan. No patient with a positive scan had a benign lesion, so that the positive scan accuracy rate was 100 per cent. All 8 patients with a benign lesion and 3 patients with a malignant lesion had negative scans, for a negative scan accurary rate of 72 per cent for benign lesions. These results give statistical validity for the usefulness of the 67Ga scan in diagnosing carcinoma of the lung (p less than 0.001). Tumor cell type had little effect on the sensitivity of 67Ga scan. The 67Ga scan was equally useful in the evaluation of peripheral and central lesions. There was little difference amount T1, T2, and T3 classified lesions in their ability to take up 67Ga. The 67Ga scan was competitive with mediastinoscopy in assessing mediastinal lymph node metastases and provides a noninvasive method of assessing hilar lymph node metastases. There was a good correlation between the clinical staging of patients with lung cancer based on a chest x-ray film and 67Ga scanning and the staging after surgical treatment based on the histology of the resected specimens.

Major colorectal cancer aetiological hypotheses do not explain mortality trends among Maori and non-Maori New Zealanders.

New Zealand colorectal cancer mortality rates are presented for the period 1947-1980. Mortality has been increasing and is now the highest in the world for both males and females in the age range 35-64; indeed New Zealand mortality rates for those aged 35-44 are approximately twice those of other countries with high mortality. By contrast, colorectal cancer mortality rates among Maoris, the indigenous New Zealanders of Polynesian descent, have been decreasing so that they are now less than half the non-Maori mortality rates. These findings cannot be explained by ethnic differences in consumption of the major proposed dietary risk factors: total fat, cholesterol, meat, fibre and beer. Possible differences in the prevalence of lactose malabsorption, in faecal mutagen activity, and in the prevalence of colorectal polyps warrant further investigation.

Prevalence of childhood disability in a southern Indian city: independent effect of small differences in social status.

A random sample of mothers living in two neighbourhoods of a southern Indian city were interviewed in order to determine the prevalence of serious disability in children 2-9 years old. These areas were selected because residents constitute either the lowest class or the next higher socioeconomic class (next-to-lowest class), with monthly incomes of US$ 10-15 and 32-42 respectively. A previously validated screening instrument was used with documented sensitivity of 100% and specificity of 95% when applied under similar conditions. Disability was found to be more common among children of the lowest class families (17.2%) when compared with the next-to-lowest class families (8.4%); with an odds ratio (OR) of 2.36 (95% confidence interval (CI): 1.08-3.64). Specific types of disability were examined and found to be consistently more prevalent in the lowest class. These results suggest that comparatively small differences in social status can be associated with important differences in health status.

PIP: Researchers analyzed data on 640 2-9 year old children who lived in either a lowest social status neighborhood or a next to lowest social status neighborhood in Madurai in Tamil Nadu State in India to determine whether small differences at the lowest end of the socioeconomic scale would be associated with differential health status. Interviewers spoke with the families in December 1990 and used a screening tool with 100% sensitivity and 95% specificity previously validated in a community based study in Bangladesh. 17.2% of families in the slum had a child with a disability compared to 8.4% in the next to lowest social class area (odds ratio=2.36 [OR]; p.001). Further disability prevalence was consistently higher among children from the lowest social class, especially sensory (4.8% vs. 0.9%; p=.003), neuromotor (8.1% vs. 3%; p=.005), and cognitive disabilities (3.5% vs. 1.2%; p=.05). In fact, the multiple logistic regression which took in consideration age, gender, number of children in the household, birth order, and social status revealed that the only significant and meaningful relationship affecting childhood disability was lowest social status (OR=2.39). These results demonstrated that the lowest status families were 2.39 times more likely to have disabled children even though the differences in income between the 2 deprived groups was small. The study did not identify what mechanism was responsible for the disparity between the 2 groups, however. The researchers encouraged other studies to identify the mechanism for disability among the lowest social class and yet not among another very resource poor group.

Working with families of suddenly and critically ill children: physician experiences.

OBJECTIVE: To describe physicians' experiences in attempting to provide optimal care for families of children who suffer from sudden, acute life-threatening conditions (SALTC). DESIGN: To generate descriptive data in this exploratory study, we used qualitative methods including focus groups and in-depth interviews. Transcripts of focus groups and interviews were analyzed for content using standard phenomenologic analysis methods, which resulted in a participant-generated conceptual model of optimal care for families of children with SALTC. SETTING: The intensive care unit of an urban pediatric teaching hospital. PARTICIPANTS: Twenty-two pediatric intensive care unit physicians, including residents, fellows, and attendings. INTERVENTION: None. MAIN OUTCOME MEASURES: Each participating physician provided qualitative descriptions of experiences caring for families of children with SALTC. RESULTS: Physicians identified 4 components of optimal care for families: (1) providing timely, accurate information about their child; (2) maintaining privacy for confidential discussions and personal grieving; (3) giving adequate emotional support; and (4) granting family members the right to hold and comfort their dying child. Physicians also described barriers to, and facilitators of this optimal care. CONCLUSIONS: Descriptive information provided in this exploratory study offers a complex model of optimal family care. Issues that affect the quality of care to families include those related to the context of providing care in a large teaching hospital, as well as subtleties of communication between parents and staff. Physicians' beliefs about optimal care of families in the pediatric intensive care unit revealed implications for both practice and training in pediatrics.

Social relationships of men at risk for AIDS.

Survey data collected in 1984-85 from a community sample of 637 gay and bisexual men were used to determine the features of social relationships that were most conductive to changes in both psychological health and AIDS-related sexual risk behavior. Multiple regression analyses showed that both the perceived availability of social support and the absence of conflicts in the social network were related to improve psychological health. At the same time, the subjective experience of integration into social networks was associated with increased psychological distress, and validation (the experience of being accepted by others) was related to a higher level of risk activity. These findings are discussed in terms of the social relationships among community members that share a common stressor--in this case the shared problem of being at risk for AIDS.

Effects of HIV infection, perceived health and clinical status on a cohort at risk for AIDS.

Data from a general population sample of 621 healthy homosexual men are used to evaluate the social and emotional effects of HIV antibody status, clinical signs detected by medical examination, and subjectively perceived symptoms. Participants are unaware of their serologic status at the time of data collection, thus allowing the effects of the virus to be separated from reactions to the knowledge of serologic status. The data show that seropositivity for HIV is not associated with elevated levels of social or emotional impairment. Clinical signs lead to impairment in baseline data, but these effects do not persist at a second wave. This weakening suggests that the effects are mediated by psychological pathways rather than biologic ones. This suspicion is confirmed in further analyses, which show that the effects of clinical signs are mediated by subjectively perceived symptoms. These results show that neither social nor emotional impairment is likely to be a prodromal sign of HIV infection in otherwise healthy homosexual men. The substantial levels of distress found among these men is more directly influenced by psychological determinants than biologic ones. This suggests that physicians should be aware of the psychological toll imposed on gay men who develop health problems in the current atmosphere of uncertainty regarding risk of AIDS.

Predictors of sexual behavior change among men requesting their HIV-1 antibody status: the Chicago MACS/CCS cohort of homosexual/bisexual men, 1985-1986.

It has been proposed that human immunodeficiency virus (HIV) antibody testing and counseling are effective means of altering sexual behavior among individuals at risk of HIV infection and transmission. However, the evidence supporting this hypothesis is inconclusive. This study examines the factors associated with sexual behavior change among a group of participants in the Chicago MACS/Coping and Change Study (CMACS/CCS) who requested their HIV antibody status when they were first given the opportunity, between 1985 and 1986. A set of demographic and psychosocial predictors were tested in association with 4 possible outcome patterns of sexual behavior change during the time of antibody status disclosure. For comparative purposes, a randomly selected sample of men who did not request disclosure of their HIV antibody status was analyzed. The results revealed that, among the 177 individuals who requested disclosure, the group experiencing an adverse sexual behavior change (i.e., from low risk before disclosure to high risk after disclosure) reported, before disclosure, the highest level of mental distress and denial-fatalism coping strategies and had the lowest levels of social support compared with other groups being analyzed. The psychosocial predictor most strongly associated with adverse sexual behavior change appears to be the use of denial-fatalism coping. Such an association was not found among the nondisclosed comparison group. These results suggest that a subgroup of at-risk, well-educated, white men, with overall high knowledge of HIV transmission, may not benefit from current HIV counseling and testing. Such men at risk for adverse behavioral outcomes might be identified in advance of HIV-1 antibody testing by their psychosocial profile, and thus appropriate counseling resources could be targeted to them.

Predictors of relapse in sexual practices among homosexual men.

Selected sociodemographic, psychosocial, and behavioral variables were used to predict maintenance or relapse in sexual practices over a 1-year interval in a cohort of homosexual men in Chicago. Univariate analyses and multivariate logistic regression were used to define predictive models for safer practices separately for insertive and receptive and sex. Demographic and psychosocial variables were not associated with subsequent relapse. Neither was HIV serostatus. Using more rigorous multiple logistic regression, only monogamous relationships, less peer support, and less assertiveness in negotiating safer sex appeared to predict relapse to less safe practices. The importance of interpersonal variables and social norms for future interventions among homosexual men is discussed.

The Health Belief Model in understanding compliance with preventive recommendations for AIDS: how useful?

The Health Belief Model (HBM) has been applied to a variety of health conditions: most are less threatening and require less complex responses than those arising in the case of AIDS. The utility of the HBM in understanding preventive behaviors in AIDS is examined in a cohort of homosexual men at two different time points. Longitudinal analyses estimated the relationship of indices assessing susceptibility, severity, benefits, and barriers, as well as sociodemographic factors, to sexual behavior across the next 18 months. Analyses further defined these associations in specific subgroups of participants, such as those initially at lower or higher risk. In general, measures of severity and socioeconomic advantage had the most consistently beneficial effect on various measures of behavior. Little or no beneficial effect was observed for other components of the HBM, notably a measure of perceived susceptibility. These analyses suggest that the special features of AIDS may require development of more adequate theoretical frameworks.

AIDS-related knowledge, attitudes, and precautionary behaviors among emergency medical professionals.

AIDS-related knowledge, attitudes, and precautionary behaviors were assessed among a random sample of Michigan-licensed emergency medical service (EMS) professionals between June and August 1988. Of 2,000 mailed questionnaires, 1,020 were returned (51 percent response), and 997 of the returned questionnaires were used in the final analysis. Survey results indicated that most respondents were able to correctly identify the transmission routes of the human immunodeficiency virus (HIV), but many respondents had misconceptions about nonviable routes, the incidence of HIV infection among health care workers, and some aspects of the natural history of HIV. More than half of the respondents (56.6 percent) believed that their chances of becoming infected with HIV were "somewhat high" or "very high," although the number of documented HIV seroconversions due to occupational HIV exposures in health care settings is low. Although only six respondents (0.6 percent) reported that they had refused treatment to patients known or suspected to be infected with HIV, 25 percent felt that EMS professionals should be allowed to refuse treatment under such circumstances. Potential exposures to HIV were assessed through respondents' reports of three activities in the 6 months prior to the survey. For each activity, use of universal precautions recommended by the Centers for Disease Control was also assessed. In general, few respondents reported the consistent use of precautions. While the majority of those attempting resuscitations (86.9 percent) reported that they always use a protective device, only 36.7 percent of those treating bleeding patients reported that they always wear gloves, and only 21.9 percent of those using needles reported that they do not recap them after use.

Characteristics and perceived needs of mothers with serious mental illness.

This cross-sectional survey determined the prevalence of motherhood among severely mentally ill women hospitalized in an inner-city facility and examined the demographic characteristics and perceived needs of the 32 mothers who were identified. Slightly less than one-quarter of these mothers had seen their children within the last week, and only about 20 percent maintained full custody of their children. However, none of the respondents reported feeling that it was unimportant whether they continued mothering their children. Approximately half described needing help in dealing with their sadness about their children. The pilot data presented in this paper suggest that motherhood is common among severely mentally ill and hospitalized women and that issues relevant to mothering remain important to them.

Breast self-examination in an urban population: estimates of prevalence and quality of performance.

Interview data from 434 women (aged greater than or equal to 20 years) in two Wellington suburban areas were used to estimate the prevalence and quality of performance of breast self-examination. Although 98% of women were familiar with breast self-examination, and 73% had performed it at least once, only 39% did so at least monthly. Its practice was significantly more common in the middle years (30-59), among Europeans, and in women with tertiary education. Thoroughness or quality of performance was assessed by comparison with Cancer Society recommendations. Scores for examination technique were generally high (mean = 73%) compared with those assessing timing (mean = 47.5%) and conditions under which breast self-examination was performed (mean = 43.3%). Results from this study were compared with 1975-76 New Zealand survey data which produced lower estimates of the prevalence of monthly breast self-examination. Both studies found that more than a quarter of women have never practiced it. Future research and intervention efforts should be directed toward this group of women.

Hospital utilization: an epidemiologic perspective on possible future trends.

Like the noted Mr. Holmes, epidemiologists work with details. This article focuses upon the use of detailed epidemiologic data to explore potential changes in hospital service utilization during the next decade. Although epidemiologists share with Mr. Holmes a commitment to inductive reasoning based on specific data, only a fictional detective would claim infallibility. In practice, data describing human populations are limited, inferences fragile, and changes always possible. These cautions need to be kept in mind when estimating future trends.

AIDS and behavioral change to reduce risk: a review.

Published reports describing behavioral changes in response to the threat of AIDS (acquired immunodeficiency syndrome) are reviewed. These studies demonstrate rapid, profound, but expectably incomplete alterations in the behavior of both homosexual/bisexual males and intravenous drug users. This is true in the highest risk metropolitan areas such as New York City and in areas with lower AIDS incidence. Risk reduction is occurring more frequently through the modification of sexual or drug-use behavior than through its elimination. In contrast to aggregate data, longitudinal descriptions of individual behavior demonstrate considerable instability or recidivism. Behavioral change in the potentially vulnerable heterosexual adolescent and young adult populations is less common, as is risk reduction among urban minorities. Reports of AIDS-related knowledge and attitudes generally parallel the pattern of behavioral changes. Nonetheless, few studies investigate the relationship of knowledge and attitudes to risk reduction. Future studies should provide much-needed information about the determinants as well as the magnitude of behavioral changes required to reduce the further spread of AIDS.

Elevation of systolic and diastolic blood pressure associated with migration: the Tokelau island migrant study.

Cross-sectional univariate and multivariate analyses estimated differences between the blood pressure of adult Tokelauan migrants to New Zealand and non-migrants still living on three Polynesian atolls. Response rates were 97 and 99% in the two locations. Among males, the difference between migrants and non-migrants after adjustment for significant covariates was 7.2 mmHg systolic pressure (p less than 0.001) and 8.1 mmHg diastolic pressure (p less than 0.001). Among females, adjusted systolic pressure was not significantly higher in migrants compared to non-migrants (1.8 mmHg, p = 0.065) and diastolic pressure was only 3.0 mmHg higher (p less than 0.001). Body mass is significantly correlated with blood pressure in this study group; nonetheless, differences in body mass explain only a small proportion of the observed migrant/non-migrant differential in blood pressure. Estimates of blood pressure differences preceding migration are also reported. These indicate that blood pressure was neither consistently nor significantly higher among those who subsequently migrated. This report provides compelling evidence linking Westernization and the development of chronic disease.

Gay identity and risky sexual behavior related to the AIDS threat.

This paper explores the relationship between risky sexual behavior and issues of gay identity in homosexual men. We identify three main conceptual categories important to gay identity: sexual identity, gay social interaction, and identity development milestones. Each of these categories are analyzed as to their predictive effect on risky sexual behavior related to the threat of HIV, at six-month and eighteen-month intervals. The results suggest that successful integration into a gay network plays a role in reducing risky sexual behavior among homosexual men, regardless of the chronological timing of personal events marking a gay man's "coming out" history.