Care Doctors Research Articles

Moise L. Levy, M.D.

I wish to thank Dr. Moise L. Levy for serving as guest editor and the authors who have contributed to this issue on “Dermatology for Plastic Surgeons” for Seminars in Plastic Surgery. Dr. Moise Levy graduated in 1979 from the University of Texas Medical School at Houston, where he also completed his pediatric internship and residency. Subsequently, he completed a dermatology residency at Baylor College of Medicine in Houston, Texas in 1986. Dr. Levy is presently Professor of Dermatology and Pediatrics, Chief, Pediatric Dermatology at Texas Children's Hospital, Baylor College of Medicine, Houston. Dr. Levy is an active member of many major dermatologic medical societies, has previously served as president of the American Academy of Pediatrics and Society for Pediatric Dermatology, and is on the board of several societies. He has to his credit 65 published scientific articles and 26 book chapters on pediatric dermatology. I know from my personal experience working closely with him that he is an excellent clinician and a caring doctor. This issue is a tribute to his hard work and is certain to be used as a superb reference for plastic surgeons treating patients with these conditions.

Plasma cholesteryl ester transfer protein concentrations predict cardiovascular events in patients with coronary artery disease treated with pravastatin

The B1B1 variant of the cholesteryl ester transfer protein (CETP) TaqIB polymorphism and high plasma CETP concentrations are associated with favourable angiographic outcomes in pravastatin-treated patients suffering from coronary artery disease (CAD). The purpose of the present study was to test whether CETP TaqIB genotypes and/or plasma CETP concentrations at baseline also predict clinical end-points in patients with CAD. Prospective longitudinal observational study. Primary care doctors (n=88) and hospitals (n=7) in Austria. A total of 1620 men and women with preexisting CAD were recruited and plasma lipids were determined at study entry. 1389 hypercholesterolaemic patients were included and 1002 patients completed the follow-up. In all patients treatment with pravastatin was started and patients were followed up for 2 years. Cardiovascular events. One hundred patients suffered at least one cardiovascular event. We observed significantly more events in patients within the lowest compared with the highest quartile of plasma CETP concentrations (odds ratio 3.20, CI95 1.65-6.23; P=0.001, adjusted for known risk factors of CAD). No significantly different numbers of cardiovascular events were found between CETP TaqIB genotypes. Plasma CETP concentrations, but not CETP TaqIB genotypes, predict cardiovascular events in patients with CAD treated with pravastatin. Despite higher LDL cholesterol concentrations, high plasma CETP concentrations at baseline are associated with fewer cardiovascular events compared with low plasma CETP concentrations in CAD patients treated with pravastatin.

Medical Care during the Depression1: A Preliminary Report upon a Survey of Wage‐Earning Families in Seven Large Cities2

The problem of giving services free has faced the doctor and the hospital during the depression to an extent unknown in any other field. A factory manager was able to economize during hard times by eliminating unproductive departments, by introducing labor-saving devices, or, as a last resort, by closing his plant until the return of prosperity. No such expedients were available to the doctor or the hospital director. Business had to continue as usual in spite of the decrease of paying patients and the tremendous increase of free care. While the writers of this paper offer no solution for these economic problems, they do have pertinent data to present on the amount of physician's, hospital, and nursing care, both pay and free, received by a group of nearly 7,000 families in seven large cities surveyed early in 1933 by the United States Public Health Service in cooperation with the Milbank Memorial Fund. The reader is referred to previous papers3 for details, method, and scope of the survey. Briefly, it consisted of a house-to-house canvass of some 12,000 white families in the poorer districts of eight large cities, one group of coal-mining communities, and a group of cotton-mill villages. The records obtained by the canvasses included (a) the economic history of the family in sufficient detail for computing family income for each year from 1929 through 1932, and (b) a record of all illness during the three months immediately preceding the date of the enumerator's visit, in the spring of 1933, with the extent of disability and of medical care for each case. The sample population discussed in the present paper comprised 28,959 individuals in 6,686 families for which the data were sufficiently complete for computing the actual income for each of the four years from 1929 to 1932. The population was largely of the wage-earning class, a considerable proportion of which had experienced loss of income due to unemployment and wage reductions. In 1929, 10 per cent of the persons surveyed were in families with an annual per capita income of $149 or less; by 1932, 43 per cent were in this class. On the other side of the picture, 42 per cent of the persons were in families with an annual per capita income of $425 or more in 1929, but by 1932 this figure had decreased to 14 per cent.

Main clinical manifestations of a bleeding diathesis: an often disregarded aspect of medical and surgical history taking

A suitable clinical evaluation of a bleeding diathesis is often forgone. The young doctor is often unprepared to describe in an accurate way the different types of bleeding. An adequate classification and adequate clinical information about a bleeding diathesis are instead of paramount importance. Bleeding may be cutaneous, mucous, articular, muscular, parenchymal, intracavitary, orificial. Each of these sites and forms may have diagnostic implications. An accurate description of the several forms of cutaneous bleeding (petechiae, purpuric spots, ecchymosis, haematomas, etc.) is needed for referrals and for controls. The correct evaluation of cutaneous bleeding manifestations of children (battered child syndrome) is absolutely important for clinical and medico-legal purposes. The same is true for the battering syndrome seen in women abused by their spouses. The grading of haemarthrosis in haemophilia patients is important for the follow-up. A proper description of haematuria is essential in suggesting the probable site of bleeding (kidney or bladder or urethra). A proper evaluation of bleeding may give also useful information on the general health status of the patients (presence of anaemia, poor nutrition, renal insufficiency, etc.). The combination of bleeding and thrombosis in the same patient is also a clinical challenge. The relationship between haemorrhage and thrombosis may be sequential or concomitant. Sequential thrombosis may occur in a patient confined in bed for a brain haemorrhage. Concomitant thrombosis and bleeding occur in DIC and in patients with thrombosis being treated with anticoagulants. Finally, it should be kept in mind that a proper evaluation of the bleeding diathesis of a given patient may help the caring doctor in ordering appropriate laboratory tests (e.g. a platelet count for petechiae, a PTT for a patient with haemarthrosis, etc.).

Race and prostate cancer: Attitudes toward diagnosis and treatment among newly diagnosed patients

6056 Background: Patient factors potentially affecting prostate cancer (PC) screening and treatment behavior may differ by race. Methods: Using Rapid Case Identification in the North Carolina Tumor Registry, we identified 84 newly diagnosed African American (AA) and 253 Caucasian (C) PC patients. Interviews assessed their socioeconomic position, health attitudes, access to care, pretreatment symptoms and treatment choices. Most men had begun their treatment. Results: AA men were younger, had less education, and lower income compared to C men (all P<0.001), but racial groups did not differ in insurance coverage or their proximity to their site of care. However, AA men more often reported foregoing a doctor's care even when they perceived a need, less often saw the same MD regularly, and reported less trust in their MD about cancer. AA men reported more relatives with prostate cancer, greater risk of and fear of prostate cancer than other men, and greater belief that fear causes most men to put off checking their prostate. AA and C men did not differ on the first evidence for their cancer, although it arose more often at special screening sessions for AA men. Their treatment choices did not differ from C men, despite a greater preference to avoid surgery. AA men reported a lower self-assessment of global health, but their self-reported ability to perform social roles without physical or mental health limitations, and their urinary, bowel and sexual function were the same as those of C men. Conclusions: Although less well educated, AA men in North Carolina are aware of their greater risk of PC and the need for treatment when diagnosed, and they tend to assume greater responsibility for getting cancer and delaying diagnosis. However, absence of strong ties to a primary physician, mistrust of physicians in general, constrained opportunities to utilize needed care, and fear of prostate cancer may present barriers to timely diagnosis. No significant financial relationships to disclose.

Race and prostate cancer: Attitudes toward diagnosis and treatment among newly diagnosed patients

6056 Background: Patient factors potentially affecting prostate cancer (PC) screening and treatment behavior may differ by race. Methods: Using Rapid Case Identification in the North Carolina Tumor Registry, we identified 84 newly diagnosed African American (AA) and 253 Caucasian (C) PC patients. Interviews assessed their socioeconomic position, health attitudes, access to care, pretreatment symptoms and treatment choices. Most men had begun their treatment. Results: AA men were younger, had less education, and lower income compared to C men (all P<0.001), but racial groups did not differ in insurance coverage or their proximity to their site of care. However, AA men more often reported foregoing a doctor's care even when they perceived a need, less often saw the same MD regularly, and reported less trust in their MD about cancer. AA men reported more relatives with prostate cancer, greater risk of and fear of prostate cancer than other men, and greater belief that fear causes most men to put off checking their prostate. AA and C men did not differ on the first evidence for their cancer, although it arose more often at special screening sessions for AA men. Their treatment choices did not differ from C men, despite a greater preference to avoid surgery. AA men reported a lower self-assessment of global health, but their self-reported ability to perform social roles without physical or mental health limitations, and their urinary, bowel and sexual function were the same as those of C men. Conclusions: Although less well educated, AA men in North Carolina are aware of their greater risk of PC and the need for treatment when diagnosed, and they tend to assume greater responsibility for getting cancer and delaying diagnosis. However, absence of strong ties to a primary physician, mistrust of physicians in general, constrained opportunities to utilize needed care, and fear of prostate cancer may present barriers to timely diagnosis. No significant financial relationships to disclose.

The Smallpox Vaccination of Health Care Workers: Professional Obligations and Defense against Bioterrorism

In early December 2002, President Bush announced plans for the immediate vaccination of approximately 500,000 health care professionals against smallpox on a voluntary basis (as well as up to 500,000 military personnel on a mandatory basis). These health care professionals would act as smallpox response teams in the event of a terror attack using this agent, treating cases and administering vaccination to the general population. Within days of Bush's announcement, however, two prominent teaching hospitals refused to vaccinate their employees against smallpox, and several others were leaning toward similar refusal? In addition, several prominent medical associations expressed concerns about smallpox vaccination prior to an actual attack using this agent, including the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatricians. An even bleaker picture emerged in an April 2003 report from the General Accounting Office to the chairman of the U.S. Senate Committee on Governmental Affairs concerning the problems implementing the smallpox vaccination program. The report observed that hundreds of hospitals and thousands of health professionals have refused to participate in pre-event vaccination until liability and compensation issues have been resolved. (2) Compensation is viewed as because many will miss work or experience medical problems as the result of vaccination. Recent studies on the safety and efficacy of diluted doses of the smallpox vaccine, conducted primarily on young, healthy college student volunteers, resulted in a third of them missing work or school as a result of reactions to the vaccine) The result was confirmed by a CDC estimate cited in the GAO report. (4) Concern about the reaction is exacerbated by the fact that many hospitals will need to keep vaccinated employees away from vulnerable patients. The smallpox vaccine is a live vaccine that infects the recipient with a related virus. After being vaccinated, the recipient can spread this infection to others (called contact vaccinia). (5) This is especially problematic in contemporary health care settings, where there are a large number of immuno-compromised individuals--people who are HIV positive or are transplant recipients, for example. Some hospitals are considering furloughing vaccinated employees for up to three weeks to prevent the vaccinia virus from spreading to patients. (6) In late April 2003, Congress finally passed the Smallpox Emergency Personnel Protection Act of 2003, which would reimburse those participating in smallpox response activities for injuries arising as a direct result of administration of the smallpox vaccine. (7) The act will provide compensation for the reasonable and necessary costs of medical care associated with a vaccine-related injury and will pay up to $262,000 to the families of those who die as a result of the vaccine. Those suffering permanent disability can receive up to $50,000 a year annually through the compensation fund, and those who are temporarily or partially disabled can receive up to $262,000 in compensation for their injuries. However, the act leaves several significant questions about vaccination compensation unanswered: for example, which injuries will be eligible for reimbursement? (8) While agreement on the compensation issue is a step forward in implementing the administration's smallpox vaccination program, it is but one of a number of concerns inhibiting health worker participation in the vaccination program. Together, these concerns reflect a broad apprehension about the risks associated with the smallpox vaccine. (9) Known risks include encephalitis (1 in 200,000 to 300,000), death (estimates range up to 3-5 per million), and other side effects that are serious enough to require a doctor's care (in sum, 1 of every 10,000 cases). (10) Recently, three people have died of heart attacks after being vaccinated, several others have experienced heart problems, leading the CDC to issue new guidelines excluding those with heart conditions from the vaccination program. …

Cybermedicine: How Computing Empowers Doctors and Patients for Better Health Care

Cybermedicine: How Computing Empowers Doctors and Patients for Better Health Care

Pap Smear Use in a Population of Older Mexican-American Women

ABSTRACT Background: Hispanic women and older women (age ≥ 50 years) in general have been identified as populations of women who often underutilize Papanicolaou (Pap) smears. Objective: To report the rates of cervical cancer screening in a group of older Mexican American women and to identify the correlates of having a Pap smear in the past three years. Data Source: The Mammography Use by Older Mexican-American Women Survey, a stratified area probability sample of 452 women ages 50–74 from three southeast Texas counties. Self-report data was collected with in-person interviews from 1997 to 1999. Results: We found that 93.1% of the women reported at least one Pap smear in their lifetime and that 64.1% reported a Pap smear in the past three years. Odds of reporting a recent Pap smear was lower for older women (OR 0.51, 95% CI 0.32–0.82) and those below the poverty line (OR 0.52, 95% CI 0.33–0.82). The odds were higher for women who had a regular doctor for female care (OR 6.49, 95% CI 2.96–14.23) or a regular clinic or hospital source for female care (OR 5.50, 95% CI 2.55–11.89). Among these older Mexican-American women, cultural factors (language of interview, acculturation, fatalism) did not have a significant effect on screening use. Conclusion: Recent Pap smear use (64.1%) falls well below the year 2010 goal of 90%. Efforts need to be made to overcome barriers to Pap smear utilization for these women, such as providing access to female medical care.

Social disadvantage: Its impact on the use of Medicare services related to diabetes in NSW

To use Medicare data to examine the impact of social disadvantage on the use of health services related to diabetes. Information on number of diabetic individuals and number of services for select Medicare item codes were retrieved by New South Wales postcodes using a Health Insurance Commission data file. The postcodes were graded into quintiles of social disadvantage. People at most social disadvantage were significantly less likely to be under the care of a general practitioner (adjusted OR 0.41; 95% CI 0.40-0.41) or consultant physician (adjusted OR 0.50; 95% CI 0.48-0.53), despite this group having the highest prevalence of diabetes. The difference in attendance to other specialists was less marked but nevertheless significant (adjusted OR 0.71; 95% CI 0.68-0.75). Once under a doctor's care, patients at most disadvantage were slightly more likely to undergo HbA1c or microalbuminuria estimation (adjusted OR 1.04; 95% CI 1.00-1.10 and adjusted OR 1.22; 95% CI 1.12-1.33, respectively) but were less likely to undergo lipid or HDL cholesterol estimation (adjusted OR 0.81; 95% CI 0.48-0.53 and adjusted OR 0.85; 95% CI 0.79-0.90, respectively). While access to medical care is decreased for people at most social disadvantage, once under a doctor's care they receive a level of monitoring that is relatively equal to that provided to people less disadvantaged. Strategies are required to ensure equal access to medical services for all persons with diabetes, especially for persons who are at most social and medical disadvantage.

Social disadvantage: Its impact on the use of Medicare services related to diabetes in NSW

Objective: To use Medicare data to examine the impact of social disadvantage on the use of health services related to diabetes. Method: Information on number of diabetic individuals and number of services for select Medicare item codes were retrieved by New South Wales postcodes using a Health Insurance Commission data file. The postcodes were graded into quintiles of social disadvantage. Results: People at most social disadvantage were significantly less likely to be under the care of a general practitioner (adjusted OR 0.41; 95% CI 0.40–0.41) or consultant physician (adjusted OR 0.50; 95% CI 0.48–0.53), despite this group having the highest prevalence of diabetes. The difference in attendance to other specialists was less marked but nevertheless significant (adjusted OR 0.71; 95% CI 0.68–0.75). Once under a doctor's care, patients at most disadvantage were slightly more likely to undergo HbA1c or microalbuminuria estimation (adjusted OR 1.04; 95% CI 1.00–1.10 and adjusted OR 1.22; 95% CI 1.12–1.33, respectively) but were less likely to undergo lipid or HDL cholesterol estimation (adjusted OR 0.81; 95% CI 0.48–0.53 and adjusted OR 0.85; 95% CI 0.79–0.90, respectively). Conclusion: While access to medical care is decreased for people at most social disadvantage, once under a doctor's care they receive a level of monitoring that is relatively equal to that provided to people less disadvantaged. Implication: Strategies are required to ensure equal access to medical services for all persons with diabetes, especially for persons who are at most social and medical disadvantage.

Safety at Scene--A Manual for Paramedics and Immediate Care Doctors

Safety at Scene--A Manual for Paramedics and Immediate Care Doctors

Safety at Scene—A Manual for Paramedics and Immediate Care Doctors

I wish this excellent little book had been in print when I was working on the Helicopter Emergency Medical Service some six years ago. It might have spared me the minor embarrassment of nearly being electrocuted by the live rail while attending an incident where a woman had thrown herself under a tube train. Vic Calland's book contains a wealth of background information about the technical aspects of accident scenes of a kind that is difficult to acquire except through personal experience. He is to be congratulated for distilling his expertise into a readable and informative text. Most doctors practise within the safe environment of the surgery or hospital. Within this setting we are accustomed to being ‘team leaders’, to making the critical decisions on priority and management, and to being in control. Outside hospital the position is very different. Accidents by their very nature present dangers to emergency service personnel, as re-emphasized by the deaths of many New York firefighters and policemen when the World Trade Center towers collapsed. In the early stages of a major incident or even a medium-size road traffic accident, chaos reigns. In such circumstances, ‘first responders’ must be constantly aware of the risks to their own safety and avoid becoming casualties themselves. The rapid re-establishment of control is the key to a successful outcome. Within this framework, doctors are not team leaders but team members who come under the control of other emergency services, usually the police or fire services. An understanding of this principle and an acceptance of an initially subordinate role of the medical services is crucial to the smooth and safe management of an accident scene. In keeping with the frequency of road traffic accidents in the UK, about half the book is devoted to incident management, vehicle safety, casualty extraction and risks of hazardous substances at the accident scene. The remainder of the text contains much valuable technical information on specific scenarios, such as chemical and radiation hazards, the basics of aircraft, rail and underground safety and even hostage situations. Having been written before autumn 2001, the section on biological agents does not cover the now feared microbes such as anthrax, plague and smallpox, but we can hardly expect the author to be clairvoyant. That said, the section on chemical decontamination procedures is comprehensive and applies equally to biological threats. My only criticism concerns the lack of a chapter on the effects of bomb blasts—familiar to many in Northern Ireland and, to a lesser extent, to the emergency services of London and other major cities in the UK. In view of recent events, this is an area of practice we may all need to revise. This concise and easy-to-read text is sensibly fitted with a laminated cover to protect against stains from coffee, blood and oil, all familiar to the immediate care practitioner. I recommend it to anybody with an interest in prehospital medicine.

The Injured Child

Pre-hospital immediate care for seriously injured children is rarely required, but when it is, the response must be prompt and effective. The key to an effective and confident approach to...

Consenso e diferenças em equipes do Programa Saúde da Família

To identify issues that promote agreement and disagreement among doctors, nurses, and health care professionals who integrate the Family Health Care Program team. A qualitative study using focus groups was carried out. The participants were male and female health care professionals, doctors and nurses from the Family Health Care Program team in Teresina, Brazil. Group sessions were conducted by a coordinator and with the participation of an observer and the following issues were raised: insertion in the program, capacitating process, main concepts of the program, relation with the organization and the prevailing health care model, relationships between the team members and the community, required and available services, work conditions and legal work situation, positive and negative factors. General issues such as community work, preventative care and teamwork brought out agreement among the three categories of professionals. Issues that reinforced the disagreement of the professional categories were salary levels, relationship with the community and team responsibility. Issues that brought out more disagreement were those that reinforced the corporate aspects of each professional category, while issues that promoted internal disagreement in each group were discussed based on external references, suggesting the need for better defining specific matters in the Family Health Care Program. Strategies to meet the community needs have proven to be a matter of urgency for the health care professionals since they are the first ones responsible for solving community health care services problems.

Assessing Undertreatment of Pain: The Patients' Perspectives

The undertreatment of pain is a major health issue in the United States, with children, elderly, and minorities at risk. An in-depth interview survey was conducted of 1,000 persons living at home with pain due to a medical condition to assess their attitudes toward pain, medications, and their doctors, as well as to identify the size and scope of undertreatment. Sixty-one percent have experienced pain for at least five years. For 40% of these patients the pain is constant; for 60%, intermittent; for 49%, moderate; for 22%, severe. Ninety percent have seen a physician; 67% are presently under a doctor's care; 86% see the same clinician for the pain and its cause; 50% see a general practitioner or family physician (GP/FP); only 13% have seen a pain specialist. Twenty-one percent have been scored on a pain scale; in half (49%) of those who were scored, a numeric scale was used; a verbal scale was used in 22%. Forty-two percent say their prescription analgesic is less than very effective; 67% indicated that t...

Basketball Coach John B. Mclendon, the Noble Revolutionary of U.S. Sport

On April 5, 1991, I met Coach John B. McLendon. The Black Studies program, under the directorship of Dr. Howard A. Mims, hosted a birthday tribute and an evening with Coach McLendon at Cleveland State University. Coach McLendon spoke on the topic, Basketball Talk: History and Lore of the Game. From April, 1991 until August, 1999, 1 was privileged to hear the voice of a man who, in his nobility, taught by example. Coach McLendon taught simply by living a life that was exemplary of action. He cut the cords of racism within institutions while he wove the strength of character in individual lives. In his passion for justice and compassion for humanity, the Coach was relentless in his efforts to go beyond the voice of rhetoric to become a quiet participant of action. Embracing the philosophy passed down through his mentor, Dr. Naismith, Coach McLendon made the sports arena his pulpit and thus changed lives through instruction and example. When I contacted coach John B. McLendon during the last week in May 1999, he immediately agreed to an interview. Because of his busy travel schedule and my summer commitments, we did not meet until Sunday, August 1, 1999. Coach McLendon informed me that he was under a doctor's care; however, he insisted that we hold the interview anyway. During the 2-hour interview, Coach McLen-

The effect of immigration and welfare reform legislation on immigrants' access to health care, Cuyahoga, and Lorain Counties.

This study examined the effect of the passage of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 and the Illegal Immigration Reform and Immigrant Responsibility Act of 1996 on immigrants' ability to access health care in two counties in Northeastern Ohio. Semistructured interviews were conducted with 251 individuals of varying immigration status and ethnicity. Data collected included type of recent illness, type and location of care received, type of health insurance, if any, and problems encountered. Significant associations were found between birth in a former Soviet-controlled area and use of public insurance. We did not detect an adverse effect of the welfare and immigration reform laws on ability to access care, most likely because a large proportion of respondents were permanent residents or asylees and were eligible for publicly funded medical care under the reform laws. The most common problems in obtaining medical care included lack of insurance and/or money, transportation, language, dissatisfaction with the doctor's care, and long waits. Individuals born in former Soviet-controlled areas as well as those who spoke Spanish or Slavic languages at home or work reported more difficulties in accessing care. Many undocumented individuals indicated that they would delay or refrain from seeking care due to fear of immigration consequences.

Rabies Vaccine Often Used Incorrectly

Primary care and emergency department (ED) doctors must routinely decide whether or not to recommend rabies prophylaxis to patients who report animal bites or scratches. A survey of practice habits at 11 urban university-affiliated EDs across the U.S. suggests that they often decide incorrectly. During a 26-month period, ED …

Rehabilitating Coleridge: Poetry, Philosophy, Excess

In April of 1816, Samuel Taylor Coleridge placed himself voluntarily in the care of a doctor, the benevolent James Gillman. Coleridge had for years been desperate break his opium habit, trying various cures, but no avail. The time had come for stringent measures, and resolved to submit himself any regimen, however severe. With this in view, wrote Dr. Joseph Adams, who had been treating him, he wishes fix himself in the house of some medical gentleman, who will have the courage refuse him any laudanum, and under whose assistance, should be the worse for it, may be relieved. After an initial interview that left Gillman, like Coleridge's Wedding Guest, almost spell-bound, without the desire of release, the poet committed himself the doctor's care for a period of one month.2 He remained eighteen