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This article describes the provider evaluation of a multifaceted system of care for pregnant women experiencing domestic violence and who receive prenatal care in an urban family practice site, one of four national demonstration projects. Providers reported changes in their own self-efficacy and behavior, but showed little improvement in overall attitudes or knowledge. Focus groups revealed that an easily accessible domestic violence coordinator was important, whereas providers stated that most domestic violence protocol materials were not useful. Guidelines that rely on training and protocols have had limited national success, suggesting that additional systems of care such as written chart prompts, quality improvement, and on-site domestic violence services may be necessary. This intervention was well received by providers, a key factor in any effort to alter provider behavior.

Objectives: The main purpose of this study was to determine whether any clinical or demographic characteristics could identify adult female patients presenting to the emergency department (ED) with a history of domestic abuse. A second objective was to describe the frequency, types, and severity of this abuse., Methods: This study was a crosssectional survey of 611 women conducted in an academically-affiliated, urban ED. Domestic abuse was described as "recent" (within the preceding 12 months) or "lifetime" (recent or past). This included emotional, physical, and sexual abuse., Results: Recent (7.9%, n = 48) and lifetime (38%, n = 232) domestic abuse was reported. For recently abused women, violence had been severe (87.5%, n = 42) and was associated with 1) trauma (OR 5.4, 95% CI = 2.6 to 11.6), 2) obstetrical and gynecological syndromes (OR 5.6, 95% CI = 2.4 to 13.2), and 3) psychiatric symptoms and substance use (OR 7.3, 95% CI = 2.4 to 22.0). The sensitivities and positive predictive values of these risk factors individually (<27.1% and <25.0%, respectively) and in aggregate (56.3% and 20.9%, respectively) were low. These indicators predicted only 27 (56.3%) of recently abused women. Lifetime domestic violence was more likely in homeless women (OR 5.8, 95% CI = 2.2 to 15.0), although less likely in immigrants (OR 0.4, 95% CI = 0.3 to 0.7)., Conclusions: Clinical presentations and demographic characteristics of women presenting to the ED may not be sensitive or predictive indicators of domestic abuse. In the absence of typical clinical or demographic findings, asking all women in the ED about domestic abuse remains a necessary priority.

Objectives: To assess prevalence of gun possession, attitudes regarding gun possession and gun violence, knowledge and influences of gun violence, and the potential role of physicians in gun violence prevention education among adolescents., Methods: An anonymous questionnaire was distributed to 9th through 12th grade high school students at 3 public high schools in New York City., Results: Three hundred forty-two surveys were distributed and returned. The prevalence of guns in the homes was 19.6%. Of respondents, 43.2% thought it was okay for anyone to have guns, and 57.3% had been injured or have had a relative injured by a gun. Although 11.6% of adolescents had felt the need to talk to an adult about guns, only 3.0% listed their physicians as one of these adults. However, if asked by their physician, 63.8% would discuss the issue with them. Only 5.7% of adolescents have had a physician speak to them about guns., Conclusions: The adolescent population surveyed is frequently exposed to gun violence. Although physicians rarely counsel adolescents regarding gun violence and firearm safety, many adolescents would be receptive to this mode of intervention.adolescence, attitude, firearm ownership, firearm violence, physician role.

1. There is no single pathognomonic sign, symptom, or clinical or laboratory test for making the diagnosis of dementia. A key element of the examination must be the inclusion of a mental status evaluation. 2. The FROMAJE--an acronym for Function, Reasoning, Orientation, Memory, Arithmetic, Judgment, and Emotion--Mental Status Guide (FMSG) has the advantage of a clear relationship between the acronym and the characteristics being measured. 3. The FMSG is meant to serve as a guide for the primary care clinician, who may have little experience in formal mental status testing. It is a convenient cognitive screening instrument to detect dementia in the elderly.

Background: Cardiopulmonary resuscitation, a potentially lifesaving procedure, is initiated on hospitalized patients who have an arrest in the absence of a written do-not-resuscitate (DNR) order. New York State Law specifies that attending physicians may write a DNR order on an adult patient either with his/her consent or that of a surrogate. Under specified circumstances, concurring physician and witness signatures are also required. This study examines potential obstacles physicians may encounter when implementing a DNR order for a hospitalized patient., Methods: Sixty house staff officers and 45 attending physicians at two New York City medical centers responded to a questionnaire listing 18 potential problems in obtaining a DNR order. Using a Likert scale, respondents rated the prevalence of each problem., Results: Analysis of the data indicates that attending physician's failure to discuss DNR issues with patients and situations involving surrogate decision making are considered major obstacles to obtaining a DNR order. Procedural regulations, including abundant paperwork and witnessed signatures, are not identified as major obstacles., Conclusions: This study suggests a need for improved communication among physicians, patients, and surrogates about advance directives, when feasible, either prior to hospitalization or early in its course, in an effort to comply with DNR legislation in a manner that reflects the patient's wishes and best interests.

The prevalence of tuberculous infection in residents of a large nursing facility in New York City was assessed. The population was predominantly female (80%) and white (86%), with almost one-half (49%) being foreign born. The mean age of the group was 86.1 years. Four hundred and fifty-five residents were given tuberculin skin tests using the two-step Mantoux test procedure. The prevalence of tuberculous infection was 27.5% with only slight differences being noted between the native-born (28.8%) and foreign-born (26.1%) residents. A 10% booster effect was noted. Tuberculous infection rates were higher in non-white than white residents. A progressive decline in the prevalence of tuberculous infection was noted with increasing age. No cases of tuberculosis were detected. Our study provides a model for collecting and evaluating epidemiologic data to assess infection prevalence and tuberculosis transmission in a long-term care facility.

The terminal phase of dementia is initiated by the inability to swallow. New techniques of enteral alimentation permit more effective, longer intubation. To assess the application of these new techniques to late-stage demented aged patients, all current intubations in a teaching nursing home were reviewed. Of 52 feeding intubations, 26 had been in situ for more than 1 year. A randomly selected comparison group of nonintubated patients was also studied. Weight increased for 48% of the intubated group versus 17% of the nonintubated group (P less than .01). Aspiration pneumonia occurred more often in the intubated group (58%) than in the nonintubated group (17%) (P less than .01). Decubitus ulcers were also more common in the intubated group (21%) than in the nonintubated group (14%). Restraints were used more in the intubated group (71%) than in the nonintubated group (56%). These differences did not reach statistical significance. All of the intubated patients were severely demented, with MMSE scores of zero. Seventy-one percent of the nonintubated group were demented, with MMSE scores of less than 23. Prolongation of the terminal phase of dementia in the aged by tube feeding is now feasible. The implications of this change in the life-span of demented nursing home patients need attention by families, nursing homes, and those who make public health policy.

To assess the utility of bedside diagnostic measures to detect prognostically significant peripheral vascular disease, we examined 60 nursing home residents by physical examination, Doppler sphygmomamometry and pneumatic oscillometry, and recorded the clinical history. Eighty-eight percent of the cases had tibial/brachial arterial systolic pressure indices below 0.95, the lower limit traditionally considered normal. Yet, no more than 5% of the patients carried a previous diagnosis of peripheral vascular disease or had intermittent claudication, leg ulcers or gangrene. Approximately half of the patients had tibial/brachial pressure indices less than 0.7, and one year later in these cases, there was significantly greater morbidity and nearly twice the mortality of patients with less severe disease. We conclude that simple bedside diagnostic tests of arterial disease used in this study discloses a high prevalence of disease in institutionalized elderly patients and identifies a group at particular risk for morbid complications.

A case-control study of patients ranging in age from 52 to 88 years was done to determine any possible relationship between health factors and senile macular degeneration. Thirty cases and 30 controls were pair-matched according to age, sex, and race. Chart reviews and telephone interviews were the methods of data collection used. The patients were interviewed concerning a history of vascular disease and other health characteristics. The data were analyzed by a paired-sample method. The results of the study showed a definite relationship with age and sex. Moreover, a significant relationship between refractive error and senile macular degeneration was noted. Such an association has not been previously reported. No relationship was found between vascular disease and senile macular degeneration.

We evaluated 4 treatment regimens using single and multiple injections of epinephrine for the initial treatment of acute asthma in children. Twenty-five patients received 2 injections of epinephrine followed by Sus-Phrine (Group EES) given 20 min apart, 25 received Sus-Phrine only (Group S), 24 received Sus-Phrine followed by 2 placebo injections 20 min apart (Group SPP), and 14 received epinephrine only (Group E). Clinical score and pulmonary function were assessed over a 2-h period. The failure rate was similar in Groups EES, S, and SPP (combined failure rate, 17.8%). The failure rate (46%) in Group E was significantly greater (p less than 0.05). The clinical score and pulmonary function was significantly better 5 min after the first injection in Group EES than in Groups S and SPP, but no significant differences were noted thereafter. At 25 min the pulmonary function was similar whether 1 or 2 epinephrine injections were administered. The number of patients exhibiting side effects was significantly greater in the groups receiving epinephrine than in the groups receiving Sus-Phrine only (p less than 0.05). The relapse rates during the 24-h period after the emergency room treatment were similar in Groups EES, S, and SPP (combined relapse rate, 14.3%). We conclude that repeated injections of epinephrine are necessary to sustain bronchodilation but that they do not have a cumulative effect. Furthermore, there is little therapeutic advantage of these repeated injections over a single injection of Sus-Phrine for the initial treatment of acute asthma.

The relation between mode of therapy and mortality rate and incidence of primary ventricular fibrillation was studied in 265 patients with diabetes mellitus and acute myocardial infarction. Sixty patients were being treated with diet only, 54 were receiving insulin and 151 were taking oral hypoglycemic agents. Fourteen patients (5.3 percent) had primary ventricular fibrillation, and all but one died. No statistically significant association was found between the incidence of primary ventricular fibrillation and the type of treatment for diabetes mellitus. Sixty-four (24.2 percent) of the 265 patients died during hospitalization. Mortality was greater among diabetic patients receiving oral therapy. However, after adjusting for age and sex, the difference among these three treatment regimens did not reach the P less than 0.05 level of significance.

Three hundred sixty-three patients representing two groups of consecutive medical admissions to a large city hospital were evaluated on admission to determine what factors might predict "non-medical" or social stay. Periodic follow-up determined when patients were ready for discharge and when their social stay began. A composite index, the 4-Score, was derived as a simple indicator of risk for subsequent social stay; it is defined as the number of positive answers to the questions: 1) Is the patient 80 years old or more? 2) Will the patient have to live somewhere new at discharge? 3) Is there any disorientation? AND 4) If so, is the disorientation chronic? Eighteen per cent of the total inpatient hospital days of this group of patients could be attributed to social stay. The 56 patients with a 4-Score of two or more on admission had on average a week each of social stay while the 307 patients with a score of less than two averaged only one social day each.

A cohort of 126 third-year medical students was followed for a year by means of self-administered questionnaires at the end of major clinical clerkships to ascertain the frequency and duration of the symptoms of their minor illnesses. Students reported an average of 4.36 illnesses per person per year, more than 80 percent of which were upper respiratory episodes. The absenteeism rate was 2.1 days per student per year. A highly significant association between the illness rate and the pediatric clerkship was documented; a less significant seasonal trend of more upper respiratory illnesses in winter than in other seasons was also observed.

Analysis of disease-free survival rates in 374 women with operable breast cancer revealed that preoperative weight, particularly in combination with serum cholesterol, is a significant prognostic determinant. Overall, women weighing under 150 pounds had a significantly higher cumulative five-year disease-free survival rate (67%) compared with women weighing more (49%) (z = 2.2298, P = 0.026). Women with low serum cholesterol levels had better cumulative five-year disease-free survival (67%) than women with high serum cholesterol levels (58%) (z = 1.1008, P = 0.27). The combination of high weight and high serum cholesterol levels was associated with an extremely poor cumulative five-year disease-free survival (32%) compared with that observed for women in whom values of either, or both, variables were low (68%) (z = 3.7843, P = 0.0004). These patterns in disease-free survival persisted even after controlling for tumor stage. The findings indicate that weight and cholesterol, in addition to their previously reported effect on the risk of breast cancer development, influence significantly the subsequent course of the disease.

High school biology students participated in a cardiovascular nutrition education program. The program was evaluated for its effect on the student's knowledge, attitudes, reported eating behavior, and serum lipid levels by matching individual's pre-and post-program results. There was a significant improvement in cardiovascular nutrition knowledge and attitudes toward a low cholesterol pattern of eating. There was also a signigicant improvement in reported eating patterns. However, the rise in serum cholesterol levels one year later did not differ from the rise in serum cholesterol levels in a control school. Improvement in attitudes and reported eating behavior was significantly greater for students whose initial cholesterol level was in the upper quartile of U.S. 16-year olds.

In evaluating these trends in the East-West comparison, one notes that the epidemiologic features connoting high risk are similar in both cultures; while they are more common in the West, they are more strongly associated in the East. Clearly, a prospective interview method of obtaining reproductive data will be more informative for such a crosscultural study with greater numbers lending better support. In summary, there exists a grouping of reproductive phenomena fairly common in Western societies that are related to higher risk for endometrial cancer, and we have noted similar characteristics in Eastern women who have developed this disease, while control groups in Eastern societies where this disease is uncommon have a low profile for such attributes in comparison to the West.

Recent studies have suggested an adverse impact on disease progression and survival in patients with prostatic cancer who undergo transurethral resection (TURP). Four hundred fifteen patients with prostatic carcinoma were reported to a Tumor Registry from 1965 to 1971. Of these, 184 charts had sufficient follow-up data to assess the impact of TURP in each stage of prostatic cancer. In Stage A the five-year survival difference between the TURP group (87.5%) and the open prostatectomy group (88%) was not significant (P = 0.54). In Stage B the five-year survival difference between the TURP group (38.7%) and the needle biopsy group (68%) was significant (P = 0.02). In Stages C and D there was no significant difference in survival between the TURP group and the needle biopsy group (P = 0.44 and P = 0.2, respectively). Our data reinforce the importance of diagnosing Stage B prostatic cancer preoperatively when curative treatment modalities may be utilized and TURP avoided. Finally, in advanced stages TURP may be efficacious in relieving prostatic obstruction while not adversely influencing survival.

A double-blind, placebo-controlled trial of single doses of thyrotropin releasing hormone (TRH) was performed on 12 patients with amyotrophic lateral sclerosis. Each patient was given subcutaneous injections of TRH 150 mg or placebo, and IV infusions of TRH 500 mg or placebo at 72- to 96-hour intervals. Eight motor and functional ratings were scored at regular intervals after each injection. Side effects were seen in all patients and were obvious to patients and examiners, making true blinding impossible. Nevertheless, statistically significant improvement was seen only in dynametric strength 1 hour after subcutaneous injection (p less than 0.05). Significant improvement occurred, in one patient only, on subjective speech testing during IV infusion of TRH. In none of six other ratings was there a significant difference between TRH and placebo. Subjective improvement was noted by 11 of 12 patients.

An investigation was conducted to examine the validity of self reported work histories obtained from a sample of 326 capacitor manufacturing workers who had participated in an epidemiological study relating health abnormalities to exposure to polychlorinated biphenyls. Based on objective personnel records obtained for 288 members of the sample group, validity scores ranged from 20% to 100% with most falling between 70% and 75%. This validity range corresponded to misclassification proportions ranging from 13% to 29%. Exposure misclassification tended to be random for men but non-random for women (overestimation of exposure). By means of multiple regression analysis, the diversity of the job categorical pattern was found to be a significant independent predictor of validity. The factors sex, duration, and time lapse were also significant validity predictors but only interactively with job diversity. There were also indications that interviewer skill could be an important factor. Knowledge of the magnitude of these factor effects could be critical in planning retrospective epidemiological studies.

ALS is the most common of the various MNDs, which also include the clinical entities of PBP, PMA, and PLS. Mean age of onset of ALS is 57 years, and there is a sex predilection for men in a ratio of 1.5:1. Area of first symptom is in the lower extremity is 36 per cent of cases, in the upper extremity in 32 per cent, and 25 per cent of patients have a bulbar onset. Motor cranial nerves in the lower brain stem from cranial nerve nuclei or corticobulbar tract degeneration are affected. This results in symptoms of speech and swallowing difficulty and emotional lability in up to 60 per cent of cases. One hundred per cent of cases have motor weakness, over 90 per cent have muscle atrophy and fasciculations, and 47 per cent have spasticity. There seems to be a pattern of progression of ALS signs and symptoms based on area of onset with LLE involvement tending to follow RLE weakness, LUE weakness following RUE onset, and RUE involvement following next in patients whose onset is bulbar. Significant numbers of ALS patients had sparing of involvement of parts of the body for follow-up times approaching 3 years. Although the majority of patients experience a deterioration that is significantly linear, seven of 28 patients or 25 per cent achieved a plateau lasting a minimum of 9 months. Survival in our series was 4.08 years for all forms of MND.(ABSTRACT TRUNCATED AT 250 WORDS)