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Context: The US primary care safety net is composed of a loose network of community health centers, hospital outpatient departments, and physicians' offices. National data on how the mix of patients and services differ across sites are needed.Objective: To develop and contrast national profiles of patient and service mix for primary care.Design, Setting, and Patients: Comparative analyses of 3 national surveys of primary care visits occurring in 1994: for data on physician's office visits, the National Ambulatory Medical Care Survey (NAMCS); for hospital outpatient department data, the National Hospital Ambulatory Medical Care Survey (NHAMCS); and for data on community health centers, the Bureau of Primary Health Care's 1994 Survey of Visits to Community Health Centers. A time trend analysis also was conducted using the 1998 NAMCS and NHAMCS.Main Outcome Measures: National estimates of primary care visit rates, types of patient presentation, patient case-mix, disposition of patients, and management interventions in 1994, and compared with 1998 data.Results: The US population made 1.3 primary care visits per person in 1994, which accounted for 43.5% of all ambulatory visits to physicians' offices, community health centers, and hospital outpatient departments. Primary care visits per person were 20% lower for Hispanics and 33% lower for black, non-Hispanic persons compared with white, non-Hispanic persons. Visits to community health centers were more likely to be made by ethnic minorities, patients with Medicaid or no insurance, and rural dwellers than visits made to the other delivery sites. Visits at hospital outpatient departments were made by sicker populations and were characterized by less continuity than the other delivery sites. Controlling for patient mix, visits made to hospital outpatient departments were more commonly associated with imaging studies, minor surgery, and specialty referrals than those made to physicians' offices. In 1998, the US population made an estimated 3. 4 visits per person, 45.6% of which were primary care visits. National estimates of primary care visit rates and patient mix and practice pattern comparisons between hospital outpatient departments and physicians' offices were similar in 1998 and 1994.Conclusions: Expanding community health centers will likely improve access to primary care for vulnerable US populations. However, enhancing access to of physicians' offices is also needed to bolster the safety net. The greater service intensity and poorer continuity for primary care visits in hospital outpatient departments that we observed raises concern about the suitability of these clinics as primary care delivery sites. JAMA. 2000;284:2077-2083. [ABSTRACT FROM AUTHOR]

Background: There are public concerns regarding OxyContin (Purdue Pharma, Canada) and charges within the pain medicine community that media coverage of the drug has been biased., Objective: To analyze and compare representations of OxyContin in medical journals and North American newspapers in an attempt to shed light on how each contributes to the 'social problem' associated with OxyContin., Methods: Using searches of newspaper and medical literature databases, two samples were drawn: 924 stories published between 1995 and 2005 in 27 North American newspapers, and 197 articles published between 1995 and 2007 in 33 medical journals in the fields of addiction/substance abuse, pain/anesthesiology and general/internal medicine. The foci, themes, perspectives represented and evaluations of OxyContin presented in these texts were analyzed statistically., Results: Newspaper coverage of OxyContin emphasized negative evaluations of the drug, focusing on abuse, addiction, crime and death rather than the use of OxyContin for the legitimate treatment of pain. Newspaper stories most often conveyed the perspectives of law enforcement and courts, and much less often represented the perspectives of physicians. However, analysis of physician perspectives represented in newspaper stories and in medical journals revealed a high degree of inconsistency, especially across the fields of pain medicine and addiction medicine., Conclusion: The prevalence of negative representations of OxyContin is often blamed on biased media coverage and an ignorant public. However, the proliferation of inconsistent messages regarding the drug from physicians plays a role in the drug's persistent status as a social problem.

Background: Potential health effects of the indoor environment in office buildings and aircraft have generated considerable concern in recent years., Aims: To analyse the prevalence of self reported respiratory symptoms and illnesses in flight attendants (FAs) and schoolteachers., Methods: Data were collected as part of a study of reproductive health among female FAs. The prevalences of work related eye, nose, and throat symptoms, wheezing, physician diagnosed asthma, chest illness, and cold or flu were calculated and stratified by smoking status in 1824 FAs and 331 schoolteachers., Results: FAs and teachers were significantly more likely to report work related eye (12.4% and 7.4 %, respectively), nose (15.7% and 8.1%), and throat symptoms (7.5% and 5.7%) than were other working women (2.9% eye, 2.7% nose, and 1.3% throat symptoms). FAs were significantly more likely than teachers and referent working women to report chest illness during the prior three years (32.9%, 19.3%, 7.2%, respectively). Both study groups were more likely to report five or more episodes of cold or flu in the past year than were other working women (10.2% of FAs, 8.2% of teachers, 2.3% of referents), and both groups were more likely to report wheezing than other working women (22.8% of FAs, 28.4% of teachers, 16.4% of referents). FAs were significantly less likely than teachers and other working women to report ever having been diagnosed with asthma (8.2%, 13.3%, 11.8%, respectively)., Conclusions: Overall, FAs and schoolteachers report a higher prevalence of work related upper respiratory symptoms, chest illness, and cold or flu than the general working population.

Background: Ethylene oxide (ETO) is a sterilant gas considered to be a human carcinogen, due primarily to excess hematopoietic cancer in exposed cohorts. ETO causes mammary tumors in mice, and has been associated with breast cancer incidence in one small epidemiologic study., Methods: We have studied breast cancer incidence in a cohort of 7576 women employed for at least one year and exposed for an average 10.7 years while working in commercial sterilization facilities. Breast cancer incidence (n = 319) was ascertained via interview, death certificates, cancer registries, and medical records. Interviews were obtained for 68% of the cohort., Results: The standardized incidence ratio (SIR) for incident breast cancer in the whole cohort using external referent rates (SEER) was 0.87 (0.77-0.97). The SIR for those in the top quintile of cumulative exposure, with a 15 year lag, was 1.27 (0.94-1.69), with a positive trend of increasing SIR with increasing exposure (p = 0.002). SIRs are underestimated because breast cancer incidence in the whole cohort was under-ascertained, due to incomplete response and lack of complete coverage by state cancer registries. In internal nested case-control analyses of those with interviews (complete cancer ascertainment), controlling for reproductive risk factors, a positive exposure-response was found with the log of cumulative exposure with a 15-year lag (p = 0.0005). The odds ratio by quintile of cumulative exposure were 1.00 (0 exposure due to 15 year lag), 1.06, 0.99, 1.24, 1.42, and 1.87., Conclusions: Our data suggest that ETO is associated with breast cancer, but a causal interpretation is weakened due to some inconsistencies in exposure-response trends and possible biases due to non-response and incomplete cancer ascertainment.

Studies of reproductive hazards in the workplace must address potential biases related to selection for employment. The National Natality Survey, a probability sample of live births to married women in 1980, was used to examine the relation between female employment during pregnancy and factors that might affect reproductive outcome by analyzing the 5,927 women with complete occupational data. Demographic and behavioral attributes as well as reproductive history were compared for the 3,712 women employed and the 2,215 women not employed during pregnancy. Employed mothers were of more optimal reproductive age, were more highly educated, had higher incomes, began prenatal care earlier, had greater weight gain during pregnancy, and were slightly less likely to be heavy smokers. Employed women had markedly fewer previous births and less favorable reproductive histories (more stillbirths, miscarriages, and induced abortions) than unemployed women, controlling for gravidity. Full- and part-time workers were similar with regard to demographic and behavioral characteristics, but part-time workers had higher parity. Differences were noted by employment sector: professional women had especially favorable demographic and behavioral traits, and women employed as operatives and service workers were less advantaged. These results indicate that substantial differences in pregnancy-related risk factors exist in relation to employment, with working women generally having more favorable demographic and behavioral characteristics and less favorable reproductive histories. This pattern could produce selection bias in studies of work and reproductive health, and it encourages the restriction of comparison groups to other employed women, with a need to consider heterogeneity among working women as well.

Historically, various interpretations of the menstrual process have been reflected in a wide, and usually negative, range of social attitudes toward menstruation. Recent clinical experience with continuation of the modern hormonal and mechanical methods of contraception that induce changes in the normal menstrual pattern suggests the need to understand current variations in attitudes and practices related to menstruation. This paper briefly outlines historical Western, Orthodox Jewish and Muslim, and contemporary US women's attitudes toward menstruation and begins to explore their relationship to contraceptive continuation.

Although fetal development is known to be sensitive to environmental agents, relatively little epidemiologic research has addressed this concern. Effects on pregnancy outcome of self-reported parental exposure to pesticides and to radiation were examined using data from the National Natality and Fetal Mortality Surveys, large national probability samples of live births and stillbirths occurring in 1980. In case-control analyses, maternal exposure to pesticides at home or work was associated with increased risk of stillbirth (odds ratios (ORs) = 1.5-1.6). Paternal pesticide exposure was associated with stillbirth (ORs = 1.2-1.4) and delivery of small-for-gestational-age infants (ORs = 1.4-2.0). A small increased risk of stillbirth (OR = 1.3) was found in relation to either parent's reported exposure to radiation. In spite of limitations in the quality of exposure data and the possibility of biased recall related to pregnancy outcome, associations of reported pesticide exposure to either parent with risk of stillbirth and small-for-gestational-age infants warrant further evaluation.

During the past year, several prominent voluntary health organizations and professional medical associations have called for a ban on all forms of promotion of tobacco products. The proposal raises complex issues, ranging from determination of the effects of tobacco promotion to assessment of the constitutionality of banning advertising of a legal product. We identify the issues that underlie the concern of health professionals, review evidence addressing these issues, and describe and discuss frequently mentioned policy options, especially the ban proposal.