Why gender is a barrier to contraception advice

In the UK, the Contraceptive Education Service is attempting to place contraception services on the health care agenda for all health providers dealing with heterosexual and bisexual men. Contraceptive education can prompt men to take more responsibility for contraception. Recent surveys indicate that the taking of sexual histories varies not only from clinic to clinic but also among various practitioners working in the same clinic. An observational study revealed that contraceptive information was not displayed in a third of general practitioners' offices and 10% of family planning and sexual health clinics. While good reasons may exist for keeping the information under the counter, clients have expressed a desire for printed information that they can take home to read. Sexual health clinics (formerly called "genito-urinary" clinics) are being targeted as one of the best places to reach sexually active men. Currently inequalities exist between what female and male patients are asked. For example, men are not asked how many unwanted pregnancies they have caused. Nurses have a special role in health education because they are perceived to be more approachable than physicians. While nurses discuss condom use whenever they have the opportunity, most feel that schools are the best place for sexual health education. The nurses also felt that, whereas most men have no need for information about oral contraceptive usage, information on emergency contraception may prove valuable. One clinic is using new forms to take sexual histories and prompt providers to cover topics such as safer sex and risk reduction.     

Viagra: what every physician should know

Viagra, an oral drug taken one hour prior to sexual activity, improves erectile function in the majority of men with erectile dysfunction who receive it. It is not an aphrodisiac and therefore will not work without sexual stimulation. The drug is absolutely contraindicated in patients on organic nitrates, as this combination can lead to severe drops in blood pressure. Patients with heart disease, suspected heart disease and risk factors for heart disease should discuss with their physicians the safety of resuming sexual activity. A cardiac work-up, including exercise treadmill testing, should be considered in appropriate patients.     

Young adolescents' comfort with discussion about sexual problems with their physician

OBJECTIVE: To identify factors associated with young adolescents' sense of comfort about discussing sexual problems with their physician. DESIGN: Confidential, assisted self-report questionnaires on physician-adolescent communication developed by the investigators and completed by participants at visits for general health examinations. SETTING: Five primary care pediatric practices at health maintenance organizations in Washington, DC. PATIENTS: A consecutive sample of all adolescents 12 to 15 years old who received a general health examination. Of 412 eligible patients, 221 received parental consent and participated. MAIN OUTCOME MEASURE: Adolescents' sense of comfort about talking to their physician about a sexually transmitted disease or some other sexual problem. This outcome was chosen for a substudy of a larger longitudinal prevention trial. RESULTS: Most adolescents valued their physicians' opinions about sex (89%) and said it was easy to talk to the physician during their visit (99%), but about half said they would be uncomfortable talking to the physician if they had a sexually transmitted disease or some other sexual problem (43%) [corrected]. Adolescents' sense of comfort was greater when physicians discussed sexual issues in the general health examination, adolescents perceived their personal risk of sexually transmitted disease to be high, adolescents had high self-esteem, and physicians were adolescents' usual physicians. CONCLUSIONS: This study emphasizes the need for physicians to discuss sexual risks with young adolescents and suggests ways physicians can help young adolescents feel more comfortable talking with them about sexual concerns.     

Sexual dysfunctions with antidepressive drugs--results of a physician survey

In a survey throughout Switzerland 7.455 general practitioners and psychiatrists were mailed a questionnaire addressing topics in sexual medicine with regard to antidepressant medication, 940 completed questionnaires (response rate 12.5%) were evaluated. 77.6% of the responders agree that knowledge in sexual medicine is important or very important. Only one half of the physicians judge their competence in sexual medicine as fair or good. There are differences in sexual history taking between general practitioners and psychiatrists; the latter addressing more frequently sexual medicine related questions. Sexual dysfunction before and during therapy with antidepressants is observed less frequently than reported in other studies. Only half of the physicians counsel their patients when sexual dysfunction occur during therapy. Treatment strategies of antidepressant induced sexual side effects are rarely seen. The results emphasize the importance of knowledge and competence in sexual medicine for general practitioners and psychiatrists, both showing interest in continuing education on this topic.     

RO 48-6791--a short acting benzodiazepine. Pharmacokinetics and pharmacodynamics in young and old subjects in comparison to midazolam

PURPOSE: Men with epilepsy appear to have an approximately fivefold increase in risk of erectile dysfunction (ED). We attempted to determine whether ED in men with epilepsy was due to a physiological basis and whether erectile function could be adequately evaluated with an ambulatory nocturnal penile tumescence and rigidity monitor. METHODS: The physiologic integrity of the sexual response in men with epilepsy and ED was assessed with an ambulatory nocturnal penile tumescence and rigidity monitor (NPTR). Six men with localization-related epilepsy of temporal lobe origin (TLE) and ED, 2 men with TLE and normal sexual function, and 1 man with nonepileptic seizures (NES) and ED underwent evaluation of nocturnal erections for at least 2 nights. RESULTS: Five of 6 men with TLE and complaints of ED had abnormal ambulatory NPTR evaluations. All others had normal ambulatory NPTR. All abnormal evaluations showed reduced levels of rigidity, often with normal levels of tumescence. CONCLUSIONS: Previous studies have shown this abnormal ambulatory NPTR pattern to be associated with neurogenic rather than vasogenic ED. Therefore, epilepsy-related ED may have a substantial neurophysiologic component.     

Asian blepharoplasty with a short-pulsed contact Nd-Yag laser: limited-incision resectable laser double fold with internal medial and lateral functional epicanthoplasty

PURPOSE: To determine how often primary care physicians screen adolescents for important risk factors and to determine how rates of screening vary by physicians' specialty and practice setting, patients' age, and type of risk factor. METHODS: A stratified random sample of 343 California physicians who are Board certified in pediatrics, family practice, or internal medicine, and physicians in these specialties who specialized in adolescent medicine were surveyed about their screening practices using a mailed questionnaire. Subjects were asked the percentage of routine comprehensive physical examination during which they personally queried or screened each age group of adolescents (11-14 years old and 15-18 years old) for each of the following risk factors: high blood pressure, alcohol use, cigarette use, sexual activity, and drug use. RESULTS: The frequency with which primary care physicians reported actually screening younger and older adolescents for the various risks were approximately: 93% and 96% for high blood pressure, 70% and 84% for alcohol use, 74% and 82% for drug use, 67% and 83% for sexual activity, and 76% and 86% for smoking, respectively. For all risk factors, providers screened older adolescents more frequently than younger adolescents (p < 0.01). Finally, screening rates varied by specialty (p < 0.01) but not by practice setting. CONCLUSIONS: This study found that California physicians frequently screen adolescents for a variety of risk factors. However, the reported rates may not be consistent with published guidelines. Interventions may need to be developed which focus on improving primary care physicians' adolescent-specific screening practices.     

Prevention of violence

Primary care physicians can easily incorporate efforts toward the primary and secondary prevention of family violence into their practices. By designing a preventive effort using the phases of the family life cycle, a developmentally appropriate system of prevention is created. The anticipatory guidance at each (annual) visit acknowledges family transitions and assures the family that abuse is a health issue and that the physician is a resource for issues of violence prevention. Using the FLC, the first phase is Coupling, when there is a risk of partner violence that continues as long as there is a partnership. Pregnancy and childbirth bring concerns of child neglect and battery. Older children are at additional risk for child sexual abuse. As families age, risks develop for elder abuse, too. The regular discussion of these issues raises the awareness that the potential for family violence continues over the life span and allows the physician opportunities to assess the risk of violence in that family and make appropriate preventive referrals. Primary care physicians are optimally positioned to address violence and its prevention in the office: they know and care for family units over time. Physicians are respected and trusted advisors who can become effective in preventing violence.     

Angiocardiographic digital still images compressed via irreversible methods: concepts and experiments

OBJECTIVE: Primary care occupies a strategic positive in the evaluation, treatment, and prevention of the mental disturbances of later life. This article highlights four themes that are crucial to understanding mental disturbances among older adults: 1) subsyndromal depression, 2) coexisting depression and anxiety, 3) comorbidity of depression and chronic medical conditions, and 4) risk factors for cognitive impairment. METHOD: The literature was selectively reviewed for each theme to ask the central question, "What can primary care physicians learn about mental disturbances of their older patients from epidemiologic and community studies?" RESULTS: The primary care setting itself is an important venue for an examination of aging issues and mental health. Workers in the "middle ground of psychiatric epidemiology"--primary health care--have not yet reached a full appreciation for the value of research in the primary care setting for enhancing our understanding of the mental disturbances of late life, and how these intersect with other salient factors. CONCLUSIONS: Primary care physicians and others who work in primary care should advocate for further mental health integration and research in primary care. Research is needed that will lead to new ways of maximizing the health and quality of life of older adults and their families.     

Laser-assisted hair removal

Primary care physicians continue to play an important role in preventing HIV transmission by targeting messages to their high-risk patients. The risk of HIV transmission cannot be eliminated entirely; however, clinicians have a variety of prevention interventions at their disposal. Behavioral and therapeutic interventions offered in a client-centered environment have the greatest chance of success. Patients can benefit from individualized prevention plans that decrease risk by treating drug addiction and by modifying sexual and drug-taking behaviors. The risk of HIV infection in health care workers can be reduced by strict adherence to universal precautions and the use of postexposure antiretroviral therapy.     

The distribution of visual attention in infants

This article compares the social and health characteristics of patients of five kinds of practitioners: family physicians (used as a baseline group); chiropractors; acupuncturist/traditional Chinese medicine doctors; naturopaths; and Reiki practitioners. The data were gathered in a large Canadian city during the period 1994 to 1995. Face-to-face interviews were conducted with 300 patients (60 from each type of treatment group). While the most striking social and health differences occur between patients of family physicians and the patients of alternative practitioners, significant differences are also evident between the different groups of alternative patients. Reiki patients, for example, have a higher level of education and are more likely to be in managerial or professional positions than other alternative patients. The profiles presented here indicate that users of alternative care should not be regarded as a homogeneous population. The findings also show that almost all alternative patients also consult family physicians. The pattern revealed is one of multiple use: patients choose the kind of practitioner they believe can best help their particular problem.     

Influence of salt concentration on the cellular fatty acid composition of the moderately halophilic bacterium Halomonas salina

CONTEXT: Little is known about the problems physicians may be encountering in gaining access to managed care networks and whether the process used by managed care plans to select physicians is discriminatory. OBJECTIVE: To investigate the incidence and predictors of denials or terminations of physicians' managed care contracts and the impact these denials and terminations had on primary care physicians' involvement with managed care. DESIGN: Cross-sectional mail survey of a probability sample of primary care physicians. SETTING: A total of 13 large urban counties in California. PARTICIPANTS: Primary care physicians (family practice, internal medicine, obstetrics and gynecology, or pediatrics) who work in office-based practice. MAIN OUTCOME MEASURES: Denial or termination from a contract with an independent practice association (IPA) or health maintenance organization (HMO) and managed care contracts. RESULTS: Of the 947 respondents (response rate, 71%), 520 were involved in office-based primary care. After adjusting for sampling and response rate, 22% of primary care physicians had been denied or terminated from a contract with an IPA or HMO, but 87% of office-based primary care physicians had at least 1 IPA or direct HMO contract. Solo practice was the strongest predictor of having experienced a denial or termination and of having neither an IPA nor a direct HMO contract. Physician age, sex, and race did not predict the level of involvement with managed care. However, physicians' patient demographics were associated with managed care participation; physicians in managed care had significantly lower percentages of uninsured and nonwhite patients in their practices. Physicians experiencing a denial or termination had fewer capitated patients in their practice. CONCLUSIONS: Denials and terminations, although relatively common, do not preclude most primary care physicians from participating in managed care. Managed care selective contracting does not appear to be systematically discriminatory based on physician characteristics, but it may be biased against physicians who provide greater amounts of care to the underserved.     

Gender, quality of life, and mental disorders in primary care: results from the PRIME-MD 1000 study

BACKGROUND: Recently there has been increased interest in the special mental health needs of women. We used data from the PRIME-MD 1000 study to assess gender differences in the frequency of mental disorders in primary care settings, and to explore the potential impact of these differences on health-related quality of life (HRQL). SUBJECTS AND METHODS: One thousand primary care patients (559 women) were interviewed during the PRIME-MD study, which was conducted at four primary care clinics affiliated with university hospitals throughout the eastern United States. Patients completed a one-page questionnaire in the waiting room prior to being seen by the physician; patients and physicians then completed together a clinician evaluation guide that used DSM-III-R algorithms to diagnose mood, anxiety, somatoform, eating, and alcohol related disorders. Health-related quality of life was assessed with the Medical Outcomes Study SF-20 General Health Survey. RESULTS: Women were more likely than men to have at least one mental disorder (43% versus 33%, P < 0.05). Higher rates were particularly prominent for mood disorders (31% of women versus 19% of men, odds ratio [OR] = 1.9, 95% confidence interval [CI] 1.4 to 2.6), anxiety disorders (22% versus 13%, OR = 1.9, CI = 1.3 to 2.8), and somatoform disorders (18% versus 9%, OR = 2.2, CI = 1.5 to 3.4). Psychiatric comorbidity was also more common in women (26% of women had two or more mental disorders versus 15% of men, P < 0.05). Unadjusted HRQL scores, ranging from 0 to 100, with 100 = best health, were all significantly lower in women than in men (eg, physical function = 67 in women versus 76 in men, P < 0.0001; mental health = 69 in women versus 76 in men, P < 0.0001). Many HRQL differences persisted after controlling for age, education, ethnicity, marital status, and number of physical disorders; however, differences in HRQL were eliminated in 5 of 6 domains after controlling for number of mental disorders. When compared with female patients of male physicians, female patients of female physicians demonstrated similar satisfaction with care, health care utilization, HRQL, and recognition rate of mental disorders. CONCLUSIONS: In the 1,000 patients of the PRIME-MD study, mood, anxiety, and somatoform disorders and psychiatric comorbidity were all significantly more common in women than men. The HRQL scores were poorer in women than men, although most of this difference was accounted for by the difference in prevalence of mental disorders. These data suggest that one of the most important aspects of a primary care physician's care of female patients is to screen for and treat common mental disorders.     

Intimacy and quality of life among sexually dysfunctional men and women

This study evaluated the associations between intimacy, quality of life, and sexual dysfunction in men and women. Participants were 145 sexually functional (43 men, 102 women) adults drawn from the general population and 198 sexually dysfunctional (114 men, 84 women) adults who came to a university sexual behavior clinic. All respondents were currently involved in a heterosexual relationship. Respondents completed a series of questionnaires to evaluate the level of intimacy in their relationships, their quality of life, and their level of sexual dysfunction. All aspects of intimacy were lower among sexually dysfunctional men than among sexually functional men for all subgroups of dysfunctionality (premature ejaculation, erectile failure, and lack of sexual desire). Levels of intimacy were less likely to discriminate between functional and dysfunctional women, with functional women only obtaining higher intimacy scores than each of the dysfunctional groups of women (inorgasmia, lack of arousal, lack of sexual desire) for social intimacy and recreational intimacy and, to a lesser extent, for sexual intimacy. Objective levels of quality of life as well as the satisfaction and importance of the quality of life domains were more likely to be lower when sexually dysfunctional women were compared with their functional counterparts than when sexually dysfunctional men were compared with their functional counterparts. The implications of these findings for an understanding of factors that contribute to sexual dysfunction, and the treatment of these disorders, is discussed.     

Withholding medical care as a physical injury--homicide from the viewpoint of the physician

Limitation and termination of intensive care and in particular life support in patients who do not have a chance to recover from their illness has become a widely accepted approach in intensive care medicine. In well defined situations, life support can be withheld or withdrawn without the risk of becoming a criminal case. Frequently, the physician must base his/her decision on the presumed will of the patient which can be difficult to assess. Existing guidelines of the Society of physicians of Germany, which are partly preliminary, are helpful for the decision process of the physicians as well as of the relatives of the patients.     

Physician's attitudes toward the ill aged and nursing homes

A survey of physicians in private practice (exclusive of pediatricians) was conducted in a medium sized suburban city in the New York metropolitan area, to determine whether physicians' attitudes toward the ill aged and nursing homes were predictors of the quality of medical care available to area nursing home patients. Questionnaires were circulated to 302 practitioners. Of the 28 percent who responded, 32 percent were psychiatrists, 15 percent primary care physicians and 8 percent orthopedists. Physicians felt competent to manage the ill aged, although 50 percent had had no significant degree of exposure to geriatric medicine in their medical education, and 70 percent of the primary care group had had none. Primary care and older physicians were more likely to treat patients in nursing homes. Almost 40 percent viewed the nursing home as a place to die. Although 85 percent studied that physicians should be involved in the nursing home displacement process, only 21 percent believed that they continued to be in charge of their patients after placement. The findings demonstrate generalized medical disinterest in the care of ill aged patients in institutions. The persons responsible for awarding government grants and those involved in planning medical school curricula should pay more attention to the needs of the chronically ill aged.     

A relationship between childhood sexual abuse and professional sexual misconduct.

This article identifies specific factors that place therapists at risk for engaging in sexual activity with clients and provides guidelines to minimize the likelihood of such behavior. In a national, randomly drawn sample of 323 mental health practitioners, 3 of 5 men who reported severe childhood sexual abuse and whose psychological symptoms met the criteria for a high degree of psychological distress reported sexual boundary violations with clients. High-risk clinicians should avoid the isolation of private practice, closely monitor their boundaries with clients, obtain ongoing professional supervision, and seek personal psychotherapy to address any remaining abuse-related issues. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Bioethics for clinicians: 14. Ethics and genetics in medicine

Information about a patient's inherited risk of disease has important ethical and legal implications in clinical practice. Because genetic information is by nature highly personal yet familial, issues of confidentiality arise. Counselling and informed consent before testing are important in view of the social and psychological risks that accompany testing, the complexity of information surrounding testing, and the fact that effective interventions are often not available. Follow-up counselling is also important to help patients integrate test results into their lives and the lives of their relatives. Genetic counselling should be provided by practitioners who have up-to-date knowledge of the genetics of and the tests available for specific diseases, are aware of the social and psychological risks associated with testing, and are able to provide appropriate clinical follow-up. Some physicians may elect to refer patients for genetic counselling and testing. However, it is inevitable that all physicians will be involved in long-term follow-up both by monitoring for disease and by supporting the integration of genetic information into patients' lives.     

Common pediatric dental problems

Physicians who provide primary care for children have a unique position to provide diagnostic, triage, educational, and preventive dental care for patients. Several papers have been published regarding primary pediatricians' participation in the preventive dental health care of their patients. One publication, a survey of physicians in Alabama focusing on physicians' overall awareness of dental issues, concluded that most physicians believe they have a role in the oral health of their patients, yet most were not aware of the American Academy of Pediatric Dentistry's recommendations. Most physicians report that they routinely perform oral examinations during physical examinations of children and deliver preventive, oral information by the age of 6 months or earlier; however, most recommend that infants' first visit should be at 3 years of age, not at the time of first-tooth eruption as the authors recommend. Furthermore, many primary care physicians do not talk about oral health during prenatal counseling. Many physicians understand the preventive advantages of fluoride, yet most do not prescribe vitamin combinations that contain fluoride. If an understanding of the aforementioned issues of dental care, as well as aspects of preventive care in infants and children, become more uniform among primary care physicians, the prevention-based practice of pediatric dentistry will become much more successful, and children and adults will enjoy better dental health.     

Rating the appropriateness of coronary angiography--do practicing physicians agree with an expert panel and with each other?

BACKGROUND: Evaluations of the appropriateness of medical care are important to monitor the quality of care and to contain costs and enhance safety by reducing inappropriate care. Experts' views are usually incorporated into evaluations of appropriateness. However, practicing physicians may not concur with these views, and physicians' clinical backgrounds may influence their beliefs. METHODS: We asked 1058 internists, family practitioners, and cardiologists in California, Florida, New York, Pennsylvania, and Texas to rate the appropriateness of coronary angiography after acute myocardial infarction for 20 common indications. Nine clinical experts also rated these indications using an established consensus method. RESULTS: For 17 of the 20 indications, median ratings of surveyed physicians and the expert panel agreed within 1 unit on a 9-unit scale. Patients' older age had a negative effect on ratings by the expert panel but not on ratings by surveyed physicians. In multivariable analyses of surveyed physicians, cardiologists rated angiography as significantly more appropriate than did primary care physicians for complicated indications, and for uncomplicated indications cardiologists who performed invasive procedures gave higher appropriateness ratings for angiography than did cardiologists who did not perform such procedures and primary care physicians. For uncomplicated indications, physicians from hospitals providing coronary angioplasty and bypass surgery rated angiography as more appropriate than physicians from other hospitals. Physicians from New York and those employed by health maintenance organizations rated angiography as less appropriate than other physicians. CONCLUSIONS: Surveyed physicians agreed with clinical experts about the appropriateness of coronary angiography after myocardial infarction for most indications, indicating that well-designed expert panels can closely reflect the views of practicing physicians. Variations in beliefs among practicing physicians suggest that evaluations of medical practice should incorporate the views of a range of relevant types of physicians.