Adverse Events After Discontinuing Medications in Elderly Outpatients.
T. Graves, et al. Archives of Internal Medicine 157 (October 27, 1997): 2205-10.

Most medications can be stopped in elderly outpatients without an adverse drug withdrawal event (ADWE), a clinically significant set of symptoms or signs caused by the removal of a drug. Practitioners should strive to discontinue drug therapy in the elderly but be vigilant for disease recurrence.

This study of 124 ambulatory elderly patients focused on the prevalence and consequences of discontinu-ing broad classes of medications in elderly outpatients. A total of 238 medications were discontinued be-cause of patient compliance, patient at risk or experiencing an adverse drug event, no indication, lack of efficacy, chronic medical condition stable, and reason unknown. Analysis of adverse events indicated that 62 drugs (26 percent) resulted in ADWEs among 38 patients. Thus, 74 percent of medications were discontinued with-out an ADWE. Drug classes most frequently associated with ADWEs were cardiovascular (42 percent) and central nervous system (18 percent). Twenty-six ADWEs (36 percent) re-quired hospitalization or emergency care. Because most ADWEs may be exacerbations of underlying diseases and can occur as long as 4 months after medication discontinuation, clinicians should carefully monitor patients for at least 4 months. In addition, certain drug classes, such as cardiovascular drugs, stand out as problematic in drug withdrawal.

AIDS Risk Behaviors, Knowledge, and Attitudes Among Pregnant Adolescents and Young Mothers.
D. Koniak-Griffin and M. Brecht. Health Education & Behavior 24 (October 1997): 613-24.

Intense and specialized AIDS/HIV educational programs, focused on sexuality issues and reducing sexual risk taking, need to be directed toward pregnant and parenting teens in alter-native schools and residential facilities.

This study assessed high-risk behaviors; basic understanding of AIDS/HIV, including HIV transmission and prevention; and related attitudes of 151 pregnant adolescents and young mothers. The sample was composed of adolescents recruited from six sites in the greater Los Angeles area: four school districts’ special programs for pregnant minors and young mothers in alternative or adult schools and two group homes. Findings suggest that adolescents who are pregnant or have given birth are at high risk for acquiring HIV and possibly transmitting the disease to their children. Knowledge about transmission was high, but the teens held common misconceptions about the spread of disease and preventive measures. Neither unplanned pregnancies nor knowledge of transmission motivated risk reduction.

Information presented in existing HIV education programs may be too general and not convince high-risk youth about the dangers of their behaviors. Educational programs for groups similar to this sample need to be personalized through experiential learning opportunities.

Herpes Simplex Virus Type 2 in the United States, 1976 to 1994.
D.T. Fleming, et al. The New England Journal of Medicine 337 (October 16, 1997): 1105-11.

Improvements in the prevention of herpes simplex virus type 2 (HSV-2) are needed, particularly since genital ulcers may facilitate the transmission of HIV.

A serologic survey of HSV-2 was conducted as part of the National Health and Nutrition Examination Surveys (NHANES) II (1976 to 1980) and NHANES III (1988 to 1994). In NHANES III, the seroprevalence of HSV-2 among study participants 12 years of age or older was 21.9 per-cent, which corresponds to 45 million infected people in the U.S. population. The age-adjusted overall prevalence of HSV-2 antibody rose from 16 percent in NHANES II to 20.8 percent in NHANES III, a relative increase of 30 percent. Seroprevalence quintupled in white teenagers and doubled among whites in their twenties. Women were about 45 percent more likely than men to be infected with HSV-2 because of the higher efficiency of HSV-2 transmission from men to women. Seroprevalence also was higher among blacks than whites. Less than 10 percent of those infected reported a history of genital herpes.

These results highlight the ongoing need to prevent HSV-2 and other sexually transmitted infections. In addition, improvements in the diagnosis and treatment of established HSV-2 infection may have some effect on the transmission of HSV-2, since sup-pressive therapy with antiviral medications has been shown to decrease viral shedding. New preventive techniques, such as the use of HSV-2 vaccines and topical microbicides now under development, are needed.

Postlicensure Effectiveness of Vari-cella Vaccine During an Outbreak in a Child Care Center.
H.S. Izurieta, et al. Journal of the American Medical Association 278 (18) (November 12, 1997): 1495-99.

Varicella vaccine administered under routine conditions in physicians’ of-fices is highly effective in preventing varicella in an outbreak characterized by intense exposure.

Varicella outbreaks can be disruptive to child care centers, cause significant morbidity, and create difficulties for parents because of the need to keep symptomatic children at home. Recent studies have suggested that the highest incidence rates for varicella are among children of preschool age.

This report describes epidemiologic and other features of cases of varicella among vaccinated children attending a child care center in DeKalb County, Georgia. Of the 184 children registered in the child care center, 148 children were eligible for the study based on absence of history of varicella before January 1, 1996. Eighty-one children (55 percent) developed varicella. Cases among children younger than 12 months were more severe than cases among older children. Varicella occurred in 9 (14 percent) of 66 vaccinated children and 72 (88 percent) of 82 unvaccinated children. Varicella was less severe and resulted in fewer days of absence from the child care center among vaccinated children. Varicella vaccine effectiveness against all forms of disease was 86 percent and against moderate to severe varicella disease it was 100 percent.

The effectiveness of postexposure administration of varicella vaccine as an outbreak control strategy should be studied. The role of asthma and other reactive airway diseases as risk factors for varicella disease and vaccine failure deserves to be investigated further.

The Relationship Between Patient Income and Physician Discussion of Health Risk Behaviors.
D.A. Taira, et al. Journal of the American Medical Association 278 (November 5, 1997): 1412-17.

To meet the recommendations of the U.S. Preventive Services Task Force (USPSTF), physicians must improve counseling on the health risk behaviors of alcohol consumption, safe sex, seat belt use, diet, exercise, and smoking.

Unhealthy behaviors were common among all income groups in a sample of 6,549 Massachusetts State employees, and physician discussion of health risk behaviors fell far short of the universal risk assessment and discussion recommended by the USPSTF. Low-income patients were more likely to be obese and smoke and were less likely to wear seat belts and exercise than high-income patients. Stress and alcohol consumption rose with income. Among patients most in need of discussion of health-related behaviors, physicians tended to discuss diet and exercise more with high-income than with low-income patients, yet they discussed smoking more with low-income patients. Low-income patients were more likely to initiate change based on the advice of their physicians.

Enhancing Mammography Use in the Inner City.
B.E. Weber and B.M. Reilly. Archives of Internal Medicine 157 (November 10, 1997): 2345-49.

A combination of interventions (reminder systems plus culturally sensitive case management by lay community health educators) enhances compliance with breast cancer screening among previously noncompliant women in inner cities.

In this randomized, controlled trial of six primary care practices, the authors compared the effect of two interventions on rates of mammography completion in women ages 52 to 77 who had not had a mammogram in the previous 2 years. Women in the physician intervention group (MD group) received a personalized letter from their primary care physician on practice letterhead reminding them they had not had a mammogram and advising them to do so, followed by usual care in their primary care practice. Women in the community health educator intervention group (CHE group) received the same primary care physician letter, followed by a standardized case management protocol that included telephone calls, home visits, office visits, and mailed cards,

scheduling, transportation, and dependent care.

Case management significantly increased completion of mammography. Within less than 4 months, 41 percent of eligible women responded to the CHE intervention by completing a mammogram, compared with 14 percent response to the MD intervention. The CHE intervention enhanced the efficacy of an already successful clinical information system providing physician reminders. Vulnerable populations, including women in inner cities, can benefit from multidimensional approaches because they often do not respond to reminder systems due to more pressing needs such as getting food and shelter.

Health Outcomes of Women Ex-posed to Household Alcohol Abuse: A Family Practice Training Site Research Network (FPTSRN) Study.
J.G. Ryan, et al. The Journal of Family Practice 45 (November 1997): 410-17.

Because exposure to alcohol abuse is associated with specific medical conditions among household members who do not abuse alcohol, primary health care providers need to screen for adverse health effects in women patients who live with family members who abuse alcohol.

In this study of 225 female patients, 70 screened positive for house-hold exposure to alcohol abuse. Exposure to alcohol abuse was not statistically associated with clinical marker conditions. However, subjects in a comparison group (N=225) who were not exposed to alcohol abuse had statistically higher scores for five of eight scales in the Medical Outcomes Study 36-Item Short Form Health Survey. The five scales were role physical, role emotional, social functioning, bodily pain, and mental health.

These results suggest that patients’ perceptions and doctors’ discharge diagnoses may differ. Even though women were not diagnosed as depressed, they described themselves as having a reduced level of mental health.

The researchers suggest that primary care physicians ask simply stated questions to screen for exposure to alcohol abuse and that exposed patients have a risk assessment for reduced quality of life and an increased need for biopsychosocial medical care.

Unplanned Pregnancy as a Major Determinant in Inadequate Use of Prenatal Care.
M. Delgado-Rodriguez, et al. Preventive Medicine 26 (6) (November/December 1997): 834-38.

Increasing knowledge of family planning may increase prenatal care usage by women with unplanned pregnancies.

The authors examined the determinants of inadequate prenatal care use in a sample of 409 women delivering at an 800-bed hospital with a referral population of 400,000 people in southern Spain. Data were obtained by personal interview and from clinical records. Twenty-two percent of women with an unplanned pregnancy used prenatal care inadequately, com-pared to only 12 percent of those with planned pregnancies who used prenatal care inadequately. Results suggest that unplanned pregnancy is one of the main predictors for inadequate use of prenatal care. This finding might establish a link between two health care programs: family planning and prenatal care. It also may imply that increasing knowledge of family planning might improve use of prenatal care.

Further research is needed to examine barriers to effective prenatal care.

Symptoms of Post-Traumatic Stress Disorder in Abused Women in a Primary Care Setting.
C. Silva, et al. Journal of Women’s Health 6 (October 1997): 543-52.

Because of the significant correlation between severity of abuse and symptoms of Post-Traumatic Stress Disorder (PTSD), routine screening and intervention for abused women in primary care settings is essential.

The purpose of this study was to describe the relationship between symptoms of PTSD and everity of abuse among women who had experienced childhood physical or sexual abuse or both. An ethnically stratified group of 131 abused women in a primary care setting was interviewed.

Intrusion (e.g., trouble falling asleep) and avoidance (e.g., trying not to think or talk about the abuse), both symptoms of PTSD, were significantly correlated with severity of abuse, regardless of ethnicity. Women who reported physical abuse had significantly higher intrusion scores; those who reported sexual abuse had significantly higher avoidance scores.Women who reported dreams, flash-backs, or terror attacks (65 percent) had significantly higher mean results for both intrusion and avoidance.

Offering community resources and safety information during each health visit is essential for the abused woman to develop a sense of control and to make decisions for her own safety. In addition, counseling and individual or group support may protect against PTSD for both the abused woman and her children.

Family Practice Physicians’ Firearm Safety Counseling Beliefs and Behaviors.
S.A. Everett, et al. Journal of Community Health 22 (October 1997): 313-24.

Educating physicians about firearm safety and counseling is needed.

This study identified 271 family physicians’ firearm safety counseling beliefs and practices. One-third agreed that it is primarily the responsibility of the criminal justice system, not the health care system, to prevent firearm injuries and deaths; 22 percent were undecided and 47 percent disagreed. Seventy-eight percent of family physicians lacked formal training on how to counsel patients about firearm safety, and almost half thought more time in residency pro-grams should be spent on firearm safety counseling. Most (84 percent) respondents never or rarely counseled patients on firearm safety, and half believed firearm safety counseling was a low priority in their delivery of primary care. The majority (52 per-cent) never counseled patients about firearm safety. The most common barriers to counseling were lack of time (53 percent), uncertainty about what to tell patients (26 percent), and the belief that patients would not heed the advice (25 percent).

The medical community can work with and support larger societal systems (e.g., criminal justice) in their efforts to reduce firearm mortality. The authors suggest that firearm safety counseling be studied further as a prevention method.

Occupational Therapy for Independent-Living Older Adults.
F. Clark, et al. Journal of the American Medical Association 278 (October 22/29, 1997): 1321-26.

Preventive occupational therapy (OT) programs may reduce the health risks of older adulthood.

In this study of 361 independent-living culturally diverse men and women aged 60 years or older, subjects were randomly assigned to an OT group, a generalized group activity ("social") control group, and a nontreatment control group. The social control group was included to rule out mere participation in group-based activities as an alternative explanation for the effects of OT and not to simulate any type of professional intervention.

Data analysis revealed a significant benefit attributable to OT treatment for several areas: quality of interaction, life satisfaction, health perception, bodily pain, physical functioning, role limitations attributable to health or emotional problems, social functioning, vitality, and general mental health.

Although health professionals have been reluctant to target older adults in preventive programs, assuming that this population would fail to benefit significantly from such efforts, results of the present study demonstrate that preventive programs designed for older adults can be effective. Activities were chosen that were health promoting and meaningful in the context of the subjects’ lives, and OT programs were highly individualized and included specific instruction on how to overcome barriers to successful daily living.

Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home.
M.E. Tinetti and C.S. Williams. The New England Journal of Medicine 337 (October 30, 1997): 1279-84.

Admissions to nursing homes may be delayed or reduced by interventions that prevent falls and their sequelae.

In this 37-month study of 1,103 people over 71 years old living in the community, 133 participants had long-term admissions to nursing homes. Compared with patients with no falls, the risk of admission in-creased progressively for those with a single noninjurious fall (relative risk=4.9), multiple noninjurious falls (relative risk=8.5), and one fall with serious injury (relative risk=19.9).

Adjustment for other risk factors lowered the ratios to 3.1, 5.5, and 10.2, respectively, but the association between falls and admission was strong and significant.

The authors recommend that preventive strategies tested in other trials, including adjustments in medications, exercise regimens, and behavioral recommendations, are feasible and relatively cost-effective, and they could be readily incorporated into the care of older persons living in the community. Given the loss of autonomy and privacy and the financial costs associated with institutionalization due to falls, the identification of potentially preventable or modifiable risk factors should be a high priority for health care providers.