HIV/AIDS News & Information

Previous research has reported a lack of regular cancer screening among Chinese American. The overall objectives of this study were to use a mail survey of primary care physicians who served Chinese Americans in San Francisco to investigate: a) the attitudes, beliefs, and practices regarding breast, cervical, and colon cancer screening and b) factors influencing the use of these cancer screening tests. The sampling frame for our mail survey consisted of: a) primary care physicians affiliated with the Chinese Community Health Plan and b) primary care physicians with a Chinese surname listed in the Yellow Pages of the 1995 San Francisco Telephone Directory. A 5-minute, self-administered questionnaire was developed and mailed to 80 physicians, and 51 primary care physicians completed the survey. A majority reported performing regular clinical breast examinations (84%) and teaching their patients to do self-breast examinations (84%). However, the rate of performing Pap smears was only 61% and the rate of ordering annual mammograms for patients aged 50 and older was 63%. The rates of ordering annual fecal occult blood testing and sigmoidoscopy at regular intervals of three to five years among patients aged 50 and older were 69% and 20%, respectively. Barriers (patient-specific, provider-specific, and practice logistics) to using cancer screening tests were identified. The data presented in this study provide a basis for developing interventions to increase performance of regular cancer screening among primary care physicians serving Chinese Americans. Cancer screening rates may be improved by targeting the barriers to screening identified among these physicians. Strategies to help physicians overcome these barriers are discussed. buy brand cialis

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Contaminated benzalkonium chloride has been implicated as the source of infection in several nosocomial outbreaks over the past 40 years and was also the most likely source of infection in this cluster of abscesses. Benzalkonium chloride solution from the clinic grew P aeruginosa as did the majority of abscesses, whereas other environmental samples and unopened vials of ТА were not contaminated. The canister containing benzalkonium chloride solution was not disinfected between batches, and once contaminated, could have contaminated successive batches. Two strains of P aeruginosa were identified among three patient isolates and P putida/fluorescens was isolated from one patient’s abscess, suggesting that the canister may have become contaminated with several Pseudomonas strains and species. Unfortunately, the isolate from the benzalkonium chloride solution was discarded before it could be compared with patient isolates.

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Epidemiologic Investigation
A total of 28 patients met the case definition; none had more than one abscess. The 28 case-patients received the injections associated with their abscesses during a 2-month period (April 20-June 22, 1995). Case-patients ranged in age from 13.6 to 79.8 years (mean = 43.2); 23 (82.1%) were female.

All case-patients had been given a corticosteroid injection to relieve allergy symptoms: Twenty-four (85.7%) received triamcinolone acetonide (ТА) (dose range: 30-80 mg), three (10.7%) received methylpred-nisolone acetate (dose: 80 mg), and for one case-patient, whether ТА or triamcinolone diacetate was given could not be determined. For two patients, we could not determine whether the injection of methylprednisolone or another injection given at the same time was the one associated with abscess formation. These case-patients were excluded from analyses involving medication. Abscesses began draining (spontaneously or surgically) a median of 75.5 (range: 32-211) days after the injection. Five (17.9%) case-patients were hospitalized for 1-13 days (median = 2 days).

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Benzalkonium chloride (ВС) is an unreliable disinfectant. A matched case-control study and environmental investigation were conducted to determine the cause of and risk factors for a cluster of postinjection abscesses at a private medical clinic where ВС was used as a disinfectant. Twenty-eight case-patients who had an abscess at the injection site were matched with 126 control patients who had received an intramuscular injection at the clinic on the same day. Risk factors for abscess development in a multivariable logistic model were corticosteroid injection and being female. All case-patients had received a corticosteroid injection from a multidose vial. Cultures of abscesses from 20 of 23 case-patients grew Pseudomonas aeruginosa. Cultures of ВС prepared at the clinic also grew Paeruginosa, suggesting that ВС was the source of infection. Injection site cleaning with ВС did not appear to be the route of infection since use of ВС at the time of injection was not associated with abscess development. A more likely route of infection was injection of contaminated corticosteroid from multidose vials that could have been inoculated with pseudomonads via needle puncture after vial septa were wiped with contaminated ВС. Benzalkonium chloride should not be used to clean injection vial septa or injection sites.

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Results
We mailed 1,030 questionnaires and received responses from 710 (70%) of 1,009 eligible subjects. We excluded 21 subjects who moved without leaving a forwarding address, died, or were no longer in practice. Respondents were predominantly white males with busy practices (Table 2). Respondents had experience with managed care, fee-for-service reimbursement (Table 3), capitation, utilization review, preauthorization by telephone, HMO review, and review by a committee of colleagues. Groups of physicians randomized to receive different versions of the questionnaire did not differ significantly in characteristics.

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In managed care, financial incentives and utilization review create conflicts of interest for physicians. We sought to determine whether these incentives would lead physicians to deny indicated services. We surveyed internists practicing in areas with at least 30% penetration of managed care. Our questionnaire included four scenarios in which a test or referral is indicated according to clearly established practice guidelines. We randomly assigned physicians to receive one of five versions of the questionnaire, which differed only in the type of reimbursement incentive and utilization review that applied to the scenarios. We received responses from 710 (70%) of 1,009 internists. Although physicians underutilized services regardless of incentives in all scenarios, physicians whose questionnaires depicted full capitation said that they would order fewer services than physicians whose questionnaires depicted fee-for-service. In the scenario in which an x-ray of the lumbosacral spine is indicated for a patient with low back pain, 86% of physicians randomized to the full capitation version said that they would order the test compared to 94% in the fee-for-service version. Similarly, physicians randomized to scenarios requiring utilization review said that they would order fewer services than those randomized to scenarios requiring completion of an insurance form. Scenarios depicting managed care incentives caused consistent, modest underutilization compared to fee-for-service scenarioes, although physicians underutilized services under all financial incentives and utilization review. In response, physicians must develop better methods for detecting underutilization and devise programs to increase the provision of indicated services.

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Parathyroid Cyst: An Uncommon Cause of a Palpable Neck Mass and Hypercalcemia

PARATHYROID CYSTS ARE rare lesions arising in the neck and anterior mediastinum. Goris reported the first case in 1905, and since then, fewer than 250 cases have been published in the literature. Parathyroid cysts constitute only 0.6% of all thyroid and parathyroid lesions, but should be considered in the differential diagnosis of anterior neck masses, particularly in the presence of hypercalcemia.

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