This is Journal Watch, a medical-literature
survey produced by the Massachusetts Medical
Society.
  Twice a week, our physician-editors summarize
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  Contents copyright 1994, Mass. Medical Society.

Journal Watch Summaries for November 1, 1994

ADVANCE DIRECTIVES: ARE THEY BEING DISCUSSED?.
  Arch Intern Med 1994 Oct 24; 154:2299-308.

CARDIOVASCULAR RISK FACTORS AND SYMPTOMS DURING
PERIMENOPAUSE.
  Arch Intern Med 1994 Oct 24; 154:2349-55.

DOES SODIUM AFFECT BONE DENSITY?.
  J Am Geriatr Soc 1994 Oct; 42:1050-5.

YET ANOTHER KIND OF HARM FROM PASSIVE SMOKING.
  Arch Fam Med 1994 Oct; 3:875-8.

POVERTY SHORTENS SURVIVAL WITH HIV.
  Lancet 1994 Oct 22; 344:1120-4.

HEPATITIS C AND HASHIMOTO'S THYROIDITIS.
  BMJ 1994 Oct 1; 309:846-7.

ADVANCE DIRECTIVES: ARE THEY BEING DISCUSSED?.
   Few patients have living wills or durable power of
attorney, although these written advance directives are
widely advocated. Two surveys examined physician and patient
attitudes toward using advance directives.
   The first study interviewed 258 consecutive patients
admitted to a medicine service of an urban hospital. Of 212
competent patients, about 85 percent said they had discussed
diagnosis and treatment with their physicians, 64 percent
had discussed severity of illness, 47 percent had discussed
CPR, and 38 percent had discussed intensive-care options.
Eighty-one percent had either discussed or wanted to discuss
advance directives, and 90 percent met at least one of three
indications for such discussions mentioned by physicians:
age of 75 or older, critical illness, and desire to discuss
directives.
   The second survey asked 277 internal medicine residents
and attending physicians at an urban hospital about barriers
to advance directive discussions. Nearly 90 percent of
physicians said they had discussed directives with fewer
than 10 percent of their patients during the past month;
half of these discussions were with inpatients. Self-
perceived lack of knowledge, time constraints, and lack of
comfort were significantly associated with physicians'
failure to initiate the discussions. Physicians' lack of
knowledge about advance directives and erroneous beliefs
about the appropriateness of discussing them predicted the
frequency of these discussions overall, whether initiated by
patient or physician.
   Comment: As an editorial notes, these studies suggest
that many physicians do not discuss advance directives with
their patients despite the fact that most patients desire or
are willing to engage in such discussions. --CD Mulrow.
   Citation: Reilly BM; et al. Can we talk? Inpatient discussions
about advance directives in a community hospital. Arch Intern Med
1994 Oct 24; 154:2299-308.
   Citation: Morrison RS; et al. Physician reluctance to discuss advance
directives. Arch Intern Med 1994 Oct 24; 154:2311-8.
   Citation: Loewy EH; Carlson RW. Talking, advance directives, and medical
practice. Arch Intern Med 1994 Oct 24; 154:2265-7.

CARDIOVASCULAR RISK FACTORS AND SYMPTOMS DURING
PERIMENOPAUSE.
   Menopause is associated with changes in lipid levels
and vasomotor symptoms. This longitudinal study of women 42
to 50 years old examined the influence of *peri*menopause on
cardiovascular risk factors and on psychological and
physical symptoms.
   During about four years of follow-up, 152 women became
perimenopausal and were examined after they had stopped
menstruating for three months; 105 of these women completed
menopause and were examined after they had stopped
menstruating for 12 months. Another 109 women with
uninterrupted menstruation constituted a premenopausal
comparison group.
   The premenopausal women and the women who became
perimenopausal during the study had small but similar
increases in low-density lipoproteins, diastolic {*filter*}
pressure, fasting glucose, and weight; both groups also had
decreases in high-density lipoproteins and height. The women
who completed menopause showed a slight continuing increase
in LDL. Perimenopausal women reported more total symptoms
(such as hot flashes, joint pain, and forgetfulness) than
either premenopausal or postmenopausal women. Menopause
status was not associated with depressive symptoms.
   Comment: Although this interesting study warrants
confirmation, it suggests that adverse changes in
cardiovascular risk factors are associated with midlife
rather than menopause itself, and that symptoms of menopause
actually peak in the perimenopausal period. --CD Mulrow.
   Citation: Matthews KA; et al. Influence of the perimenopause on
cardiovascular risk factors and symptoms of middle-aged healthy women.
Arch Intern Med 1994 Oct 24; 154:2349-55.