Program evaluation in health care.
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Canada↗
Biomedical subjects
A Fink
Publications and source records attributed to A Fink.
Endometrial morphology and hormonal profiles in in vitro fertilization patients.
Endometrial biopsy was performed in 27 infertile women participating in the IVF program. Their mean age was 31.8 years, 33% of the women being over 35 years old. The average duration of infertility was 6.9 years. The superovulation protocol consisted of hMG/hCG in 5 cases, of combined GnRH analog/gonadotropin therapy in 20 women, and 2 patients received combined contraceptive pill/gonadotropin treatment. Judging by hormonal profiles, follicular growth rate and number of oocytes retrieved, the response to stimulation was normal. The mean estradiol (E2) levels increased from 132.7 pg/ml on day -5 (SEM = 9.67) to 1272 pg/ml (SEM = 103.7) on the day of hCG administration and to 1813 pg/ml (SEM = 209.6) 1 day later. One day before the hCG application, the mean progesterone and LH levels were 1.34 ng/ml and 8.38 IU/ml, respectively. Only one patient had clinical hyperstimulation syndrome. Ova were harvested in all women, the mean number of oocytes being 7.7 (SEM = 0.83) per patient. In all 27 cases lack of fertilization or faulty ovum cleavage were observed. Thus, an endometrial biopsy (EB) was performed 72 h after oocytes retrieval. The mean estrogen and progesterone levels on the EB day were 610.9 pg/ml (SEM = 78.44) and 45.4 ng/ml (SEM = 7.53), respectively. Histologic examination of the endometrium showed normal secretory endometrium consistent with day 16-17 of spontaneous ovulatory cycle. Two women who received combined contraceptive pills/gonadotropin therapy showed inactive endometrium with subnuclear vacuoles and decidual reaction in the stroma similar to that observed in women on estrogen-progestin birth control medication.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Initial testing of a novel urine culture device.
The Diaslide urine culture device consists of a hinged case containing two opposing agar media separated by a sampler with a handle at one end and two bent sampler tips at the opposite end. The tips of the sampler are first dipped into the urine. The sampler is then pulled out through the casing, simultaneously inoculating both agar surfaces with a streaking dilution. As a result, individual colonies can be observed even when bacterial concentrations exceed 10(6) CFU/ml. The number of colonies on the Diaslide correlated linearly with CFU per milliliter as determined by dilution plating. The clinical performance of the Diaslide was compared with those of ordinary dipslides and conventional cultures with a sample of 473 prescreened hospital urine specimens. The sensitivity, specificity, and positive predictive value of Diaslide versus those of culture at the 10(4)-CFU/ml cutoff level were 97.5, 98.3, and 98.3%, respectively, compared with 98.8, 95.7, and 97.2%, respectively, for dipslide versus culture. Similar results were found at the 10(5)-CFU/ml cutoff level. Only 5.5% of the Diaslides required subculturing, compared with 14.7 and 9.4% of the dipslides and conventional cultures, respectively. The Diaslide proved more convenient than an ordinary dipslide for sampling low volumes of urine. These data suggest that the Diaslide is a simple, effective device for culturing of urine specimens.
Bacteria↗
[Superselective interventional angiography].
The authors report on the clinical application of superselective interventional angiography within the framework of revascularisation and occlusion. A coaxial catheter system is used for probing, consisting of an F 5 angiography catheter as guiding catheter and an F 3 catheter as internal catheter. The internal catheter is equipped with a shaft with segments of different flexibility and can take up a guide wire of 0.018" that is sufficiently stable to be rotated and guided. The interplay between the guide wire, which can be manipulated, and the flexible internal catheter enables superselective probing even of peripheral vascular areas. As may be required by the basic disease, the necessary interventional measures can be taken via the superselectively placed microcatheter. Superselective interventional angiography is indicated as an occlusive measure in preoperative vascular occlusion followed by palliative tumour resection, embolisation in haemangioma, chemoembolization in tumours of the liver. Superselective angiography is used for revascularisation in the local lysis of peripheral vessels. Due to the on-target superselective approach, side effects are markedly less than those observed with the interventions performed to date.
Angiography↗
Prenatal programs: what the literature reveals.
OBJECTIVES: To review evaluations of prenatal health care programs, examine their methodologic features, and synthesize the findings of high-quality studies. DATA SOURCES: We combined a computerized search of the literature and recommendations of experts to select evaluations published between 1981-1991. METHODS OF STUDY SELECTION: After reviewing the quality of each evaluation in relation to methods and clinical applicability, we selected the highest-quality evaluations and summarized their methods and findings. DATA EXTRACTION AND SYNTHESIS: Trained researchers used a standardized abstraction form for information on main objectives and activities, setting, study design and sample, data collection methods, results, and conclusions. Seven of 22 evaluations met the review criteria. Maternal care coordination and visits by nurses, and specially targeted smoking and nutrition programs, were associated with optimized pregnancy outcomes for certain women, including the poor and very young. Longer participation in prenatal care was an important factor in achieving positive outcomes. Women receiving care from nurse-midwives did not differ in their pregnancy outcomes from women cared for by physicians. CONCLUSIONS: No evaluation met all the review criteria. Selection biases are likely, and thus positive findings may have reflected the types of women who were likely to comply with care rather than the effects of program participation. Many topics were not systematically evaluated. Carefully controlled evaluations of the content, number, and timing of prenatal care visits for women with differing medical and social risks are essential in identifying effective ways to achieve the nation's public health objectives regarding maternal and infant mortality.
Female↗
Failure of physicians to recognize functional disability in ambulatory patients.
OBJECTIVE: To assess the ability of internists to identify functional disabilities reported by their patients. DESIGN: Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. SETTING: A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. SUBJECTS: Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. MEASUREMENTS AND MAIN RESULTS: Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. CONCLUSIONS: Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.
Activities of Daily Living↗
Oral colon lavage solutions containing polyethylene glycol may interfere with ELISA detection of tumor-associated antigens in colonic effluent.
Immunologic methods for detection of colorectal neoplasia based on examination of stool or colonic effluent are being developed. Most current oral lavage preparations contain polyethylene glycol (PEG), and if PEG adversely interferes with immunologic testing these tests may become less useful. We describe a decrease in sensitivity of ELISA for tumor-associated antigens (TAA) when effluent samples are diluted in PEG-electrolyte lavage solution, equivalent to a commonly used oral lavage solution based on PEG. Radioisotope-labeled antigen binding to plastic plates was decreased by dilution in the PEG lavage solution. Antigen binding, present in colonic effluent collected by the laxative purge method, was absent in effluent collected by PEG oral lavage from the same patient. We conclude that PEG and PEG-containing lavage solutions interfere with ELISA detection of TAA in colonic effluents. We speculate that the in vitro, and possibly the in vivo, effect occurs at the level of antigen binding to the plate either by a steric effect or alteration of charge by the nonpolar properties of PEG.
Absorption↗
Insulin-tumour interrelationships in thymoma bearing mice. Effects of dietary glucose and fructose.
Control (C) or Thymoma (T) implanted male C57BL/6J mice received a basal diet containing 16.5% glucose (G) or fructose (F). Compared to the C-G group, the C-F mice consumed more food and less water, and gained more weight. The blood glucose, insulin and triglyceride levels were higher in the C-F than in the C-G mice. Thymoma implantation into the right flank caused a transient decrease in body weight followed by a steady increase due to tumour growth. Tumours were detected earlier and tumour size was greater in the T-F group than in the T-G mice. Tumour chemical composition was similar in both groups. Blood analysis showed that the T mice had lower glucose and higher insulin and triglyceride levels than the C group. Carcasses from the T groups contained more water and ash and less fat than their C counterparts, but the type of sugar did not affect the body composition of the C or T groups. The results suggest that dietary fructose may enhance the growth of tumour via its hyperinsulinaemic action.
Animals↗
Geriatrics faculty in the United States: who are they and what are they doing?
Despite increases in geriatrics training at all levels of medical education, there is a nationwide shortage of geriatrics faculty. This shortage may be due in part to demands for clinical responsibilities that preclude adequate time for teaching and research. To learn about the professional activities of geriatrics faculty, we conducted a national survey of a 50% sample of all medical schools and their affiliated residency programs that focused on physician and non-physician geriatrics faculty in internal medicine, family practice, psychiatry, neurology, and physical medicine and rehabilitation. Although we found minor differences across specialties, in general, approximately one-third of physician faculty time is spent in teaching, the majority of which is clinical teaching. Less than 15% of physician faculty time is spent in research, and fewer than 10% of physician geriatrics faculty devote over half of their time to research. The percentage of time that non-physician faculty (other than "Research Only" faculty) spend in research is only slightly higher. These findings suggest that efforts to increase geriatrics education at all levels and promote research advances will be limited unless geriatricians devote substantially more of their time to these responsibilities.
Clinical Medicine↗
Screening recommendations for the elderly.
BACKGROUND: Studies have documented the potential contributions of preventive health care programs. Yet little is known about which screening tests should be included in public health programs for older persons. This study offers recommendations regarding these tests. METHODS: The recommendations come from synthesizing the findings of the US Preventive Services Task Force, the literature, and the consensus of experts in geriatrics, gerontology, and health policy research. The literature was evaluated to identify methodologically sound studies of the prevalence of selected disorders and benefits and availability of screening procedures for those disorders. Experts from various fields specializing in the care of the elderly formed panels to assist in evaluating the literature and providing further information from gerontological and public health perspectives. RESULTS: We recommend vision testing for refractive error; inspection of the skin surface for fungal infection and skin cancer, drug eruptions, and xerosis; a history for symptoms of xerosis; audiometric testing for presbycusis; surveys for hearing loss; otoscopic inspection for cerumen impaction; dental examination for caries; measurement of blood pressure for hypertension; and breast examination and mammography for cancer. CONCLUSIONS: Our study suggests that these screening procedures are useful for public health screening programs. More information is needed on the effects of screening services on the health and functioning of older persons.
Aged↗
[Screening for colorectal neoplasms].
We screened groups at high risk for colorectal neoplasms, determining the efficacy of the leukocyte adherence inhibition test (LAI) for early detection, in comparison with that of the fecal occult blood (Hemoccult) test and sigmoidoscopy or colonoscopy. Those screened included 549 first-degree relatives of patients with colorectal cancer, 190 patients with a past history of colorectal adenoma or carcinoma and 67 with a past history of breast or gynecological cancer or inflammatory bowel disease. 146 normal volunteers served as controls. In 782 of those fully screened during a 3-year period, 121 had adenomas (15.5%) and 5 had invasive cancer (0.6%). The LAI test was positive in 21% of those at high risk and in 7.5% of the controls. The hemoccult test was positive in only 4.8%, but in 1/3 of them neoplasms were found. This predictive value of 33% compares with only 16% for the LAI test. That most of the neoplasms found were adenomas and not invasive cancer may be due to the relative youth of most of those screened. We conclude that the groups studied were indeed at high risk. The LAI test is not sensitive enough to identify benign adenomas but might serve as another risk-market for colorectal neoplasms. Long-term follow-up of those at high-risk with positive LAI tests may prove that we have identified a subgroup truly at risk.
Adenoma↗
Moving child abuse and neglect prevention programs forward: improving program evaluations.
This paper focuses on evaluations of programs to prevent child abuse and neglect. It discusses the quality of the evaluations and offers suggestions for improvement to evaluators, program planners, and funders. Thirteen evaluations recommended by experts and published from 1978 through 1988 were reviewed. Using the true experiment as the standard of quality, we found evaluations frequently characterized by careful attention to methodologic detail. Evaluators describe eligibility criteria; half of the studies had control groups or followed progress. However, to learn more about prevention of abuse and neglect the caliber of evaluation research must improve. Evaluators do not define abuse or neglect; they accept reports of abuse. This has the effect of shifting the responsibility to others whose concerns and reporting standards differ. Lack of definition is reflected in a paucity of valid measurements; we could not assess the characteristics of families who benefit most from programs. Evaluators also omit important topics. Although seven evaluations studied health-related variables, no comprehensive analysis of the consequences and costs of medical neglect could be found; very little information on costs and benefits of any kind was available.
Child↗
A comparison of implicit and explicit methods of process quality assurance for blunt trauma patients.
We compared explicit (objective) and implicit (subjective) methods of process quality assurance to understand how the findings of each method are related. The charts of 100 blunt trauma patients who were admitted to the ICU, underwent surgery, or died in the emergency department were reviewed for compliance with six explicit process-of-care criteria previously established by the ED faculty. The results of this explicit review were compared with the results of an ongoing quality assurance program that uses implicit review. In the implicit review, a faculty member reviewed patients' charts and responded to three questions regarding the process of care. All blunt trauma patients who met the admission criteria were to be included in this review. Only 44 of the 100 charts were subjected to implicit review. Of these, 26 were judged satisfactory by both methods, two were judged unsatisfactory by both methods, two failed only the implicit review, and 14 failed only the explicit review. The null hypothesis, that the two methods were equivalent, was rejected (McNemar's test, P less than .003). These results suggest that process-of-care assessments of the quality of care must be interpreted with caution as they are method dependent and may not correlate with patient outcomes.
Adult↗
Insulin-tumour interrelationship in EL4 lymphoma or thymoma-bearing mice. I. Alloxan-diabetic or non-diabetic mice.
A study has been carried out in which a comparison was made between EL4 lymphoma (assumed to be an insulin-producing secreting tumour) and thymoma (an insulin-dependent tumour). Tumour development and incidence, 3H-thymidine incorporation and insulin content in tumours, the host's food intake, blood insulin, glucose and cholesterol were determined in non-diabetic and alloxan-diabetic mice. Whereas no significant differences were observed between the diabetic and non-diabetic EL4 tumour-bearing mice, the diabetic, thymoma tumour-bearing mice showed reduced tumour growth and lower tumour incidence as compared with their non-diabetic counterparts. Insulin administration to diabetic tumour bearing mice, enhanced 3H-thymidine incorporation in the thymoma tumour cells only, and the insulin content of the EL4 tumours was found to be higher than that of the thymoma tumours. Rapid diabetes remission was observed in the diabetic, EL4 tumour-bearing mice as compared with the thymoma tumour-bearing mice.
Animals↗
Insulin-tumour interrelationships in EL4-lymphoma or thymoma-bearing mice. II. Effects of dietary omega-3 and omega-6 polyunsaturated fatty acids.
Male C57BL/65 mice received a basal diet supplemented with 4% soya-bean oil, linseed oil or fish oil, in which the major polyunsaturated fatty acids were linoleic acid, alpha-linolenic acid and long chain omega-3 fatty acids, respectively. Groups of animals were injected into the right flank with EL4-lymphoma cells, others with thymoma cells. Tumour implantation caused a gradual decrease in food consumption with both types of tumour, while body weight increased, especially in the EL4-bearing animals receiving the soya-bean diet. The weight gain was due to body water accumulation and was accompanied by decreases in body fat and minor changes in carcass protein and ash contents. The dietary treatments did not produce significant differences in tumour incidence and mortality, but tumour size was decreased by diets supplying omega-3 fatty acids: in the EL4 mice tumour weight was markedly depressed by linseed oil, compared to soya-bean oil, whereas thymoma tumour weight was lowest in mice receiving fish oil and highest in the soya-bean oil group. Both types of tumour caused pronounced hypoglycaemia and hyperinsulinaemia in the hosts, and the effect was modulated by the diets in the EL4 but not in the thymoma animals: the plasma glucose level was especially low in the linseed oil group and relatively highest in the soya-bean oil treatment. The degree of hyperinsulinaemia depended on the diet only in the thymoma-bearing mice, with linseed and fish oils producing higher insulin levels than soya-bean oil. A slight hyperinsulinaemia was also observed in linseed and fish oil-fed control mice. Serum triglycerides were elevated in tumour-bearing animals, without consistent differences between dietary treatments. Although no clear pattern emerged concerning total cholesterol and LDL levels, HDL values were strongly affected by the type of oil: in the control animals linseed oil caused an increase in HDL-cholesterol compared to the other two oils. The thymoma-bearing mice responded to the linseed and fish oil diets with greatly elevated HDL-cholesterol levels. The results point to important differences in the responses of the two implanted tumours and hosts not only to the omega-6 and omega-3 fatty acids, but also to the type of dietary omega-3 fatty acids, namely alpha-linolenic acid and long chain fish oil polyunsaturated fatty acids.
Animals↗
Geriatrics in residency programs.
To determine how well geriatrics has been integrated into residency training, the authors surveyed a random 33% sample of all the 378 family practice (n = 126) and 420 internal medicine (n = 140) training programs in the United States in 1988. All the programs responded. On average, the internal medicine programs had more geriatrics faculty than did the family practice faculty, but these numbers were insufficient to meet current or future needs. Fewer than half of the residencies had geriatrics inpatient or ambulatory-care evaluation units, geriatrics consult services, geropsychiatry wards, or geriatrics clinics available as training sites. In contrast, nursing homes were available for 93% of the family practice programs and 58% of the internal medicine programs. A total of 80% of the family practice programs but only 36% of the internal medicine programs had geriatrics curricula in place. The authors conclude that integration of geriatrics content into residency training is far from universal, largely because of a shortage of faculty and clinical training sites.
Curriculum↗
Leukotriene C4 decreases the activity of respiratory cilia in vitro.
In the present study we assessed the effect of leukotriene C4 on ciliary beat frequency in vitro. Chicken tracheas were sliced into thin rings and ciliary activity was viewed microscopically. Ciliary beat frequency was measured through an optical fibre by a fast Fourier transformer analyser and recorded on an oscilloscope. Ciliary beat frequency was measured at one fixed point during 30 min at room temperature in RPMI-HEPES medium alone and in medium containing leukotriene C4 at a range of concentrations (10(-6)-10(-9) M). Our results demonstrate that leukotriene C4 (10(-7) and 10(-8) M) caused a significant decrease in ciliary beat frequency in all tracheal rings tested (mean decrease of 24%). The specificity and Ca2(+)-dependency of leukotriene C4 activity was elucidated by the ability of FPL 55712 (SRS-A specific antagonist), Ca2(+)-free medium, calcium channel blockers (nifedipine and verapamil) and the calmodulin inhibitor trifluroperazine to abrogate its effect on ciliary beating.
Adenosine Triphosphate↗
Gallstone dissolution agents.
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Administration, Oral↗