Biomedical subjects

C R Stein

Publications and source records attributed to C R Stein.

5 recordsLinked to original sources

PubMed2000

The urology residency matching program in practice.

PURPOSE: We evaluate behaviors and attitudes among resident applicants and program directors related to the American Urological Association (AUA) residency matching program and recommend changes to improve the match. MATERIALS AND METHODS: Written questionnaires were mailed to 519 resident applicants and 112 program directors after the 1999 American Urological Association match. Subjects were asked about their observations, behaviors and opinions towards the match. RESULTS: Questionnaires were returned by 230 resident applicants and 94 program directors (44% and 83% response rates, respectively.) Of the resident applicants 75% spent $1,001 to $5,000 for interviewing. Of the program directors 47% recalled that applicants asked how programs would rank the applicant and 61% of applicants recalled that program directors asked applicants how they would rank programs. Dishonesty was acknowledged by 31% of program directors and 44% of resident applicants. Of program directors 82% thought applicants "lied", while 67% of applicants thought that programs "lied" (quotations indicate questionnaire language). Participants characterized their own dishonesty as "just playing the game" or they "did not feel badly." Of program directors 81% and of applicants 61% were "skeptical" or "did not believe" when informed they were a "high" or "number 1" selection. Being asked about marital status was recalled by 91% of male and 100% of female (p = 0. 02), if they had children by 53% of male and 67% of female, (p = 0. 03), and intent to have children by 25% of male and 62% of female (p <0.001), applicants, respectively. Free-form comments were written by 132 resident applicants and 28 program directors. The most frequent comments suggested the need to improve ethical behavior, modify the process so applications could be transmitted electronically and modify interviews to reduce applicant financial burden. Nine female applicants commented on their perceptions of sexual discrimination during the interviews. CONCLUSIONS: Resident applicants and program directors violate match code rules frequently. Program directors and resident applicants are skeptical of each other. Patterns of faculty behavior differ based on applicant gender. Interviews are costly for applicants. We recommend that 1) programs adopt policies to enhance fairness, 2) applications be filed electronically, 3) programs assist resident applicants with interview accommodation to reduce financial burden and 4) a post-interview code of limited or noncommunication be adopted.

Administrative Personnel↗

PubMed1998

Incidence of fecal and urinary incontinence following radical perineal and retropubic prostatectomy in a national population.

PURPOSE: Since 1991 we have performed more than 300 anatomical radical perineal prostatectomies at Brooke Army and Wilford Hall Medical Centers, and were initially aware of 8 patients who presented with unsolicited postoperative fecal incontinence. We determined the incidence of fecal and urinary incontinence following radical prostatectomy, defined parameters to identify patients at risk for fecal complaints following radical prostatectomy, and estimated the impact of fecal incontinence on lifestyle and activities. MATERIALS AND METHODS: Initially a validated 26-question telephone survey was used to evaluate 227 patients who had previously undergone radical prostatectomy at 1 of our 2 institutions. Based on results of the telephone survey a national survey was mailed to 1,200 radical prostatectomy patients randomly selected from a nationwide database of Department of Defense health care system beneficiaries. All patients had undergone radical perineal or retropubic prostatectomy at least 12 months before being contacted for the survey. RESULTS: Responses to the telephone survey from 227 patients revealed that fecal incontinence was a problem after radical retropubic (5%) and perineal (18%) prostatectomy and less than 50% of those with fecal incontinence had told the physician. Our mail survey (response rate 80% and 78% usable for analysis, 784 radical perineal and 123 perineal) strongly indicated that fecal incontinence after radical prostatectomy is a problem nationwide. Frequency of fecal incontinence (daily, weekly, monthly or less than monthly occurrences) was significantly higher among radical perineal (3, 9, 3 and 16%) compared to retropubic prostatectomy (2, 5, 3, and 8%) patients (p=0.002). Fecal incontinence had a significant negative effect on patient social or entertainment activities (p=0.029), and travel and vacation plans (p=0.043). Radical perineal compared to retropubic prostatectomy patients were more likely to wear a pad for stool leakage (p=0.013), experienced more accidents (p=0.001), had larger amounts of stool leakage (p=0.002) and had less formed stools (p=0.001). Of radical perineal prostatectomy patients only 14% and of retropubic only 7% with fecal incontinence had ever told a health care provider about it, even when the incontinence was severe. Responses to our survey concerning urinary incontinence showed that radical perineal prostatectomy patients had a lower rate of urinary incontinence immediately after prostatectomy compared to retropubic (79 versus 85%, p=0.043). A higher proportion of perineal patients reported that all urinary leakage had ceased, that is full continence had returned (perineal 70%, retropubic 53%, p=0.001). A smaller proportion of perineal patients found it necessary to wear a pad to protect from urinary incontinence (perineal 39%, retropubic 56%, p=0.004). CONCLUSIONS: Fecal incontinence following radical prostatectomy occurs more frequently than previously recognized. In general fecal incontinence among radical perineal and retropubic prostatectomy patients surpasses the expected incidence rate of 4% for this age group (60 to 70 years) but incidence is significantly higher for radical perineal prostatectomy patients. However, radical perineal prostatectomy patients have a significantly lower incidence of urinary incontinence than those treated with retropubic prostatectomy. Surgeons who perform radical retropubic and perineal prostatectomy should be aware of the possibility of fecal and/or urinary incontinence and associated symptoms.

Activities of Daily Living↗

PubMed1997

Development of a decision-making tool to predict risk of prostate cancer: the Cancer of the Prostate Risk Index (CAPRI) test.

OBJECTIVES: To provide a simple and reliable clinical prediction for an individual patient's overall risk of cancer at biopsy by deriving an easily implemented test based on a generalizable model. Four variables are analyzed for inclusion in the model: prostate-specific antigen (PSA) level, digital rectal examination (DRE) results, race, and age. METHODS: Two populations were used to develop and validate the test: a model (n = 633) and an independent, geographically separate, external population (n = 766). Pathology records for patients who underwent prostate biopsy between 1991 and 1995 were reviewed and screened for the presence of PSA and DRE results. Records where age and race could be determined were extracted. Multiple logistic regression was used with an iterative approach to optimize each test factor. The Wald chi-square test, receiver operating characteristic (ROC) curve, and Hosmer-Lemingshaw test were used to evaluate the model's predictive capability in the two populations. RESULTS: The model and external populations were significantly different for racial mix, PSA level, age, and biopsy detection rate, providing diverse populations to validate the test. Within a combined model, PSA, DRE, race, and age all demonstrated independent capability to predict cancer at biopsy. Predictive power of the overall test was high within the model population (ROC 80.8%), with minimal loss of power in the external population. The test demonstrated no significant lack of fit in either population. CONCLUSIONS: Within a combined test, PSA, DRE, race, and age all contribute significantly to prediction of prostate cancer at biopsy in an individual patient. The test depicts individual risk in an easily understood, visually provocative manner and should assist the clinician and patient in reaching a decision as to whether biopsy is appropriate.

Age Factors↗

PubMed1996

Use of New York Medicaid PASs (Products of Ambulatory Surgery) with emergency surgical episodes.

The New York Products of Ambulatory Surgery (PAS) patient classification system was implemented by the state of New York for reimbursement of Medicaid ambulatory surgery claims. Using a national claims based database, the PAS system was evaluated for use with emergency department-generated surgical episodes. The PAS system performed well, but would benefit from the inclusion of age, comorbidity, and presence of multiple surgical procedures. Further, model power increased significantly when focused on total episode versus surgical charges alone. The study indicated the high degree to which emergency department-generated charges are closely tied to other charges in any overall care delivery system.

Ambulatory Surgical Procedures↗

PubMedDate not supplied

Race, treatment, and long-term survival from prostate cancer in an equal-access medical care delivery system.

OBJECTIVE: To evaluate long-term survival of black and white prostate cancer patients in an equal-access medical care system to help distinguish biological from medical and social explanations of mortality differences. DESIGN AND SETTING: Retrospective study of US Department of Defense tumor registry patients with prostate cancer. Ethnicity, age, diagnosis, staging, risk factors, treatment, and survival end points were extracted. PATIENTS: Prostate cancer patients (N = 1606; 7.5% black, 92.5% white) who were active-duty personnel, dependents, or retirees eligible for care in the military medical system. MAIN OUTCOME MEASURES: Racial differences in tumor stage and grade, risk factors, recurrence, and treatment wait time (time between initial diagnosis and initial treatment); influence of stage, grade, treatment, wait time, age, and race on survival. RESULTS: No differences were found in behavioral risk factors or tumor grade or size, but blacks entered active treatment (P < .001) and exhibited a higher relative risk of cancer (P = .01) in younger age groups, presented with higher stage (P < .001), and demonstrated increased progression in distant metastatic disease (P = .01). No significant differences were detected in overall wait time. When adjusted for stage, no difference was found in type of treatment. Overall, stage, grade, and age were found to affect survival (P = .04 to P < .001), but race did not. When analyzed by stage, blacks demonstrated a clear trend of longer survival for distant metastatic disease (P = .04 to P = .06). This trend was confirmed using Kaplan-Meier estimates (P = .04, likelihood ratio). CONCLUSIONS: This analysis suggests that in an equal-access medical care system there are no stage-specific differences in treatment between black and white prostate cancer patients. Survival among blacks is similar to that among whites and may surpass it for high-stage disease.

Adult↗