Biomedical subjects

Nae-Yuh Wang

Publications and source records attributed to Nae-Yuh Wang.

At least 19 recordsLinked to original sources

PubMed2006

Association of childhood socioeconomic status with subsequent coronary heart disease in physicians.

BACKGROUND: Adult socioeconomic status (SES) is an independent risk factor for the development of coronary heart disease (CHD), but whether low childhood SES has an effect in adults who have achieved high SES is unknown. METHODS: We examined the risk of CHD and mortality associated with low childhood SES in 1131 male medical students from The Johns Hopkins Precursors Study, a prospective cohort of graduates of The Johns Hopkins University School of Medicine from 1948 to 1964 with a median follow-up of 40 years. RESULTS: Of 1131 subjects, 216 (19.1%) were from low-SES families. Medical students from low-SES families were slightly older at graduation (26.8 vs 26.2 years; P = .004) and gained more weight over time (P = .01). Low childhood SES conferred a 2.40-fold increased hazard of developing CHD on or before age 50 years (95% confidence interval, 1.21-4.74) but not at older ages. The impact of low SES on early CHD was not reduced by adjusting for other CHD risk factors, including body mass index, cholesterol level, amount of exercise, depression, coffee drinking, smoking, hypertension, diabetes mellitus, and parental CHD history. Low childhood SES did not confer an increased risk of all-cause mortality. CONCLUSIONS: Low childhood SES is associated with an increased incidence of CHD before age 50 years among men with high adulthood SES. This risk is not mediated by traditional risk factors for CHD. These findings highlight the importance of childhood events on the development of CHD early in adulthood and the persistent effects of low SES.

Adult↗

PubMed2006

Attitudes and illness factors associated with low perceived need for depression treatment among young adults.

BACKGROUND: We do not yet fully understand how low perceived need for treatment leads many young adults to not seek care for their depression. METHODS: A cross-sectional study of 10,962 depressed young adults (ages 16-29) who visited a depression screening/education Internet website. Based on the Theory of Reasoned Action, we developed a multivariate model to determine the effects of beliefs and attitudes, social norms, past treatment behavior, and symptom severity on low perceived depression treatment need (i.e., not agreeing that one needs depression treatment). RESULTS: Negative beliefs and attitudes, social norms, and past treatment behavior predicted low perceived depression treatment need and explained more than half the model variance. Even after adjusting for depression severity and symptoms of other mental disorders, lacking confidence in either a biological or counseling based explanation or treatment approach for depression predicted low perceived depression treatment need. CONCLUSIONS: Lack of helpful treatment experiences and/or confidence in either of the currently practiced depression treatment models may prevent many young adults from seeking depression treatment.

Adolescent↗

PubMed2006

Are physicians' attitudes of respect accurately perceived by patients and associated with more positive communication behaviors?

OBJECTIVE: To explore the domain of physician-reported respect for individual patients by investigating the following questions: How variable is physician-reported respect for patients? What patient characteristics are associated with greater physician-reported respect? Do patients accurately perceive levels of physician respect? Are there specific communication behaviors associated with physician-reported respect for patients? METHODS: We audiotaped 215 patient-physician encounters with 30 different physicians in primary care. After each encounter, the physician rated the level of respect that s/he had for that patient using the following item: "Compared to other patients, I have a great deal of respect for this patient" on a five-point scale between strongly agree and strongly disagree. Patients completed a post-visit questionnaire that included a parallel respect item: "This doctor has a great deal of respect for me." Audiotapes of the patient visits were analyzed using the Roter Interaction Analysis System (RIAS) to characterize communication behaviors. Outcome variables included four physician communication behaviors: information-giving, rapport-building, global affect, and verbal dominance. A linear mixed effects modeling approach that accounts for clustering of patients within physicians was used to compare varying levels of physician-reported respect for patients with physician communication behaviors and patient perceptions of being respected. RESULTS: : Physician-reported respect varied across patients. Physicians strongly agreed that they had a great deal of respect for 73 patients (34%), agreed for 96 patients (45%) and were either neutral or disagreed for 46 patients (21%). Physicians reported higher levels of respect for older patients and for patients they knew well. The level of respect that physicians reported for individual patients was not significantly associated with that patient's gender, race, education, or health status; was not associated with the physician's gender, race, or number of years in practice; and was not associated with race concordance between patient and physician. While 45% of patients overestimated physician respect, 38% reported respect precisely as rated by the physician, and 16% underestimated physician respect (r=0.18, p=0.007). Those who were the least respected by their physician were the least likely to perceive themselves as being highly respected; only 36% of the least respected patients compared to 59% and 61% of the highly and moderately respected patients perceived themselves to be highly respected (p=0.012). Compared with the least-respected patients, physicians were more affectively positive with highly respected patients (p=0.034) and provided more information to highly and moderately respected patients (p=0.018). CONCLUSION: Physicians' ratings of respect vary across patients and are primarily associated with familiarity rather than sociodemographic characteristics. Patients are able to perceive when they are respected by their physicians, although when they are not accurate, they tend to overestimate physician respect. Physicians who are more respectful towards particular patients provide more information and express more positive affect in visits with those patients. PRACTICE IMPLICATIONS: Physician respectful attitudes may be important to target in improving communication with patients.

Adolescent↗

PubMed2006

Speech recognition at 1-year follow-up in the childhood development after cochlear implantation study: Methods and preliminary findings.

The Childhood Development after Cochlear Implantation (CDaCI) study is a longitudinal multicenter investigation designed to identify factors influencing spoken language in young deaf children with cochlear implants. Normal-hearing peers serve as controls. As part of a comprehensive evaluation battery, a speech recognition hierarchy was designed to assess how well these children recognize speech stimuli across developmental stages. Data were analyzed for the earliest measures in 42 pairs of children reaching 1 year of follow-up. A number of children in the cochlear implant group who met criteria for testing approached levels of performance similar to the normal-hearing controls, and some could identify sentences in competition. These results demonstrate the responsiveness of the speech recognition hierarchy in tracking emergent skills from a sample of the CDaCI cohort.

Case-Control Studies↗

PubMed2006

Randomized trial of hormone therapy in women after coronary bypass surgery. Evidence of differential effect of hormone therapy on angiographic progression of disease in saphenous vein grafts and native coronary arteries.

Clinical trials indicate that hormone therapy (HT) does not decrease cardiovascular disease events or angiographic coronary disease progression. The effects of HT on SVG vessels are unknown. To determine whether postmenopausal hormone therapy started after coronary bypass surgery (CABG) decreases saphenous vein graft (SVG) disease, we conducted a multicenter randomized placebo-controlled angiographic study of estradiol+/-medroxyprogesterone started within 6 months of CABG in 83 postmenopausal women. Angiographic and intravascular ultrasound (IVUS) assessment at 6 and 42 months was planned to assess SVG disease progression. The study was stopped early following publication of the Women's Health Initiative Estrogen/Progestin study. Eighty-three subjects underwent a 6-month angiogram with 63 undergoing IVUS. Forty-five subjects completed the 42-month angiogram (20 underwent 42-month IVUS). In analysis of paired 6- and 42-month angiogram and IVUS studies, HT slowed angiographic progression of SVG disease assessed by mean percent stenosis (p<0.001), minimal lumen diameter (p=0.029), and total plaque volume (p=0.006). In contrast, HT accelerated disease progression in non-bypassed native coronary arteries (minimum lumen diameter, p=0.01). SVG disease and closure occurred in 38% subjects within 1-year post-CABG. The groups had similar frequency of cardiovascular events expect for angioplasty that occurred in eight HT compared to one placebo subject (p<0.05). In HT subjects angioplasty was indicated for native coronary arterial stenoses while in the placebo subject angioplasty was indicated for SVG stenosis. This study suggests that hormone treatment may slow SVG disease progression while accelerating atherosclerosis in non-bypassed native coronary arteries.

Coronary Angiography↗

PubMed2006

Lifetime weight patterns in male physicians: the effects of cohort and selective survival.

OBJECTIVE: The natural history of lifetime weight change is not well understood because of conflicting evidence from cross-sectional and longitudinal studies. Cross-sectional analyses find that adult weight is highest at approximately 60 years of age and lower thereafter. Longitudinal analyses have not found this pattern. Our objective was to test whether cohort effects and selective survival may explain the differences observed between cross-sectional and longitudinal studies. RESEARCH METHODS AND PROCEDURES: We analyzed data on white men from the Johns Hopkins Precursors Study (n = 1197). Weight and height were measured at enrollment during medical school. The Precursors Study collected subsequent weight measurements by self-report and follows all participants for mortality. RESULTS: In preliminary analyses that ignored cohort and survival effects, average weight increased 0.16 kg/yr to age 65 (p < 0.001) and declined 0.10 kg/yr thereafter (p = 0.002). When controlling for differing rates of weight change by cohort and survival group, the apparent decline after 65 years of age was mostly explained. DISCUSSION: These data suggest that, in white men, weight increases steadily until age 65 and then plateaus. These findings emphasize the necessity of longitudinal rather than cross-sectional data to describe lifetime weight patterns.

Age Factors↗

PubMed2006

Primary care patients' involvement in decision-making is associated with improvement in depression.

BACKGROUND: Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes. OBJECTIVE: The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms. DESIGN: Prospective cohort study. SETTING: Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care. SUBJECTS: Primary care patients with current symptoms and probable depressive disorder. MEASUREMENTS: Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors. RESULTS: For each 1-point increase in IDM ratings, the probability of patients' report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004). CONCLUSIONS: Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.

Adolescent↗

PubMed2006

Compliance with American Academy of Pediatrics and American Public Health Association illness exclusion guidelines for child care centers in Maryland: who follows them and when?

BACKGROUND: In 1992, the American Academy of Pediatrics and the American Public Health Association jointly published guidelines for temporary exclusion of sick children from child care. However, little is known about key stakeholders' compliance with these guidelines. OBJECTIVES: The purpose of this work was to compare pediatricians', parents', and child care providers' compliance with American Academy of Pediatrics guidelines and determine predictors for higher rates of compliance. METHODS: We conducted a cross-sectional survey of 215 randomly selected Maryland pediatricians, 223 parents, and 192 child care providers from 22 Baltimore, Maryland, child care centers from January to July 2004. Questionnaires contained the following 6 case vignettes depicting common child care illnesses: upper respiratory infection, conjunctivitis, gastroenteritis, mild febrile illness, tinea capitis, and atopic dermatitis. The instrument measured the correctness of exclusion and inclusion decisions (using American Academy of Pediatrics/American Public Health Association guidelines as gold standard) according to varying levels of fever, disease severity (eg, clear versus yellow eye discharge), familiarity with the child, and parent work schedule flexibility. RESULTS: Response rates were 71% for pediatricians, 56% for parents, and 85% for child care providers. Guideline compliance was higher for pediatricians (74%) than for child care providers (60%) and parents (61%). Only 23% of pediatricians and parents and 29% of child care providers reported familiarity with American Academy of Pediatrics/American Public Health Association guidelines by name. In general, child care providers and parents had lower false-negative rates (allowed fewer children to attend who met criteria for exclusion) than pediatricians, suggesting that pediatricians may underexclude. Child care providers and parents correctly excluded in 65%-98% of cases requiring exclusion, whereas pediatricians correctly excluded 31%-86% of cases requiring exclusion, depending on the vignette. Yet pediatricians were much more specific about which children met criteria (pediatricians correctly included 61%-93% of cases requiring inclusion versus child care providers and parents who correctly included 20%-75% of such cases), suggesting that child care providers and parents may overexclude. Compliance rates varied significantly by stakeholder, vignette (disease), level of fever, and disease severity but did not vary with the stakeholder's familiarity with the child or the flexibility of the parent's work schedule. CONCLUSIONS: Pediatricians, parents, and child care providers were unfamiliar with American Academy of Pediatrics/American Public Health Association illness exclusion guidelines by name but moderately compliant with them. When noncompliant, child care providers and parents generally overexcluded, and pediatricians underexcluded. Stakeholder- and disease-specific predictors for noncompliance gleaned from this study suggest how educational interventions aiming to increase guideline compliance could be individually tailored to child care providers, parents, and pediatricians.

Academies and Institutes↗

PubMed2005

Differential susceptibility to hypertension is due to selection during the out-of-Africa expansion.

Hypertension is a leading cause of stroke, heart disease, and kidney failure. The genetic basis of blood pressure variation is largely unknown but is likely to involve genes that influence renal salt handling and arterial vessel tone. Here we argue that susceptibility to hypertension is ancestral and that differential susceptibility to hypertension is due to differential exposure to selection pressures during the out-of-Africa expansion. The most important selection pressure was climate, which produced a latitudinal cline in heat adaptation and, therefore, hypertension susceptibility. Consistent with this hypothesis, we show that ecological variables, such as latitude, temperature, and rainfall, explain worldwide variation in heat adaptation as defined by seven functional alleles in five genes involved in blood pressure regulation. The latitudinal cline in heat adaptation is consistent worldwide and is largely unmatched by latitudinal clines in short tandem repeat markers, control single nucleotide polymorphisms, or non-functional single nucleotide polymorphisms within the five genes. In addition, we show that latitude and one of these alleles, GNB3 (G protein beta3 subunit) 825T, account for a major portion of worldwide variation in blood pressure. These results suggest that the current epidemic of hypertension is due to exposures of the modern period interacting with ancestral susceptibility. Modern populations differ in susceptibility to these new exposures, however, such that those from hot environments are more susceptible to hypertension than populations from cold environments. This differential susceptibility is likely due to our history of adaptation to climate.

Acclimatization↗

PubMed2005

Predictive models for cochlear implantation in elderly candidates.

OBJECTIVE: An aging American population carries a high prevalence of profound sensorineural hearing loss. We examined the performance of multichannel cochlear implant recipients in a large database of adult subjects. DESIGN: Nonconcurrent prospective study of a national cohort with multivariate regression analysis of preoperative and postoperative performance variables in multichannel cochlear implant recipients. We applied models of prediction established in previous studies to the observed results. SETTING: Referral centers with active cochlear implant programs. PATIENTS: Adolescents and adults with profound hearing loss (N = 749; age range, 14-91 years). MAIN OUTCOME MEASURE: Postoperative monosyllabic word recognition. RESULTS: The population 65 years and older demonstrated a clinically insignificant 4.6%-smaller postoperative word score compared with the population younger than 65 years. When duration of deafness exceeded 25 years, elderly recipients demonstrated higher word scores than their younger counterparts. A more significant factor affecting outcomes is the ratio of duration of deafness to age at implantation. CONCLUSIONS: Age at implantation carried relatively little predictive value for postoperative performance in subjects 65 years and older. Although a small decrement in mean speech recognition scores was evident, the clinical significance of this difference is questionable when all of the results observed in elderly patients are considered. A shorter percentage of life spent in severe-to-profound sensorineural hearing loss suggests a foundation of acoustic/auditory processing in the elderly cohort that may mitigate potential physiological effects associated with advanced age. This study confirms and extends previous observations that duration of profound deafness and residual speech recognition carry higher predictive value than the age at which an individual receives an implant.

Adolescent↗

PubMed2005

Mild vs severe pulmonary hypertension before heart transplantation: different effects on posttransplantation pulmonary hypertension and mortality.

BACKGROUND: Pulmonary hypertension (PH) is common in severe heart failure, but the effect of mild PH on posttransplantation PH and survival after heart transplantation has not been well described. METHODS: This cohort study examined preoperative and postoperative hemodynamics in 172 heart transplant recipients at Johns Hopkins Hospital followed for up to 15.1 years. PH was defined as pulmonary vascular resistance > or =2.5 Wood units, as measured during routine right heat catheterization; mild to moderate PH was defined as PVR between 2.5 and 4.9 Wood units; and severe PH was defined as PVR > or =5.0 Wood units. RESULTS: Seventy-one patients (41.3%) had PH, mostly of mild/moderate severity (77.5%), at the last routine hemodynamic monitoring before transplantation (median time before transplantation, 2.7 months). During follow-up, 105 patients (62.9%) developed PH at some point after transplantation, and 48 patients died (cumulative incidence, 76.5%). Mild/moderate preoperative PH was associated with increased risk of posttransplantation PH at 1, 3, and 6 months, but not with later episodes of PH. Mild/moderate preoperative PH was not associated with a higher mortality rate, but each 1 Wood unit increase in preoperative PVR demonstrated a trend toward increased mortality. Severe preoperative PH was associated with death within the first year after adjusting for potential confounders, but not with overall mortality or mortality at other time points. CONCLUSIONS: Mild to moderate preoperative PH is associated with increased risk of developing early but not late posttransplantation PH and may suggest different management strategies. Although PH was not consistently associated with mortality, increasing severity of the preoperative PH suggests potentially worse prognosis.

Academic Medical Centers↗

PubMed2005

Patient satisfaction, preventive services, and emergency room use among African-Americans with type 2 diabetes.

The aim of this study was to determine the relationship between patient satisfaction and diabetes- related preventive health care and emergency room (ER) use. We studied 542 urban African-Americans with type 2 diabetes aged > or =25 years who were enrolled in a primary carebased intervention trial to improve diabetes control and reduce adverse health events; 73% female, mean age 58 years, 35% had yearly household incomes of <$7500, and all participants had health insurance. All completed a baseline interview-administered questionnaire. Patient satisfaction was measured using a modified version (nine questions) of the Consumer Assessment of Health Plans Survey (CAHPS) and use of diabetes-related preventive health care and ER were assessed by self-report. We then followed participants for 12 months to determine ER use prospectively. In general, participants gave favorable ratings of their care; over 70% reported that they had no problem getting care, over 60% reported the highest ratings on the communication and courtesy domains, and mean ratings (0-10 scale) for personal doctor and overall health care were high (8.8 and 8.4, respectively). Using poisson regression models adjusted for age, education, and self-reported rating of health, several aspects of patient satisfaction were associated with subsequent ER use. Participants who reported that medical staff were usually helpful or that doctors and nurses usually spent enough time were 0.49 and 0.37 times, respectively, less likely to use the ER (all p < 0.05). However, few aspects of patient satisfaction were associated with better preventive services. These data suggest that greater patient satisfaction was associated with lower ER use in urban African-Americans. Whether measures to improve patient satisfaction would reduce ER use requires further prospective study.

Adult↗

PubMed2005

Serial audiometry in a clinical trial of AIED treatment.

OBJECTIVE: We analyzed pure-tone and speech audiometric results from a prospective trial of anti-inflammatory treatment of subjects with active autoimmune inner ear disease (AIED). We sought to characterize the pattern and size of the treatment effect as reflected in clinical audiometry and to identify audiometric predictors of response to steroid treatment of AIED. SUBJECTS: Adult participants demonstrated clinically established criteria for AIED (n = 116). Eligibility required audiometric evidence of active AIED as indicated by idiopathic sensorineural hearing loss with threshold elevations within 3 months of enrollment. METHODS: We evaluated audiometric changes after 4 weeks of treatment with pharmacologic doses (60 mg/day) of prednisone. We examined the relationship between audiometric pure-tone thresholds at baseline and changes in word intelligibility score (WIS) using parametric and nonparametric analyses. Magnitudes of change were assessed using independent or paired t-tests. Separate analyses were performed on subgroups that did or did not show improved WIS score with steroid treatment. RESULTS: Overall mean pure-tone averages improved from baseline to closeout of prednisone treatment in better hearing ears from 52.4 to 48.3 dB (p < .0001). Mean WIS improved in the better ear from 71.4% to 78.1% (p < .0001). Of pure-tone measures, only the six-tone average showed significant correlation with both the absolute improvements in WIS and with the percentage change in WIS after treatment. Individual frequencies at baseline showed no significant relationship with changes in WIS score after treatment. In 69 (59.5%) of 116 subjects, WIS improved (range, 2-80%) in the better ear. In these subjects, the baseline pure-tone thresholds and pure-tone averages correlated significantly and positively with improvement in WIS. CONCLUSIONS: Steroid treatment in AIED-mediated hearing loss produce variable but significant hearing gains. Neither a focal, cochleotopic region of greatest vulnerability to AIED nor frequency-specific amenability to treatment were evident. We did observe that analysis of predictors and the degree of treatment effect vary with different approaches to measuring change in the WIS. Depending on the approach adopted, the size of the treatment effect may be greatest across intermediate hearing levels at baseline. These observations offer an audiometric database that may enable greater precision in judging clinically meaningful parameters for future studies of AIED treatment and other interventions for sensorineural hearing loss.

Adolescent↗

PubMed2005

Suicide compared to other causes of mortality in physicians.

Physicians frequently are early adopters of healthy behaviors based on their knowledge and economic resources. The mortality patterns of physicians in the United States, particularly suicide, have not been rigorously described for over a decade. Previous studies have shown lower all-cause mortality among physicians yet reported conflicting results about cause-specific mortality such as suicide. In this study, we compared all-cause and cause-specific mortality in a sample of physicians to the age-gender matched general U.S. population from 1948 through 1998. We also compared the mortality experience across medical specialties. The risk of all-cause mortality was 56% lower than expected in men, and 26% lower in women, compared to the general population. Standardized mortality ratios (SMRs) were markedly lower for diseases strongly linked to smoking, e.g., cardiovascular diseases, respiratory diseases, and lung cancer. Suicide was the only cause of death where risk was greater than the general population. Overall, we found that physicians are at substantially lower risk of dying compared to the general population for all causes of death except suicide. The findings for suicide are strikingly different than other causes of death and should provide impetus for new research on the mental health of physicians.

Adult↗

PubMed2005

Vital capacity as a predictor of incident type 2 diabetes: the Atherosclerosis Risk in Communities study.

OBJECTIVE: To test the hypothesis that lower vital capacity is cross-sectionally associated with features of insulin resistance and is an independent predictor of incident type 2 diabetes. RESEARCH DESIGN AND METHODS: We conducted a prospective cohort study of vital capacity as a predictor of incident type 2 diabetes using 9-year follow-up data on 11,479 middle-aged adults without diabetes at baseline from the Atherosclerosis Risk in Communities (ARIC) Study. RESULTS: Forced vital capacity (FVC) and forced expiratory volume in 1 s were measured at baseline using standard spirometry. Incident type 2 diabetes cases were ascertained during follow-up. At baseline, low FVC (% predicted) was independently associated with indicators of the insulin resistance syndrome, including higher fasting levels of glucose, insulin, and triglycerides; lower fasting HDL cholesterol; and higher systolic blood pressure. In prospective analyses, there were graded associations between low FVC (% predicted) and incidence of type 2 diabetes in men and women. These associations persisted in multivariable analyses that adjusted for age, race, adiposity, smoking, physical activity, and ARIC center. Compared with individuals in the highest quartile of FVC (% predicted), the fully adjusted hazard ratio (95% CI) of diabetes in individuals in the lowest quartile was 1.6 (1.3-2.0) in men and 1.7 (1.3-2.1) in women. These relationships were stronger in those who have never smoked. CONCLUSIONS: Lower vital capacity is an independent predictor of incident type 2 diabetes. Pulmonary factors related to vital capacity deserve attention as possible risk factors for insulin resistance and diabetes.

Arteriosclerosis↗

PubMed2004

Prelinguistic communication and subsequent language acquisition in children with cochlear implants.

OBJECTIVE: To investigate the relationship between prelinguistic communication behaviors and subsequent language development after cochlear implantation in deaf children. Evaluative tools with predictive validity for language potential in very young deaf children remain elusive. SETTING: A tertiary care cochlear implant center and a preschool setting of spoken language immersion in which oral language development is emphasized through auditory and oral motor subskill practice. SUBJECTS: Eighteen prelingually deaf children who underwent unilateral implantation at an average age of 15 months also underwent testing with the Communication and Symbolic Behavior Scales (CSBS) before device activation and with the Reynell Developmental Language Scales (RDLS) at an average of 20 months after cochlear implantation. METHODS: A prospective study correlated preoperative communication behavior assessments of 18 children who were candidates for cochlear implantation. We examined the value of prelinguistic behavioral testing with the CSBS in predicting later language level after cochlear implantation as reflected in RDLS scores. RESULTS: We found positive, though weak, correlations between prelinguistic communication skills (CSBS scores) and language learning after cochlear implantation (RDLS scores). Linear correlation between test results failed to reach statistical significance (receptive comparisons, P =.17; expressive comparisons, P =.13). CONCLUSIONS: Evaluating the quality of prelinguistic communication behaviors potentially adds important predictive information to profiles of children who are candidates for cochlear implantation. Correlative analysis suggests that early CSBS testing may provide useful clinical information. Poor CSBS scores may serve as a precaution: if children lack an appropriate prelinguistic behavioral repertoire, the emergence of age-appropriate formal language may be at risk. Observations suggest that symbolic prelinguistic behaviors are necessary, but not sufficient, for the development of strong linguistic skills. The variability of behavioral measures in very young deaf children poses challenges in designing objective measures with predictive value for later language level.

Adolescent↗

PubMed2004

A randomized controlled trial of the effects of nurse case manager and community health worker team interventions in urban African-Americans with type 2 diabetes.

The objective of the study was to determine the effectiveness and cost-effectiveness of primary care and community-oriented interventions in managing HbA1c, blood pressure, and lipids, and reducing hospitalizations and emergency room visits over 2 years. We describe an ongoing, randomized controlled trial of 542 urban African-Americans with type 2 diabetes ages 25 years and older who are members of a university-affiliated managed-care organization in Baltimore, MD. The participants are 74% female, have a mean age of 58 years, and 35% have yearly incomes greater than 7500 US dollars. Participants were randomized to one of two intervention groups for a period of 2 years: (1) usual medical care plus minimal telephone intervention implemented by a trained lay health educator (control group) or (2) usual medical care plus intensive intervention implemented by a nurse case manager (NCM)/community health worker (CHW) team. The intensive NCM/CHW team executes individual plans of care using evidence-based algorithms that focus on traditional diabetes self-management, screening and management of diabetes-related complications, and social issues surrounding diabetes care. Face-to-face NCM visits are conducted in the clinic once per year and CHW visits are conducted in the participant's home one to three times per year, both with additional follow-up contacts as needed. Written and verbal feedback (when necessary) is provided to the participant's primary care physician. All participants are expected to attend a 24-month follow-up visit where data are collected by interviewers blinded to intervention assignment. As of May 1, 2003, recruitment is complete, interventions are being fully implemented, and 24-month follow-up visits are beginning. Baseline sociodemographic characteristics, health-care utilization, health behaviors, and clinical characteristics of the study population are reported. This study is designed to test the hypothesis that a primary-care-based NCM plus CHW team approach is an effective, practical, and economically feasible strategy for translating current knowledge about type 2 diabetes into high-quality health care for urban African-Americans.

Black or African American↗

PubMed2004

The impact of international medical graduate status on primary care physicians' choice of specialist.

BACKGROUND: Approximately one fourth of practicing physicians in the United States graduated from medical schools in other countries. It is unknown how the role of international medical graduate status affects physician decision-making. OBJECTIVE: The objective of this study was to determine whether a primary care physicians' knowledge of a specialist's international medical graduate status affects his or her decision to refer patients to that specialist. RESEARCH DESIGN AND SUBJECTS: We studied a national, cross-sectional study of primary care physicians who see adult patients. The sample was drawn from the American Medical Association Physician's Professional Data. Each physician received 2 clinical case vignettes describing a patient for whom referral to a specialist was considered necessary. Each vignette was followed by 5 vignette specialist descriptions with medical school graduate status varied randomly alongside other physician characteristics. MEASURE: We measured the decision to refer to an international versus U.S. medical graduate specialist. RESULTS: Of 1054 eligible physicians, 623 (59.1%) responded. Respondents were significantly more likely to refer to a U.S. medical graduate (USMG) compared with an international medical graduate (IMG) (63% vs. 54%, P <0.05). After adjustment for age, race, sex, and referral characteristics of the vignette specialists, a positive referral decision was noted in a higher proportion of vignettes in which the vignette specialist was described as a USMG versus an IMG (63% vs. 51%, P <0.05). CONCLUSION: With other factors being equal, vignette specialists described as IMGs versus USMGs were significantly less likely to be associated with a positive referral decision. Although specialist IMG status, relative to other factors, might not have a major effect on referral decisions, it is possible that negative views of international medical graduates could lead to suboptimal choices in referral decisions. Potentially, a patient could be referred to an USMG who happens to have inferior clinical skills than an IMG with superior clinical skills.

Adult↗