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PubMed1993

Predicting occult lymph node metastasis in parotid cancer.

To determine the factors predictive of occult cervical metastases, we retrospectively reviewed the charts of 99 previously untreated patients with a primary parotid malignancy who underwent elective neck dissection between 1960 and 1985. Univariate and multivariate analyses were performed to determine the predictive value of 11 factors. The univariate study found facial nerve paralysis, extraparotid extension, and perilymphatic invasion statistically significant. In the multivariate analysis of preoperative factors, facial nerve paralysis was most predictive of occult disease. If the variable pool was expanded to include a fine-needle biopsy, tumor grade became the most important preoperative variable. When the analysis was further expanded to include a parotidectomy, the most influential factors were patient age, perilymphatic invasion, and extraparotid tumor extension. This report identifies the variables predictive of occult neck disease in parotid cancer.

Adolescent↗

PubMed2001

Evaluation of youth preferences for rapid and innovative human immunodeficiency virus antibody tests.

OBJECTIVE: To determine youth preferences for Food and Drug Administration (FDA)-approved and investigational human immunodeficiency virus (HIV) antibody collection and testing methods before and after subjects learned of test result response times; to determine how influential test result response times are on participants' preferences. DESIGN: After health educators explained and demonstrated 6 different HIV antibody collection and testing strategies (3 saliva, 1 urine, and 2 fingerstick methods), participants completed a confidential survey about test method preference and tried the different testing methods. The participants had an opportunity to re-rank their test method preference after learning about each test's result response time. SETTING: Health education sessions in both clinical and community settings. PARTICIPANTS: Youths aged 12 to 24 years. RESULTS: An oral collection device with a rapid saliva test was the most highly preferred test method. The preference for this method and the rapid response test methods via fingerstick procedures improved significantly after subjects learned of the rapid result response time, while the other methods were given significantly lower preference rankings after subjects learned of the longer result response times. Shifts in preference rankings were not related to sex, age, ethnic group, experience with HIV testing, or practice of risk behaviors. CONCLUSIONS: Our research supports the use of noninvasive and rapid HIV testing methods with rapid response times for adolescents to assist in the early identification of HIV status, while offering HIV prevention opportunities and immediate linkage to care.

Adolescent↗

PubMed2003

Parental decision making and the choice of communication modality for the child who is deaf.

BACKGROUND: Early intervention decisions for a deaf or hard of hearing child are difficult to make, partly because of the lack of definitive proof of the superiority of any particular communication approach. OBJECTIVE: To compare the relative importance of the child's hearing loss and parental attitudes, beliefs, values, and aspirations in the decision process. METHODS: Eighty-three parents were surveyed about decision factors that may have affected their choice of communication modality, including resource availability, attitudes and beliefs about hearing loss, values, trade-offs, and goals. Parental preference ratings on hypothetical outcomes were also collected in 4 domains: communication, academic performance, social functioning, and emotional well-being. RESULTS: The child's extent of hearing loss was the most influential decision factor (P<.001). Beyond the extent of hearing loss, logistic regression further showed that parental cognitive-attitudinal factors were important in the inclination to favor an oral approach-if they believed that deafness can and should be corrected and if they desired the child to be able to speak (P =.03 and.04, respectively). Technology that aims at improving the child's ability to speak (eg, cochlear implants) had no significant impact on the decision to choose oral only training. CONCLUSIONS: Professionals who work with deaf children and their parents should recognize the presence of many relevant issues beyond the extent of the child's hearing loss. Interventions may be most effective if aimed at balancing parental beliefs and aspirations and audiologic considerations.

Adolescent↗

PubMed1983

Factors influencing initiation of breast-feeding.

We used the critical incidence method to study factors motivating 33 primigravidas and 39 multigravidas to initiate breast-feeding of their infants. Women chose breast-feeding because they believed that it would provide protection to the infant against infection, establish maternal-infant bonding, was convenient, provided better nutrition than cow's milk formula, was emotionally satisfying, and was the natural way to feed infants. The decision to breast-feed was made well in advance of pregnancy by primigravidas and shortly before pregnancy by multigravidas. Friends who had successfully nursed infants were as influential as immediate family members in influencing our study subjects in their decision to breast-feed. Prenatal counseling, though important, may not be the optimal period for motivating women to breast-feed.

Adult↗

PubMed1986

The status of research in ambulatory pediatrics.

To investigate the status of clinical research in ambulatory pediatrics and to characterize those environments that produce the most research activities and receive funding for research, a questionnaire survey was undertaken of all ambulatory pediatrics programs in the United States and Canada (N = 143). Our response rate was 68%. We found that divisions of ambulatory pediatrics that conduct clinical research have more faculty with formal research training, faculty with more time devoted to research endeavors, a designated research coordinator, research funding, and regular research seminars. Divisions of ambulatory pediatrics that have funding for research have more faculty with formal research training, fellows, a designated research coordinator, and regular research seminars. Funding for research is a more influential factor in producing clinical research than the number of faculty members in the division. The most frequently mentioned barrier to doing research was lack of time. Divisions of ambulatory pediatrics must continue to stress formal research training, faculty time set aside for research, and skills in grant writing if they hope to compete for academic recognition in the years ahead.

Pediatrics↗

PubMed1993

The morbidity of cardiac nondisease revisited. Is there lingering concern associated with an innocent murmur?

BACKGROUND: The phenomenon of cardiac nondisease was first reported in 1967 to call attention to the fact that some children were being restricted from their normal activities because their parents believed that they had a heart problem when, in fact, the child's heart was perfectly normal. This influential article and others have suggested that there may be significant morbidity in children who have been found to have innocent cardiac murmurs. METHODS: Parents of 71 schoolchildren were interviewed 1 to 5 years after their child had been examined by a pediatric cardiologist. Parents were asked about the presence of a family history of heart disease, their recall of the diagnosis and recommendations made by the cardiologist, and their level of satisfaction with the visit to the cardiologist. Parents were extensively questioned for evidence of restriction of the child's activities and for the presence of a belief that their child's murmur was something to still be concerned about. RESULTS: None of the parents reported restricting their child's activity, but 12 (17%) were still concerned about the murmur. A statistically significant relationship between parents reporting being less than "very satisfied" with the visit to the cardiologist and the presence of concern was found (P = .0006 by chi 2, Yates' correction). No other associations were noted. CONCLUSION: The association with a lower degree of satisfaction suggests that communication issues are relevant to the presence of lingering parental concern. Because the parents of a child with an innocent murmur may consider him or her to be "vulnerable," primary care physicians should follow up with parents of children referred to pediatric cardiologists for evaluation of a murmur so that any potential misunderstandings can be clarified.

Activities of Daily Living↗

PubMed1994

A program to develop residents as teachers.

Residents are recognized as important and influential teachers of medical students. Although they are expected to teach and evaluate students, few residents have been taught how, and most would like to receive training to develop and improve their skills as teachers. We developed a "Residents as Teachers" retreat based on our faculty development program for clinical preceptors. We focused on clinical precepting skills, including evaluation/feedback, and the ability to prepare and deliver a brief presentation. The program increased knowledge and skills and improved attitudes about teaching, as reflected in self-reports, observed performance, and medical student ratings. The retreat also provided a valuable social experience for residents. The program has been considered beneficial by residents, program faculty members, medical students, the student clerkship director, and the residents' primary care preceptors. The retreats form the centerpiece of our curriculum for residents as teachers and have become an annual tradition in the residency program.

Attitude of Health Personnel↗

PubMed1997

Relationship of education to the racial gap in neonatal and postneonatal mortality.

OBJECTIVE: To examine the impact of education on race differences in neonatal and postneonatal mortality. METHODS: Data were from North Carolina's Linked Birth and Infant Death File for 1988 through 1993. The study population included 169,601 African American births and 400,359 European American births, with 2606 and 3060 deaths, respectively. Multiple logistic regression was used to assess the effects of race and education on neonatal and postneonatal mortality, adjusting for sociodemographic, lifestyle, and medical risk factors. RESULTS: Risks of death were higher for African Americans than for European Americans, more so in the neonatal than in the postneonatal period. Odds ratios (with 95% confidence intervals in parentheses) comparing African Americans to European Americans were as follows: neonatal deaths, 2.2 (1.9-2.5), 2.3 (2.1-2.6), and 2.8 (2.5-3.2) for less than 12, 12, and more than 12 years of education; and postneonatal deaths, 1.3 (1.1-1.6), 1.5 (1.3-1.7), and 2.1 (1.7-2.6), respectively. The biggest gap was for deaths in the first day of life, with odds ratios ranging from 2.8 to 3.6. Education had no impact on neonatal mortality in either race. Medical factors were more influential in the neonatal than in the postneonatal period, whereas environmental and social factors appeared to play a greater role in the postneonatal period. CONCLUSIONS: Racial differences in neonatal death are increasing and may be related to inequities in the provision of health care. The racial gap in the postneonatal period, although declining, has not disappeared and may be more related to environmental, social, and economic factors.

Adult↗

PubMed1977

The offspring of schizophrenics. II. Perinatal factors and IQ.

Within a sample of 60 children of schizophrenic parents, IQ and the correlates of IQ were examined. The Wechsler Intelligence Scale for Children was administered at age 7. The offspring of parents with schizophrenia were found to have a slightly lower IQ than their matched controls. This deficit could be attributed entirely to the male offspring. Using a second comparison group numbering several thousand, we computed correlations for various perinatal and socioeconomic factors with seven-year IQ. These correlations were also computed for the children of schizophrenics, and the difference in correlations was examined. IQs for the offspring of "continuous schizophrenics" (chronic, borderline, and chronic schizo-affective schizophrenics) were found to have lower correlations with socioeconomic indices and higher correlations, in a negative direction, with certain perinatal events. The findings were found to a lesser, nonsignificant degree among the small sample of offspring of acute schizophrenics. If these perinatal events are more negatively correlated with IQ because the children of continuous schizophrenics are specifically susceptible to them, it is possible that these factors are also influential in the later development of schizophrenia.

Acute Disease↗

PubMed1988

Civil commitment in the psychiatric emergency room. III. Disposition as a function of mental disorder and dangerousness indicators.

In 251 evaluations observed in five California public psychiatric emergency rooms, patients who were retained, whether new to the system or having histories of hospitalization, rated higher on measures of danger to self, danger to others, and grave disability than patients who were released. They were also more severely symptomatic and more often given major diagnoses. The combination of dangerousness and mental disorder predicted disposition for 93% of new patients and 88% of recidivist patients. Impulsivity was the most influential aspect of mental disorder.

Adult↗

PubMed2003

Role for opinion leaders in promoting evidence-based surgery.

HYPOTHESIS: "Opinion leaders" can be identified by surgeons from among their peers, and opinion leaders have a role in promoting best surgical practice. DESIGN: Postal survey. SETTING AND PARTICIPANTS: Four hundred eighteen (77% response fraction) randomly selected fellows of the Royal Australasian College of Surgeons. MAIN OUTCOME MEASURES: Number of opinion leaders identified locally, statewide, and nationally; ratings of 22 possible attributes in conferring status as an opinion leader; and views about and ratings of the role of opinion leaders. RESULTS: Most respondents were unable to identify a local colleague whom they considered to be an opinion leader in their own specialty (mode, 0; and median, 1) or in surgery in general (mode, 0; and median, 0). Estimated numbers of opinion leaders were significantly higher at the state and national levels for the respondents' own specialty and for surgery in general (P<.001 for all). Surgical expertise and teaching skills were rated most highly as conferring status as an opinion leader. Academic and professional contributions received the lowest ratings. Most surgeons (88%; 95% confidence interval, 84%-91%) agreed that opinion leaders could influence them to change their practice. Opinion leaders were rated as "very influential" by significantly more surgeons than clinical audit (38% vs 27%, chi21 = 13.6, P<.001) and clinical practice guidelines (38% vs 24%, chi21 = 21.4, P<.001) (McNemar test for both). CONCLUSIONS: Australian surgeons support the concept of opinion leaders. Although few local colleagues whom they consider as fulfilling such a role can be identified, opinion leaders are evident at a national level. Once opinion leaders are identified using attributes ranked in our survey, interventional studies will further delineate their influence in improving evidence-based surgical practice.

Adult↗

PubMed1983

The place of abdominal aortography in abdominal aortic aneurysm resection.

We analyzed 110 patients who underwent abdominal aortography as a routine preliminary to abdominal aortic aneurysm resection. In 11 of the 15 patients for whom the procedures were useful in planning the operative tactics, the aortograms would have been performed anyway on clinical indications. In two patients, the changes in surgical maneuvers would not have been made through anatomic inspection at the time of the operations, but the lesions were asymptomatic. Biplane views and views of the femoropopliteal systems were rarely influential. Morbidity from the angiography was minimal and mortality was zero, but about seven aortograms were performed for each one that effected a change in procedure. We concluded that abdominal aortography as a preliminary to aneurysmectomy could be reasonably limited to patients in whom it was indicated by clinical features, including important hypertension, impaired renal function, diminished or absent femoral pulses, suspected mesenteric ischemia, suspected suprarenal extension of the aneurysm, or suspected (from the chest roentgenograms) thoracic aneurysm.

Aorta, Abdominal↗

PubMed1984

Rural rotations for senior surgical residents. Influence on future practice location.

No information is available on factors that influence a surgeon's decision of where to practice. We surveyed all recent graduates of a surgical training residency program from a single institution to determine factors that influence this decision. An attempt was made to determine if a rural rotation during training ultimately influenced surgeons to locate their practices in rural areas. Ninety percent of 58 graduates responded: 44% entered a rural practice and 56% an urban and/or academic practice. A rural rotation during residency had been completed by 64% of the respondents. A significantly larger number of those who entered rural practice had completed a rural rotation than those who entered urban practice. Hometown size, level of debt, and other factors thought to be influential for other subpopulations of physicians were not found to be significant in this review.

Decision Making↗

PubMed1991

Why surgeons prefer not to care for trauma patients.

A survey of the Washington State Chapter of the American College of Surgeons was undertaken to document the opinions of surgeons on trauma care issues. Thirty-nine percent of the total sample of surgeons who responded would prefer not to treat any trauma patients. These surgeons were more likely to be older, to practice in an urban setting, to feel that trauma call has a negative impact on elective practice, and to believe more strongly that reimbursement from trauma patients is not equal to that of nontrauma patients. They also agreed more strongly with the statements that these patients require a greater time commitment and pose an increased medicolegal risk. The most significant influence on preference not to treat trauma patients was exerted by the perception of a negative impact on practice, older age, and perception of increased medicolegal risk. Reimbursement issues and location of practice were less influential factors. This information can be used to target concerns and barriers to active, willing participation in a trauma care system and to tailor strategies to deal with them effectively.

Adult↗

PubMed1994

William Tod Helmuth and Andrew Jackson Howe. Surgical sectarianism in 19th-century America.

Nineteenth-Century American society was particularly prone to the establishment of numerous unorthodox medical practices and their alternative therapies. The most influential of the unorthodox medical groups were the homeopathic and eclectic sects. From within the ranks of homeopathy and eclecticism, William Tod Helmuth and Andrew Jackson Howe, respectively, emerged to become the best-known sectarian surgeons of their era. Through a review of their lives this forgotten chapter in the history of American surgery is recollected.

Eclecticism, Historical↗

PubMed1998

Issues in comparisons between meta-analyses and large trials.

CONTEXT: The extent of concordance between meta-analyses and large trials on the same topic has been investigated with different protocols. Inconsistent conclusions created confusion regarding the validity of these major tools of clinical evidence. OBJECTIVE: To evaluate protocols comparing meta-analyses and large trials in order to understand if and why they disagree on the concordance of these 2 clinical research methods. DESIGN: Systematic comparison of protocol designs, study selection, definitions of agreement, analysis methods, and reported discrepancies between large trials and meta-analyses. RESULTS: More discrepancies were claimed when large trials were selected from influential journals (which may prefer trials disagreeing with prior evidence) than from already performed meta-analyses (which may target homogeneous trials) and when both primary and secondary (rather than only primary) end points were considered. Depending on how agreement was defined, kappa coefficients varied from 0.22 (low agreement) to 0.72 (excellent agreement). The correlation of treatment effects between large trials and meta-analyses varied from -0.12 to 0.76, but was more similar (0.50-0.76) when only primary end points were considered. When both the magnitude and uncertainty of treatment effects were considered, large trials disagreed with meta-analyses 10% to 23% of the time. Discrepancies were attributed to different disease risks, variable protocols, quality, and publication bias. CONCLUSIONS: Comparisons of large trials with meta-analyses may reach different conclusions depending on how trials and meta-analyses are selected and how end points and agreement are defined. Scrutiny of these 2 major research methods can enhance our appreciation of both for guiding medical practice.

Bias↗

PubMed1998

Is there a sex bias in choosing editors? Epidemiology journals as an example.

CONTEXT: Editors, authors, and reviewers are influential in shaping science. The careers of women in public health have received less scrutiny than those of women in medicine and other branches of science. The performance of women as editors, authors, and reviewers in epidemiology has not been previously studied. OBJECTIVE: To examine changes over time in the representation of women at the editorial level in US epidemiology journals compared with the proportion of women authors and reviewers. DESIGN AND SETTING: Cross-sectional study of 4 US epidemiology journals, American Journal of Epidemiology, Annals of Epidemiology, Epidemiology, and the Journal of Clinical Epidemiology (formerly the Journal of Chronic Diseases), for 1982, 1987, 1992, and 1994. SUBJECTS: Editors, authors, and reviewers for the selected years. MAIN OUTCOME MEASURES: Sex of editors, authors, and reviewers. RESULTS: We identified 2415 reports associated with 8005 authors. One of 7 editors in chief was a woman, a position she shared with a man. For all journals, the proportion of editors who were women ranged from 5 (6.5%) of 77 in 1982 to 42 (16.3%) of 258 in 1994. Over all journals and all years, women comprised a higher proportion of authors (28.7% [2225/7743]) compared with reviewers (26.7% [796/2982]) or editors (12.8% [89/696]). CONCLUSIONS: Fewer women in public health hold editorial positions than are authors and reviewers. The reasons for this important discrepancy, including the possibility of a selection bias favoring men, should be further investigated.

Authorship↗

PubMed1999

Methods to encourage the use of antenatal corticosteroid therapy for fetal maturation: a randomized controlled trial.

CONTEXT: Antenatal corticosteroids for fetal maturation have been underused, despite evidence for their benefits in cases of preterm birth. OBJECTIVE: To evaluate dissemination strategies aimed at increasing appropriate use of this therapy. DESIGN AND SETTING: Twenty-seven tertiary care institutions were randomly assigned to either usual dissemination of practice recommendations (n = 14) or usual dissemination plus an active, focused dissemination effort (n = 13). SUBJECTS: Obstetricians and their preterm delivery cases at participating hospitals. INTERVENTION: Recommendations by a National Institutes of Health (NIH) Consensus Conference held in late February-early March 1994 were disseminated in early May 1994. Usual dissemination was publication of the recommendations and endorsement by the American College of Obstetricians and Gynecologists. Active dissemination was a year-long educational effort led by an influential physician and a nurse coordinator at each facility, consisting of grand rounds, a chart reminder system, group discussion of case scenarios, monitoring, and feedback. MAIN OUTCOME MEASURE: Use or nonuse of antenatal corticosteroids was abstracted from medical records of eligible women delivering at the participating hospitals in the 12 months immediately prior to release of the NIH recommendations (average number of records abstracted, 130) and in the 12 months following their release (average number of records abstracted, 122). RESULTS: Active dissemination significantly increased the odds of corticosteroid use after the conference. Use increased from 33.0% of eligible patients receiving corticosteroids to 57.6%, or by 75% over baseline, in usual dissemination hospitals. Use increased from 32.9% to 68.3%, oran 108% increase, in active dissemination hospitals. Gestational age and maternal diagnosis affected use of the therapy in complex ways. CONCLUSION: An active, focused dissemination effort increased the effectiveness of usual dissemination methods when combined with key principles to change physician practices.

Anti-Inflammatory Agents↗