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Influence of medical school applicants' demographic and cognitive characteristics on interviewers' ratings of noncognitive traits.

BACKGROUND: Interviews are commonly used to measure noncognitive traits of medical school applicants. The present study investigated the influence of knowledge of applicants' cognitive abilities on interviewers' ratings of noncognitive traits. METHOD: Academic and demographic predictors of interview ratings of applicants' noncognitive traits were examined at the Medical University of South Carolina College of Medicine during two years: 1992, when applicants' Medical College Admission Test (MCAT) total scores and undergraduate grade-point averages (GPAs) were available to interviewers; and 1993, when MCAT and GPA data were not available. In 1992, 226 applicants met study criteria (i.e., they received ratings from three interviewers in addition to having MCAT and GPA data on file); in 1993, 245 applicants met the criteria. Step-wise regression analyses were conducted to measure the influences of seven independent variables on applicants' interview ratings. Two-way analyses of variances and t-tests were used to determine the effects of gender of applicants and interviewers. Cronbach's alpha coefficients were used as measures of interviewers' reliability. RESULTS: GPA was the best predictor for both years but accounted for double the amount of variance in interview ratings in 1992 (15.7%) compared with 1993 (7.4%). The reliability coefficients for the interviewers were .496 for 1992 and .473 for 1993. CONCLUSION: If the goal of the medical school admission interview is to assess noncognitive traits independently from academic skills, the authors recommend that MCAT and GPA data not be available to interviewers during interviews. The authors also found that gender and race influenced interview ratings in accordance with affirmative-action goals. Finally, the authors found that interview scores were only moderately reliable across different interviewers. They discuss ways to increase their reliability.

Analysis of Variance↗

Misrepresentation of authorship by applicants to pediatrics training programs.

PURPOSE: To determine whether applicants to pediatrics residency and fellowship programs misrepresented authorship of publications. METHOD: The authors sampled 1995 applications to the University of Washington School of Medicine's pediatrics residency program and pediatrics pulmonary fellowship program. They submitted all publications claimed in the submitted applications to extensive efforts to authenticate both their existence and authorship. RESULTS: Among the 404 pediatrics residency program applications studied, 147 claimed authorship of publications; 29 (19.7%) of these contained at least one unverifiable publication. Of the 401 publications claimed in the 147 applications, 41 (10.2%) could not be confirmed. Among 31 fellowship applications, 14 claimed publications. At least one citation was unverifiable for each of the 14 applications. Of the total 77 publications claimed, 31 (40%) could not be confirmed. CONCLUSION: Misrepresentation occurs on graduate medical education applications; solutions are needed to address this problem.

Authorship↗

A comparison of the MMPI results for psychiatric patients and male applicants for transsexual surgery.

Previous studies have been evenly divided in concluding that male sex change applicants do or do not evidence signs of psychopathology on Minnesota Multiphasic Personality Inventory testing. To clarify the discrepant findings, Minnesota Multiphasic Personality Inventory scale comparisons were made between sex change applicants who had been living continuously as women, applicants who had been living predominantly as men, and groups of psychiatric inpatients and outpatients. Findings revealed that members of both applicant groups were more likely than psychiatric patients to score high on a measure of femininity. However, applicants living as men were as disturbed as psychiatric patients on all other measures of psychopathology, whereas those living as women showed a notable absence of psychopathology. Like the psychiatric patients, applicants living as men produced significant elevations on the Depression, Psychopathic Deviate, Psychasthenia, and Schizophrenia Scales. A variety of group comparisons also revealed serious emotional disturbance in one sex change applicant group and none in the other. The results help to explain the previous discrepancies in the literature and underline the importance of the "living as female" variable for predicting disturbance in sex change applicants.

Adult↗

Second application of low-energy shock waves has a cumulative effect on free nerve endings.

Some physicians recommend treating tendinopathies with multiple sessions of shock waves. Some evidence, however, suggests shock wave application can induce nerve fiber degeneration. We questioned whether repeated shock wave application provides a cumulative effect on nerve fibers compared with the effect of one application. One thousand shock wave impulses of an energy flux density of 0.08 mJ/mm were applied to the foot pad of 32 rats. After 14 days, 16 rats received a second application. The foot pads were resected on Days 7, 14, 28, and 42. Sections were processed immunohistochemically using antibodies for sensory nerve. We compared the number of epidermal nerve fibers in rats that received one application of shock waves with the fibers in rats that received two applications. During the first 4 weeks, there was nearly complete degeneration of epidermal nerve fibers in both groups. By the end of 6 weeks, reinnervation of the epidermis began in the single-treatment group. Reinnervation occurred slower in the repeated-treatment group. These data show that a second application has a cumulative effect on nerve fibers. Our data suggest multiple applications of low-energy shock waves might a provide longer-lasting antinociceptive effect.

Animals↗

Applicability and clinical relevance of results in randomized controlled trials: the Cochrane review on exercise therapy for low back pain as an example.

STUDY DESIGN: A critical appraisal of the literature. OBJECTIVES: To increase awareness of the importance of applicability and clinical relevance of the results of randomized controlled trials (RCTs) in the field of spinal disorders by formulating a list of items for assessment of applicability and clinical relevance of results of RCTs. SUMMARY OF BACKGROUND DATA: In systematic reviews of randomized controlled trials (RCTs), critical appraisal of methodologic quality is considered important. Less attention has been paid to the assessment of the applicability and the clinical relevance of the results. METHODS: RCTs in an update of the Cochrane review on exercise therapy for low back pain were used. Most of the trials did not score positively on the five Cochrane Back Review Group basic items describing patients: intervention and setting, outcome, effect size, and benefits related to adverse effects. Item 1 was met by 88% of the trials, but item 2 only by 51%, item 3 by 67%, item 4 by 35%, and item 5 by 0%. Subsequently, a more comprehensive list of items for the assessment of applicability and clinical relevance of results of RCTs was developed. These criteria were pilot tested on the RCTs. After pilot testing and a subsequent consensus meeting, the list of items was drafted and circulated among the members of the Editorial Board of the Cochrane Back Review Group. Changes were made in response to comments. RESULTS: The final list consists of 40 items. The items are ordered on two headings: Does the report enable the assessment of applicability? Are the study results clinically relevant? We present examples of informative and noninformative reporting of RCTs in order to illustrate how information on applicability and clinical relevance of results can be assessed. CONCLUSIONS: Authors of RCTs should adequately report on items that are essential to assess the applicability and clinical relevance of results. The presented list of items may help clinicians reading RCTs and authors of systematic reviews to draw more balanced conclusions on applicability and clinical relevance of results.

Humans↗

Computer-aided design of two-dimensional electric-type hyperthermia applicators using the finite-difference time-domain method.

A hyperthermia applicator design tool consisting of a finite-difference time-domain (FDTD) technique in combination with a graphical display of electric fields and normalized linear temperature rise is described. This technique calculates, rather than assumes, antenna current distributions; it includes mutual interactions between the body and the applicator, and it calculates driving-point impedance and power delivered to the applicator. Results show that the fundamental limitation of 2-D electric-type applicators is overheating of the fat by normal components of the electric field, which exist because of near fields and capacitive coupling with the muscle. Two factors which contribute to the capacitance are the muscle conductivity and the small antenna size in air. Two examples of applicators designed to avoid fat overheating are described: a 27-MHz segmented dipole for heating large tumors to 7 cm depth, and a 100-MHz dipole for small tumors to 5 cm depth. The first uses a water bolus, and the second uses a water bolus with low-permittivity strips to reduce normal fields at the antenna ends. The results of this study describe fundamental limitations of electric field applicators, and illustrate the use of a powerful applicator design tool that allows rapid evaluation of a wide range of ideas for applicators which would require months and years to test experimentally.

Algorithms↗

Emergency medicine residency applicant educational debt: relationship with attitude toward training and moonlighting.

OBJECTIVES: Heated debate persists regarding the role of resident moonlighting in emergency medicine (EM). The attitudes of EM residency applicants have not been assessed. The objectives of this study were to assess: 1) the level of educational debt among EM residency applicants, 2) their perception of increased risk potential to patients from unsupervised EM resident practice, and 3) their opposition to laws restricting moonlighting. The authors then report the relationship between the degree of indebtedness and these stated positions. METHODS: Fifty-four EM residency programs returned 393 responses to a 1996 anonymous survey. Applicants recorded: 1) their indebtedness, 2) whether they believed that EDs should hire only physicians who have completed full training in an EM residency, and 3) whether they believed that unsupervised EM practice prior to completing EM training carries a higher risk of adverse patient outcomes. The authors used a t-test and logistic regression to determine whether there was any significant difference in debt between responders who answered yes and those who answered no to the various questions. A p-value < 0.05 was considered significant. RESULTS: The mean +/- SD debt was $72,290 +/- 48,683 (median $70,000). Most EM applicants (84.8%) agreed that unsupervised medical care by EM residents carries a higher risk of adverse patient outcomes. Paradoxically, only half the applicants opposed a moonlighting ban. Responses did not statistically correlate with educational debt. CONCLUSIONS: Emergency medicine residency applicant debt is large. The EM applicants' opposition to laws that would restrict moonlighting was mixed. This was inconsistent with the majority acknowledging an increased risk potential to patients. Nearly all EM applicants would still select EM as a career, even if moonlighting were to be banned.

Adult↗

Control of interstitial thermal coagulation: comparative evaluation of microwave and ultrasound applicators.

This study presents a comparative evaluation of the control of heating and thermal coagulation with microwave (MW) and ultrasound (US) interstitial applicators. Helical coil MW antennas (17 mm and 25 mm length radiating antennae) were tested using an external implant catheter (2.2 mm o.d.) with water-cooling. US applicators with tubular transducers (2.2 and 2.5 mm o.d., 10 mm length, single-element and 3-element) were utilized with a direct-coupled configuration and internal water-cooling. Measurements of E-field distributions (for MW) and acoustic beam distributions (for US) were used to characterize the applicator energy output. Thermal performance was evaluated through multiple heating trials in vitro (bovine liver) and in vivo (porcine thigh muscle and liver) at varied levels of applied power (20-40 W for microwave, 15-35 W for ultrasound) and heating times (0.5-5 min). Axial temperature distributions in the tissue were recorded during heating, and dimensions of the resulting lesions of thermal coagulation were measured. Both MW and US applicators produced large volumes of tissue coagulation ranging from 8 to 20 cm3 with singular heating times of 5 min. Radial depth of lesions for both MW and US applicators increased with heating duration and power levels, though US produced notably larger lesion diameters (30-42 mm for US vs 18-26 mm for MW, 5 min heating). Characteristic differences between the applicators were observed in axial energy distribution, tissue temperatures, and thermal lesion shapes. MW lesions increased significantly in axial dimensions (beyond the active applicator length) as applied power level and/or heating duration was increased, and lesion shapes were generally not uniform. US provided greater control and uniformity of heating, with energy deposition and axial extent of thermal lesions corresponding to the length of the active transducer(s). The improved ability to control the extent of thermal coagulation demonstrated by the US applicators provides greater potential to target a specific region of tissue.

Animals↗

Calculation of beta-ray dose distributions from ophthalmic applicators and comparison with measurements in a model eye.

Dose distributions throughout the eye, from three types of beta-ray ophthalmic applicators, were calculated using the EGS4, ACCEPT 3.0, and other Monte Carlo codes. The applicators were those for which doses were measured in a recent international intercomparison [Med. Phys. 28, 1373 (2001)], planar applicators of 106Ru-106Rh and 90Sr-90Y and a concave 106Ru-106Rh applicator. The main purpose was to compare the results of the various codes with average experimental values. For the planar applicators, calculated and measured doses on the source axis agreed within the experimental errors (<10%) to a depth of 7 mm for 106Ru-106Rh and 5 mm for 90Sr-90Y. At greater distances the measured values are larger than those calculated. For the concave 106Ru-106Rh applicator, there was poor agreement among available calculations and only those calculated by ACCEPT 3.0 agreed with measured values. In the past, attempts have been made to derive such dose distributions simply, by integrating the appropriate point-source dose function over the source. Here, we investigated the accuracy of this procedure for encapsulated sources, by comparing such results with values calculated by Monte Carlo. An attempt was made to allow for the effects of the silver source window but no corrections were made for scattering from the source backing. In these circumstances, at 6 mm depth, the difference in the results of the two calculations was 14%-18% for a planar 106Ru-l06Rh applicator and up to 30% for the concave applicator. It becomes worse at greater depths. These errors are probably caused mainly by differences between the spectrum of beta particles transmitted by the silver window and those transmitted by a thickness of water having the same attenuation properties.

Beta Particles↗

A patch source model for treatment planning of ruthenium ophthalmic applicators.

Beta-ray emitting Ru-106/Rh-106 ophthalmic applicators have been used for close to 4 decades in the treatment of choroidal melanoma. The form factor of these applicators is a spherically concave silver bowl with an inner radius of curvature between 12 and 14 mm, and a total shell thickness of 1 mm. The radioactive nuclide is deposited in a layer 0.1 mm below the concave surface of the applicator. Calculation of dose distributions for clinical treatment planning purposes is complicated by the concave nature of the distributed source, the asymmetric shape of the active region of some applicators, imperfections in the manufacturing process which can result in an inhomogeneous distribution of activity across the active surface, and absorption and scatter in the 0.1 mm layer of silver which seals and protects the radioactive layer. A semi-empirical method of calculating dose distributions for these applicators is described which is fundamentally compatible with treatment planning systems that use the AAPM TG43 brachytherapy formalism. Dose to water is estimated by summing a "patch source" dose function over a discrete number of overlapping patches uniformly distributed over the active surface of the applicator. The patch source dose function differs conceptually from a point source dose function in that it is intended to represent the macroscopic behavior of a small, disk-like region of the applicator. The patch source dose function includes an anisotropy term to account for angular variation in absorption and scatter as particles traverse the 0.1 mm silver window. It geometrically models the nearfield of a patch with properties akin to both a small disk and infinite plane, and models the farfield as if the patch were a point. This allows a manageable number of discrete patches (300 to 1000) to provide accuracy appropriate for clinical treatment planning. This approach has the advantages of using familiar concepts and data structures, it is computationally quick, and it readily adapts to asymmetric applicator shapes and inhomogeneities in the radionuclide distribution. A method for optimizing the patch source dose function parameters is presented, and the dosimetric calculations are compared with published Monte Carlo calculations and measurements.

Algorithms↗

Attenuation of intracavitary applicators in 192Ir-HDR brachytherapy.

Unlike the penetrating monoenergetic 662 keV gamma rays emitted by 137Cs LDR sources, the spectrum of 192Ir used in HDR brachytherapy contains low-energy components. Since these are selectively absorbed by the high-atomic number materials of which intracavitary applicators are made, the traditional neglect of applicator attenuation can lead to appreciable dose errors. We investigated the attenuation effects of a uterine applicator, and of a set of commonly used vaginal cylinders. The uterine applicator consists of a stainless steel source guide tube with a wall thickness of 0.5 mm and a density of 8.02 g/cm3, whereas the vaginal cylinders consist of the same stainless steel tube plus concentric polysulfone cylinders with a radius of 1 or 2 cm and a density of 1.40 g/cm3. Monte Carlo simulations were performed to compute dose distributions for a bare 192Ir-HDR source, and for the same source located within the applicators. Relative measurements of applicator attenuation using ion-chambers (0.125 cm3) confirmed the Monte Carlo results within 0.5%. We found that the neglect of the applicator attenuation overestimates the dose along the transverse plane by up to 3.5%. At oblique angles, the longer photon path within applicators worsens the error. We defined attenuation-corrected radial dose and anisotropy functions, and applied them to a treatment having multiple dwell positions inside a vaginal cylinder.

Algorithms↗

Dosimetric analysis of a shielded applicator for nasopharyngeal carcinoma intracavitary brachytherapy: Monte Carlo calculation.

In nasopharyngeal cancer (NPC) intracavitary brachytherapy, an anatomical dose reference point (in line with that for gynecology work), e.g., at the sphenoid floor, is more precise than the empirical point of 1 cm from the source. However, such increases of the single-source-plan treatment distances may deliver excessive doses inferiorly, to the soft palate. As shielding may help, its efficacy was studied by Monte Carlo simulations in water for 20 and 30 mm diameter spherical NP applicators (representing extremes of sizes for the small NP cavity), with/without lead shielding inferiorly, using a single linear Ir-192, 2 mm steps, equal dwell times for 5 (5DP) and 9 dwell positions (9DP). Dose reductions of the selected points of interest ranged from 1.2% to 40.5% for the 20 mm shielded applicator and a range of 2.9% to 17.9%, for the 30 mm shielded applicator. Dose volume histograms of the "region of interest" (ROI)-a cuboid of 4 x 4 x 0.5 cm3 at the most inferior aspect of the applicator, also differed significantly. The highest doses of the 50% (D50) and 20% (D20) volumes of ROI (for 5DP and 9DP plans) were reduced by 11.9% to 17.9% for the 20 mm applicator and a range of 9.0% to 11.5% for the 30 mm shielded applicator. Doses in unshielded directions were insignificantly changed, for example, with a 20 mm applicator simulated in a 5DP plan, the dose distribution close to the source in the unshielded direction has less than 4% difference at the 50% isodose relative to the dose prescription point. For the 30 mm shielded applicator, despite smaller dose reduction percentages, a more pronounced effective dose reduction was obtained than nominal values when considering radiobiological equivalent doses. Our system was demonstrated to be ready for clinical assessment.

Brachytherapy↗

The importance of applicator design for intraluminal brachytherapy of rectal cancer.

An important aspect of designing an applicator for radiation treatment of rectal cancer is the ability to minimize dose to the mucosa and noninvolved parts of the rectum wall. For this reason we investigated a construction of a flexible multichannel applicator with several channels placed along the periphery of a cylinder and a construction of a rigid cylinder with a central channel and interchangeable shields. Calculations of the dose gradient, dose homogeneity in the tumor, and shielding ability were performed for the two applicators in question. Furthermore, the influence on dose distribution around a flexible multichannel applicator from an unintended off-axis positioning of the source inside a bent channel was investigated by film measurements on a single bent catheter. Calculations showed that a single-channel applicator with interchangeable shields yields a higher degree of shielding and has a better dose homogeneity in the tumor volume than that of a multi-channel applicator. A single-channel applicator with interchangeable shields was manufactured, and the influence of different size of shield angle on dose rate in front of and behind the shields was measured. While dose rate in front of the shield and shielding ability are closely independent of the size of the shield angle when measured 1 cm from the applicator surface, dose rate in more distant volumes will to some extent be influenced by shield angle due to volume scatter conditions.

Brachytherapy↗

Thermographically determined specific absorption rate patterns of 434-MHz applicators.

The specific absorption rate (SAR) patterns of two 434-MHz hyperthermia applicators, models TCA 434-1 (9 X 20 cm) and TCA 434-2 (13 X 25 cm), were evaluated thermographically using a phantom model. The phantom model consisted of a 2-cm-thick layer of fat and a 10-cm depth of muscle contained in a 30 X 30 cm base Plexiglas box. The model was bisected in the middle. Polyester screens at the interface allowed the synthetic gel to make electrical contact between the two halves of the muscle tissue. Octyl alcohol was applied to the fat interface to ensure continuity of dielectric properties. Thermograms were taken for both applicators over the following areas of the exposed model: (1) fat surface, (2) internal surface with E-field parallel to interface, and (3) internal surface with E-field perpendicular to interface. SAR's were calculated from the temperature rise (8 degrees C maximum), net input power (550-650 W), exposure time (15-60 s), and specific heat of the muscle (0.86 kcal/kg degrees C). A factor of 0.42 needs to be multiplied to correct for the specific heat of fat. High localized SAR's along the broad sides of the applicators were seen when the applicators were in direct contact with the phantom. With the use of a 0.8-cm polystyrene foam spacing, the SAR's within the aperture of the applicators were relatively uniform. The patterns of the two applicators were quite similar. However, the TCA 434-1 applicator is smaller and more applicable for clinical conditions.

Absorption↗

Evaluation of captive bolus applicators.

Three square (L, M, MS) and one rectangular (HN) applicators with captive boluses were provided by the Clini-Therm Corporation for evaluation. Surface cooling is achieved by attaching a mineral oil captive bolus to the built in water-circulating tubes at the aperture of the applicators. These applicators were tested on a phantom with a 2-cm fat slab over 10-cm-thick muscle. Surface and sagittal heating patterns were obtained using a thermograph. All captive-bolus applicators have heating patterns similar to that of the regular Clini-Therm applicators. Due to hot spots at the edges of the applicators where the E fields terminate, these modified applicators should not be placed in direct contact with patients when boluses are not used. Tests with Clini-Therm regular water bolus instead of the captive oil bolus indicated that the orientation of water flow should be parallel to the E field to minimize perturbation of the heating patterns. Thermal conduction studies showed that the captive bolus reacts too slowly for skin temperature control. The modified captive bolus applicators did not improve the performance of the system.

Adipose Tissue↗

Air-cooling of direct-coupled ultrasound applicators for interstitial hyperthermia and thermal coagulation.

The feasibility of using air-cooling to improve the thermal penetration of direct-coupled interstitial ultrasound (US) applicators was investigated using biothermal simulations, bench experiments, phantom testing, and in vivo thermal dosimetry. Two applicator configurations using tubular US transducers were constructed and tested. The first design, intended for simultaneous thermobrachy-therapy, utilizes a 2.5 mm OD transducer with a central lumen to accommodate a radiation source from remote afterloaders. The second applicator consists of a 2.2 mm OD transducer designed for coagulative thermal therapy. Both designs provide cooling of the inner transducer surface by the counterflow of chilled air or CO2 gas through the annulus of the enclosed applicator. The average convective heat transfer (ha) associated with each applicator was determined empirically from curve-fits of radial steady-state temperatures measured in a tissue-mimicking phantom. High levels of convective heat transfer (ha > 500 W m-2 degrees C-1) were demonstrated in both designs at relatively low flow rates (< 5 L min-1). Transient and steady-state radial heating profiles were also measured in vivo (pig thigh muscle) with and without cooling. The therapeutic radius for hyperthermia (41-45 degrees C) was extended from 5-6 mm (without cooling) to 11-19 mm with air-cooling (4.8 L min-1, airflow 10 degrees C), effectively doubling and tripling the thermal penetration in vivo. Similar improvements were demonstrated at higher temperatures with the thermal coagulation applicator. Biothermal simulations, which modeled the physical, thermal, and acoustic parameters of the air-cooled applicator and surrounding tissue, were also used to investigate potential improvements in heating patterns. The simulated radial heating profiles with transducer cooling demonstrated significantly enhanced thermal penetration over the experimental range of convective transfer, and also agreed with in vivo results. These theoretical and experimental results clearly show air-cooling controls the transducer surface temperature, significantly increases thermal penetration, and produces a greater treatment volume for direct-coupled US applicators in hyperthermia and thermal coagulation.

Acoustics↗

Topical application of ionic polymers affects skin permeability barrier homeostasis.

We previously demonstrated that the external electric potential affected skin barrier homeostasis. On the other hand, topical application of an ionic polymer formed a diffusion electric double layer on the surface of the skin. Thus, we evaluated effects of topical application of ionic polymers on the damaged skin barrier. Application of a nonionic polymer did not affect barrier recovery. Application of sodium salts of anionic polymers accelerated barrier recovery, while that of cationic polymers delayed it. Topical application of a sodium-exchange resin accelerated barrier recovery, but application of a calcium-exchange resin had no effect even when the resins had the same structure. Application of a chloride-exchange resin delayed barrier recovery. Topical application of ionic polymers influenced skin barrier homeostasis.

Administration, Cutaneous↗

Response of rat conjunctival mast cells to multiple versus single applications of compound 48/80.

A single application of the mast cell secretagogue compound 48/80 to the surface of the rat eye induces significant histologic changes. Ocular anaphylaxis is usually the result of repeated, not single, exposures to allergenic substances. The response of conjunctival mast cells to repeated daily applications of compound 48/80 was, therefore, evaluated. Ninety rats received one dose of compound 48/80 or phosphate-buffered saline almost daily for 17 days. The frequency and degree of mast cell degranulation and the number of mast cells and other inflammatory cells in the subepithelial conjunctiva were determined histologically. The clinical response was most marked after one application of compound 48/80; repeated daily applications markedly reduced the clinical response. In eyes treated with multiple applications, 75% fewer mast cells were observable in the conjunctiva by light microscopy compared with phosphate-buffered saline treated eyes. Most mast cells were granulated; a few showed mild to moderate degranulation. Except for epithelial damage, no tissue injury was associated with multiple applications of compound 48/80. In contrast to conjunctivae subjected to a single application of compound 48/80, conjunctivae receiving multiple applications resembled that of phosphate-buffered saline controls.

Administration, Topical↗