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PubMed2000

Pancreatic cancer and serum organochlorine levels.

Occupational exposure to p,p'-dichlorodiphenyltrichloroethane (DDT) has been associated with increased pancreatic cancer risk. We measured organochlorine levels in serum obtained at the study enrollment from 108 pancreatic cancer cases and 82 control subjects aged 32-85 years in the San Francisco Bay Area between 1996 and 1998. Cases were identified using rapid case-ascertainment methods; controls were frequency-matched to cases on age and sex via random digit dial and random sampling of Health Care Financing Administration lists. Serum organochlorine levels were adjusted for lipid content to account for variation in the lipid concentration in serum between subjects. Median concentrations of p,p'-dichlorodiphenyldichloroethylene (DDE, 1290 versus 1030 ng/g lipid; P = 0.05), polychlorinated biphenyls (PCBs; 330 versus 220 ng/g lipid; P<0.001), and transnonachlor (54 versus 28 ng/g lipid; P = 0.03) were significantly greater among cases than controls. A significant dose-response relationship was observed for total PCBs (P for trend <0.001). Subjects in the highest tertile of PCBs (> or =360 ng/g lipid) had an odds ratio (OR) of 4.2 [95% confidence interval (CI) = 1.8-9.4] compared to the lowest tertile. The OR of 2.1 for the highest level of p,p'-DDE (95% CI = 0.9-4.7) diminished (OR = 1.1; 95% CI = 0.4-2.8) when PCBs were included in the model. Because pancreatic cancer is characterized by cachexia, the impact of this on the serum organochlorine levels in cases is difficult to predict. One plausible effect of cachexia is bioconcentration of organochlorines in the diminished lipid pool, which would lead to a bias away from the null. To explore this, a sensitivity analysis was performed assuming a 10-40% bioconcentration of organochlorines in case samples. The OR associated with PCBs remained elevated under conditions of up to 25% bioconcentration.

Adult↗

PubMed2000

Microsatellite analysis provides evidence of neoplastic transformation in long-segment, but not in short-segment, Barrett's oesophagus.

It has been suggested that the high prevalence of short segments of specialised intestinal metaplasia (SIM) at the gastro-oesophageal junction is associated with the rising incidence of oesophageal adenocarcinoma. Our aims were to document the prevalence of short segments of SIM at the gastro-oesophageal junction in patients attending for routine endoscopy and to determine if there was molecular evidence of neoplastic transformation in those with SIM. Patients (n = 101) were recruited from randomly selected upper gastro-intestinal endoscopy lists. Biopsy specimens were taken at the squamo-columnar junction to assess the prevalence of SIM. Frozen sections were assessed for molecular evidence of neoplastic transformation using microsatellite analysis. Squamo-columnar biopsies were suitable for analysis in 95 patients, of whom 20 (21%) had oesophagitis and 2 (2%) had Barrett's oesophagus (>3 cm of endoscopically apparent columnar-lined oesophagus). Twenty patients had SIM at the gastro-oesophageal junction, including 2 with Barrett's oesophagus and 18 with short segments of SIM, one of whom had an associated intramucosal adenocarcinoma detected incidentally by histology. Three of the 20 cases with SIM exhibited novel microsatellite alleles, 2 with Barrett's oesophagus and 1 with short segment SIM and an associated adenocarcinoma. The 18 patients with short segments of SIM at the gastro-oesophageal junction were significantly older than those without SIM.

Adenocarcinoma↗

PubMed2000

Haemostatic and lipid determinants of prothrombin fragment F1.2 and D-dimer in plasma.

The determinants of plasma levels of prothrombin fragment F1.2 (F1.2) and D-dimer in different populations are unclear and this may complicate their interpretation as predictors of thrombotic risk, particularly in the case of D-dimer. We therefore measured F1.2 and D-dimer levels together with a number of other haemostatic and lipid variables in a cross-sectional community-based study of 150 healthy adults (73 male, 77 female), age range 23-80 years, identified from the list of a general practice by stratified random sampling within sex and decade of age. Plasma F1.2 was significantly higher in females than males and was independently and positively associated with age, factor VII activity (FVIIc) and C1 inhibitor, and inversely associated with high density lipoprotein (HDL) cholesterol. Plasma D-dimer showed a quadratic association with age (p <0.0001). In those < or =55 years D-dimer was inversely associated with dilute clot lysis time (DCLT) and activated protein C (APC) ratio. In those >55 years it was significantly higher in females than males and associated positively with age, fibrinogen and, in males, activated factor XII (FXIIa). In a multiple-linear model which combined both age groups, F1.2 and D-dimer were independently associated with each other (r = 0.22, p = 0.03). Thus, thrombin generation and fibrin turnover/fibrinolysis are associated in healthy subjects. HDL cholesterol (inversely) and FVIIc are associated with basal thrombin generation (i.e. F1.2). Determinants of D-dimer differ according to age and interpretation of the biological significance of D-dimer levels in epidemiological studies may therefore not be straightforward.

Adult↗

PubMed1992

Subspecialization within pediatric practice: a broader spectrum.

This study was undertaken to describe subspecialty characteristics and practices of the population of pediatricians given the ongoing controversy regarding a projected manpower oversupply of general pediatricians. A questionnaire was mailed to a national random sample of 1620 United States physicians listed in the American Medical Association's Physician Masterfile as being in office-based pediatric practice. The final response rate was 63%. Seventy percent of respondents designated their practices as "general pediatrics" versus 17% as "general pediatrics with a specific subspecialty interest" and 13% as "subspecialty practice." The general pediatricians with a specific subspecialty interest were intermediate in the proportion that had some training in a pediatric fellowship program (general pediatricians with a specific subspecialty interest, 63% versus general pediatricians, 14%, P < .0001, and pediatricians with a subspecialty practice, 92%, P < .0001) and that were certified in a pediatric subspecialty by the American Board of Pediatrics (general pediatricians with a specific subspecialty interest 16% versus general pediatricians, 2%, P < .0001, and pediatricians with a subspecialty practice, 62%, P < .0001). They were also intermediate in the proportion involved in various academic pursuits. Their practices, however, more closely resembled general pediatricians than pediatricians with a subspecialty practice in their location, setting, associates, and commitment to primary care. They were more likely than general pediatricians to utilize or provide specialized tests or procedures. A large percentage of pediatricians incorporate subspecialty elements into their general pediatric practices. Models of current and projected pediatric manpower supply need to be reassessed in light of this form of practice.

Adult↗

PubMed1992

Perceptions and use of performance measures by hospital pharmacy directors.

The extent to which hospital pharmacy directors use and value specific pharmacy department performance measures was studied. Questionnaires were mailed to pharmacy directors at 834 randomly selected hospitals. The questionnaires contained a list of seven data collection methods and 32 financial, 25 productivity, and 9 quality assurance measures obtained from a review of the literature. Respondents were asked to indicate familiarity, perception of usefulness, and current use of each method or measure. Perception of usefulness was measured on a five-point scale (1 = not useful, 5 = very useful). Respondents were also asked if the measures were requested by hospital administration or an external consultant. The overall response rate was 24.1%. Less than 30% of the respondents indicated that they used any of the data collection methods; however, the mean value for perceived usefulness was higher than 3 for almost all of the methods. Only five of the financial measures, two of the productivity measures, and two of the quality assurance measures were being used by more than 50% of the respondents. The value for mean perceived usefulness was higher than 3 for all but two of the measures. Most of the measures showed significantly higher frequency of use when they were requested by hospital administrators than when they were not. Requests by external consultants showed less effect on the use of the measures. The use of performance measures was low, but hospital pharmacy directors were familiar with many of these measures and perceived them to be useful.

Efficiency↗

PubMed2005

Social and geographical boundaries around senior nurse and physician leaders: an application of social network analysis.

The purpose of this study was to describe the social and geographical boundaries around the networks of senior nurse executives and physician leaders and managers in acute-care hospitals in the United Kingdom. A telephone survey was conducted using standard social network methods. A random sample was drawn from a national list and repeatedly sampled until 100 respondents were interviewed. The response rate was 49.5%. Both groups tended to discuss "important professional matters" with others who were similar to themselves in terms of profession, gender, age, and seniority, with physicians being more extreme in this regard. The implication is that gaps in the network of informal ties will impede the dissemination of information and the spread of social influence between these 2 important groups. Managers (non-clinically qualified) appear to occupy a powerful "brokerage" role. Informal networks are mainly composed of local ties. The authors argue that dissemination and influence strategies that take features of the social structure into account are more likely to be successful.

Geography↗

PubMed1990

[Comparison of 6 and 8 French catheters for arterial catheterization and coronarography: prospects of the development of coronarography in ambulatory care].

The aim of this study was to evaluate day-hospital coronary angiography as a valid method to reduce hospital recovery costs and patient waiting lists. We evaluated its technical feasibility by randomizing sixty hospital patients. These were divided into two groups, and 6 or 8 French Judkins of Amplatz coronary angiography catheters were used for each group following the Judkins technique. Patients were invited to walk after four hours. Local complications, the number of catheters used, their stability and maneuverability, as well as the radiological resolution of the image were evaluated. No major cardiac complications occurred. One transient cerebral ischemic episode during 6F coronary angiography was quickly resolved by medical therapy. Two local haemorrhages and three cases of hypotension were observed in the 8 French group, while minor bleeding phenomena were similar in both groups (3 vs 5). Differences occurred in local haematoma incidence after 24 hours (13 in 8F vs 2 in 6F); there was no difference in the number of catheters used, the completion time of the examination, or the radiological resolution. Maneuverability and stability of the 6F group were reduced, but not so much as to compromise examination. The AA concluded that 6F catheters are useful in day-hospital coronary angiography, with a similar examination quality, and a reduction in local complication.

Aged↗

PubMed1996

Cigarette smoking is associated with differences in nutritional habits and related to lipoprotein alterations independently of food and alcohol intake.

OBJECTIVE: To assess the effects of smoking on serum lipoprotein levels taking into account current nutritional intakes. DESIGN: Case-control study comparing smokers and non-smokers. SETTING: Ambulatory subjects of the Urban Community of Lille examined at home or at the Health Care Center. SUBJECTS: Men, between 45 and 65 years of age; n = 89 smokers (cases) and n = 91 non-smokers (controls); non-smokers were randomly selected from the voter's registration lists, 7 smokers and 2 non-smokers were excluded for hyperlipidemia. INTERVENTIONS: Blood sampling, medical examination and three-day food records validated by a registered dietician. RESULTS: Smokers were younger (P < 0.001) and thinner (P = 0.003), chose more frequently visible fats of animal origin (P = 0.03) and reported significantly larger daily meat servings (P = 0.01) than non-smokers. Smokers had a significantly higher intake of non-alcoholic energy (P < 0.05), lipids of animal origin (P = 0.003), saturated fat (P < 0.01) and monounsaturated fat (P < 0.01) and a lower P/S ratio (P = 0.02) than non-smokers. After adjustment on age and body mass index, smokers had significantly higher levels of mean serum triglycerides (P = 0.03), VLDL-cholesterol (P = 0.0003) and systolic blood pressure (P = 0.02) and lower values of HDL-cholesterol (P = 0.02) than non-smokers. Additional adjustment for alcohol consumption showed significantly lower apo A-I values (P = 0.03) in smokers than non-smokers. Further adjustment for the intake of lipids of animal origin revealed higher apo B values (P = 0.04) in smokers than non-smokers. CONCLUSIONS: (1) Smoking is associated with serum lipid and lipoprotein alterations independently of nutritional factors, (2) Nutritional habits of smokers are less 'healthy' than those of non-smokers (3) Smokers is a group of particular importance in terms of multifactorial public health intervention.

Aged↗

PubMed1997

[Detection by a computer program of drug interactions in chronic patients. Its practical usefulness in a health center].

OBJECTIVES: To evaluate a computer programme which was used to detect drug interactions (DI) from the Long Treatment Cards (LTC) and to analyse the factors possibly linked to these interactions. DESIGN: An observational, descriptive study. SETTING: Primary Health Care: an urban Health Centre. PATIENTS: The reference context was 1,640 chronic patients being cared for at a nursing clinic. We selected 141 cases at random by taking 10 LTCs from each list. (Alpha risk = 0.05; Confidence Interval = 0.05). RESULTS: The sample was mainly feminine (2:1), with an average age of 67. The most common diagnosis was Diabetes or AHT. 55% had accumulated 4 or more medicines per card, with multiple medication most common among men. The programme enabled 58 drug interactions, affecting 34% of the LTCs, to be identified. CONCLUSIONS: Special attention should be paid to the LTCs with 7 or more drugs prescribed because of their association with DI and NIV. The programme's efficacy would increase, both if the DIs were more accurately defined and if the programme could be computerised and applied massively to chronic treatments.

Aged↗

PubMed1997

Advance directive: a study on the knowledge and attitudes among general practitioners in Singapore.

Recent calls for the Advance Directive (AD) to be implemented in Singapore have raised issues regarding the dearth of knowledge and attitude among local healthcare professionals. The present study aims to find out the attitudes and to assess the extent of knowledge regarding the AD among General Practitioners (GPs) in Singapore. This was a cross-sectional, descriptive survey with a sample size of 199 doctors randomly drawn from the Singapore Medical Council list, forming a sampling fraction of 16%. The response rate obtained was 78%. The results showed that while GPs generally supported the concept of the AD, their views were divided on the issue of legislation. They had a basic knowledge of the AD, such as the definition of the AD, that it could be revoked, and the continuity of care and pain relief even after withdrawal of life-sustaining measures. However, only half knew when it should be executed. Many GPs were concerned that the legislation of the AD would lead to the acceptance of euthanasia. They believed that they were in the best position to decide on the treatment of choice for their patients, although they would respect their patients' wishes.

Adult↗

PubMed2003

Triptans for treatment of acute pediatric migraine: a systematic literature review.

The purpose of this article is to evaluate the effectiveness and safety of triptans for the treatment of acute migraine in children and adolescents. Randomized and open label trials of triptans in acute pediatric patients (ages 6-18 years) were identified by Medline (1966-2002) and PubMed (1991-2002). Additional reports were identified from the reference list of the retrieved studies. To study effectiveness, only randomized controlled trials were included, but open label studies were also included to study adverse effects. Pharmacokinetic studies of triptans in pediatric patients were also searched. Four randomized controlled trials were identified. One study reported oral sumatriptan, another oral rizatriptan, and two studies reported nasal spray sumatriptan. Rizatriptan is well tolerated but not clearly beneficial when used in adolescents. Effectiveness of nasal spray sumatriptan in acute pediatric migraine where other medications had failed was supported. Effectiveness of oral sumatriptan was not established. Adverse effects were minor for oral sumatriptan and rizatriptan and nasal sumatriptan. Pharmacokinetics of sumatriptan in pediatric patients has not been established. In conclusion, nasal spray sumatriptan should be considered in acute pediatric migraine in patients not experiencing adequate relief with other interventions.

Acute Disease↗

PubMed2005

A randomized evaluation of quality-of-life therapy with patients awaiting lung transplantation.

Research shows that patients wait-listed for lung transplantation have very poor quality of life (QOL). This study evaluated the effectiveness of Quality-of-Life Therapy (QOLT) in improving QOL, mood disturbance and social intimacy in adults awaiting lung transplantation. Thirty-five adults were randomized to QOLT (n = 17) or supportive therapy (ST; n = 18) and received individual, telephone-based treatment sessions. QOL, mood and social intimacy assessments were conducted at baseline and at 1 and 3 months after treatment. Repeated measures analyses of variance showed significant Condition x Time interaction effects for all three primary outcome measures. Subsequent post hoc analyses showed that the two groups did not differ significantly at baseline, but did differ significantly at the 1- and 3-month follow-up assessments. When compared to ST patients, QOLT patients had significantly higher QOL scores at the 1- and 3-month assessments, lower mood disturbance scores at the 3-month assessment, and higher social intimacy scores at the 1-month assessment. Results indicate that a patient's QOL, mood state and relationship with the primary caregiver can be positively impacted by a brief psychological intervention prior to lung transplantation.

Activities of Daily Living↗

PubMed2005

Physicians' communication with a cancer patient and a relative: a randomized study assessing the efficacy of consolidation workshops.

BACKGROUND: Although patients with cancer are often accompanied by a relative during medical interviews, to the authors' knowledge little is known regarding the efficacy of communication skills training programs on physicians' communication skills in this context. The objective of the current study was to assess the efficacy of 6 consolidation workshops, 3 hours in length, that were conducted after a 2.5-day basic training program. METHODS: After attending the basic training program, physicians were assigned randomly to consolidation workshops or to a waiting list. Training efficacy was assessed through simulated and actual interviews that were recorded on an audio tape at baseline, after consolidation workshops for the consolidation-workshops group, and 5 months after the end of basic training for the waiting-list group. Communication skills were assessed according to the Cancer Research Campaign Workshop Evaluation Manual. Patients' and relatives' perceptions of and satisfaction with physicians' communication performance were assessed using a 15-item questionnaire. RESULTS: Sixty-two physicians completed the training program. Compared with physicians who participated to the basic training program, when addressing the patient, physicians who were randomized to the consolidation workshops used more open, open directive, and screening questions (P = 0.011 in simulated patient interviews and P = 0.005 in actual patient interviews) and elicited and clarified psychologic concerns more often (P = 0.006 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the relative, physicians who were randomized to the consolidation workshops gave less premature information (P = 0.032 in simulated patient interviews and P < 0.001 in actual patient interviews). When they addressed the patient and the relative simultaneously, physicians who were randomized to the consolidation workshops used more empathy, educated guesses, alerting to reality, confronting, negotiating, and summarizing (P = 0.003 in simulated patient interviews and P = 0.024 in actual patient interviews). Patients, but not relatives, who interacted with physicians in the consolidation-workshops group were more satisfied globally with the interviews (P = 0.022). CONCLUSIONS: Six 3-hour consolidation workshops resulted in improved communication skills addressed to patients and to relatives. The current results showed that the transfer of skills addressing relatives' concerns remained limited and that consolidation workshops should focus even more systematically on the practice of three-person interviews.

Communication↗

PubMed2007

Acupuncture treatment for chronic knee pain: a systematic review.

OBJECTIVES: To evaluate the effects of acupuncture on pain and function in patients with chronic knee pain. METHODS: Systematic review and meta-analysis of randomized controlled trials of adequate acupuncture. Computerized databases and reference lists of articles were searched in June 2006. Studies were selected in which adults with chronic knee pain or osteoarthritis of the knee were randomized to receive either acupuncture treatment or a control consisting of sham (placebo) acupuncture, other sham treatments, no additional intervention (usual care), or an active intervention. The main outcome measures were short-term pain and function, and study validity was assessed using a modification of a previously published instrument. RESULTS: Thirteen RCTs were included, of which eight used adequate acupuncture and provided WOMAC outcomes, so were combined in meta-analyses. Six of these had validity scores of more than 50%. Combining five studies in 1334 patients, acupuncture was superior to sham acupuncture for both pain (weighted mean difference in WOMAC pain subscale score = 2.0, 95% CI 0.57-3.40) and for WOMAC function subscale (4.32, 0.60-8.05). The differences were still significant at long-term follow-up. Acupuncture was also significantly superior to no additional intervention. There were insufficient studies to compare acupuncture with other sham or active interventions. CONCLUSIONS: Acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional intervention in improving pain and function in patients with chronic knee pain. Due to the heterogeneity in the results, however, further research is required to confirm these findings and provide more information on long-term effects.

Acupuncture Analgesia↗

PubMed1997

[The quality of voter registration lists and participation factors during a community survey of elderly people].

Electoral registers are often used to randomly select persons for epidemiological surveys. The importance and the different types of inaccurate informations found in these lists were studied during a survey among an elderly population of 5,161 persons aged 75 and over in Tarn area. Information was found to be inaccurate in 13.7% of the cases (people who have died 3%, moved out of the area 10.5%, inaccurate date of birth 0.2%), this increased with age and with size of the parish. The overall participation was 65.3%. The corrected participation (with exclusion of inaccurate information) was 75.7% and was higher in rural parishes and where the help of local organizations of elderlies was available.

Age Factors↗

PubMed1978

Visual laterality patterns for pure- versus mixed-list presentation.

In Experiment 1, an overall left visual field advantage for nonverbal form recognition was found in a pure list of forms, but an overall right visual field form recognition advantage was found when the form trials were randomly intermixed with word recognition trials. Form complexity also influenced the form recognition laterality pattern, but the complexity effects were independent of (i.e., additive with) those produced by randomly mixing forms with words. Experiment 2 found that the mixed-list laterality pattern was unchanged by a pretrial cue indicating whether a word or form would follow. Experiments 3 and 4 demonstrated that holding two nouns in memory on each trial in a pure list of forms has much the same effect on laterality pattern as mixing forms with words but that the combined effect of these two variables is no larger than the effect of either variable alone. The entire pattern of results suggests that (a) laterality patterns are caused by the interaction of several factors, (b) the effects of random mixing and concurrent verbal memory are both caused by selective left-hemisphere activation, and (c) the form-complexity effects are caused by some other mechanism--perhaps subtle difference in stimulus codability.

Discrimination, Psychological↗

PubMed1992

Increased familial cardiovascular mortality in obese schoolchildren: the Muscatine Ponderosity Family Study.

Total and cause-specific mortality was investigated in 387 first- and second-degree deceased adult relatives of three groups of children selected from those who participated in three biennial school surveys in Muscatine, Iowa: the lean group (students in the first quintile of relative weight on all three surveys); the random group (a random sample of all eligible students); and the heavy group (students in the fifth quintile of relative weight on all three surveys). A greater proportion of death certificates for heavy group relatives listed a cardiovascular cause of death (60%) compared with lean (48%) and random (43%) group relatives. The relative risk of dying of cardiovascular disease for heavy group vs random group relatives was 1.41 (95% confidence interval 1.01, 1.98). In a subset of heavy group families identified by children with elevated systolic blood pressure, the proportion of death certificates listing a cardiovascular cause was even higher (76%) and the estimate of relative risk vs random group relatives was 2.20 (95% confidence interval 1.43, 3.37). These results indicate that persistent obesity in children, particularly when accompanied by persistent blood pressure elevation, identifies families whose members are at increased risk of dying of cardiovascular disease.

Adult↗

PubMed1977

Images on serving marijuana, alcoholic beverages, and soft drinks.

The images on serving marijuana, beer, bourbon, and soft drinks at a small informal party were compared with use of a posttest only with a control group experimental design. A total of 249 Ss were randomly assigned and received one of four shopping lists of a person planning the party. The four shopping lists were identical except for the fifth product; i.e., Ss received a shopping list including either marijuana, beer, bourbon, or soft drinks. Significant differences in images between the four products were found.

Alcohol Drinking↗