Biomedical subjects

A C Justice

Publications and source records attributed to A C Justice.

At least 19 recordsLinked to original sources

PubMed2006

Explaining variability in the relationship between antiretroviral adherence and HIV mutation accumulation.

OBJECTIVES: Determining the relationship between antiretroviral adherence and resistance accumulation is important for the design and evaluation of adherence interventions. Our objective was to explain heterogeneity observed in this relationship. METHODS: We first conducted a systematic review to locate published reports describing the relationship between adherence and resistance. We then used a validated computer simulation to simulate the patient populations in these reports, exploring the impact of changes in individual patient characteristics (age, CD4, viral load, prior antiretroviral experience) on the shape of the adherence-resistance (A-R) curve. RESULTS: The search identified 493 titles, of which 3 contained relevant primary data and 2 had sufficient follow-up for inclusion (HOMER and REACH cohorts). When simulating HOMER, the A-R curve had a high peak with a greatly increased hazard ratio (HR) of accumulating mutations at partial compared to complete adherence (simulation, HR 2.9; HOMER, HR 2.7). When simulating REACH, the A-R curve had a shallow peak with a slightly increased hazard of accumulating mutations at partial adherence (simulation, HR 1.2; REACH, HR 1.4). This heterogeneity was primarily attributable to differences in antiretroviral experience between the cohorts. CONCLUSIONS: Our computer simulation was able to explain much of the heterogeneity in observed A-R curves.

Anti-Retroviral Agents↗

PubMed2006

Rates and predictors of hepatitis C virus treatment in HCV-HIV-coinfected subjects.

BACKGROUND: True treatment rates and the impact of comorbidities on treatment rates for hepatitis C virus in the HCV-HIV-coinfected subjects are unknown. AIM: To quantify the rates of treatment prescription and the effect of comorbidities on hepatitis C virus treatment rates in HCV-HIV-coinfected veterans. METHODS: The Veterans Affairs National Patient Care Database was used to identify all hepatitis C virus-infected subjects between 1999 and 2003 using ICD-9 codes. Demographics, comorbidities and pharmacy data were retrieved. We used logistic regression to compare the predictors of hepatitis C virus treatment in hepatitis C virus-monoinfected and HCV-HIV-coinfected subjects. FINDINGS: We identified 120 507 hepatitis C virus-infected subjects, of which 6502 were HIV coinfected. 12% of the hepatitis C virus-monoinfected and 7% of the -coinfected subjects were prescribed hepatitis C virus treatment (P < 0.0001). Those not prescribed treatment were older (48.6 years vs. 47.7 years, P = 0.007) and more likely to be black (52% vs. 32%, P < 0.0001). HIV coinfected was less likely to be prescribed hepatitis C virus treatment (OR 0.74, 95% CI: 0.67-0.82). Among the coinfected subjects, the following were associated with non-treatment (OR, 95% CI): black race (0.45, 0.35-0.57); Hispanic race (0.56, 0.38-0.82); drug use (0.68, 0.53-0.88); anaemia (0.17, 0.11-0.26); bipolar disorder (0.63, 0.40-0.99); major depression (0.72, 0.53-0.99); mild depression (0.47, 0.35-0.62). CONCLUSIONS: A small number of HCV-HIV-coinfected veterans are prescribed treatment for hepatitis C virus. Non-treatment is associated with increasing age, minority race, drug use and psychiatric illness. Further studies are needed to determine the eligibility for treatment and reasons for non-treatment for hepatitis C virus.

Cohort Studies↗

PubMed2006

Characteristics of HIV infected patients cared for at "academic model for the prevention and treatment of HIV/AIDS" clinics in western Kenya.

BACKGROUND: With the new initiatives to treat large numbers of HIV infected individuals in sub-Saharan Africa, policy makers require accurate estimates of the numbers and characteristics of patients likely to seek treatment in these countries. OBJECTIVE: To describe characteristics of adults receiving care in two Kenyan public HIV clinics. DESIGN: Cross-sectional cohort analysis of data extracted from an electronic medical records system. SETTING: Academic Model for the Prevention and Treatment of HIV/AIDS (AMPATH) HIV clinics in Kenya's second national referral (urban) hospital and a nearby rural health center. SUBJECTS: Adult patients presenting for care at HIV clinics. MAIN OUTCOME MEASURES: Gender and inter-clinic stratified comparisons of demographic, clinical, and treatment data. RESULTS: In the first nineteen months, 790 adults visited the urban clinic and 294 the rural clinic. Mean age was 36 +/- 9 (SD) years. Two-thirds were women; a quarter had spouses who had died of acquired immune deficiency syndrome (AIDS). HIV/AIDS behavioural risk factors (multiple sexual partners, rare condom use) and constitutional symptoms (fatigue, weight loss, cough, fever, chills) were common. Rural patients had more symptoms and less prior and current tuberculosis. Men more commonly presented with symptoms than women. The cohort CD4 count was low (223 +/- 197 mm3), with men having significantly lower CD4 count than women (185 +/- 175 vs. 242 +/- 205 p = 0.0007). Eighteen percent had an infiltrate on chest radiograph. Five percent (most often men) had received prior antiretroviral drug therapy, (7% in urban and 1% in rural patients, p = 0.0006). Overall, 393 (36%) received antiretroviral drugs, 89% the combination of lamivudine, stavudine, and nevirapine. Half received prophylaxis for tuberculosis and Pneumocystis jirovecii. Men were sicker and more often received antiretroviral drugs. CONCLUSIONS: Patients presenting to two Kenyan HIV clinics were predominantly female, ill and naive to retroviral therapy with substantial differences by clinic site and gender. Behavioural risk factors for HIV/AIDS were common. A thorough understanding of clinical and behavioural characteristics can help target prevention and treatment strategies.

Acquired Immunodeficiency Syndrome↗

PubMed2004

Association of hypocholesterolaemia with hepatitis C virus infection in HIV-infected people.

OBJECTIVE: To study the impact of hepatitis C virus (HCV) status on serum cholesterol levels in HIV-infected patients. METHODS: We retrospectively analysed data from the 881 participants of the Veterans Ageing Cohort 3 Site Study. Four different models were constructed using total cholesterol, low-density lipid (LDL) cholesterol, high-density lipid (HDL) cholesterol and triglycerides as dependent variables. The relevant covariates included HCV antibody status, HIV medication class, CD4 count, HIV viral load, glucose level, lipid-lowering drug use, gender, race, age, liver function test results, ethanol use, drug use, and HIV exposure category. Variables excluded from the final model included niacin use, gender, race, age, current ethanol use, and HIV exposure category. RESULTS: Of the 881 HIV-positive patients enrolled in the study, 700 (79%) were screened for HCV antibody, with 300 (42.8%) HCV antibody positive and 400 (57.2%) HCV antibody negative. A positive HCV antibody status was independently associated with lower total cholesterol levels (P=0.001) and LDL cholesterol levels (P<0.001) but not with lower HDL cholesterol or triglyceride levels. HCV-positive patients had predicted LDL levels 19 mg/dL lower than those of HCV-negative subjects. HCV infection was also associated with a decreased use of lipid-lowering medication, and protease inhibitor use was associated with increased LDL and total cholesterol levels. CONCLUSIONS: HCV infection has been associated with lower cholesterol levels in HIV-negative individuals, and the same appears to be true with HIV-infected patients. This is an interesting finding given that HCV particles bind to LDL receptors in vitro and also because HCV-lipid interactions appear to be important in the HCV replication cycle.

Antiretroviral Therapy, Highly Active↗

PubMed2004

Alcohol abuse among patients with and without HIV infection attending public clinics in western Kenya.

OBJECTIVE: To evaluate the prevalence of hazardous drinking among persons with and without HIV/AIDS attending both urban/hospital-based and rural clinics in western Kenya. DESIGN: Cross sectional survey. SETTING: The Moi Teaching and Referral Hospital and the Mosoriot rural health care Centre. SUBJECTS: Two hundred and ninety nine adults with and without HIV/AIDS at a teaching and referral hospital and rural health centre. MAIN OUTCOME MEASURES: Results of the World Health Organization's Alcohol Use Disorders Identification Test (AUDIT) where a score of > 8 is indicative of hazardous alcohol consumption. Independent correlates of hazardous drinking were identified using logistic regression analysis including adjustment for common covariables. RESULTS: Study participants were relatively young (38 +/- 9 years) with 55% being male and 54% completing the AUDIT in Kiswahili. Home-made alcohol was more commonly drunk by patients attending the rural health centre while commercial beer was more commonly drunk by patients attending the teaching and referral hospital clinics. Approximately half (54%) of participants reported hazardous drinking behaviour (AUDIT score=9.9 +/- 9.4). Hazardous drinking was most prevalent among men attending the rural health centre (83% hazardous drinkers, AUDIT score=16.0 +/- 9.1). In multivariable analyses adjusting for age, sex and site of care, men remained more than nine times (odds ratio=9.3, 95% C.I.=5.1-16.9) likely to report hazardous drinking behaviour compared to women. CONCLUSIONS: Hazardous drinking is common among patients with and without HIV/ AIDS in western Kenya and is dramatically more common among rural men than women. Effective interventions for HIV/AIDS in this setting must include a concetrated effort to reduce hazardous drinking.

Adult↗

PubMed2001

Justification for a new cohort study of people aging with and without HIV infection.

This supplement contains a series of papers supporting the justification, design, and implementation of a longitudinal cohort study of an aging HIV-positive and HIV-negative veteran population called the Veterans Aging Cohort Study (VACS). Although the papers cover a wide range of topics and several papers address methodologic issues not unique to a study of aging veterans, all are motivated by a unifying set of assumptions. Specifically: (a) HIV/AIDS is a chronic disease in an aging population; (b) conditions among HIV-positive and -negative patients in care have overlapping etiologies; (c) individuals with pre-existing organ injury are at increased risk for iatrogenic injury; (d) cohort studies are uniquely suited to the study of chronic disease complicated by aging, comorbid conditions, drug toxicities, and substance use/abuse; (e) VACS is well positioned to study HIV as a chronic disease in an aging population.

Aging↗

PubMed2001

Veterans Aging Cohort Study (VACS) meeting summary.

The Veterans Aging Cohort Study (VACS) planning meeting was the first of a series of organizational meetings and VA-sponsored conference calls designed to build the scientific foundation and methodological infrastructure for a multisite, longitudinal study of HIV and chronic disease outcomes among aging veterans. More specifically, it served as a consensus conference to determine scientific priorities, develop hypotheses, and to assemble working groups and committees to outline the specific methodological approaches needed. Scientists, physicians from 20 VA clinical facilities in the United States, community members, and experts in the fields of immunology, cancer, sociology, aging, cognition, psychiatry and mental health, epidemiology, large database analysis, and health services research gathered for an intense, 2-day meeting held in Pittsburgh, PA, November 8-9, 2000.

Aging↗

PubMed2001

General medical and psychiatric comorbidity among HIV-infected veterans in the post-HAART era.

We examined the prevalence of HIV, general medical, and psychiatric comorbidities by age based on a recent multisite cohort of HIV infected veterans receiving care: the Veterans with HIV/AIDS 3 Site Study (VACS 3). VACS 3 includes 881 adult patients with HIV infection enrolled between June 1999 and July 2000. Providers reported their patients' CDC-defined HIV comorbidities, general medical comorbidities (based on Duke and Charlson comorbidity scales), and psychiatric comorbidity. Mean age of participants was 49 years and 54% were African-American. The most common HIV comorbidities were oral candidiasis (21%), peripheral neuropathy (16%), and herpes zoster (16%). The most common general medical comorbidities included chemical hepatitis (53%), hypertension (24%), and hyperlipidemia (17%). The mean number of HIV and general medical comorbidities experienced by patients were respectively 1.1 and 1.4 (P < .001). Older (> or = 50 years) HIV-infected patients experienced a greater number of general medical comorbidities than those < 50 years (respectively 1.7 versus 1.2, P < .001). There was no significant difference in mean HIV comorbidity number by age. Based on patient report, 46% had significant depressive symptoms (> or = 10 on 10-item CES-D) and 21% reported at-risk drinking (> or = 8 on AUDIT). Providers reported 32% of patients had anxiety, 4% mania, 4% schizophrenia, and 11% cognitive impairment/dementia. General medical and psychiatric comorbidities constituted a higher disease burden for HIV-infected veterans than HIV comorbidities. Whether these comorbidities are due to antiretroviral drug toxicity or are age or lifestyle-associated conditions, the substantial prevalence of these "non-HIV" comorbidities suggest an important role for general medical and psychiatric management of HIV-infected patients.

AIDS-Related Opportunistic Infections↗

PubMed2001

Veterans aging cohort three-site study (VACS 3): overview and description.

Outcomes for middle-aged and older individuals with HIV infection are poor, and are likely to be mediated by age-related differences in risks and resources (access to care, relationship with the provider, comorbid conditions, health habits, and changes brought about by aging). The goal of the Veterans Aging Cohort Three-Site Study (VACS 3) is to study the influence of age and mediating factors on outcomes with HIV in order to identify mutable mediators of poorer outcomes. VACS 3 is an observational, longitudinal study. Data sources include patient and provider surveys and electronic medical data collected at baseline and 12-month follow-up from the Infections Disease Clinics at three Veterans Affairs Medical Centers (Cleveland, OH, Houston, TX, and Manhattan, NY). Trained Survey Coordinators at each site determined which patients are HIV infected, obtained consent, and asked the patient to complete a questionnaire. The primary provider also completed a questionnaire. Twelve-month follow-up will be completed July 2001. Of all veterans with HIV seen in these clinics 85% (881) have consented and enrolled. Of the 881 corresponding provider surveys, 92% were completed. Mean age is 49; 55% are African-American; 38% of the sample were men who have sex with men; and less than 2% are women. Almost a third (32%) have been without a permanent address. Complimentary or alternative therapies are common as are the use of cigarettes, alcohol, and illicit drugs. The majority (87%) of the patients are taking multiple antiretroviral medications. The median CD4 count is 331 mm(3), and the median viral load was 714 copies/ml. There is substantial variation by site. Veterans with HIV infection have characteristics that will likely become more prevalent among HIV-infected persons in the United States: they are older, commonly suffer comorbid disease, and are members of minority populations. VACS 3 may help inform the design of future clinical interventions to improve outcomes for people aging with HIV.

Aged↗

PubMed2001

Development and validation of a self-completed HIV symptom index.

Traditional, open-ended provider questions regarding patient symptoms are insensitive. Better methods are needed to measure symptoms for clinical management, patient-oriented research, and adverse drug-event reporting. Our objective was to develop and initially validate a brief, self-reported HIV symptom index tailored to patients exposed to multidrug antiretroviral therapies and protease inhibitors, and to compare the new index to existing symptom measures. The research design was a multistage design including quantitative review of existing literature, qualitative and quantitative analyses of pilot data, and quantitative analyses of a prospective sample. Statistical analyses include frequencies, chi-square tests for significance, linear and logistic regression. The subjects were from a multisite convenience sample (n = 73) within the AIDS Clinical Trials Group and a prospective sample from the Cleveland Veterans Affairs Medical Center (n = 115). Measures were patient-reported symptoms and health-related quality of life, physician-assessed disease severity, CD4 cell count, and HIV-1 RNA viral quantification. A 20-item, self-completed HIV symptom index was developed based upon prior reports of symptom frequency and bother and expert opinion. When compared with prior measures the index included more frequent and bothersome symptoms, yet was easier to use (self-report rather than provider interview). The index required less than 5 minutes to complete, achieved excellent completion rates, and was thought comprehensive and comprehensible in a convenience sample. It was further tested in a prospective sample of patients and demonstrated strong associations with physical and mental health summary scores and with disease severity. These associations were independent of CD4 cell count and HIV-1 RNA viral quantification. This 20-item HIV symptom index has demonstrated construct validity, and offers a simple and rational approach to measuring HIV symptoms for clinical management, patient-oriented research, and adverse drug reporting.

Antiretroviral Therapy, Highly Active↗

PubMed2001

Patient- and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence.

We seek to develop a clinically useful measure of antiretroviral medication adherence. Because there is no gold standard for adherence, we will assess the clinical validity of patient- and provider-reported adherence by the strength of their expected associations with current viral load, depressive symptoms, alcohol and illicit drug use, and homelessness. The Veterans Aging Cohort 3 Site Study (VACS 3) is a multisite study of 881 patients at Cleveland, Houston, and Manhattan Veterans Affairs health care systems. Data was collected on adherence using patient report and provider assessment; depressive symptoms using the Center for Epidemiological Studies Depression (CESD) and provider assessment; alcohol use using the Alcohol Use Disorders Identification Test (AUDIT) and provider assessment; and homelessness using patient report only. Viral load was collected from electronic laboratory data. Although agreement between providers and patients about the patient's adherence was not better than chance (61%; weighted kappa =.07), both patient and provider-reported adherence were related to viral load (P <.001), current alcohol use (P <.01), current drug use (P <.01), and depressive symptoms (P <.001). Patient-reported adherence was also associated with homelessness (P <.05). In multivariate regression models, provider assessment of adherence demonstrated independent associations with viral load (P <.001), current alcohol use (P <.001), current drug use (P <.001), and depressive symptoms (P <.001) after adjustment for the patient's report of adherence (also significantly associated). The consistent and largely independent association between patient and provider reported adherence and a range of variables previously shown to be associated with adherence suggests that patient- and provider-reported adherence independently measure actual adherence. Future work will explore how patient- and provider-reported adherence might best be combined, and whether the measure may be further enhanced with pharmacy refill data.

Antiretroviral Therapy, Highly Active↗

PubMed2001

History and mobility exam index to identify community-dwelling elderly persons at risk of falling.

BACKGROUND: Falls are common in community-dwelling elderly persons and are a frequent source of morbidity. Simple indices to prospectively stratify people into categories at different fall-risk would be useful to health care practitioners. Our goal was to develop a fall-risk index that discriminated between people at high and low risk of falling. METHODS: We evaluated the risk of falling over a one-year period in 557 elderly persons (mean age 81.6) living in a retirement community. On the baseline interview, we asked subjects if they had fallen in the previous year and evaluated risk factors in six additional conceptual categories. On the follow-up interview one year later, we again asked subjects if they had fallen in the prior year. We evaluated risk factors in the different conceptual categories and used logistic regression to determine the independent predictors of falling over a one-year period. We used these independent predictors to create a fall-risk index. We compared the ability of a prior falls history with other risk factors and with the combination of a falls history and other risk factors to discriminate fallers from nonfallers. RESULTS: A fall in the previous year (OR = 2.42, 95% CI = 1.49-3.93), a symptom of either balance difficulty or dizziness (OR = 1.83, 95% CI = 1.16-2.89), or an abnormal mobility exam (OR = 2.64, 95% CI = 1.64-4.26) were independent predictors of falling over the subsequent year. These three risk factors together (c statistic =.71) discriminated fallers from nonfallers better than previous history of falls alone (c statistic =.61) or the symptomatic and exam risk factors alone (c statistic =.68). When combined into a risk index, the three independent risk factors stratify people into groups whose risk for falling over the subsequent year ranges from 10% to 51%. CONCLUSION: A history of falling over the prior year, a risk factor that can be obtained from a clinical history (balance difficulty or dizziness), and a risk factor that can be obtained from a physical exam (mobility difficulty) stratify people into groups at low and high risk of falling over the subsequent year. This risk index may provide a simple method of assessing fall risk in community-dwelling elderly persons. However, it requires validation in other subjects before it can be recommended for widespread use.

Accidental Falls↗

PubMed2001

Clinical importance of provider-reported HIV symptoms compared with patient-report.

BACKGROUND: Although the patient experiences the symptoms, only symptoms that providers recognize and report "count" in most clinical and research settings. Reliance upon provider-report has been justified by the claim that providers report only "clinically important" symptoms. OBJECTIVE: To determine whether provider-reported symptoms constitute a more "clinically important" subset of patient-reported symptoms in HIV infection. DESIGN: Secondary analyses of AIDS Clinical Trials 175 (ACTG 175), a randomized controlled trial of combination antiviral therapy among patients with moderate HIV disease. SETTING: Large, multicenter study. PATIENTS: 1,262 patients who participated in the health-related quality of life (HRQOL) sub-study and for whom providers completed symptom forms. MEASUREMENTS: Patient- and provider-reported symptoms, HRQOL, risk of recent hospitalization, survival, CD4 cell count, and plasma HIV-1 RNA levels. RESULTS: On average, providers reported 3-fold fewer symptoms than patients did, but the degree of under report varied by symptom. When patient-reports were used as a gold standard, provider-reports demonstrated poor sensitivity (mean 0.25) and good specificity (mean 0.96). Agreement beyond chance was fair (mean kappa 0.35) and did not improve when weighted by symptom severity. Site specific variation was greater for provider than for patient-reported symptoms (R2: 0.15 and 0.05 respectively). Patient-reported symptoms were substantially more strongly associated with the physical health scale and all HRQOL subscales than provider-reported symptoms (P <0.0001). Patient-reported symptoms were equally strongly associated with survival (P >0.50) and recent hospitalization as provider-reported symptoms (P >0.48). Of note, patient-reported symptoms were independently associated with survival and recent hospitalization after adjustment for CD4 cell count and plasma HIV-1 RNA levels (P <0.05). CONCLUSIONS: Provider-reported symptoms are not a more clinically important subset of patient-reported symptoms. Patient-reported symptom checklists are likely to be more complete and more strongly associated with HRQOL. Further, patient-reported symptoms are as related to recent hospitalization and survival as provider-reported symptoms. An HIV specific, patient-completed symptom checklist might substantially improve symptom reporting for adverse drug event monitoring, clinical management and medical research.

Adult↗

PubMed1999

Sensitivity, specificity, reliability, and clinical validity of provider-reported symptoms: a comparison with self-reported symptoms. Outcomes Committee of the AIDS Clinical Trials Group.

BACKGROUND: If symptoms are to be recognized and effectively addressed in clinical research, they must be collected using sensitive, specific, reliable, and clinically meaningful methods. OBJECTIVE: To perform a comparison of self-administered symptom survey data with data from conventional provider-reports. DESIGN/METHODS: Secondary data analysis of AIDS Clinical Trials Group Study 081 (ACTG 081), a randomized trial taking place in 33 sites comparing three approaches to prophylaxis for Pneumocystis carinii-related pneumonia that found no difference among treatment arms. The study was performed on 842 subjects with advanced HIV infection. No intervention was undertaken as a result of this study. ACTG 081 included data on functional status, global quality of life and survival, and two methods of symptom measurement: an open-ended, provider-reported symptom assessment (provider-report) and a self-administered symptom survey (self-report). Agreement was measured using kappa scores. Sensitivity and specificity were calculated using self-report as the standard. Reliability was measured by intersite variation and test-retest reliability (8 weeks later). Clinical validity was evaluated by testing expected associations with functional status, global quality of life, and survival. RESULTS: Symptom data were available for 808 patients (96%). Patient and provider agreement was poor (mean kappa, 0.14; range, 0.07-0.25). Compared with self-report, providers underreported the presence and severity of symptoms (mean symptom count, 5.2 versus 1.3; mean severity score, 1.3 versus 0.74). provider-report demonstrated greater variability by site (R2 associated with site, 0.02 versus 0.16) and poorer test-retest reliability (mean kappa, 0.34 versus 0.25). Provider-report severity scores were less strongly associated than were self-report with functional status (chi2, 252 versus 80), global quality of life (R2 for model, 0.57 versus 0.15), and survival (chi2, 38 versus 24). Self-reported symptom severity was strongly correlated to patient-reported global quality of life (p, 0.75; p < .0001). CONCLUSIONS: Provider-reported symptoms as currently collected within the ACTG are less sensitive and reproducible than a self-administered symptom survey. Provider-reported severity scores are also more weakly associated with functional status, global quality of life, and survival. A self-reported symptom survey may provide a better method of symptom measurement for HIV research.

Acquired Immunodeficiency Syndrome↗

PubMed1999

Assessing the generalizability of prognostic information.

Physicians are often asked to make prognostic assessments but often worry that their assessments will prove inaccurate. Prognostic systems were developed to enhance the accuracy of such assessments. This paper describes an approach for evaluating prognostic systems based on the accuracy (calibration and discrimination) and generalizability (reproducibility and transportability) of the system's predictions. Reproducibility is the ability to produce accurate predictions among patients not included in the development of the system but from the same population. Transportability is the ability to produce accurate predictions among patients drawn from a different but plausibly related population. On the basis of the observation that the generalizability of a prognostic system is commonly limited to a single historical period, geographic location, methodologic approach, disease spectrum, or follow-up interval, we describe a working hierarchy of the cumulative generalizability of prognostic systems. This approach is illustrated in a structured review of the Dukes and Jass staging systems for colon and rectal cancer and applied to a young man with colon cancer. Because it treats the development of the system as a "black box" and evaluates only the performance of the predictions, the approach can be applied to any system that generates predicted probabilities. Although the Dukes and Jass staging systems are discrete, the approach can also be applied to systems that generate continuous predictions and, with some modification, to systems that predict over multiple time periods. Like any scientific hypothesis, the generalizability of a prognostic system is established by being tested and being found accurate across increasingly diverse settings. The more numerous and diverse the settings in which the system is tested and found accurate, the more likely it will generalize to an untested setting.

Calibration↗

PubMed1999

When doctors marry doctors: a survey exploring the professional and family lives of young physicians.

BACKGROUND: Soon, half of all physicians may be married to other physicians (that is, in dual-doctor families). Little is known about how marriage to another physician affects physicians themselves. OBJECTIVE: To learn how physicians in dual-doctor families differ from other physicians in their professional and family lives and in their perceptions of career and family. DESIGN: Cross-sectional survey. SETTING: Two medical schools in Ohio. PARTICIPANTS: A random sample of physicians from the classes of 1980 to 1990. MEASUREMENTS: Responses to a questionnaire on hours worked, income, number of children, child-rearing arrangements, and perceptions about work and family. RESULTS: Of 2000 eligible physicians, 1208 responded (752 men and 456 women). Twenty-two percent of male physicians and 44% of female physicians were married to physicians (P < 0.001). Men and women in dual-doctor families differed (P < 0.001) from other married physicians in key aspects of their professional and family lives: They earned less money, less often felt that their career took precedence over their spouse's career, and more often played a major role in child-rearing. These differences were greater for female physicians than for male physicians. Men and women in dual-doctor families were similar to other physicians in the frequency with which they achieved career goals and goals for their children and with which they felt conflict between professional and family roles. Marriage to another physician had distinct benefits (P < 0.001) for both men and women, including more frequent enjoyment from shared work interests and higher family incomes. CONCLUSIONS: Men and women in dual-doctor families differed from other physicians in many aspects of their professional and family lives, but they achieved their career and family goals as frequently. These differences reflect personal choices that will increasingly affect the profession as more physicians marry physicians.

Child↗

PubMed1999

Editorial freedom.

Explore the source record for details and available documents.

American Medical Association↗

PubMed1999

The relationship between clinical assessments of nutritional status and adverse outcomes in older hospitalized medical patients.

BACKGROUND: Malnutrition is common in hospitalized older people and may predict adverse outcomes. Previous studies of the relationship between nutritional status and hospital outcomes are limited by inadequate accounting for other potential predictors of adverse outcomes, the failure to consider functional outcomes, and the omission of clinical assessments of nutritional status. OBJECTIVE: To measure the relationship between a clinical assessment of nutritional status on hospital admission and subsequent mortality, functional dependence, and nursing home use. DESIGN: Prospective cohort study SETTING: A tertiary care hospital PATIENTS: A total of 369 patients at least 70 years old (mean age 80.3, 62% women) admitted to a general medical service MEASUREMENTS: Nutritional status was measured with the Subjective Global Assessment, a validated measure of nutritional status based on historical and physical exam findings. Patients were classified as severely malnourished (generally at least a 10% weight loss over the previous 6 months and marked physical signs of malnutrition), moderately malnourished (generally a 5 to 10% weight loss and moderate physical signs), or well nourished. Vital status, independence in activities of daily living, and nursing home use were determined through patient or surrogate interview at admission and 90 days and 1 year after discharge. Indices of comorbidity and illness severity were determined from chart review. RESULTS: 219 patients (59.3%) were well nourished, 90 (24.4%) were moderately malnourished, and 60 (16.3%) were severely malnourished. Severely malnourished patients were more likely than moderately malnourished or well nourished patients to die by 90 days (31.7%, 23.3%, and 12.3%, respectively, P < .001) and 1 year (55.0%, 35.6%, and 27.9%, P < .001) after discharge. In logistic regression models controlling for acute illness severity, comorbidity, and functional status on admission, severely malnourished patients were more likely than well nourished patients to die within 1 year of discharge (OR = 2.83, 95% CI, 1.47-5.45), to be dependent in activities of daily living 3 months after discharge (OR = 2.81, 1.06-7.46), and to spend time in a nursing home during the year after discharge (OR = 3.22, 1.05-9.87). CONCLUSION: Malnutrition was common in hospitalized patients with medical illness and was associated with greater mortality, delayed functional recovery, and higher rates of nursing home use. These adverse outcomes were not explained by greater acute illness severity, comorbidity, or functional dependence in malnourished patients on hospital admission.

APACHE↗