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Biomedical subjects

G Norman

Publications and source records attributed to G Norman.

At least 55 records · Page 3Linked to original sources
PubMed1996

The preterm prediction study: maternal stress is associated with spontaneous preterm birth at less than thirty-five weeks' gestation. National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.

OBJECTIVE: Our purpose was to determine whether various measures of poor psychosocial status in pregnancy are associated with spontaneous preterm birth, fetal growth restriction, or low birth weight. STUDY DESIGN: Anxiety, stress, self-esteem, mastery, and depression were assessed at 25 to 29 weeks in 2593 gravid women by use of a 28-item Likert scale. Scores for each psychosocial subscale were determined, and an overall psychosocial score was calculated. Scores were divided into quartiles, and the lowest quartile scores were used to define poor psychosocial status. The percent spontaneous preterm birth, low birth weight, and fetal growth restriction in women with low and high psychosocial scores were compared. Logistic regression analyses provided the odds ratios and 95% confidence intervals. RESULTS: Analyses revealed that stress was significantly associated with spontaneous preterm birth and with low birth weight with odds ratios of 1.16, p = 0.003, and 1.08, p = 0.02, respectively, for each point on the scale. A low score on the combined scale or on any subscale other than stress did not predict spontaneous preterm birth, fetal growth restriction, or low birth weight. After multivariate adjustment was performed for psychosocial status, substance use, and demographic traits, black race was the only variable significantly associated with spontaneous preterm birth, fetal growth restriction, and low birth weight; stress and low education were associated with spontaneous preterm birth and low birth weight. CONCLUSION: Stress was associated with spontaneous preterm birth and low birth weight even after adjustment for maternal demographic and behavioral characteristics. Black race continues to be a significant predictor of spontaneous preterm birth, fetal growth restriction, and low birth weight even after adjustment for stress, substance use, and other demographic factors.

Adult↗
PubMed1996

Performance-based assessment of clinical ethics using an objective structured clinical examination.

PURPOSE: To further examine the objective structured clinical examination (OSCE) as a performance-based assessment method for clinical ethics. METHOD: In the spring of 1993, a volunteer sample of 88 final-year medical students from all five Ontario medical schools took a four-station OSCE that used standardized patients and involved decisions to forego life-sustaining treatment. Performance was scored on a checklist of behaviors unique to each case. Data were analyzed for reliability using intraclass correlation coefficients and the Spearman-Brown prophecy formula. RESULTS: Reliability of the test was only .28 as a result of a low average inter-station correlation of .07. To achieve a test reliability of .8, 41 stations (almost seven hours of testing time) would be required. CONCLUSION: Because of its low test reliability, the OSCE is not a feasible stand-alone method for summative evaluation of clinical ethics. This performance-based evaluation method should be combined with other, more reliable evaluation methods. The OSCE has promise for formative evaluation.

Educational Measurement↗
PubMed1996

Evaluating communication skills in the OSCE format: reliability and generalizability.

In most objective structured clinical examinations (OSCEs), communication skills are assessed as an 'add-on' to history-taking stations, rather than in stations designed to assess communication skills in the broadest sense. This study investigated the feasibility of developing such stations. In part one, 60 clinical clerks and 36 residents were rated in four 10-min emotionally charged situations portrayed by standardized patients. Inter-rater reliability was demonstrated (r = 0.59-0.63) and a highly significant effect of educational level was found. Generalizability between communication stations was low (0.17-0.20). Several explanations for poor generalizability, including poor discrimination as a result of low score variance and the confounding effect of content knowledge, were addressed in part 2. Ninety-five final-year medical students participated in an OSCE in which six 10-min encounters examined the students' ability to manage difficult emotional situations such as fear, anxiety, mania, sadness, confusion and anger. Half the students encountered a patient with moderate emotional symptoms and half an extreme emotional state. For difficult stations, students' scores were lower and standard deviation higher, suggesting that manipulating difficulty increases score variance and potentially discrimination. However, a strong interaction was found between difficulty and station content, and communication scores were highly correlated with content. Scenarios which created major communication difficulties (such as mania) resulted in much larger differences in scores between the easy and difficult versions. Communication OSCE stations can be created with acceptable reliability including difficult cases which address communication skills beyond simple history taking. Nevertheless, a generalizable set of communication skills remains elusive.

Canada↗
PubMed1996

Content specificity and oral certification exams.

This study reports on the generalizability of different skills assessed in the oral certification examinations in Internal Medicine of the Royal College of Physicians and Surgeons of Canada. Assessments from the 1992 examination were examined prospectively to determine (i) inter-rater reliability, (ii) correlation from morning to afternoon sessions, and (iii) overall test reliability. While inter-rater reliability was acceptable and in the range reported from previous studies, the generalizability across sessions was very low, ranging from 0.30 to 0.47, presumably reflecting content specificity. As a consequence, the overall test reliability was low, ranging from 0.57 to 0.69. Collapsing the overall scores into three decision categories (pass, borderline, fail) lowered the test reliability still further. Strategies to resolve this problem are suggested.

Adult↗
PubMed1996

Preventive care and barriers to effective prevention. How do family physicians see it?

OBJECTIVES: To assess how adequately family physicians think they are delivering preventive care and to examine barriers to providing preventive care. DESIGN: Cross-sectional survey. SETTING: Primary care medical practices in south-central Ontario. PARTICIPANTS: Four hundred eighty family physicians and general practitioners who graduated from medical school between 1972 and 1988. MAIN OUTCOME MEASURES: Satisfactory preventive care delivery versus self-assessed coverage of patients for 15 preventive maneuvers. Perceived reasons for lack of success in providing recommended preventive care. RESULTS: For 10 of the 15 maneuvers, the proportion of physicians who regarded 90% or higher as satisfactory coverage was twice as great as the proportion who thought they provided that level of coverage. For 11 of the 15 maneuvers, most respondents reported coverage lower than the level they regarded as satisfactory. For six maneuvers, more than two thirds thought they provided less than satisfactory coverage. More than two thirds of respondents suggested these barriers to providing recommended preventive care: patient is healthy and does not visit; patient refuses, is not interested, or does not comply; no effective systems to remind patients to come in for preventive care; and priority given to presenting problem. CONCLUSION: Many family physicians and general practitioners in south-central Ontario provide preventive care to their patients at lower levels than they consider satisfactory. They identified barriers to providing preventive services successfully; these barriers suggest approaches for improving care.

Attitude of Health Personnel↗
PubMed1996

Do female primary care physicians practise preventive care differently from their male colleagues?

OBJECTIVE: To assess whether female primary care physicians' reported coverage of patients eligible for certain preventive care strategies differs from male physicians' reported coverage. DESIGN: A mailed survey. SETTING: Primary care practices in southern Ontario. PARTICIPANTS: All primary care physicians who graduated between 1972 and 1988 and practised in a defined geographic area of Ontario were selected from the Canadian Medical Association's physician resource database. Response rate was 50%. MAIN OUTCOME MEASURES: Answers to questions on sociodemographic and practice characteristics, attitudes toward preventive care, and perceptions about preventive care behaviour and practices. RESULTS: In general, reported coverage for Canadian Task Force on the Periodic Health Examination's (CTFPHE) A and B class recommendations was low. However, more female than male physicians reported high coverage of women patients for female-specific preventive care measures (i.e., Pap smears, breast examinations, and mammography) and for blood pressure measurement. Female physicians appeared to question more patients about a greater number of health risks. Often, sex of physician was the most salient factor affecting whether preventive care services thought effective by the CTFPHE were offered. However, when evidence for effectiveness of preventive services was equivocal or lacking, male and female physicians reported similar levels of coverage. CONCLUSION: Female primary care physicians are more likely than their male colleagues to report that their patients eligible for preventive health measures as recommended by the CTFPHE take advantage of these measures.

Adult↗
PubMed1995

Design and validation of a bedside decision instrument to elicit a patient's preference concerning allogenic bone marrow transplantation in chronic myeloid leukemia.

The objective of this study was to design and validate a bedside decision instrument to be used by patients with chronic myeloid leukemia and their physicians in deciding between the therapeutic alternatives of bone marrow transplantation and conservative management during the early phase of disease. A decision board was constructed containing detailed scenarios associated with the treatment alternatives, together with estimates of survival probabilities at various periods of followup. The instrument was tested on 42 healthy hospital personnel and validated by measuring the extent to which systematic alterations in the scenarios with respect to toxicities and survival probabilities produced predicted shifts in treatment preferences. A subgroup of respondents was randomized to receive information through the decision board alone or a shorter and less informative version of the instrument, followed by the decision board. The direction and strength of stated preferences were compared, together with satisfaction for these preferences. The direction and strength of preferences between bone marrow transplantation or conservative chemotherapy were influenced in a predictable way by changes in the toxicity and survival descriptions in the scenarios. Using the test-retest method in 16 subjects, the stated preferences were found to be highly reliable (intraclass correlation coefficient, 0.87). The mean level of satisfaction with the stated preference, on a scale from not at all satisfied = 1 to very satisfied = 5, was higher for those exposed to the decision board (3.7, SD 1.06) compared with those presented with the short version (2.95, SD 0.67) (P < 0.01). The results demonstrate the feasibility and acceptability of the instrument in healthy individuals. The preferences elicited by the instrument appear to be reliable and valid according to prespecified constructs of the relation between the information provided and the preferences predicted. These results support further testing of this approach in actual patients.

Bone Marrow Transplantation↗
PubMed1994

Evaluation of a multicenter ethics objective structured clinical examination.

The purpose of this study was to evaluate a six-station ethics objective structured clinical examination (OSCE) on a volunteer sample of 66 medical students and 33 residents from three Ontario medical schools. The internal consistency reliability was 0.46 and the median interrater reliability was 0.675 (range 0.30 to 0.89). The residents' scores were higher than those of the medical students (F = 2.24, 0.046). Also, the scores differed among the three schools (F = 3.19, p = 0.0004). The ethics OSCE has adequate interrater reliability and construct validity, but low internal consistency reliability. There are differences among the schools that may assist in ethics curriculum evaluation and development.

Brain Death↗
PubMed1994

Refusing care to emergency department of patients: evaluation of published triage guidelines.

STUDY OBJECTIVE: To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care. DESIGN: Historical cohort study. SETTING: A public hospital ED. TYPE OF PARTICIPANTS: All patients triaged during a one-week period who were not in the most acute triage category. MEASUREMENTS: Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome. MAIN RESULTS: Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized. CONCLUSION: When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Adult↗
PubMed1993

Automated in vivo quantification of emphysema.

A computer program to automatically determine lung volume and percentage of emphysema from computed tomographic (CT) chest sections was developed. To test it, the authors reviewed scans obtained in 89 patients. Any computer errors in identification of normal or emphysematous lungs were corrected manually by tracing the boundaries of the lungs or eliminating areas of nonemphysematous lung with a roller ball. The corrected values were compared with the uncorrected values. In 33 patients from the study group, lung volumes and the percentage of emphysema were calculated by using a currently available "voxel highlighting" program. Successful computerized analysis of entire lungs was performed in 1 minute, compared to more than 1 hour for manual analysis. Correlation was high (r = .99) between results obtained manually and those obtained with the computer. Although the difference between uncorrected and corrected values of the percentage of emphysema was statistically significant, this converted to a correction of only 0.1%. The computer program allowed quick, accurate, and reproducible quantification of emphysema.

Adult↗
PubMed1992

Markers for endothelial injury, clotting and platelet activation in preeclampsia.

The etiology of disseminated intravascular coagulation (DIC) in preeclampsia is not well understood. We measured plasma levels of fibronectin (FN), which may reflect endothelial cell injury, fibrinopeptide A (FPA), a specific marker of clotting, platelet counts (PLC) and mean platelet volumes (MPV), as well as beta-thromboglobulin (beta TG) and platelet factor 4 (Pf4), products of irreversible platelet activation in 24 preeclamptic patients and 24 controls matched for age, gestational age, labor status, and parity. In preeclampsia, FN and FPA were significantly elevated while PLC were significantly decreased (P less than 0.0001, less than 0.05 and less than 0.01, respectively). beta TG, Pf4, and MPV values did not show significant differences. These findings support the hypothesis that endothelial injury, clotting activation and platelet consumption are increased in preeclampsia. However, the much closer association of preeclampsia with FN levels as compared to FPA, beta TG, Pf4, suggests that endothelial injury is a more basic mechanism of preeclampsia than clotting or platelet activation.

Adolescent↗
PubMed1992

The teaching of behavioural sciences.

Medical science over the last few decades has undergone vast changes. Technologically it has advanced at a rapid pace. There has been a realization as well that the behaviour of individuals and communities also influences the occurrence of disease. Medical schools around the globe have realized the need for incorporating behavioural sciences as an integral part of the basic sciences taught to medical students. This paper presents the experience of Christian Medical College, Vellore in teaching behavioural sciences. Students are taught sociology, psychology and medical anthropology through a community-based, problem-oriented teaching programme. The students have first-hand experience of living in a community and learn by observation and interaction. Pre- and post-assessment has shown a significant improvement of their knowledge and attitude. Feedback from students also indicates that they find this programme relevant and interesting.

Behavioral Sciences↗
PubMed1991

Barium meal or endoscopy? A prospective randomized study of patient preference and physician decision making.

This study examines the preference of 64 out-patients for either a barium meal or an upper gastrointestinal endoscopy. The sequence of the examinations was randomized to avoid order bias. An initial preference for a barium meal of almost two-to-one, with 53% having no preference, was changed after the investigations to a preference for endoscopy of two-to-one with 5% having no preference. The use of mild sedation and the skill of the endoscopist had a major impact on the patients' opinion of the endoscopic procedure, and on their choice of examination for any repeat study. There was little agreement between clinical diagnosis and the result of investigation, but clinicians tended to accept the reported result of the investigation, especially if the result was abnormal. Despite a change in diagnosis in 34 of 49 patients there was little change in management as a result of the investigations, supporting the view that young patients with dyspepsia may be managed with symptomatic treatment initially, and without investigation. This study lends further support to the view that endoscopy should be the investigation of choice in patients with persistent dyspepsia, especially those whose age or infirmity may make barium examination suboptimal.

Barium Sulfate↗