Promotion of women physicians in academic medicine.
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Career Mobility↗
Biomedical subjects
M T Ruffin
Publications and source records attributed to M T Ruffin.
Screening for prostate cancer.
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Decision Support Techniques↗
Surrogate endpoint biomarkers for cervical cancer chemopreventive trials.
Cervical intraepithelial neoplasia (CIN) represents a spectrum of epithelial changes that provide an excellent model for developing chemopreventive interventions for cervical cancer. Possible drug effect surrogate endpoint biomarkers are dependent on the agent under investigation. Published and preliminary clinical reports suggest retinoids and carotenoids are effective chemopreventive agents for CIN. Determination of plasma and tissue pharmacology of these agents and their metabolites could serve as drug effect intermediate endpoints. In addition, retinoic acid receptors could serve a both drug and biological effect intermediate endpoints. Possible biological effect surrogate endpoint biomarkers include cytomorphological parameters, proliferation markers, genomic markers, regulatory markers, and differentiation. Given the demonstrated causality of human papillomavirus (HPV) for cervical cancer, establishing the relationship to HPV will be an essential component of any biological intermediate endpoint biomarker. The pathologic effect surrogate endpoint biomarker for cervical cancer is CIN, used clinically for years. The desired effect for chemopreventive trials is complete regression or prevention progression. In planning chemoprevention trials, investigators need to consider spontaneous regression rates, the subjective nature of detecting CIN, and the impact of biopsy on regression. If intermediate endpoint biomarkers that met the above criteria were available for cervical cancer, then new chemopreventive agents could be rapidly explored. The efficacy of these new agents could be determined with a moderate number of subjects exposed to minimal risk over an acceptable amount of time. The impacts on health care for women would be significant.
Anticarcinogenic Agents↗
Vaginal smears after hysterectomy.
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Female↗
Disqualifying criteria in a preparticipation sports evaluation.
BACKGROUND: This study was undertaken to demonstrate the relative frequency of disqualifying criteria in a complete history and physical sports examination. METHODS: A review was conducted of 2574 preparticipation physical evaluations (PPEs) performed on 11- to 18-year-old student athletes to determine which factors are associated with denial of unrestricted sports participation. RESULTS: Eighty-five percent of the student athletes passed the screening. Of those who did not, the denial decision was based on the medical history alone in 58% of cases (P < .05). A logistic regression analysis identified seven items associated with denial: dizziness with exercise, history of asthma, body mass index, systolic blood pressure, visual acuity, heart murmur, and musculoskeletal examination. CONCLUSIONS: Although physicians often take a complete history and perform physical examinations, relatively few variables appear related to denial of eligibility for participation in organized sports. The history is one of the most important aspects of the PPE. A directed PPE may be more efficient, thereby allowing more time to address other important issues.
Adolescent↗
Effect of distance and travel time on rural women's compliance with screening mammography: an UPRNet study. Upper Peninsula Research Network.
BACKGROUND: The purpose of this study was to determine whether the distance and time required for rural women to travel for a mammogram is associated with their compliance with screening mammography recommendations. METHODS: Women who were > or = 40 years old and visiting family physician offices for any reason were given a questionnaire regarding their frequency of mammography during the past 4 years, the distance and travel time from their homes to the nearest mammography unit, their attitudes and knowledge about mammography, and demographics. The study was conducted in the 12 family practices of the Upper Peninsula Research Network (UPRNet), a Michigan rural family practice research network. RESULTS: Eighty-eight percent (N = 416) of the women in the study had previously had mammography, but 41% were not compliant with American Cancer Society guidelines regarding mammography screening. After controlling for confounding, none of the measures of travel time or distance were associated with mammography compliance. CONCLUSIONS: In this rural population, mammography compliance is not affected by distance, travel time, or transportation. A population-based study in a more remote area is needed to further explore geographic barriers to mammography compliance among rural women.
Adult↗
Management of thyroid nodules.
Clinically apparent thyroid nodules occur in about 5 percent of the population. Because most patients with thyroid nodules present initially to their primary care physician, family physicians should have a thorough understanding of the diagnosis and treatment of thyroid nodules. The history and physical examination may be helpful in detecting thyroid nodules but are not useful in predicting malignancy. Furthermore, laboratory studies, ultrasonography and nuclear medicine scans do not reliably differentiate between benign and malignant thyroid nodules. In most cases, fine-needle aspiration biopsy can accurately identify malignant thyroid nodules. Fine-needle aspiration biopsy is safe and can be performed in an office setting.
Biopsy, Needle↗
Evaluation and management of fatigue.
Fatigue is a common symptom among patients of primary care physicians. For many physicians and patients, interactions related to the subject of fatigue are frustrating and unsatisfying, because of differences in expectations, a narrow focus on biomedical origins or solutions, and failure to include psychosocial issues in evaluation and management. The initial office visit should focus on the patient's history, to determine the type of fatigue and establish an effective therapeutic relationship. Few, if any, laboratory tests should be ordered. The second office visit should be used to review the information collected, add any new information from the patient's diary or reports from the patient's significant others, and perform a complete physical examination. Patients whose fatigue is diagnosed as physiologic or secondary to a medical problem should receive specific therapeutic interventions. The management of other patients requires interventions that combine biomedical and psychosocial therapies with a commitment to long-term follow-up. The key to successful management of fatigue is an effective therapeutic relationship with the patient.
Decision Trees↗
Patients' interpretation of qualitative probability statements.
BACKGROUND: Physicians often use qualitative probability statements to compare treatment options or describe risks of treatment, especially if exact numerical information is not readily available. OBJECTIVES: To determine (1) the effect of context, experience, age, gender, race, occupation, and education on patients' numerical interpretation of probability terms and (2) patient preferences for information about side effects (qualitative or numerical). DESIGN: Cross-sectional survey. SETTING: A university-based family practice in Ann Arbor, Mich. PARTICIPANTS: Patients 18 years of age and older and parents of patients younger than 18 years of age seen during January and February 1993 for any reason except complete physical examination. METHODS: A questionnaire presented scenarios of minor and major complications related to four different medical conditions. Participants were asked to estimate how many people of 100 would have a complication if their physician described the risk for the complication in each scenario as unlikely. Participants were then asked whether they preferred receiving information from their physician about the risk for complications in words or numbers. RESULTS: Of 345 questionnaires distributed, 307 patients (89%) completed them. The rates assigned to the minor complications were significantly higher than the rates assigned to the major complications (P = .0001). Participants who had experienced the described complication reported significantly higher rates for the minor complications of vaccination and surgery (P = .0001 and P = .0235, respectively). Education had a significant effect only on the rates assigned to vaccination complications (P = .0069). Occupation had a significant effect only on the rates assigned to antibiotic side effects (P = .0090). CONCLUSIONS: When a physician uses qualitative probability statements, he or she must be sensitive to the patient's previous experience with that procedure or medication. Also, if one wants to convey the same potential rate of occurrence for major and minor side effects, then one needs to use different words for each.
Adult↗
A multivariate model for specialty preference by medical students.
BACKGROUND: Numerous studies have demonstrated differences among students regarding their preference of a medical specialty. The goal of the present research was to develop a model for the selection of a primary care specialty (ie, family practice, general internal medicine, medicine/pediatrics, and general pediatrics). METHODS: A self-administered questionnaire was mailed to 822 first-year through fourth-year medical students at the University of Michigan Medical School in Ann Arbor. Students listed their first preference for medical specialty, anticipated income and work hours, and the influence of attitudinal and social factors on their preference. A total of 645 (78.5%) students responded. Average age was 25; 58% were male, and 77% resided in Michigan. RESULTS: Overall, 34.3% of the medical students who responded to the questionnaire expressed a preference for a surgical specialty; 27.3%, primary care; 19.9%, a hospital-based practice; and 18.5%, nonprimary care and non-hospital based practice. A multiple logistic regression model developed on preference for a primary care specialty achieved a classification accuracy of 82%. The most important factors influencing specialty preference were sex, expected income, attitudes about general medicine issues, attitudes about surgery, and the influence of other people. CONCLUSIONS: No single factor dominates a student's preference for primary care. Students preferring primary care were most strongly influenced by their perceptions of practice variations. Students preferring nonprimary care specialties were more interested in income, prestige, and hospital-based practice. Medical school faculty had no significant impact on the preferences of either group of students.
Adult↗
A closer examination of sex bias in the treatment of ischemic cardiac disease.
BACKGROUND: Past studies have conflicted regarding the existence of sex bias in the treatment of women with ischemic cardiac disease. This study explored the effect of different analytic models on conclusions about sex bias. METHODS: A retrospective analysis of medical records was performed on 787 patients evaluated for potential acute cardiac ischemia in the emergency departments of two nonteaching community hospitals. The Acute Coronary Ischemia Time Insensitive Predictive Instrument (ACI-TIPI) was used to estimate the likelihood of ischemic disease. The decisions to admit to hospital, not to admit to hospital, and to discharge with diagnosis of myocardial infarction were the outcome variables. RESULTS: Logistic regression models of increasing levels of detail were applied and evaluated. Analysis using summary data (similar to discharge abstracts or claims data) revealed that patient sex affected admission decisions, but an analysis of clinically detailed data by hospital was required to reveal the nature of the effect. There was disparity in admission decisions by sex at one hospital but not at the other. The odds ratio for admission (women vs men) was 0.546 (95% CI, 0.33 to 0.91) at Hospital A, and 1.22 (95% CI, 0.72 to 2.05) at Hospital B. This disparity appeared to be related to a high rate of admission (67%) among men with low (< 10%) probability of acute ischemia. CONCLUSIONS: Differences in treatment of suspected acute cardiac ischemia by sex may be a practice variation phenomenon rather than a uniform bias. When these differences occur, they may represent overtreatment of men rather than inadequate treatment of women. Because summary or billing datasets lack clinical detail, they are inadequate for the study of physician decision-making.
Aged↗
Fellowship training in family medicine: results of a national survey.
BACKGROUND: Family medicine fellowship training has increased in extent and diversity over the past 15 years. We conducted a national survey to study the present status of fellowship training in our discipline. METHODS: We surveyed all departments and divisions of family medicine in the United States as well as sources of other known training programs. Information was requested regarding type of fellowship, source of funding, location, benefits, curricula, degree programs, and positions offered and filled. RESULTS: Data was obtained for 190 programs. Faculty development programs comprised the greatest proportion of fellowship programs (n = 45 or 24%) and positions (n = 129 or 33%), followed by geriatrics, sports medicine, and obstetrics. Programs with the highest fill rates were adolescent medicine (80%), substance abuse (75%), and obstetrics (74%). Faculty development, geriatrics, and sports medicine, with the largest number of fellowship positions, filled 35%, 54%, and 50% of available slots respectively. Duration, structure, and benefits of fellowship programs varied considerably. CONCLUSIONS: Fellowship training in family medicine offers a wide variety of opportunities for career development, but this data suggests that there are areas in which special attention should be placed to facilitate the most appropriate advancement of fellowship training in our discipline.
Capital Financing↗
The rational management of labor.
Some practices and procedures that are common during the management of childbirth lack proof of efficacy, and some have adverse effects. The practice of withholding food and liquids and using intravenous fluids during labor may pose risks such as fluid overload, and maternal and fetal hyperglycemia. Enemas should be reserved for women with painful constipation. Evidence does not support the value of shaving the perineal area. Nonpharmacologic measures to control pain during labor are safe and moderately effective. Pharmacologic methods of analgesia and anesthesia provide good pain relief but pose significant risks. Continuous electronic fetal monitoring should be considered a diagnostic procedure, not a screening procedure. Amniotomy may shorten labor but can result in abnormally high uterine forces, infection, umbilical cord prolapse and fetal laceration. Position changes and alternative birth positions promote greater comfort and efficiency during labor. Finally, episiotomy has not been shown to reduce severe lacerations or prevent pelvic relaxation, and use of this procedure should be limited.
Amnion↗
Factors associated with human papillomavirus infection in women encountered in community-based offices.
OBJECTIVE: To assess risk factors for cervical human papillomavirus (HPV) infection in women presenting to community-based offices because of vaginal symptoms or for preventive screening. DESIGN: Cross-sectional analysis of history, physical examination, and microbiological infection variables. SETTING: Two community-based family practice offices in southeastern Michigan. PATIENTS: Two hundred seventy-three women, 18 to 50 years of age, presenting to the study sites because of vaginal symptoms or for a pelvic examination for preventive screening. MAIN OUTCOME MEASURE: Human papillomavirus infection of the uterine cervix as determined by polymerase chain reaction testing. RESULTS: Human papillomavirus infection was detected in 21.2% of the women (24.9% and 13.1% of women with and without vaginal symptoms, respectively); 34% of these infections were HPV types 16 or 18. Fifty-four percent of the women with HPV infection who underwent colposcopy had condyloma or cervical intraepithelial neoplasia verified on biopsy. Independent associations were found between HPV infection and the following female risk factors: the presence of vaginal itching, odor, or swelling; knowing the current sexual partner less than 24 months; age less than 40 years; household income of $14,000 or less; and ever having had six or more sexual partners. CONCLUSIONS: In addition to three previously described risk factors for genital HPV infection, two previously unrecognized risk factors were identified in this lower-risk population. These risk factors included the presence of vaginal symptoms of itching, odor, or swelling and having known the current sexual partner less than 24 months. Nevertheless, using risk factors alone, two thirds of the women infected with HPV in this population were not identified as being at high risk of infection. No subset of sexually active women was identified who were at no risk of HPV infection.
Adolescent↗
Presence of human papillomavirus infection of the uterine cervix as determined by different detection methods in a low-risk community-based population.
OBJECTIVE: To evaluate the effectiveness of various screening tests for detecting genital human papillomavirus (HPV) in a community-based population and to determine the prevalence of cervical lesions on colposcopically directed biopsies in patients found to have HPV by any screening test. DESIGN: Cross-sectional analysis of 208 female patients screened for HPV by clinical examination, Papanicolaou test, dot blot hybridization test (ViraPap, Digene Inc, Silver Spring, Md), and polymerase chain reaction (PCR) analysis. All persons with abnormal or positive results by any method were offered colposcopic evaluation. SETTING: Two community-based family practice offices in southeastern Michigan. MAIN OUTCOME MEASURES: The presence of HPV as determined by each test and results of colposcopic biopsies (gold standard) in patients who had HPV identified by any test. RESULTS: The prevalence of HPV infection was 20.3% by PCR analysis, 3.1% by ViraPap, 3.0% by the Papanicolaou test, and 0% by clinical examination. Symptomatic patients (those with complaints of vaginal odor, swelling, or itching) were more likely to harbor HPV as determined by PCR analysis than were asymptomatic women (P = .03, odds ratio = 2.65). Human papillomavirus type 16 or 18 was found in 41% of patients with positive PCR analyses and in all patients with positive ViraPap tests that were typed. Colposcopy with biopsy (gold standard for the presence of HPV disease) was performed on 34 of the 41 patients who tested positive for HPV by PCR analysis. Histologic results revealed that 79.4% of these patients had cervical disease: 14.6% had cervical intraepithelial neoplasia, 38.3% had condyloma, and 26.5% had cervicitis. CONCLUSIONS: Human papillomavirus as detected by PCR analysis was present in 20.3% of women in our population and was often one of the higher-risk types (16 or 18). A positive PCR analysis was predictive of cervical disease on colposcopic biopsy. The ViraPap test, Papanicolaou test, and clinical examination were insensitive measures for detecting HPV-related lesions in this population.
Adolescent↗
Cervical cancer screening. Issues of collection tools and reporting.
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Cervix Uteri↗
Selection criteria for breast cancer chemoprevention subjects.
Early phase chemoprevention trials differ from standard therapeutic clinical trials because asymptomatic, healthy people are treated with a potentially toxic intervention for a prolonged period of time. Current subject selection protocols have relied upon epidemiological methods to identify high-risk individuals. Most available data provide risk estimates for various individual risk factors, but few have reported risk estimates for combinations of risk factors. Selection criteria for the large tamoxifen intervention trial (NSABP P1) were developed from the work of Gail et al. [1]. The Gail model takes into account non-genetic factors (e.g., nulliparity, age at menarche, preexisting pathological conditions) and genetic factors (family history). Using a lifetime risk of 10% of developing breast cancer as a standard to intervene, NSABP P1 uses the Gail algorithm to select pre- and postmenopausal women for a primary intervention trial. This approach has been criticized for being insufficiently selective (i.e., all women > or = 60 yrs), but appears to be the best available method to select subjects for a chemoprevention trial. Other approaches have been based on identification of very high-risk women with acknowledged pathologic conditions [lobular carcinoma in situ, ductal carcinoma in situ (DCIS)]. Attempting to use these proliferative lesions as pathologic endpoints for drug effect has not been attempted. DCIS as a risk factor for tamoxifen intervention was excluded because of controversies over its management and because of frequent difficulties in distinguishing microinvasive from non-invasive lesions. Women treated for early stage breast cancer (Stage I) may be subjects for early stage chemopreventive interventions.(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
Anterior knee pain: the challenge of patellofemoral syndrome.
Pain in the anterior region of the knee is one of the most common musculoskeletal complaints in children, adolescents and adults. Difficult and frustrating for the patient to endure, the disorder is also difficult for the physician to manage. The precipitating events and the location and duration of the pain are important factors in narrowing the differential diagnosis. A detailed physical examination further aids in the differential diagnosis. The treatment and rehabilitation of patellofemoral dysfunction, the most common cause of anterior knee pain, has four phases--acute, subacute, chronic and maintenance. These phases involve medication, a structured knee exercise program and activity modification before returning to normal activity. More than 80 percent of patients with patellofemoral dysfunction respond well to a nonsurgical approach.
Acute Disease↗