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PubMed2002

Functional outcomes after treatment of squamous cell carcinoma of the base of the tongue.

OBJECTIVE: To compare functional outcome and quality of life after various treatments for squamous cell carcinoma of the base of the tongue. DESIGN: Retrospective survey using statistical comparison. SETTING: Academic medical center, institutional practice. PARTICIPANTS: Patients treated for squamous cell carcinoma of the base of the tongue between 1976 and 2000. Living patients 3 or more months after treatment were eligible. Questionnaire packets including validated site-specific quality-of-life instruments were mailed to 105 qualifying patients. Sixty-one patients participated, forming a volunteer sample. Patient responses were grouped according to treatment modality, operative vs nonoperative. MAIN OUTCOME MEASURES: The planned outcome was that nonoperative therapy would result in better function than operative treatment. RESULTS: Most comparisons indicated no statistical difference in outcome between operative and nonoperative groups. Significant differences (95% confidence interval) were calculated for age, interval since treatment, and T stage. Group comparisons of patient responses revealed significant differences only in xerostomia and days hospitalized. CONCLUSIONS: The tongue remains dysfunctional after both surgical and nonoperative treatment. Nonoperative treatment might more adversely affect saliva. Surgery is associated with a longer hospital stay.

Aged↗
PubMed2004

Time course in the relief of nasal blockage after septal and turbinate surgery: a prospective study.

OBJECTIVE: To evaluate prospectively the time course of the change in efficacy of septal and turbinate surgery in relieving nasal obstruction. DESIGN: Interventional study, before-after trial. SETTING: Referral center, institutional practice, hospitalized care. PATIENTS: Thirty-four consecutive patients undergoing septal and turbinate surgery were recruited. Seven patients were unwilling to complete the follow-up after surgery. No patient withdrawal was because of adverse effects. Twenty-five normal subjects with no nasal obstruction were included as control subjects. INTERVENTION: Functional nasal septal and turbinate surgery was performed to relieve nasal obstruction. MAIN OUTCOME MEASURE: Patient assessment of severity of nasal blockage on a 0-mm (no blockage) to 100-mm (maximum blockage) visual analog scale before surgery and at fixed intervals after surgery. RESULTS: The mean nasal blockage scores significantly decreased from the preoperative values at all intervals of follow-up. For the whole group, the nasal blockage score was on average 52% of the preoperative value at the last follow-up. The probability of having at least a 50% reduction in blockage decreased from 73%, to 60%, to 41%, and then to 27% at 3 months, 6 months, 1 year, and 2(1/2) years, respectively. CONCLUSIONS: Improvement in nasal blockage was found in patients after functional septal and turbinate surgery. However, the probability of substantial relief gradually decreased with time. Patients should be followed up after septal and turbinate surgery for possible recurring symptoms.

Adult↗
PubMed2004

Managing disturbing snoring with palatal implants: a pilot study.

OBJECTIVE: To evaluate the safety and efficacy of polyethylene terephthalate implants in the soft palate to modify disturbing snoring. DESIGN: Interventional study, before-after trial. SETTING: Referral center, institutional practice, hospitalized care. PATIENTS: Twelve consecutive patients with disturbing snoring and an apnea-hypopnea index less than 15 per hour and a body mass index of 30 or less were recruited. One patient with no adverse effects was lost to follow-up. Extrusion of implants occurred in 2 patients. Complete data in 9 patients were available for analysis. INTERVENTION: Polyethylene terephthalate implants were inserted in the soft palate. MAIN OUTCOME MEASURES: Safety of the procedure and evaluation of the loudness of snoring by bed partners using a visual analog scale. RESULTS: There were no complications of infection or bleeding. Extrusion of implants occurred in 2 patients with no clinical sequelae. The mean (SD) loudness of snoring at baseline, as assessed by bed partners using a visual analog scale of 0 to 100, was 79 (17.2). This significantly decreased to 48 (20.4) at 3 months (Wilcoxon signed rank test, P =.008). Daytime sleepiness as measured with the Epworth Sleepiness Scale also decreased from an average score of 8.9 at baseline to 5.7 at 3 months (P =.007). There were no significant changes in the apnea-hypopnea index and body mass index from baseline to 3 months' follow-up. CONCLUSIONS: Polyethylene terephthalate implants in the soft palate are safe. Snoring decreased significantly at 3 months after surgery. Polyethylene terephthalate implants in the soft palate should be further explored as a treatment for snoring.

Adult↗
PubMed2005

GJB2 and GJB6 mutations: genotypic and phenotypic correlations in a large cohort of hearing-impaired patients.

OBJECTIVES: To analyze the clinical features of hearing impairment and to search for correlations with the genotype in patients with DFNB1. DESIGN: Case series. SETTING: Collaborative study in referral centers, institutional practice. Patients A total of 256 hearing-impaired patients selected on the basis of the presence of biallelic mutations in GJB2 or the association of 1 GJB2 mutation with the GJB6 deletion (GJB6-D13S1830)del. MAIN OUTCOME MEASURES: The prevalence of GJB2 mutations and the GJB6 deletion and audiometric phenotypes related to the most frequent genotypes. RESULTS: Twenty-nine different GJB2 mutations were identified. Allelic frequency of 35delG was 69%, and the other common mutations, 313del14, E47X, Q57X, and L90P, accounted for 2.6% to 2.9% of the variants. Concerning GJB6, (GJB6-D13S1830)del accounted for 5% of all mutated alleles and was observed in 25 of 93 compound heterozygous patients. Three novel GJB2 mutations, 355del9, V95M, and 573delCA, were identified. Hearing impairment was frequently less severe in compound heterozygotes 35delG/L90P and 35delG/N206S than in 35delG homozygotes. Moderate or mild hearing impairment was more frequent in patients with 1 or 2 noninactivating mutations than in patients with 2 inactivating mutations. Of 93 patients, hearing loss was stable in 73, progressive in 21, and fluctuant in 2. Progressive hearing loss was more frequent in patients with 1 or 2 noninactivating mutations than in those with 2 inactivating mutations. In 49 families, hearing loss was compared between siblings with similar genotypes, and variability in terms of severity was found in 18 families (37%). CONCLUSION: Genotype may affect deafness severity, but environmental and other genetic factors may also modulate the severity and evolution of GJB2-GJB6 deafness.

Chromosome Deletion↗
PubMed2005

Age as a prognostic factor for complications of major head and neck surgery.

OBJECTIVE: To determine if age alone is a prognostic indicator of surgical outcomes for major head and neck procedures. DESIGN: Retrospective cohort study over a 4-year period. SETTING: Academic referral center, institutional practice, hospitalized care. PATIENTS: Included in this study were patients who had undergone ablative, reconstructive, and other major surgical procedures of the head and neck, including neck dissection, laryngectomy, maxillectomy, thyroidectomy with lymphadenectomy, and composite resection of the oral cavity with reconstruction, for both malignant and benign disease. MAIN OUTCOME MEASURES: Patient data and intraoperative and postoperative course factors were recorded. Comorbidity was graded using an Adult Comorbidity Evaluation 27 test, Charlson Comorbidity Index, and American Society of Anesthesiology score. Postoperative complications were dichotomized, and multiple logistic regression was used for data analysis. RESULTS: Medical chart review identified 157 cases. Analysis of data revealed that time under general anesthesia was the only factor consistently related to complications (P<.006), and it was the only factor consistently related to length of stay (P<.001). Analysis of major complications (6% incidence) as an outcome using univariate analysis resulted in a strong positive correlation with both comorbidity indexes: Adult Comorbidity Evaluation 27 (P = .002) and Charlson Comorbidity Index (P = .005). Multiple logistic regression showed no significant relationship between age 70 years or older (20% of patients) and either complications or hospital length of stay. CONCLUSIONS: Patient's age alone is not a prognostic indicator of surgical outcome for major head and neck procedures. However, comorbidity is an important predictive factor for postoperative complications in any age group. Time under general anesthesia showed a statistically significant relationship with complication rate and hospital length of stay in multivariate analyses. Consequently, prevention of complications should focus on optimizing preoperative comorbid conditions.

Adolescent↗
PubMed1994

A prospective study of ingested foreign bodies in Singapore.

OBJECTIVE: To evaluate the following: the symptoms, physical signs, investigation, and treatment of impacted foreign bodies (FBs); the dimensions of FBs according to site of impaction; and epidemiology, risk factors, and complications of FB ingestion. DESIGN: Prospective analysis of 397 patients with a history of FB ingestion. SETTING: Department of Otolaryngology, Tan Tock Seng Hospital, Singapore, a referral center with institutional practice. PATIENTS: Of the 397 patients treated between May and December 1991, ingested FBs were found in 197 patients. INTERVENTION: Foreign bodies were removed with forceps under direct or indirect vision; if this was impossible, removal was done endoscopically. RESULTS: Dysphagia, positive laryngeal rub, and drinking water tests had high sensitivity and specificity for esophageal FBs. Large and rigid FBs of various shapes tend to lodge in piriform fossae and esophagus and might cause complications if not removed early. The risk factors of FB ingestion were use of dentures and Chinese method of cooking and eating. The complication rate of impacted FBs was 5.1% and increased with the delay in seeking treatment. Flexible esophagoscope was found to be as effective as rigid esophagoscope in retrieving esophageal FBs. Lesions simulating impacted FBs were found in nine patients. In 162 patients in whom no FB was found, the symptoms resolved spontaneously within 16 days. CONCLUSION: Dysphagia, positive laryngeal rub, and drinking water tests are indicative of impacted FBs that must be removed early to prevent complications. Ability to use both rigid and flexible esophagoscopes is advantageous in FB retrieval.

Adolescent↗
PubMed1994

Aerodynamic and temporal disruptions of speech in laryngeal insufficiency.

OBJECTIVES: To describe the effects of laryngeal insufficiency on aerodynamic and temporal aspects of speech breathing and speech production. DESIGN: A survey study with statistical comparisons of patient and normal subject groups. SETTING: Private and institutional practice. PATIENTS: A convenience sample of 23 subjects with laryngeal insufficiency was compared with a volunteer sample of 20 normal-speaking subjects. Patients had frank unilateral recurrent nerve paralysis-paresis or idiopathic laryngeal insufficiency as verified by videostrobolaryngoscopy. MAIN MEASURES: Mean airflows, air volumes, and durations for speech inspirations, speech phrases, and non-inspiratory pauses during samples of monologue speech. RESULTS: In comparison with the normal group, the patient group had significantly (P < .01) higher expiratory airflows and volumes during speech and reduced speech phrase durations. In addition, breaths per minute, inspiratory minute volume, and inspiratory airflow were significantly (P < .01) higher for the patient group. An experimental measure of aerodynamic yield for speech increased the statistical separation of the patient and normal groups compared with analyses using simple expiratory airflow measures alone. CONCLUSIONS: Insufficient contact of the true vocal folds during speech can affect more than just voice quality. Likely effects include (1) reduced speech phrase duration, (2) increased breaths per minute, (3) increased inspiratory minute volume, and (4) increased inspiratory airflow rate.

Adult↗
PubMed1996

Age at onset of puberty following high-dose central nervous system radiation therapy.

OBJECTIVE: To determine if a relationship exists between age at irradiation, sex of the patient, and age at onset of puberty and pubarche in children treated with high-dose radiation to the central nervous system. DESIGN: Case series. SETTING: Tertiary care institutional practices and clinics. PATIENTS: Thirty-six children treated with high-dose irradiation (hypothalamic pituitary dose, 30-72 Gy) by conventional (n = 29) or hyperfractionated (n = 7) schedules. Girls were treated before age 8 years and boys before age 9 years. Twenty-six of the 36 children also received chemotherapy. All tumors were distant from the hypothalamic-pituitary region. MAIN OUTCOME MEASURE: Age at onset of puberty and pubarche. RESULTS: In girls, the median age at onset of puberty was 9.3 years vs 10.9 years for controls (P < .01); pubarche occurred at 9.4 years vs 11.2 years for controls (P < .01). In boys, the median age at onset of puberty--genital II--was 11.0 years vs 11.5 years for controls (P = .30); pubarche occurred at a median age of 10.5 years vs 12 years for controls (P = .25). A censored-data normal linear regression model was used to account for children (n = 6) who had not reached puberty. Age at diagnosis (P < .01) and sex (P = .01) were significant predictors of age at onset of puberty. Body mass index SD score (z score) was inversely related to age at onset of puberty (r = -0.77) and was greater at onset of puberty in girls than in boys. CONCLUSION: In children who have received high-dose cranial radiation therapy, a significant positive correlation exists between age at diagnosis and age at onset of puberty in boys and girls.

Adolescent↗
PubMed1994

Changes in serum amylase level following hepatic resection in chronic liver disease.

OBJECTIVE: Factors that were likely to cause hyperamylasemia following hepatic resection were studied. DESIGN: Case-comparison study. SETTING: Institutional practice. PATIENTS: Seventy-one patients who underwent hepatic resection because of primary or secondary liver tumors and other benign disease, and who had no history of pancreatitis, were divided into four groups. Patients were divided into groups according to the presence or absence of underlying liver disease and the vascular occlusion methods used during hepatic resection (Pringle maneuver or the hemihepatic vascular occlusion technique). The Pringle maneuver was chosen for patients in whom the duration of liver parenchymal transection was expected to be short and/or the hepatic hilum had severe adhesion precluding the safe dissection of the hepatic artery and portal vein. MAIN OUTCOME MEASURES: Serum amylase levels were measured on the preoperative day and on postoperative days 1, 2, 4, 6, 7, 10, and 14. Preoperative liver function, operative blood loss, operative time, and vascular occlusion time were examined. RESULTS: Patients with chronic liver disease (CLD group) had high serum amylase levels during the preoperative and postoperative periods. Patients in the CLD group who underwent the Pringle maneuver (Pringle-L group) had significantly elevated postoperative serum amylase levels in comparison with their preoperative serum amylase levels. Pancreatitis developed in two patients in the Pringle-L group--one of them died. CONCLUSION: These results strongly suggest that prolonged complete occlusion of the portal vein for hepatectomy in patients with chronic liver disease has a serious influence on postoperative serum amylase levels.

Adult↗
PubMed1996

The role of whole-body positron emission tomography with [18F]fluorodeoxyglucose in identifying operable colorectal cancer metastases to the liver.

OBJECTIVE: To compare the accuracy of whole-body position emission tomography (PET)using [18F]fluorodeoxyglucose (FDG) with conventional radiological imaging techniques in identifying operable colorectal cancer metastases to the liver. DESIGN: A double-blind comparative study of FDG-PET as the criterion standard vs conventional radiological imaging methods as the criterion standard, in staging of recurrent colorectal cancer. SETTING: Institutional practice in a tertiary referral center. PATIENTS: Thirty-four consecutive patients with suspected colorectal cancer metastases recruited for the study between May 1993 and October 1994. INTERVENTIONS: Conventional radiological methods of cancer staging included abdominal computed tomography (CT) (n = 34), chest x-rays (n = 15), and chest CT (n = 19) to evaluate extrahepatic disease. Twenty-seven patients were subsequently considered to have apparently isolated cancer metastases to the liver. Anatomical resectability was assessed by magnetic resonance imaging (n = 24) or CT angiography (n = 3) in all study patients. The FDG-PET studies (n = 34) were performed within 8 weeks of conventional radiological imaging. MAIN OUTCOME MEASURES: Malignancy of suspected lesions detected by means of FDG-PET and conventional radiological imaging was confirmed by histopathologic examination of resected specimens and percutaneous biopsy specimens and by serial CT scans demonstrating progression of disease. RESULTS: Unsuspected extrahepatic malignant disease that was missed by conventional radiological imaging was detected by FDG-PET in 11 patients (32%). The PET-detected extrahepatic malignant disease included retroperitoneal nodal metastases (n = 6), pulmonary metastases (n = 3), and locoregional cancer recurrences (n = 2). The additional information afforded by PET consequently had an influence on the clinical management in 10 patients (29%). CONCLUSIONS: The FDG-PET method enabled selection of patients with apparently curable colorectal cancer metastases to the liver for hepatic resection.

Colorectal Neoplasms↗
PubMed1999

Effects of writing about stressful experiences on symptom reduction in patients with asthma or rheumatoid arthritis: a randomized trial.

CONTEXT: Nonpharmacological treatments with little patient cost or risk are useful supplements to pharmacotherapy in the treatment of patients with chronic illness. Research has demonstrated that writing about emotionally traumatic experiences has a surprisingly beneficial effect on symptom reports, well-being, and health care use in healthy individuals. OBJECTIVE: To determine if writing about stressful life experiences affects disease status in patients with asthma or rheumatoid arthritis using standardized quantitative outcome measures. DESIGN: Randomized controlled trial conducted between October 1996 and December 1997. SETTING: Outpatient community residents drawn from private and institutional practice. PATIENTS: Volunteer sample of 112 patients with asthma (n = 61) or rheumatoid arthritis (n = 51) received the intervention; 107 completed the study, 58 in the asthma group and 49 in the rheumatoid arthritis group. INTERVENTION: Patients were assigned to write either about the most stressful event of their lives (n = 71; 39 asthma, 32 rheumatoid arthritis) or about emotionally neutral topics (n = 41; 22 asthma, 19 rheumatoid arthritis) (the control intervention). MAIN OUTCOME MEASURES: Asthma patients were evaluated with spirometry and rheumatoid arthritis patients were clinically examined by a rheumatologist. Assessments were conducted at baseline and at 2 weeks and 2 months and 4 months after writing and were done blind to experimental condition. RESULTS: Of evaluable patients 4 months after treatment, asthma patients in the experimental group showed improvements in lung function (the mean percentage of predicted forced expiratory volume in 1 second [FEV1] improved from 63.9% at baseline to 76.3% at the 4-month follow-up; P<.001), whereas control group patients showed no change. Rheumatoid arthritis patients in the experimental group showed improvements in overall disease activity (a mean reduction in disease severity from 1.65 to 1.19 [28%] on a scale of 0 [asymptomatic] to 4 [very severe] at the 4-month follow-up; P=.001), whereas control group patients did not change. Combining all completing patients, 33 (47.1%) of 70 experimental patients had clinically relevant improvement, whereas 9 (24.3%) of 37 control patients had improvement (P=.001). CONCLUSION: Patients with mild to moderately severe asthma or rheumatoid arthritis who wrote about stressful life experiences had clinically relevant changes in health status at 4 months compared with those in the control group. These gains were beyond those attributable to the standard medical care that all participants were receiving. It remains unknown whether these health improvements will persist beyond 4 months or whether this exercise will prove effective with other diseases.

Adaptation, Psychological↗
PubMed1999

Extent of margin positivity as a predictor for local recurrence after breast conserving irradiation.

The extent of positivity of the final excision margin in relationship to other relevant factors was evaluated as a predictor for local recurrence after breast conservation therapy (BCT). As part of an institutional practice policy for BCT in 509 stage I/II breast carcinomas, 105 cases had a final excision margin, which was positive. The median age for this cohort was 58 years and the median follow-up was 86 months. All positive margin patients received whole breast irradiation to 50 Gy-50.4 Gy followed by a boost to the tumor bed for an additional 20 Gy. The extent of positivity (EOP) of the excision margin was graded according to a four-point scale: focal, minimal, moderate, extensive. Cases were then analyzed for local failure according to EOP grade, histology, age, tumor size, total excision volume, re-excision, tamoxifen therapy, and chemotherapy. A focal or minimal EOP grade was found in 70% of specimens while an additional 26% were moderate or extensive. The incidence of invasive carcinoma with prominently associated DCIS was significantly greater in cases with an EOP grade of moderate/extensive. There were nine ipsilateral breast recurrences, eight of which could be evaluated for EOP grade. All recurrences were in or near the previous biopsy cavity. A Kaplan-Meier plot of freedom from local failure showed a significant (P = 0.008) difference between cases grouped by EOP grade of focal/minimal as compared to moderate/extensive. A Cox proportional hazards regression model found that the only variable significantly related at the P < or = 0.05 level to local failure was an EOP grade of moderate/extensive. For breast excision specimens with a positive final margin, an EOP grade of moderate/extensive is a predictor for local recurrence after BCT, which may be independent of other variables such as age or histology.

Adult↗
PubMed2003

Deep versus shallow suction of endotracheal tubes in ventilated neonates and young infants.

BACKGROUND: Mechanical ventilation is commonly used in Neonatal Intensive Care Units to assist breathing in a variety of conditions. Mechanical ventilation is achieved through the placement of an endotracheal tube (ETT) which is left in-situ. The ETT is suctioned to prevent a build-up of secretions and therefore blockage of the airway. Methods of suctioning the endotracheal tube vary according to institutional practice and the individual clinician performing the task. The depth of suctioning is one of these variables. The catheter may be passed to the tip of the ETT or beyond the tip into the trachea or bronchi to facilitate removal of secretions. However, trauma to the lower airways may result from the suction catheter being passed into the airway beyond the tip of the endotracheal tube. OBJECTIVES: To compare the effectiveness and complications of deep (catheter passed beyond the tip of the ETT) versus shallow (catheter passed to length of ETT only) suctioning of the endotracheal tube in ventilated infants. SEARCH STRATEGY: Using text words and subject headings relevant to endotracheal suctioning, searches were made of the Oxford Database of Perinatal Trials, Cochrane Register of Controlled Trials (The Cochrane Library, Issue 3, 2002), MEDLINE (from January 1966 to December 2002, all languages), CINAHL (from 1982 to 2002). In addition, a call was placed on the list servers, NICU-NET and Neonatal-Talk for unpublished trials, conference presentations and current trials. SELECTION CRITERIA: Controlled trials using random or quasi-random allocation of neonates receiving ventilatory support via an endotracheal tube to either deep or shallow endotracheal suctioning. DATA COLLECTION AND ANALYSIS: No studies were found meeting the criteria for inclusion in this review MAIN RESULTS: No studies were found meeting the criteria for inclusion in this review REVIEWER'S CONCLUSIONS: There is no evidence from randomised controlled trials concerning the benefits or risks of deep versus shallow suctioning of endo-tracheal tubes in ventilated neonates and infants. Further high quality research would be required to conclusively establish whether there are any benefits to deep or shallow suctioning. However, as it may be considered unethical to conduct a trial of deep suctioning given anecdotal evidence regarding possible damage to the airway, it is proposed that a randomised controlled trial comparing deep with shallow suctioning may be considered in a NICU where the standard practice includes a deep suctioning technique.

Humans↗
PubMed2006

Retroperitoneal sarcoma: a population-based analysis of epidemiology, surgery, and radiotherapy.

BACKGROUND: No population-based studies of retroperitoneal sarcoma (RPS) have been conducted, and the use and timing of adjuvant radiotherapy for RPS is controversial. The objective of this study was to examine the incidence and treatment of RPS, specifically regarding the use of adjuvant radiotherapy. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to evaluate the incidence of RPS over a 29-year period (1973-2001). The rate of surgery, the rate and timing of adjuvant radiotherapy, and the influence of demographic factors on treatment were evaluated. RESULTS: A total of 2348 cases of RPS were identified. The mean annual incidence of RPS was 2.7 cases per 10(6) persons and did not change significantly over time (2.6 in 1973 vs. 2.8 in 2001; P = .92). Most patients (1654; 70.4%) underwent surgical resection. Radiotherapy was used in 428 patients (25.9%) who underwent surgery; radiation was given postoperatively in 366 (85.5%), preoperatively in 20 (4.7%), and intraoperatively or unknown in 42 (9.8%). Patients who received any adjuvant radiotherapy were on average 5 years younger than those who underwent surgery alone (P < .0001). Radiotherapy was more commonly used among whites than African Americans (25.8% vs. 16.7%; P = .02) and there was significant variation in the use of adjuvant radiotherapy by geographic location (P = .003). On multivariate analysis, race (P = 0.004), age (P < .0001), and geographic location (P = .006) were independently associated with the use of adjuvant radiotherapy. CONCLUSION: The incidence of RPS, a rare disease, appears stable. Most patients who undergo surgery do not receive any adjuvant radiotherapy, and very few receive preoperative radiotherapy. Differences in adjuvant radiotherapy use related to demographic and geographic factors suggest that at least some treatment variations reflect differences in individual and institutional practice patterns.

Adolescent↗
PubMed2007

Physicians are different when they learn communication skills: influence of the locus of control.

PURPOSE: Although it is widely recognised that educational interventions may be more effective for people with an 'internal' Locus of Control (who believe that life outcomes are controlled by their own characteristics or actions) compared to people with an 'external' Locus of Control (who believe that life outcomes are controlled by external forces such as luck, fate or others), no study has yet assessed the influence of physicians' Locus of Control (LOC) on communication skills learning. This study aims to test the hypothesis that, in a communication skills training program, physicians with an 'internal' LOC would demonstrate communication skills acquisition to a greater degree than those with an 'external' LOC. METHODS: A non-randomised longitudinal intervention study was conducted between January 1999 and April 2001. Sixty-seven volunteer physicians from private and institutional practice in Belgium participated in a learner-centred, skills-focused, practice-oriented communication skills training program. Communication skills changes were assessed in 2 standardised simulated interviews before and after training (one two-person and one three-person interview). Communication skills were assessed using the Cancer Research Campaign Workshop Evaluation Manual. Physicians' LOC was assessed using the Rotter I-E scale. Communication skills changes of the upper and lower third of physicians in respect of their scores on this scale were compared using group by time repeated measures of variance. RESULTS: In the two-person and three-person interviews, changes in the use of open directive questions were more important among physicians with an "internal" LOC compared with changes observed among physicians with an 'external' LOC (P=0.066 and P=0.004, respectively). In the three-person interview, changes in the use of directive questions, assessing functions and moderate feelings stated explicitly were more important among physicians with an 'internal' LOC compared with changes observed among physicians with an 'external' LOC (P= 0.001; P=0.002 and P=0.011 respectively). CONCLUSION: This study shows that physicians' LOC is a psychological characteristic that could influence the efficacy of a communication skills training program. This evidence supports the idea that a psychological characteristic such as 'internal' LOC may facilitate communication skills acquisition through physicians' belief that communication with patients may be controlled by physicians themselves.

Adult↗
PubMed2001

A standardized multidisciplinary approach reduces the use of allogeneic blood products in patients undergoing cardiac surgery.

PURPOSE: Individual and institutional practices remain an independent predictor factor for allogeneic blood transfusion. Application of a standardized multidisciplinary transfusion strategy should reduce the use of allogeneic blood transfusion in major surgical patients. METHODS: This prospective non randomized observational study evaluated the effects of a standardized multidisciplinary transfusion strategy on allogeneic blood products exposure in patients undergoing non-emergent cardiac surgery. The developed strategy involved a standardized blood conservation program and a multidisciplinary allogeneic blood transfusion policy based mainly on clinical judgement, not only on a specific hemoglobin concentration. Data obtained in a first group including patients operated from September 1997 to August 1998 (Group pre: n=321), when the transfusion strategy was progressively developed, were compared to those obtained in a second group, including patients operated from September 1998 to August 1999 (Group post: n=315) when the transfusion strategy was applied uniformly. RESULTS: Patient populations and surgical procedures were similar. Patients in Group post underwent acute normovolemic hemodilution more frequently, had a higher core temperature at arrival in the intensive care unit and presented lower postoperative blood losses at day one. Three hundred forty units of packed red blood cells were transfused in 33% of the patients in Group pre whereas 161 units were transfused in 18% of the patients in Group post (P <0.001). Pre- and postoperative hemoglobin concentrations, mortality and morbidity were not different among groups. CONCLUSION: Development of a standardized multidisciplinary transfusion strategy markedly reduced the exposure of cardiac surgery patients to allogeneic blood.

Aged↗
PubMed2006

Infertility, ovulation induction treatments and the incidence of breast cancer--a historical prospective cohort of Israeli women.

CONTEXT: Ovulation induction drugs may be associated with increased breast cancer risk. Results so far have been inconclusive. OBJECTIVE: To evaluate the association between infertility, exposure to ovulation induction drugs and the incidence of breast cancer. DESIGN: Historical prospective cohort and nested case-control study. SETTING: Institutional practice PATIENTS: About 5,788 women attending five infertility centers in Israel between 1964 and 1984. INTENTION: Abstracting of medical records and telephone interviews. MAIN OUTCOME MEASURE: Breast cancer incidence was determined through linkage with the National Cancer Registry database. Standardized incidence ratios (SIRs) and 95% confidence intervals were computed by comparing the observed to the expected cancer rates in the general population. In addition, a nested case-control study within the cohort was performed with interviews of breast cancer cases and two matched controls. RESULTS: The study cohort included 120,895 women years of follow-up. Compared to 115.2 expected breast cancer cases, 131 cases were observed (SIR = 1.1; 95% CI 0.9-1.4). Risk for breast cancer was significantly higher for women treated with clomiphene citrate (SIR = 1.4; 95% CI 1.0-1.8). Similar results were noted when comparisons were carried out between treated and untreated women, and when multivariate models were applied. In the nested case-control study, higher cycle index (OR = 2.2; 95% CI 1.0-4.8) and treatment with clomiphene citrate (OR=2.7; 95% CI 1.3-5.7) were associated with higher risk for breast cancer. CONCLUSION: Infertility and usage of infertility drugs in general are not associated with increased risk for breast cancer. However, for infertile women treated with clomiphene citrate, breast cancer risk is elevated.

Adult↗
PubMed2001

Getting scientists to think about what they are doing.

Research scientists are trained to produce specialised bricks of knowledge, but not to look at the whole building. Increasing public concern about the social role of science is forcing science students to think about what they are actually learning to do. What sort of knowledge will they be producing, and how will it be used? Science education now requires serious consideration of these philosophical and ethical questions. But the many different forms of knowledge produced by modern science cannot be covered by any single philosophical principle. Sociology and cognitive psychology are also needed to understand what the sciences have in common and the significance of what they generate. Again traditional modes of ethical analysis cannot deal adequately with the values, norms and interests activated by present-day technoscience without reference to its sociological, political and economic dimensions. What science education now requires is 'metascience', a discipline that extends beyond conventional philosophy and ethics to include the social and humanistic aspects of the scientific enterprise. For example, students need to learn about the practices, institutions, career choices, and societal responsibilities of research scientists, and to rehearse in advance some of the moral dilemmas that they are likely to meet. They need also to realise that science is changing rapidly, not only in its research techniques and organisational structures but also in its relationships with society at large.

Education↗