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PubMed2000

Why are internal medicine residents at university medical centers not pursuing fellowship training in gastroenterology? A survey analysis.

OBJECTIVE: The decrease in available GI fellowship positions appears to be associated with a disproportionate decrease in the quality of applicants. Thus, the aims of this study were: 1) to determine the current interest in advanced training of nonprimary care internal medicine residents at university medical centers, and 2) to identify the reasons why fellowship-bound residents are not pursuing GI. METHODS: Postage prepaid survey cards were distributed directly to the campus mailboxes of 1862 internal medicine residents at 61 university medical centers at the beginning of their second postgraduate year of training. E-mail questionnaires were then sent to 144 residents planning fellowship training and careers in academia other than in GI/hepatology. RESULTS: A total of 592 residents (32% response) returned completed survey cards. Overall, 392 (66%) indicated that they will pursue fellowship training and approximately 60% wanted to remain in academia. However, <10% indicated an interest in GI/hepatology. E-mail replies were then obtained from 122 residents (87% response) planning academic careers but not in GI. The major reasons for disinterest in GI/hepatology include the perception that jobs are not widely available, that the field is intellectually unchallenging, as well as that is too procedure-oriented. CONCLUSIONS: The majority of residents at university training programs plan advanced training and want to pursue careers in academia, but not in GI/hepatology. Efforts to attract highly qualified residents to GI must emphasize the improved job market, especially as it exists in academia; must advertise research opportunities; and must de-emphasize the procedural nature of this subspecialty.

Academic Medical Centers↗
PubMed2001

Motivations and concerns of patients with access to genetic testing for hereditary pancreatitis.

OBJECTIVES: Direct DNA testing is now available for hereditary pancreatitis (HP). This study aimed to identify the factors that motivated individuals to participate in research and to determine how research participants used their genetic test results. METHODS: A survey was mailed to 247 participants (110 male, 137 female) who were > or =18 yr of age and living in the US. Data analysis was primarily a description of frequency distribution of the responses. RESULTS: Ninety-one of 247 participants (37%) completed the survey. Of the 55 female and 36 male respondents, 60% were 31-55 yr old, and a total of 54% tested positive for HP. The most common reason for participating in research was "to help a relative/family member" (61%), and genetic testing was pursued because of "the disturbance of seeing affected relatives" (48%) and "the desire to help future generations" (33%). Perceived risk of developing HP in the future was the least important motivating factor in seeking genetic testing. Sixty-two percent of respondents had received their genetic test results. All but one chose to share their results with at least one person: most often with family members (96%) and physicians (62%), and least often with insurance companies (4%). The most common influential factor in withholding information was "the fear of insurance discrimination" (23%). CONCLUSIONS: The major motivations to participate in the HP genetic research study were to obtain genetic testing and to help current family members and future generations. The major concern was insurance discrimination. Participants clearly appreciate the availability of genetic testing for HP. These results suggest that a mechanism to disclose results to research participants should be considered, and effective ways to protect at-risk individuals from insurance discrimination must remain a genetics health care priority.

Adult↗
PubMed1998

A prospective, multicenter study of a pneumonia practice guideline.

OBJECTIVE: To study the effect of a length of stay practice guideline on patient outcomes. DESIGN: A prospective, nonrandomized, interventional trial. SETTING: Six geographically distributed hospitals. PATIENTS: Two hundred forty-two consecutively hospitalized "low-risk" patients with pneumonia. MEASUREMENTS AND RESULTS: One hundred fifty-two patients (63%) completed the mailed postdischarge survey and were included in the analysis. Data were prospectively collected for 85 patients from the baseline observation period (B) and 67 patients from the intervention period (I). During the I, case managers provided physicians with patient risk information based on guideline recommendations. There was no significant change in guideline compliance (B vs I: 76.5% vs 83.6%; p=0.32) or length of stay (B vs I: 3.5 days [95% confidence interval, 3.2 to 3.8] vs 3.6 days [95% confidence interval, 3.3 to 4.0]). Also, there were no statistically significant effects of the intervention on patient outcomes, care following hospital discharge, and patient satisfaction scores. CONCLUSION: Patients in this study often had shorter lengths of stay than recommended by the practice guideline. This suggests that the external environment may have had a greater effect on physician behavior and length of stay than the practice guideline itself. Moreover, it demonstrates the importance of continuous assessment of physician practices immediately prior to, during, and after application of the clinical practice guideline.

Activities of Daily Living↗
PubMed1999

Management of indigenous North American deer at the end of the 20th century in relation to large predators and primary production.

Five deer species occupy North America: caribou (3.6 x 10(6) individuals), moose (1.1 x 10(6)), white-tailed deer (28.5 x 10(6)), mule deer (5.0 x 10(6)) and wapiti (1.1 x 10(6)). Caribou characterise the north of the boreal forest and the tundra, whereas moose dominate in coniferous and mixed forests growing further south. White-tailed deer are typical of the deciduous forests of the east while mule deer replace them in the mountainous terrain of the west. Wapiti possess the smallest range, mostly adjacent to the prairies to the west. The two large obligate carnivores preying on deer show a reduced distribution: wolves are almost restricted to Canada, and cougar to the mule deer range. We determined the current status of each species with the help of a questionnaire mailed to all jurisdictions harbouring deer. Most reports of threatened populations concerned caribou whereas many jurisdictions declared overabundance of white-tailed deer and wapiti. Hunting was allowed for all species when they abounded in a jurisdiction. Hunters harvested annually 7.0 x 10(6) deer on the continent, 87% being white-tailed deer. The two species that caused most conflicts with humans had the highest harvest rate: 16-17%. In terms of biomass, white-tailed deer and wapiti yielded the highest harvests, with 55 and 39 kg x km-2 of range, respectively. The average standing biomass of deer in winter ranged between 28 kg x km-2 in Nevada to 901 kg x km-2 in Indiana. The lowest standing biomasses occurred in the boreal forest (predators), in the prairies (agriculture) and in the south-west (aridity), and the highest ones in the south-east, where only white-tailed deer is present. The current abundance of deer in North America parallels, in general, the primary production of the landscape (r2 = 0.38; P < 0.0001), but predators and human activity modify this pattern.

Animals↗
PubMed1986

Psychiatric symptomatology in patients with primary hyperparathyroidism.

A retrospective investigation was made of the occurrence of psychiatric symptoms among 441 patients operated on for primary hyperparathyroidism in Uppsala in 1956-79, and of the relationship between such symptoms and age, sex and degree of hypercalcaemia. A follow-up, using a mailed questionnaire, was carried out 4-27 years postoperatively. Psychiatric symptoms were found in 23% of the patients (102/441). The patients with these symptoms had the same sex distribution and serum calcium levels as the other patients, but were significantly older. Severe symptoms occurred more frequently in older patients. Such symptoms were noted not only in patients with very high serum calcium values but also in association with mild or moderate hypercalcaemia. The most common symptoms were depressive and anxiety states, which occurred in 78 patients. Psychosis with hallucinations and paranoid ideas was found in four patients. Eight patients had an organic brain syndrome and a further 12 patients had minor cerebral impairment. At the follow-up half of the patients reported an improvement after the first postoperative year. Most of them considered that this improvement was sustained at the time of follow-up. This study indicates that psychiatric symptoms are common among patients with hyperparathyroidism and can occur even with moderate hypercalcaemia. Elderly patients seem to be more vulnerable and more often develop severe symptoms such as psychosis or organic brain syndrome.

Age Factors↗
PubMed1999

Development of a questionnaire to investigate patient compliance with antirheumatic drug therapy.

OBJECTIVE: To develop a rheumatology oriented questionnaire that measures compliance to drug regimen and identifies factors that contribute to suboptimal compliance in patients with rheumatoid arthritis (RA), polymyalgia rheumatica (PMR), and gout. METHODS: Thirty-two patients (16 RA, 8 PMR, 8 gout) participated in semistandardized home interviews about their attitude toward their antirheumatic medication, actual drug intake, and reasons for not taking medication. A focus group interview with 7 patients (3 RA, 2 PMR, 2 gout) was held. Following an advertisement in the rheumatology patient organization magazine (>8000 patients) 14 patients (9 RA, 5 PMR) telephoned and explained their reasons for noncompliance. All interviews were recorded on tape, transcribed, and independently reviewed by 2 investigators. Thirty-one statements were selected. After a field test, the phrasing of some items was revised. The questionnaire was then sent by mail to 117 consecutive outpatients (58 RA, 30 PMR, 29 gout). RESULTS: Twelve items were excluded because of low or high corrected item-total correlation or skew distribution of the answers. Internal consistency of the remaining 19 items was intermediate (0.71). Discriminant analyses with an overall patient self-report compliance measure showed a sensitivity of 98%, a specificity of 67%, and a Cohen's kappa of 0.71. Stepwise discriminant analyses revealed that 3 items classified 84% of all cases correctly with a sensitivity of 99%, specificity 80%, and kappa 0.78. CONCLUSION: The 19 item measure was well accepted. It is useful to detect possible barriers for optimal compliance and to predict patient compliance to drug regimen.

Aged↗
PubMed1992

[Cost of a mass screening program for colorectal cancer using the occult blood test].

The Cancer Registry of Burgundy, France, set up a controlled study involving 91,000 people aged 45 to 74 to ascertain the cost-effectiveness of mass screening for colorectal cancer with the Hemoccult test. The aim of this study was to estimate the cost of the first part of the screening campaign, which took place in 1988 and 1989. The overall cost of the campaign was 2,275,589 FF. The cost for the GPs' instruction course was 3.9 percent and the press campaign, 8.4 percent of total costs. The cost related to the distribution or prescription of tests by the GPs was 60.3 percent of the total cost of the campaign. The average cost per test was 39.8 FF when it was distributed by the GPs. The average cost per test was 116.4 FF when bought individually in drugstores or pharmacies. The average cost per test was 70.1 FF when mailing was used. The average cost per test for the analysis was 12.7 FF that is to say 13.7 percent of the total cost. The cost of scientific follow-up and analysis was 13.8 percent. The cost for one person completing the test averaged 92.7 FF. The preliminary results of the cost-effectiveness analysis make it possible to estimate the cost of the mass screening campaign for colorectal cancer. Better cost/effectiveness ratios have already been made according to these results.

Aged↗
PubMed1994

Teaching neurology residents in the outpatient setting.

OBJECTIVE: To determine how residency programs are responding to the shift of neurological practice into the outpatient setting. DESIGN: A nine-item questionnaire was sent to the directors of all US neurology residency programs. Each item had two parts, the first describing the current program, and the second describing an "ideal" program designed to optimize resident education. The same questionnaire was also sent to all house officers and faculty associated with a single residency program to assess variability in perceptions. SETTING: United States neurology residency programs (mail survey). PARTICIPANTS: Directors of neurology residency programs and all house officers and faculty members at a single residency program. RESULTS: Eighty-one (70%) of the 116 questionnaires distributed were returned. There were four areas of general consensus among the program directors: (1) more time should be devoted to outpatient care during residency training; (2) more continuity at the resident level should be provided for patients seen in subspecialty clinics; (3) faculty should provide more supervision of residents when they see follow-up patients; and (4) conferences specifically directed at outpatient management issues should be developed. CONCLUSIONS: Neurology residency directors agree that current approaches to teaching in the outpatient setting fall short of an educationally ideal system. Four areas of perceived deficiency have been identified. Creative solutions will be necessary to correct these perceived deficiencies.

Ambulatory Care↗
PubMed1998

Neuroblastoma screening in the United States: results of the Texas Outreach Program for neuroblastoma screening.

BACKGROUND: Mass screening of infants for neuroblastoma began in Japan after studies suggested that survival rates could be improved by early detection. This study was initiated in 1991 to test the methodology and feasibility of screening for neuroblastoma within the U. S. health care system. METHODS: Infants ages 5-10 months (mean age, 9 months, 25 days) who were born in Texas were screened for neuroblastoma. An enzyme-linked immunoadsorbent assay (ELISA) for homovanillic acid (HVA) and vanillylmandelic acid (VMA) used to quantify the HVA and VMA was performed on urine extracted from specimens dried on filter paper. Infants were recruited to participate in the study by several methods, and the effectiveness of each method was determined by calculating compliance rates. RESULTS: Between February 1991 and June 1994 a total of 14,046 infants were recruited to participate in neuroblastoma screening. Neuroblastoma was detected in 2 children for an incidence rate of 1 in 7023. A total of 291,158 screening kits were distributed to the parents of these infants, resulting in an overall compliance rate of only 4.8%. Compliance rates varied by method of distribution of the test kits: Houston Women, Infants, and Children (WIC) clinic (53%), volunteers (31%), Rio Grande Valley WIC clinics (14.5%), the patient's private physician (9.9%), and by mail (4.7%). CONCLUSIONS: Early detection of neuroblastoma in infants ages 5-10 months was achieved using ELISA. Compliance rates were poor, but clinics with a preventive health focus, such as the WIC clinics, achieved higher compliance rates than did private physicians.

Enzyme-Linked Immunosorbent Assay↗
PubMed1985

Trends in the management of breast cancer.

Responses of general surgeons to a questionnaire on breast cancer were analyzed to determine the current trends in the management of this disease. A 21-item questionnaire was mailed to members of the New Jersey Chapter of the American College of Surgeons in 1982 and the responses, received on noncoded, anonymous answer sheets, were analyzed for frequency distribution. These responses were compared to previously recorded responses to the same questions for 1971 and 1977. Seventy-six percent of the respondents in 1982 performed needle aspirations often or always, compared to 36% in 1971 and 80% in 1977. The use of routine mammography has increased from 16% in 1971 and 20% in 1977 to 38% in 1982. Modified radical mastectomy is now the most common type of procedure employed in the management of stage I breast cancer, with 89% of respondents in favor of this approach compared to 15% in 1971 and 60% in 1977. Fifty-nine percent of the respondents are not opposed to breast reconstruction following mastectomy versus 14% in 1971 and 49% in 1977. For patients with axillary nodes, chemotherapy with multiple agents was recommended by 76% of general surgeons in 1982, compared to 58% in 1977. These results indicate a continuing trend towards increasing use of needle aspiration and routine mammography for diagnosis and for employment of chemotherapy with multiple agents in the adjuvant treatment of patients with positive axillary nodes. Furthermore, modified radical mastectomy is the operation of choice for stage I cancer of the breast for increasing numbers of surgeons.

Breast Neoplasms↗
PubMed1994

Role of radiology in medical education: perspective of nonradiologists.

RATIONALE AND OBJECTIVES: We asked our nonradiologist colleagues to evaluate and comment on the most desirable format for radiology education. METHODS: Questionnaires were distributed to 631 nonradiologist physicians affiliated with the University of Minnesota and representing all medical specialties and academic ranks. Three hundred twenty-seven surveys were returned after one mailing. RESULTS: Residency was retrospectively noted to be indispensable for consolidating knowledge of radiology. The overwhelming majority of clinicians in all specialties believed that formal radiologic instruction should be mandatory for medical students (279 of 322; 87%). Film interpretation was believed to be an indispensable part of a medical student radiology rotation (226 of 321; 70%), but many clinicians indicated a need for additional training. A marked disparity in the perceived level of confidence in interpreting radiologic tests during medical school and residency between those who had and those who had not received formal radiologic instruction during medical school was evident. This difference in perceived level of confidence was present even among the most experienced clinicians. CONCLUSIONS: Collectively, the nonradiologist clinicians emphasized the need for a mandatory and clinically oriented radiology curriculum during medical school.

Attitude of Health Personnel↗
PubMed1998

Management of neonatal candidiasis. Neonatal Candidiasis Study Group.

OBJECTIVE: To identify areas of consensus and controversy in the management of neonatal candidiasis. METHODS: A questionnaire was distributed to US-based members of the Pediatric Infectious Diseases Society and a sampling of US neonatologists. RESULTS: Three hundred eighty evaluable questionnaires were returned (42% of those mailed). Ninety-five percent of respondents have cared for an infant with systemic candidiasis in the past 2 years. Fluconazole and liposomal amphotericin are used to some extent by 90 and 69% of respondents, respectively. A single blood culture positive for Candida led to a recommendation for immediate treatment by 99%; amphotericin B was the preferred therapy for candidemia (88%). More than 80% of respondents would request cerebrospinal fluid, urine and repeat blood cultures and ophthalmologic examination in the evaluation of candidemia. If a cerebrospinal fluid culture is positive, 25% would use amphotericin B alone whereas 62% would add flucytosine. For candiduria Society members chose fluconazole therapy more often than did neonatologists, 23% vs. 3.4% (P<0.001). There was no consensus concerning duration of therapy, use of an amphotericin B test dose or management of a central catheter in place during candidemia. CONCLUSIONS: Systemic candidiasis in neonates is a frequently encountered clinical problem. There is agreement that prompt therapy with amphotericin B is required if a blood culture is positive for Candida and that such infants require additional evaluations. Other antifungals (fluconazole, liposomal amphotericin B) are used to some extent in this population. Many issues in management have no clear consensus and warrant further research.

Amphotericin B↗
PubMed1992

Some tools for the diffusion of biomedical information using research networks.

Research and academic computer networks provide e-mail and other services to all members of participating institutions. Their usage by biomedical researchers and clinicians is still limited because of several reasons, including limited awareness of the available network resources. An increased use of these networks within the biomedical community would allow fast, effective communications and convenient remote access to information sources. As an example and pilot study, we prepared two network tools to make some information services maintained by our institution also accessible through e-mail. Both tools were implemented using PMDF e-mail software on a DEC MicroVAX connected to the Italian academic and research network (GARR), which is linked to the U.S. Internet. A network server takes care of automatic distribution of documents (files) reporting results of an oncology research/education project. An information server provides for semiautomated support of a consulting service on use of drugs. The feasibility of implementing these tools, based on existing software, further illustrates the potential usefulness of research computer networks for the dissemination of biomedical information.

Computer Communication Networks↗
PubMed2003

Can the Internet be used to improve sexual health awareness in web-wise young people?

OBJECTIVES: To assess Internet use amongst young people to determine whether it would be a practical way to provide sex education and information. METHODS: Year 10 students (aged 14-15 years) from North Nottinghamshire schools were asked to participate in focus groups to discuss the Internet. A series of predefined questions were directed to the whole group to generate debate. Areas explored included: Internet access and site; frequency and purpose of Internet use; websites visited; ideas for a genitourinary medicine (GUM) website. Responses were recorded by a hand count or as individual verbal responses. RESULTS: Thirteen focus groups were held involving 287 students of approximately equal sex distribution. All had access to Internet facilities at school and 224 (78.0%) had access elsewhere. Access was at least once a week by 178 (62.0%) mostly for e-mail, games, chatlines and homework. No one accessed for health information. One hundred and seventy-nine (62.4%) participants said they would use a GUM website. A 'question line' where they could e-mail questions to a health care professional was of interest to 202 (70.4%) participants. CONCLUSIONS: The Internet would be a practical and accessible way of delivering sexual health education to young people, particularly if it is incorporated into activities and websites they enjoy.

Adolescent↗
PubMed1997

Studying ulcerative colitis over the World Wide Web.

OBJECTIVES: The Internet may provide a cost-effective means to collect outcomes data needed to improve the quality and efficiency of medical care. We explored the feasibility and methodology of a longitudinal outcomes study of Internet users who have ulcerative colitis (UC). METHODS: We created an open-enrollment electronic survey of Internet users who have UC and recorded the number of respondents, their demographics, and their willingness to participate. RESULTS: In a 2-month period, 582 users browsed the survey, 172 (30%) completed the questionnaire, and 162 (95%) reported willingness to enroll this study. Eighty-three percent were willing to release their medical records to verify their diagnosis. Most (> 70%) had the same E-mail address over 2 yr, suggesting that long-term follow-up could be performed electronically. In comparison with the male predominance of Internet users, respondents had gender distribution similar to that of patients who have UC. In comparison with the general population, respondents have higher education and higher household income. CONCLUSIONS: The Internet community could serve as a resource for general population outcome studies. Selection bias due to limited availability and use of the networked computers may affect results. The Internet community, however, is expanding rapidly, so it should become more representative of the general population.

Adult↗
PubMed1996

Validation study of self-reported measures of fat distribution.

OBJECTIVE: To determine the validity of self-reported body circumferences and indices of body fatness in comparison with the same variables measure by technicians. DESIGN: Cross-sectional survey. SUBJECTS: 66 women aged 40-81 years. MEASUREMENTS: Self-reported weight and height and waist, hip, chest and bust circumferences, by mail questionnaire. The same measurements taken by a trained technician during a clinic visit. Derived variables of body mass index, waist-to-hip ratio, and conicity index, based on both self-reports and technician measurements. RESULTS: Mean differences between technician measurements and self measurements indicated that, on average, women tended to systematically underestimate their body circumferences. Age-adjusted Pearson correlations between technician measurements and self measurements ranged from 0.93 (95% confidence interval: 0.89, 0.96) for hips to 0.99 (95% Cl: 0.98, 0.99) for weight. For derived variables (quotients of measures), the highest agreement (r = 0.98, 95% Cl: 0.97, 0.99) was observed for body mass index (weight in kg/height in m2). The ratio of circumferences of the waist and hips was correlated less strongly (r = 0.76, 95% Cl: 0.63, 0.85). The correlation for conicity index, a measure of fat distribution that is independent of hip measurement variability, was 0.82 (95% Cl: 0.72, 0.88). Overall, accuracy of self measurements did not appear to vary according to age. There was an indication that with increasing values of weight and waist measurements, there was an increasing tendency for women to underestimate the measurement. This was also reflected in the accuracy of the derived variables body mass index and waist-to-hip ratio, but not the conicity index. CONCLUSIONS: These results indicate that self measurements of these anthropometric variables are highly accurate even when used to formulate derived variables, and are therefore appropriate for epidemiologic studies.

Adult↗
PubMedDate not supplied

[From the Mailing List SIN: expected and unexpected professional risks for the nephrologists--reflections from an outbreak of Burkholderia cepacia bacteremia in a hemodialysis unit].

An outbreak of bacteremia in 20 hemodialysed patients who developed central venous catheter (CVC) infection related to Burkholderia cepacia is reported, introducing medical and professional responsibilities in nephrology units. The cepacia was documented in the blood stream, in the CVC biofilm, in the water supply and in the distribution. This and other confounding factors delayed the identification of the contamination source. Finally, it was isolated, clonally identical to that found in the blood stream, from ammonium chloride solution used to disinfect the skin and distributed in a sterile disposable kit. Burkholderia cepacia was clonally different in blood with respect to water. The possible differing responsibilities in the organizational steps of nephrology activity are discussed.

Ammonium Chloride↗
PubMed2006

[Acute effects on the health of children after accidental exposure to epichlorohydrine].

PURPOSE: In September 2002, two freight trains collided at Bad Muender, Germany. The inhabitants were potentially exposed to combustion products and to the human carcinogen epichlorohydrine (ECH). We aimed to describe the geographical distribution of and potential risk factors for acute symptoms among children residing in Bad Muender. METHODS: The parents of a random sample of children were invited to answer a mail-in questionnaire (response rate 63%). The main outcome measures were self-reported acute symptoms potentially associated with combustion products (e. g., irritation of the eyes, nose, or throat) and stress-related unspecific symptoms (e. g., gastrointestinal complaints, sleep problems, headaches). The main location during the first 26 hours after the train accident served as exposure proxy measure. In addition, potential predictors for the symptoms under study were assessed. RESULTS: The prevalence of symptoms associated with combustion products was 5.9%. Unspecific symptoms were reported for 6.3% of the children. Main location and prevalence of symptoms were not significantly associated. Physician-diagnosed asthma and nasal allergies were the main predictors of symptoms. CONCLUSION: The prevalence of acute symptoms was relatively high in a random sample of children living close to the incident. However, associations between exposure to the accident and symptoms could not be established conclusively.

Accidents↗