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Enhancing the effectiveness of tobacco package warning labels: a social psychological perspective.

OBJECTIVE: To outline social psychological principles that could influence the psychosocial and behavioural effects of tobacco warning labels, and to inform the development of more effective tobacco warning labels. DATA SOURCES: PsycInfo and Medline literature searches and expert guided selection of principles and theories in social psychology and of tobacco warning labels, including articles, books, and reports. CONCLUSIONS: Tobacco warning labels represent a potentially effective method of influencing attitudes and behaviours. This review describes social psychological principles that could be used to guide the creation of more effective warning labels. The potential value of incorporating warning labels into a broader public health education campaign is discussed, and directions for future research are suggested.

Consumer Product Safety↗

Note on "Comparison of model selection for regression" by Vladimir Cherkassky and Yunqian Ma.

While Cherkassky and Ma (2003) raise some interesting issues in comparing techniques for model selection, their article appears to be written largely in protest of comparisons made in our book, Elements of Statistical Learning (2001). Cherkassky and Ma feel that we falsely represented the structural risk minimization (SRM) method, which they defend strongly here. In a two-page section of our book (pp. 212-213), we made an honest attempt to compare the SRM method with two related techniques, Aikaike information criterion (AIC) and Bayesian information criterion (BIC). Apparently, we did not apply SRM in the optimal way. We are also accused of using contrived examples, designed to make SRM look bad. Alas, we did introduce some careless errors in our original simulation--errors that were corrected in the second and subsequent printings. Some of these errors were pointed out to us by Cherkassky and Ma (we supplied them with our source code), and as a result we replaced the assessment "SRM performs poorly overall" with a more moderate "the performance of SRM is mixed" (p. 212).

Models, Neurological↗

[Minerals in the nutrition of extremely low birth weight infants].

OBJECTIVE: To review the literature on the role of calcium, phosphorus and trace elements in the nutrition of extremely low birth weight infants, considering their importance for metabolism, bone mineralization and as dietary components. SOURCES OF DATA: MEDLINE, the Cochrane Database of Systematic Reviews and books on nutrition were searched between 1994 and 2004. Original research studies and reviews were selected. SUMMARY OF THE FINDINGS: Extremely preterm infants are frequently growth-restricted at hospital discharge as a consequence of difficulties in the provision of adequate nutrition. The long-term effects of this growth restriction need to be determined. There is a paucity of studies about the role of minerals, especially micronutrients, in the nutrition of extremely preterm infants. The principal focus of this review was on calcium and phosphorus metabolism, bone mineralization and parenteral and enteral supplementation. A critical evaluation of post-discharge nutrition and its influence upon growth and bone mineralization was presented. Selenium and zinc requirements and the role of selenium as an antioxidant with possible effects on free radical diseases of the preterm infant were discussed. CONCLUSIONS: Extremely preterm infants have low mineral reserves and, as a consequence, may have deficiencies in the postnatal period if they do not receive parenteral or enteral supplementation. More studies are needed to elucidate the actual requirements and the appropriate supplementation of micronutrients. There are controversies about the outcome and the influence of post-discharge nutrition on bone disease of prematurity.

Calcification, Physiologic↗

[Well-child care today: an evidence-based view].

OBJECTIVES: Health promotion is one of the chief activities of pediatricians, although still lacking enough scientific bases. This article reviews the scientific support for the main preventive interventions, as well as who should make them, when and how they should be made. SOURCES: Systematic review of recent literature, through the search of Medline and Lilacs databases, using the terms well-child care, health supervision and health promotion (both in English and Portuguese); non-systematic review of reference lists of book chapters; non-systematic Internet search of organizations that make recommendations on health supervision; selection of classic articles within this field. SUMMARY OF THE FINDINGS: Pediatricians must seek integration with other professionals in providing preventive services, as well as in establishing effective partnerships with all community sectors. It is essential to improve communication skills. The ideal number of health supervision visits has never been established; interventions must be individually adapted according to family and community contextual risk factors. There is scientific evidence of the effectiveness of prenatal visits, preventive guidance, metabolic screening, immunization, and vision and hearing screening. Growth monitoring and development screening must be rationalized. The systematic repetition of complete physical examinations and laboratory tests is not warranted. CONCLUSIONS: Pediatricians play a fundamental role in child and adolescent health promotion, but their actions regarding well-child care must no longer be totally empirical. There are innumerous evidence-based resources to guide pediatricians as to the most effective interventions.

Child↗

Interdisciplinary andrology. STDs. AIDS research.

Multidisciplinary andrology deals with clinical application and modern technology for the evaluation and differential diagnosis of male infertility with emphasis on morphological, anatomical, biochemical, immunological, hereditary, and microbiological parameters. Little is known about the effects of diet, disease, stress, environmental, and drugs on male-related unexplained infertility of couples. Regional, national, and international centers of multidisciplinary andrology should provide (1) extensive and unique clinical services; (2) a computerized "patient referral center," (3) self-learning packages (slides/tape programs) for patients; and (4) a computer link to the National Library of Medicine and the Drug Information Center. Specialized laboratories and clinics can be served by expert consultants, visiting professors, bilingual and well-trained clinicians, nurses, laboratory technologists, computer operators, and related allied health personnel. Patient education pamphlets, updated every few years, can be distributed during training workshops when an extensive network of remote teleprinters can be utilized. Qualified client location may install a printer to allow on-site printing of reports in the shortest possible time. Special mailing containers are provided to clients who wish to mail their laboratory specimens. Other clinical services may include the following: 1. Central source of communication and information in andrology; 2. International roster of multidisciplinary andrology centers; 3. Patient referral to centers and consultations for developing countries; 4. Screening of husbands and wives for in vitro fertilization/embryo transfer (IVF/ET); 5. Screening of couples with unexplained infertility for sexually transmitted diseases (STDs) including AIDS; 6. Exchange of research material and methodology; 7. Coordination of multicenter research; 8. Organizing training workshops for clinicians, nurses, and laboratory technicians; 9. Establishing a repository of films, video tapes, slides, catalogs, instrumentation, books, SEM photos, and atlases; 10. Publication and editorial assistance; 11. Consultation for the appropriate selection, purchase, and quality control of instrumentation (all on one computer system); 12. Evaluation of new diagnostic tools for idiopathic infertility and fertility regulation; 13.(ABSTRACT TRUNCATED AT 400 WORDS)

Acquired Immunodeficiency Syndrome↗

Screening for osteoporosis.

PURPOSE: To review evidence that screening for osteoporosis by measuring bone mass in postmenopausal women would reduce fracture incidence. DATA IDENTIFICATION: An English-language literature search using MEDLINE (1966 to 1989), bibliographic reviews of book chapters and review articles, technology assessments of bone mass measurement, and other publications. STUDY SELECTION: We summarize prospective studies of fracture risk prediction done with widely used bone mass measurement techniques, and we document noncontroversial or peripheral points with recent papers and reviews. DATA EXTRACTION: Without osteoporosis screening trials, no quantitative analysis is possible. Instead, we assess the ability of screening tests to measure bone mass and define fracture risk categories, the ability of risk categories to determine treatment, and the ability of treatment to reduce fracture incidence. RESULTS OF DATA SYNTHESIS: Bone mass measurement meets many of the criteria for a screening test, and indirect evidence suggests that a screening program might reduce osteoporosis-related fracture incidence. No trial has shown this directly; however, and questions remain about overall benefits and costs of mass screening. CONCLUSIONS: Although there are clinical indications for bone mass measurement, unselective screening for osteoporosis cannot be recommended until a specific program is formulated and justified.

Absorptiometry, Photon↗

A conversation with John Sulston.

Sir John Sulston was a co-winner of the Nobel Prize for Medicine in 2002. He won the prize for his discoveries concerning "genetic regulation of organ development and programmed cell death," along with his colleagues sydney Brenner and H. Robert Horvitz. Dr. Sulston was founding director of the Sanger Centre, Cambridge, England, which he headed from 1992 to 2000. From 1993 to 2000, he led the British arm of the international team selected to work on the Human Genome Project. He is co-author of the book The Common Thread: A Story of Science, Politics, Ethics, and the Human Genome, published by Joseph Henry Press in 2002.This interview was conducted on December 20, 2002, shortly after Dr. Sulston was awarded his Nobel Prize and was originally broadcast on that date on radio station WPKN-FM in Bridgeport, Connecticut. The interview was conducted by Valerie Richardson, the Managing Editor of The Yale Journal of Biology and Medicine.Dr. Sulston has been an outspoken advocate against letting the data from the Human Genome Project become property of commercial interests that would charge the world's scientific community for its use. Since leaving the Sanger Institute, he has worked with OxFam, the Oxford Campaign for Famine Relief.

Animals↗

[Electronic expert system in medicine. For example ILIAD].

Expert systems are knowledge data bases founded on patient data, literature searches and opinions of experts. With these systems it is for instance possible to test or to take clinical decisions. ILIAD, USA version 4.2, an adaptable software using probabilistic strategies, was investigated. This system is, among other uses, employed for quality assurance and documentation, as a teaching instrument as well as a knowledge base. It comprises the ICD-9 index of diagnoses and a selected and commented up-to-date review of the literature from 'Mosby's Year Book of Medicine'. The features of ILIAD are presented, and the possibilities and limitations of its use as well as that of expert systems in general are discussed.

Diagnosis, Computer-Assisted↗

Counselling for depression in primary care.

BACKGROUND: There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. OBJECTIVES: To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. SEARCH STRATEGY: The search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned. Contact was made with subject experts and CCDAN members. SELECTION CRITERIA: Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. DATA COLLECTION AND ANALYSIS: Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. MAIN RESULTS: Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care. REVIEWER'S CONCLUSIONS: Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.

Controlled Clinical Trials as Topic↗

Pneumococcal conjugate vaccines for preventing vaccine-type invasive pneumococcal disease and pneumonia with consolidation on x-ray in children under two years of age.

BACKGROUND: Pneumonia, most commonly caused by Streptococcus pneumoniae (Pnc), is a major cause of morbidity and mortality among young children especially in developing countries. Recently, the prevalence of antibiotic-resistant Pnc has increased worldwide such that the effectiveness of preventive strategies, like the new pneumococcal conjugate vaccines (PCV) on rates of invasive pneumococcal disease (IPD) and pneumonia, needs to be evaluated. OBJECTIVES: To determine the efficacy of PCV in reducing the incidence of IPD due to vaccine serotypes (VT) and x-ray confirmed pneumonia with consolidation of unspecified etiology in children who received PCV before 12 months of age. SEARCH STRATEGY: We searched the following databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 1 2004), MEDLINE (1990 to March 2004) and EMBASE (1990 to December 2003). Reference list of articles, and books of abstracts of relevant symposia, were hand searched. Researchers in the field were also contacted. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing PCV with placebo, or another vaccine, among children below two years with IPD and clinical/radiographic pneumonia as outcomes. DATA COLLECTION AND ANALYSIS: Two reviewers independently identified eligible studies, assessed trial quality, and extracted data. Differences were resolved by discussion. The inverse variance method was used to pool effect sizes. MAIN RESULTS: We identified four trials assessing the efficacy of PCV in reducing the incidence of IPD, two on x-ray confirmed pneumonia as outcome, and one on clinical pneumonia, with or without x-ray confirmation. Results from pooling HIV-1 negative children from the South African study with the other studies were as follows: the pooled vaccine efficacy (VE) for vaccine-type IPD was 88% (95% confidence interval (CI) 73% to 94%; fixed effect and random effects models), the effect measure was statistically significant (p <0.00001) and there was no heterogeneity (p = 0.77I2 0%); the pooled VE for all-serotype IPD was 66% (95% CI 46% to 79%; fixed effect model), the effect measure was statistically significant (p <0.00001) and there was no statistical heterogeneity (p = 0.09, I2 51%); the pooled VE for x-ray confirmed pneumonia was 22% (95% CI 11% to 31%; both fixed effect and random effects models) and there was no statistical heterogeneity (p = 0.80, I2 0%). Analyses that included all the children in the South African study (HIV-1 negative and HIV-1 positive children) and pooled with data from the other studies gave very similar results. REVIEWERS' CONCLUSIONS: PCV is effective in reducing the incidence of IPD from all serotypes but exerts a greater effect in reducing VT IPD. Although PCV is also effective in reducing the incidence of x-ray confirmed pneumonia, there are still uncertainties about the definition of this outcome. Additional randomised controlled trials are currently in progress.

Humans↗

Society of Gynecologic Investigation: what gets published?

OBJECTIVE: To compare publication rates of the plenary slide presentations (plenary), concurrent slide presentations (concurrent), and poster presentations (poster) at Society for Gynecologic Investigation (SGI) meetings for the interval 1990 to 1999. METHODS: The SGI program and abstract books for years 1990-1999 were examined, with all plenary and twice the number of randomly selected concurrent and poster abstracts identified. For each abstract, PUBMED was used to search for authors and subject topics, if needed. Rates of publication in various journals were compared: group 1: weekly general journals (New England Journal of Medicine [NEJM], Journal of the American Medical Association [JAMA], Nature); group 2: monthly obstetrics/gynecology journals (American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology); and group 3: other journals (Placenta, Journal of Maternal Fetal Medicine, Fertility and Sterility, etc). Factors predicting ultimate publication were assessed by multivariable analysis. RESULTS: Over the 10-year period, 75% of the plenary, 75% of the concurrent, and 66% of the poster abstract presentations were published (P = not significant [NS]), with the majority being published in group 3 journals. Multivariable analysis did not find any factor predictive of publication in plenary, concurrent, or poster groups. Sixty-five percent of all presentations were basic science-related and this did not change over time. CONCLUSIONS: SGI presentations have an overall publication rate of 68%, which is higher than that reported in the literature for other societies (29-45%). Furthermore, the plenary and concurrent publication rates were not different from the poster publication rate. This suggests that all types of presentations are of quality as measured by publication rate. The SGI continues to publish predominantly basic science research, which is one of its missions.

Congresses as Topic↗

Evolution of the management of depression in Spain from the psychiatrist's perspective. A comparative analysis: 1997 vs 1982.

The main problem of depression is not only the high prevalence of the disorder but also its serious consequences on the patient's quality of life and the associated social costs in terms of health care resource utilization and productivity losses. In recent years, there has been a considerable improvement in the knowledge of depression from the pathogenic, clinical and therapeutic perspectives. The present study analyzes whether such advances are reflected in a positive evolution of the treatment of depression in Spain. To this effect we have contrasted the results of two socio-sanitary studies published in this country: the White Book editions of 1982 and 1997 (WB82 and WB97, respectively). From the methodological perspective, the physician selection criteria employed were very uniform (structured questionnaires delivered to 128 (WB82) and 300 (WB97) randomly selected psychiatrists). The origin of patients consulting for specialized care has varied over this 15-year period. In effect, WB82 patients were essentially referred by friends (87.5%) and from the primary care setting (44.5%), whereas in the WB97 study referral from primary care predominated (50.1%), followed by the patient's personal decision (24.8%). In turn, 40.7% and 51.7% of the psychiatrists in WB97 respectively considered the diagnostic and therapeutic means available in primary care to be insufficient. The priorities for improving patient quality of life, as reflected by both editions of the study, were the training of primary care physicians and the adequate provision of means in the mental health care centers. On the other hand, fewer problems for establishing a correct diagnosis were referred in the 1997 edition of the study (28.7%) than in 1982 (48.4%). In this sense, the main problem reported in WB82 was the lack of specialized training, whereas the masking of depression by some other disease process or symptoms was the main problem in WB97 (67.6% vs 21.1% according to WB82). The main symptoms upon which the diagnosis of depression are based do not seem to have evolved much in the past 15 years. The most frequently cited manifestations were a worsening of mood, loss of interest and leisure capacity, sleep alterations and diminished vitality. A comparative analysis of the therapeutic resources used was not possible, for prior to 1982 the only drugs available to physicians were the classical tricyclic agents and some MAO inhibitors; the selective serotonin reuptake inhibitors (SSRIs) - possibly the greatest advance in the treatment of depression in these 15 years - had not yet been introduced. Nevertheless, it should be pointed out that 98% of the psychiatrists consulted in WB97 considered pharmacologic treatment to be the most widely adopted form of management once depression has been diagnosed.

Antidepressive Agents↗

Effects of using recommended coping strategies on drinking outcome following a brief intervention.

AIMS: To explore the unique contribution to outcome drinking of clients' use of six strategies for moderating drinking, after statistically accounting for variance explained by some client and intervention variables. DESIGN: An exploratory hierarchical regression analysis assessed the contributions to variance in drinking outcome of pre-intervention (client characteristics, baseline drinking), assignment (level of assessment, therapist experience) and early follow-up variables. Data came from an experimental trial which evaluated the effect of adding assessment to provision of a self-help book to heavy drinkers. SETTING: Diverse Ontario communities. PARTICIPANTS: Heavy drinkers (99 males, 56 females) were selected from 185 media-recruited applicants who were screened by telephone to exclude cases with severe alcohol-related problems. Their mean (+/- SD) pre-admission weekly quantity of alcohol consumed was 22 +/- 15 drinks. Follow-up rates at 3 and 12 months were 92% and 88%. MEASUREMENTS: Regressed onto weekly quantity at follow-up were: client characteristics, previous measures of weekly quantity, experimental condition and use of the menu of strategies (setting goals for drinking, keeping track of drinking, pacing drinking, planning ahead to avoid heavy drinking, developing free-time activities and coping with problems without drinking). FINDINGS: At 3 months the variables predicting lower weekly quantity were: pre-intervention weekly quantity, developing free-time activities, setting goals for drinking and condition. Lower weekly quantity at 12 months was predicted by lower 3-month and pre-intervention weekly quantity, and regular use of: coping with problems without drinking, setting goals for drinking and keeping track of drinking. CONCLUSIONS: This descriptive study revealed a positive association between level of use of recommended coping strategies at follow-up and drinking outcome. Controlled studies of the effects of strategy use on drinking outcome are therefore warranted.

Adaptation, Psychological↗

Diagnostic and therapeutic use of proton pump inhibitors in non-cardiac chest pain: a metaanalysis.

OBJECTIVES: To assess (i) the efficacy of short-term proton pump inhibitors (PPIs) in non-cardiac chest pain (NCCP) and (ii) the performance of an empirical short-term treatment with PPI (PPI test) to establish a diagnosis of abnormal acid reflux in NCCP. METHODS: Metaanalysis of English language studies identified by searching MEDLINE (1966-May 2004), EMBASE (1980-May 2004), Cochrane Controlled Trials Register, and abstract books from major gastroenterology meetings (1993-2004). For the metaanalysis of PPI efficacy in NCCP, we selected randomized controlled trials (parallel group and crossover designs) comparing PPI therapy with placebo. For the metaanalysis of PPI test performance, we selected uncontrolled studies comparing the test with a standard reference. RESULTS: Eight studies were included in the PPI efficacy analysis. The pooled risk ratio for continued chest pain after PPI therapy was 0.54 (95% CI 0.41-0.71). The overall number needed to treat was 3 (95% CI 2-4). The pooled sensitivity, specificity, and diagnostic odds ratio for the PPI test versus 24-h pH monitoring and endoscopy were 80%, 74%, and 13.83 (95% CI 5.48-34.91), respectively. All studies were small and there was evidence of publication bias or other small study effects. CONCLUSION: PPI therapy reduces symptoms in NCCP and may be useful as a diagnostic test in identifying abnormal esophageal acid reflux.

Anti-Ulcer Agents↗

The business of good doctoring or doctoring as good business: reflections on Freidson's view of the medical game.

This paper reflects on selected aspects of the work of Eliot Freidson and is based mainly on his three latest books--Profession of Medicine, Professional Dominance, and Doctoring Together--in which he draws together his various contributions and elaborates a substantial argument concerning the dominant position of physicians within the institution of medicine in particular and, more generally, their unique position within the broader society. Freidson's work is considered from the perspective of political economy. The paper discusses, on a broad level, some of the assumptions underlying his analysis, the adequacy of his theoretical orientation and level of analysis for understanding the House of Medicine in the United States, and some implications that follow.

Economics, Medical↗

[Effect of dapsone on survival in HIV infected patients: a meta- analysis of finished trials].

BACKGROUND: The aim of the study was to estimate the effect of dapsone on survival in HIVinfected patients. METHOD: The method was a metaanalysis. Data searches used MEDLINE, AIDS TRIALS, and AIDS DRUGS databases from 1983 to January 1996, clinical trials registries of appropriate collaborative research groups, abstract books of International Conferences on AIDS and infectious diseases between 1988 and 1996, references listed within selected articles and active experts in HIV infection. Were considered as eligible: randomized clinical trials, conducted in adults, with one arm evaluating dapsone as prophylactic agent for Pneumocystis Carinii Pneumonia (PCP). Each primary investigator was asked to provide the most recent aggregated study data by completing a standardized questionnaire and to provide files of individual patient data whenever possible. RESULTS: Overall, 17 trials (4343 patients) were eligible for the metaanalysis. The analysis of all available aggregated data included 16 trials (4267 patients) and showed no deleterious effect of dapsone on survival: OR=1.11, 95% Confidence Interval (CI)=0.961.29. There was no evidence of heterogeneity among studies (p=0.50). The analysis of individual data included 10 trials (3115 patients) (OR for aggregated data from those trials=1.10, CI=0. 931.29) and confirmed the absence of deleterious effect of dapsone on survival: stratified Hazard Ratio=1.12, CI=0.991.27 (logrank test: p=0.08). In this subsample, there was evidence of a deleterious effect of dapsone used as secondary prophylaxis. However, this result did not remain when the trial reporting the greatest negative effect of dapsone on survival was omitted. CONCLUSION: Dapsone may be used safely as a primary prophylactic regimen for PCP or toxoplasmosis. However, no definitive recommendation can be made for the use of dapsone as secondary PCP prophylaxis.

AIDS-Related Opportunistic Infections↗

On the logical relationship between natural selection and self-organization.

Most evolutionary biologists cherish Darwin's theory of natural selection (NS) as the process of adaptive evolution more than 140 years after publication of his first book on the subject. However, in the past few decades the study of self-organization (SO) in complex dynamical systems has suggested that adaptation may occur through intrinsic reorganization without NS. In this study, we attempt to describe the logical framework that relates the general process of SO to the specific process of NS. We describe NS as a mechanism that coordinates the coevolution of species in an ecosystem to effectively capture, process and dissipate solar energy into the earth's shadow. Finally, we conclude that NS is an emergent process founded on the same thermodynamic imperatives that are thought to underlie all SO. This perspective suggests that the theory of self-organizing systems offers a broader physical context in which to understand the process of NS, rather than contesting it. It even suggests the possibility that there may be a physical basis for understanding the origin of the process of NS. Rather than being merely a fluke of nature, the origin of NS that may be driven by energy flows across gradients.

Adaptation, Biological↗