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Cohort, gender and practice organization: examining the bounds of collaborative medicine among newly established female and male family physicians in Ontario.

This paper analyzes data from a 1993 survey of 395 newly established female and male family physicians in Ontario, Canada, to examine the relationship between practice organization and gender. Previous research suggests that younger physicians, particularly women, tend to enter group practice. Compared to solo practice, groups may offer more predictable incomes, more manageable workloads, peer collaboration and review, and economies of scale. Further, female physicians in groups may develop distinctive styles of collaborative medicine. The results show that a majority of physicians in our cohort are in private community-based group practice. However, while many groups share premises, staff and expenses, and many have common charts and practice guidelines, only a minority incorporate regular meetings to discuss business or patient care, have shared care of hospitalized patients, or audits of physicians' practices. Few gender differences are observed in private group practice: although women physicians attract larger proportions of female patients than do their male colleagues, women and men organize their groups in similar ways and have similarity strong patient-centered attitudes.

Attitude of Health Personnel↗

Predicting the adoption of electronic health records by physicians: when will health care be paperless?

OBJECTIVES: The purpose of this study was threefold. First, we gathered and synthesized the historic literature regarding electronic health record (EHR) adoption rates among physicians in small practices (ten or fewer members). Next, we constructed models to project estimated future EHR adoption trends and timelines. We then determined the likelihood of achieving universal EHR adoption in the near future and articulate how barriers can be overcome in the small and solo practice medical environment. DESIGN: This study used EHR adoption data from six previous surveys of small practices to estimate historic market penetration rates. Applying technology diffusion theory, three future adoption scenarios, optimistic, best estimate, and conservative, are empirically derived. MEASUREMENT: EHR adoption parameters, external and internal coefficients of influence, are estimated using Bass diffusion models. RESULTS: All three EHR scenarios display the characteristic diffusion S curve that is indicative that the technology is likely to achieve significant market penetration, given enough time. Under current conditions, EHR adoption will reach its maximum market share in 2024 in the small practice setting. CONCLUSION: The promise of improved care quality and cost control has prompted a call for universal EHR adoption by 2014. The EHR products now available are unlikely to achieve full diffusion in a critical market segment within the time frame being targeted by policy makers.

Attitude of Health Personnel↗

Role of computed tomography in the management of vasospasm after subarachnoid hemorrhage.

The role of computed tomography (CT) in the management of vasospasm from subarachnoid hemorrhage was evaluated in 242 consecutive cases with CT performed within 7 days after hemorrhage. Only 20% of these cases did not show a detectable subarachnoid hemorrhage on CT. Subsequent angiograms showed vessel narrowing in 56% of the cases; associated clinical deterioration was noted in 34% of the cases. On later CT, clear ischemic areas were detected in 20% of the cases. A strict correlation between the amount of cisternal blood and the subsequent development of vasospasm was observed: although absent or thin cisternal depositions were rarely associated with vasospasm, consistent or thick depositions were frequently linked to vasospasm (72% of the cases) and to ischemic disturbances (51% of the cases), as well as to clear ischemic areas on later CT (30% of the cases). Regarding the morphology of the cisternal blood collection, the risk of developing vasospasm was at its lowest (42%) for depositions only in the frontal interhemispheric fissure and was at its highest (79%) for depositions in multiple cisterns. The site of cisternal deposition corresponded closely to the area of ischemia on later CT. The persistence of subarachnoid blood more than 72 hours after hemorrhage probably increases the risk of vasospasm, although our data are not conclusive. The definition of a CT scan "at risk" for vasospasm--based on the previous findings--gives practical advantages: proper selection of patients in regard to timing of operation, closer observation and the possibility of prophylactic treatment in patients "at risk," and more adequate evaluation of different therapeutic modalities for vasospasm. With regard to the last point, the incidence of vasospasm was not statistically different between two groups of patients uniformly "at risk": the first group submitted to early operation and the second awaiting operation.

Adolescent↗

Effect of 4- and 8-wk intensive Tai Chi Training on balance control in the elderly.

PURPOSE: The objective of this study was to examine whether 4 and/or 8 wk of intensive Tai Chi practice could improve balance control in the healthy elderly subjects. METHODS: Forty-nine community-dwelling elderly subjects (aged 69.1 +/- SD 5.8 yr) voluntarily participated in an intervention program of either supervised Tai Chi or general education for 1.5 h, 6x wk for 8 wk. Two balance tests were administered using computerized dynamic posturography before, at 4 and 8 wk during training, and at 4 wk after training ended: 1) the sensory organization test measured subjects' abilities to use somatosensory, visual, and vestibular information to control their body sway during stance under six sensory conditions; and 2) the limits of stability test measured subjects' abilities to voluntarily weight shift to eight spatial positions within their base of support. These outcome measures were compared between the two intervention groups, and with those of experienced Tai Chi practitioners having means of 7.2 and 10.1 yr of practice from two previous studies. RESULTS: Statistical analysis demonstrated that, after 4 and 8 wk of intensive Tai Chi training, the elderly subjects achieved significantly better 1) vestibular ratio in the sensory organization test (P = 0.006) and 2) directional control of their leaning trajectory in the limits of stability test (P = 0.018), when compared with those of the control group. These improvements were maintained even at follow-up 4 wk afterward. Furthermore, the improved balance performance from week 4 on was comparable to that of experienced Tai Chi practitioners. CONCLUSIONS: The above findings indicated that even 4 wk of intensive Tai Chi training are sufficient to improve balance control in the elderly subjects.

Accidental Falls↗

Twinning and birth weight in the Israeli Jewish versus Muslim maternities.

Ethnicity differences account for genetic, environmental, lifestyle, and reproductive variables, influencing the rate of twinning (Nylander, 1981). Frequently, ethnic differences correlate with variable perinatal care leading to differences in outcome. Free access to antenatal care, and to facilities for delivery and neonatal care is available for the entire population in Israel, and therefore differences attributed to levels of medical care are practically negligible. We previously evaluated the overall relationship between ethnicity and outcome in a population-based cohort of mothers of twins (Goldman et al., 2001). However, the overall comparison may have masked some differences that could be present. The purpose of this study was to evaluate whether ethnicity is associated with differences in perinatal outcome in randomly selected, matched-controlled Israeli Jewish and Muslim mothers of twins.

Arabs↗

Cost methodology of COMBINE.

OBJECTIVE: This article describes the methodology used in estimating the mean cost per patient of the interventions delivered in COMBINE, a randomized controlled trial (RCT) comparing pharmacotherapies and behavioral interventions for outpatient treatment of alcohol dependence. METHOD: Our methodology identifies a broad list of nonresearch activities necessary to implement the COMBINE interventions in standard clinical practice. For each activity, we include the time costs of clinical assessments and interventions by staff, the cost of space, laboratory charges and the cost of medical supplies. We also estimate the patients' time used for each of these activities. RESULTS: We present the estimated cost per activity for 15 intake assessments plus the Medical Management (MM) and Combined Behavioral Intervention (CBI) sessions for 9 of the 11 COMBINE sites. Labor costs represent the bulk of the total cost for all activities. The Form 90 AIR/ED is the most expensive intake activity both in terms of labor and space costs. The CBI session is more expensive than the MM session. CONCLUSIONS: Our methodology estimates the cost to treatment providers and to patients of implementing the COMBINE intervention in standard practice. Compared with previous methods, the prospective design of our methodology allows for higher quality data, and the detailed activity costing helps identify key cost drivers. Future analyses will present actual COMBINE intervention cost estimates based on trial data. Although this cost study is specific to the COMBINE interventions, the concepts, instruments and methods used here can be applied to any RCT.

Alcoholism↗

[Frequency and determinants of breastfeeding in the State of São Paulo, Brazil].

OBJECTIVE: To meet the information need of Brazilian municipalities concerning breastfeeding practices as part of health care planning, a study was carried out to describe breastfeeding and to identify weaning-related factors. METHODS: Of all municipalities in the State of São Paulo, Brazil, openly called to participate in the study, 84 joined in. Personnel underwent training to collect data during the national mass immunization day in 1998. A sample strategy, proportional to the infant population, was developed for each participant. Standardized questionnaires were applied to assess infant feeding practices in the previous 24 hours. Descriptive statistic analysis on breastfeeding prevalence and logistic regression analysis of risk factors for discontinuing exclusive breastfeeding of infants aged less than 4 months and weaning of infants aged less than a year were performed. RESULTS: Exclusive breastfeeding rates in the first four months of life were under 30%. The risk factors were: lower maternal education status; lack of access to the so-called "Baby Friendly Hospital Initiative"; primiparity; and early age pregnancy. Around 50% of children under a year old were breastfed. CONCLUSIONS: Lacks of access to the "Baby Friendly Hospital Initiative", primiparity, and mother's unemployment or engagement in an informal occupation activity were risk factors for weaning. Local breastfeeding rates are extremely variable in the State of São Paulo, reinforcing the importance of local, swift, and easily feasible health care actions.

Brazil↗

[Factors interfering in the experience of women in childbirth process and in childbirth].

Childbirth is a relevant happening in a woman's life, as it is a unique moment for the mother-child binomial. This study aimed at understanding the factors that interfere in the experience lived by childbearing women. Seven women who gave birth through normal childbirth in a public maternity in Fortaleza-Ceará participated in the study. Data were collected from June to August, 2003. Ethnonursing was the method used for data collection and analysis. The findings were reflected in the framework of Leininger's Diversity and Universality of Cultural Care Theory, which were organized in three categories: Fear; Influence of the beliefs and religiosity; previous pregnancy. The practice of cultural care to women showed the importance of communication and consideration of women's beliefs and values at the moment of the childbirth process and delivery.

Adult↗

Performance of a commercial immunoassay for detection and differentiation of periodontal marker bacteria: analysis of immunochemical performance with clinical samples.

BACKGROUND: We employed a commercial immunoassay for simultaneous detection and differentiation of marker bacteria Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis, and Prevotella intermedia and reassessed the immunochemical performance of the assay. METHODS: We compared the analytical performance of the immunoassay in our study of clinical samples from 249 periodontal patients in 2 private periodontal practices with the previously reported analytical performance of the same immunoassay. We also compared immunoassay measurements of the marker bacteria in clinical samples with values obtained in other studies by direct culture of the same organisms. RESULTS: The assay produced 3 times more high-end readings than reported previously. We also reassessed and revised previously published calibration curves for the immunoassay. The immunoassay provided measurements of the marker bacteria in clinical samples from our patients that were comparable to and consistent with measurements of the same bacteria by direct culture in other studies. CONCLUSIONS: We ascribe the increased sensitivity of the immunoassay in our study to: 1) a more standardized and vigorous sample dispersion that improves release of particulate and soluble antigens from dental plaque biofilm, and 2) better visualization of the reaction product of the enzyme-linked immunoassay. High-technology assays, such as diagnostic immunoassays, have a significant potential for future development in dental diagnosis, because they simplify detection and measurement of biologically important markers such as specific bacteria in clinical samples. Commercial assays also have an important potential for standardization of clinical measurements of biological markers.

Aggregatibacter actinomycetemcomitans↗

AIDS and sexual behavior reported by gay men in San Francisco.

In November 1983, we surveyed 655 gay men in San Francisco regarding their sexual practices during the previous month and the same month one year ago. The sample was selected to include men in situations that would lead to high risk of sexual activities related to AIDS (acquired immune deficiency syndrome) transmission (i.e., men frequenting bathhouses and gay bars) as well as men in low-risk situations (those going to neither place and men in primary relationships). The Bath group showed little change in frequency of bathhouse use and in number of sexual partners from that location. The other groups showed substantial reductions in frequency of sexual contacts from bars, baths, T-rooms, or parks. Men in monogamous relationships showed little change in sexual behavior within their relationship. Men in non-monogamous relationships and men not in relationships reported substantial reductions in high-risk sexual activity, but not a corresponding increase in low-risk sexual behavior. Knowledge of health guidelines was quite high, but this knowledge had no relation to sexual behavior. Using sex to release tension, use of sex to express gay identity, and knowledge of persons with AIDS in the advanced stages of disease were related to frequency and type of sexual behavior.

Acquired Immunodeficiency Syndrome↗

The prevalence of high-risk sexual behavior in male intravenous drug users with steady female partners.

A sample of 149 (70 White, 79 Black) male intravenous drug users with steady female sexual partners was interviewed in 1987, in treatment and street settings, about sexual practices during the previous five years. Eighty-three percent had multiple partners, 15 percent reported male sexual contact, 38 percent reported heterosexual anal intercourse, and 73 percent never used condoms. Thirty-seven White and 30 Black subjects reported bisexuality or heterosexual and intercourse or both.

Acquired Immunodeficiency Syndrome↗

Therapeutic potential of inhibiting Bruton's tyrosine kinase, (BTK).

BTK (Bruton's tyrosine kinase) is a member of the TEC family of tyrosine kinases that plays a central but diverse modulatory role in various cellular processes. The unique role of BTK in a multitude of signaling pathways, its function as a dual regulator of apoptosis and its involvement in a number of developmental processes makes BTK a desirable target for potential anti-cancer, anti-inflammatory and anti-viral agents as well as other treatments. The biochemistry and signaling networks of BTK were well described in numerous detailed reviews written by members of our team and others before us. Therefore in this particular review we are going to concentrate on the possible practical application of previously obtained knowledge to specific diseases and disorders.

Agammaglobulinaemia Tyrosine Kinase↗

"Should I have an affair?" A case study.

Forced to face the possibility of dying of cancer soon, a patient may question previous values and practices. A medical practitioner can learn a lot from such patients about fear, guilt, depression, and hope.

Adult↗

Predicting the yield and composition of mature cow carcasses.

Cow carcasses (n = 60) were selected based on conformation and external fat to develop more current and useful prediction equations for estimating yield and composition. Adjusted preliminary yield grade was highly correlated to percentage of the carcass as fat (.91), percentage fat in the total lean (.89), and percentage fat in the lean trimmings (.88) of carcasses from non-grain-fed mature cows. Equations for predicting percentage of the carcass as chemical fat had higher -R2 values than equations predicting other compositional end points. The "best" regression equation for predicting total yield (i.e., whole muscle cuts plus lean trimmings adjusted to 10% chemical fat) included hot carcass weight (HCWT), adjusted preliminary yield grade (APYG), longissimus area (LMA), and marbling (MARB), with R2 = .75 and residual standard deviation (RSD) = 2.47. A similar equation predicting total yield from unribbed carcass data included HCWT, APYG, and conformation (CONF) with R2 = .69 and RSD = 3.11. These two equations were applied to a test group of cow carcasses (n = 20), and the average difference between the actual and predicted total yield values from ribbed data and unribbed data was .45 and .83% of HCWT; simple correlations between the actual and predicted values were .74 and .69, respectively. These equations contain relatively simple independent variables to identify and more nearly represent current industry processing practices than equations previously available.

Aging↗

Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data.

OBJECTIVE: To describe the workload profile in a network of Australian skin cancer clinics. DESIGN AND SETTING: Analysis of billing data for the first 6 months of 2005 in a primary-care skin cancer clinic network, consisting of seven clinics and staffed by 20 doctors, located in the Northern Territory, Queensland and New South Wales. MAIN OUTCOME MEASURES: Consultation to biopsy ratio (CBR); biopsy to treatment ratio (BTR); number of benign naevi excised per melanoma (number needed to treat [NNT]). RESULTS: Of 69 780 billed activities, 34 622 (49.6%) were consultations, 19 358 (27.7%) biopsies, 8055 (11.5%) surgical excisions, 2804 (4.0%) additional surgical repairs, 1613 (2.3%) non-surgical treatments of cancers and 3328 (4.8%) treatments of premalignant or non-malignant lesions. A total of 6438 cancers were treated (116 melanomas by excision, 4709 non-melanoma skin cancers [NMSCs] by excision, and 1613 NMSCs non-surgically); 5251 (65.2%) surgical wounds were repaired by direct suture, 2651 (32.9%) by a flap (of which 44.8% were simple flaps), 42 (0.5%) by wedge excision and 111 (1.4%) by grafts. The CBR was 1.79, the BTR was 3.1 and the NNT was 28.6. CONCLUSIONS: In this network of Australian skin cancer clinics, one in three biopsies identified a skin cancer (BTR, 3.1), and about 29 benign lesions were excised per melanoma (NNT, 28.6). The estimated NNT was similar to that reported previously in general practice. More data are needed on health outcomes, including effectiveness of treatment and surgical repair.

Australia↗

Non-uniformity of blood ethanol elimination: its exaggeration after chronic consumption.

In baboons blood ethanol disappearance was 11.6% faster at high ethanol (HE) concentrations (45-20 mM) than at low ethanol concentrations (LE) (15-5 mM). The feeding of alcohol in a liquid diet for three months or up to five years augmented the difference between HE and LE to 14 and 28.6% respectively. These results were confirmed in a preliminary experiment with a human volunteer given ethanol for four weeks under metabolic ward conditions. The findings are in favour of the existence and induction of a non-ADH high Km pathway for ethanol oxidation. The common medicolegal practice of calculation previous blood-ethanol levels by linear extrapolation should be re-considered.

Alcohol Oxidoreductases↗

[Influence of scalp shaving on prevention of postoperative intracranial infection].

Shaving of the whole scalp is ordinarily performed prior to neurosurgical operation. Although it is performed in order to prevent postoperative intracranial infection, there has been no apparent basis for this practice published in previous reports. We examined whether shaving the whole scalp reduced the rate of postoperative infection or not. We divided 274 cases, who received their first intracranial operation in the last 2 years, into two groups; a whole shaving group and a partial shaving group. We compared the rate of postoperative intracranial infection between the two groups according to age, diagnosis, operation, operation time and placement of drainage. Overall, 12 cases out of 274 (4.38%) had postoperative intracranial infection. The long operation time and the long term placement of drainage mechanism increased the postoperative intracranial infection rate. There was no postoperative intracranial infection in 74 patients who received burr-hole/twist-drill operation. As for craniotomy/craniectomy operations, 7 cases out of 83 (8.4%) in the partial scalp-shaving group whole scalp shaving group and 5 cases out of 117 (4.2%) had postoperative intracranial infections. Thus, there was no significant difference in the rate of postoperative intracranial infection between the two groups, if anything, the whole scalp shaving group tended to show a higher rate. According to these results, partial scalp shaving did not increase the rate of postoperative intracranial infection. Considering that patients who have lost their hair find it embarrassing to return to society, it is well to know that the whole scalp shaving is not absolutely necessary for all first craniotomy.

Craniotomy↗

Adverse effects of paclitaxel in patients with alcohol abuse histories.

Paclitaxel is a taxane antineoplastic agent formulated in polyoxyethylated castor oil (Cremophor El) and dehydrated alcohol. This case report describes the development of central nervous system toxicity and threatened sobriety related to the alcohol content in a paclitaxel infusion. Nurses need to be aware of the alcohol contained in paclitaxel and other drugs used in oncology practice and document previous and current alcohol use prior to beginning therapy. Alternative chemotherapy regimens may need to be offered to patients with alcohol abuse histories.

Alcoholism↗