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The authors reflect on the conflict of interest in medical publishing. They emphasize that conflict of interest reaches a level of concern when an observer might wonder if the individual's behavior or judgment was motivated by his or her competing interests. They further stresses that conflict of interest can undermine the credibility of research results and damage public trust in medical journals.

Reviews the most frequently used maintenance strategies for power systems. Maintenance policies in electric utilities; Mathematical models linking reliability and maintenance.

Objective: To measure the effect on patient satisfaction of medical student participation in care and the presence of medical student teaching.Design: Prospective cohort study.Setting: Eight outpatient internal medicine departments of a university-affiliated HMO in Massachusetts.Patients: Two hundred seven patients seen on teaching days (81 patients who saw a medical student-preceptor dyad and 126 patients who saw the preceptor alone), and 360 patients who saw the preceptor on nonteaching days. Five hundred (88%) of 567 eligible patients responded.Measurements and Main Results: Thirteen closed-response items on a written questionnaire, measuring satisfaction with specific dimensions of care and with care as a whole. Visit satisfaction was similar among patients on teaching and nonteaching days. Ninety-one percent of patients seeing a medical student, 93% of patients seeing the preceptor alone on teaching days, and 93% of patients on nonteaching days were satisfied or very satisfied with their visit; less than 2% of patients in each group were dissatisfied with their visit. Satisfaction on all measured dimensions of care was similar for patients seeing a medical student, patients seeing the preceptor alone on teaching days, and patients seeing the preceptor on nonteaching days.Conclusions: Medical student participation and the presence of medical student teaching had little effect on patient satisfaction. Concerns about patient satisfaction should not prevent managed care organizations from participating in primary care education. [ABSTRACT FROM AUTHOR]

Clinicians can now base clinical decisions on the results of rigorous studies of the performance of diagnostic tests. In selecting the tests, clinicians should take into account their sensitivity (the proportion of patients with the disease who have a positive test result) and specificity (the proportion of patients without disease who have a negative test results). Sensitivity and specificity are affected by the "spectrum" of patients studied i.e. the severity of disease in those with disease and the clinical characteristics of those without disease. Test results are interpreted by predictive values--the proportion of patients with a positive (negative) test result who have (do not have) the disease. Predictive values depend on both test sensitivity and specificity and disease prevalence. The information content of a test is further increased by taking into account where the cut-off point between normal and abnormal is placed, the degree of abnormality of the result, and the results of the preceding tests (done either in parallel or in series). Describing test performance in terms of likelihood ratios facilitates this process. Readers should be able to critique published studies of diagnostic tests which are still far from perfect. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effects of peer review and editing on manuscript quality.Setting: Editorial offices of Annals of Internal Medicine.Design: Masked before-after study. MANUSCRIPTS: 111 consecutive original research manuscripts accepted for publication at Annals between March 1992 and March 1993.Measurements: We used a manuscript quality assessment tool of 34 items to evaluate the quality of the research report, not the quality of the research itself. Each item was scored on a 1 to 5 scale. Forty-four expert assessors unaware of the design or aims of the study evaluated the manuscripts, with different persons evaluating the two versions of each manuscript (before and after the editorial process).Results: 33 of the 34 items changed in the direction of improvement, with the largest improvements seen in the discussion of study limitations, generalizations, use of confidence intervals, and the tone of conclusions. Overall, the percentage of items scored three or more increased by an absolute 7.3% (95% CI, 3.3% to 11.3%) from a baseline of 75%. The average item score improved by 0.23 points (CI, 0.07 to 0.39) from a baseline mean of 3.5. Manuscripts rated in the bottom 50% showed two- to threefold larger improvements than those in the top 50%, after correction for regression to the mean.Conclusions: Peer review and editing improve the quality of medical research reporting, particularly in those areas that readers rely on most heavily to decide on the importance and generalizability of the findings. [ABSTRACT FROM AUTHOR]

There is increasing recognition that the concepts traditionally taught by epidemiologists are essential for all medical graduates, most of whom will be clinicians, and not just for the minority who will specialize in population-based disciplines. This paper presents the recommendations of a Canadian conference which considered objectives for teaching epidemiology to medical undergraduates. These objectives are presented as the attitudes, knowledge and skills medical students should acquire. Recommendations concentrate on what should be learnt, rather than whet should be taught, or who should teach it. It was the consensus that epidemiologists are responsible for assuring that basic epidemlological attitudes, knowledge and skills be acquired, though the subjects need not be taught exclusively by epidemiologists themselves. [ABSTRACT FROM PUBLISHER]

Cervical cancer is an important cause of cancer mortality in black women. Pap tests may prevent such deaths, but poor, rural black women are relatively less likely than others to be screened. In order to understand why that is so, the authors surveyed 149 women in three rural North Carolina counties. Thirty-three percent of the women interviewed had not had a Pap test in the preceding three years. Variables independently associated with not having a recent Pap test included: having no identifiable source of medical care; having more than one source of gynecologic care; having an internist provide gynecologic care; and perceiving psychological barriers to Pap tests and pelvic examinations. Income, educational level, and health insurance status were not associated with having a recent Pap test. Although access to care remains a problem for some, better use should be made of the medical care encounters available. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy of glucose tolerance factor (GTF)-chromium for increasing serum levels of high-density lipoprotein (HDL) cholesterol in patients taking beta-blockers.Design: Randomized, double-blind, placebo-controlled trial.Setting: Mixed primary and referral-based outpatient clinic at a university-affiliated VA Medical Center.Patients: Referred sample of 72 men receiving beta-blockers, mainly for hypertension. Sixty-three patients (88%) completed the study.Interventions: Current medications, including beta-blockers, were continued. During the 8-week treatment phase, patients in the chromium group received a total daily dose of 600 micrograms of biologically active chromium divided into three equal doses; control patients received a placebo of identical appearance and taste.Measurements: Serum levels of total cholesterol and HDL cholesterol were measured.Main Results: Mean baseline levels of HDL and total cholesterol (+/- SD) were 0.93 +/- 0.28 mmol/L and 6.0 +/- 1.0 mmol/L (36 +/- 11.1 mg/dL and 232 +/- 38.5 mg/dL), respectively. The difference between groups in adjusted mean change in HDL cholesterol levels, accounting for baseline HDL cholesterol levels, age, weight change, and baseline total cholesterol levels, was 0.15 mmol/L (5.8 mg/dL) (P = 0.01) with a 95% Cl showing that the treatment effect was greater than +0.04 mmol/L (+1.4 mg/dL). Mean total cholesterol, triglycerides and body weight did not change significantly during treatment for either group. Compliance as measured by pill count was 85%, and few side effects were reported. Two months after the end of treatment, the between-group difference in adjusted mean change from baseline to end of post-treatment follow-up was -0.003 mmol/L (-0.1 mg/dL).Conclusion: Two months of chromium supplementation resulted in a clinically useful increase in HDL cholesterol levels in men taking beta-blockers. [ABSTRACT FROM AUTHOR]

Objective: To determine the characteristics of good peer reviewers.Design: Cross-sectional analysis of data gathered during a randomized controlled trial.Setting: The Journal of General Internal Medicine.Participants: 226 reviewers of 131 consecutively submitted manuscripts of original research. 201 (91%) completed the review and submitted a curriculum vitae.Measurements and Main Results: The quality of each review was judged on a scale from 1 to 5 by an editor who was blinded to the identity of the reviewer. Reviewer characteristics were taken from the curricula vitae. 86 of the 201 reviewers (43%) produced good reviews (a grade of 4 or 5). Using logistic regression, the authors found that when a reviewer was less than 40 years old, from a top academic institution, well known to the editor choosing the reviewer, and blinded to the identity of the manuscript's authors, the probability that he or she would produce a good review was 87%, whereas a reviewer without any of these characteristics had a 7% probability of producing a good review. Other characteristics that were significant only on bivariate analysis included previous clinical research training, additional postgraduate degrees, and more time spent on the review. There was a negative but statistically nonsignificant association between academic rank and review quality: 37% of full professors, 39% of associate professors, and 51% of assistant professors or fellows produced good reviews (p = 0.11).Conclusions: Good peer reviewers for this journal tended to be young, from strong academic institutions, well known to the editors, and blinded to the identity of the manuscript's authors. [ABSTRACT FROM AUTHOR]