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Despite recent tobacco control efforts, adolescent vaping remains an epidemic in the United States. The purpose of our study was to understand high school student vaping behaviors using the perceptions of Massachusetts school personnel during the critical window from when the Massachusetts statewide flavor ban legislation was passed in November 2019 through the first year of the COVID-19 pandemic.High school personnel throughout Massachusetts were invited to complete a cross-sectional survey. Analysis of survey responses was conducted in R.A total of 162 respondents completed the survey representing 137 schools that draw enrollments from 216 (61%) of the 352 cities and towns in Massachusetts. The most popular products that respondents believed their students were using were JUULs (95.7%), other e-cigarettes (85.3%), and disposable vapes (79.6%). Following the flavor ban, the majority (90.7%) did not report an increase in combusted tobacco product use. All participants (100%) reported wanting more access to prevention and treatment resources.Our findings suggest that a comprehensive flavor ban may be an effective tobacco control policy that does not appear to promote student switching from vaping products to combusted tobacco products. These data also indicate that schools report needing additional resources to address the vaping epidemic.

Methods for classification of two-dimensional (2-DE) electrophoresis gels based on multivariate data analysis are demonstrated. Two-dimensional gels of ten wheat varieties are analyzed and it is demonstrated how to classify the wheat varieties in two qualities and a method for initial screening of gels is presented. First, an approach is demonstrated in which no prior knowledge of the separated proteins is used. Alignment of the gels followed by a simple transformation of data makes it possible to analyze the gels in an automated explorative manner by principal component analysis, to determine if the gels should be further analyzed. A more detailed approach is done by analyzing spot volume lists by principal components analysis and partial least square regression. The use of spot volume data offers a mean to investigate the spot pattern and link the classified protein patterns to distinct spots on the gels for further investigation. The explorative approach in analysis of 2-D gels makes it possible, in a fast and convenient way, to screen many gels in order to determine the protein patterns that form clusters and could be selected for further examination.

Multivariate analysis has been applied as support to proteome analysis in order to implement an easier and faster way of data handling based on separation by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The characterisation phase in proteome analysis by means of simple visual inspection is a demanding process and also insecure because subjectivity is the controlling element. Multivariate analysis offers, to a considerable extent, objectivity and must therefore be regarded as a neutral way to evaluate results obtained by proteome analysis. Proteome analysis of storage proteins from the wheat gluten complex based on two-dimensional electrophoresis and analysis of the N-terminal sequence has revealed a protein homologous to gamma-gliadins, tentatively associated with quality and within the molecular weight range 27-35 kDa. Further examinations of gliadin data based on mass spectrometry revealed that quality among wheat varieties could be determined by means of principal component analysis. Further examinations by interval partial least squares made it possible to encircle an overall optimal molecular weight interval from 31.5 to 33.7 kDa. The use of multivariate analysis on data from mass spectrometry has thus shown to be a promising technique to minimize the number of two-dimensional gels within the field of proteome analysis.

The majority of tobacco use emerges in individuals before they reach 21 years of age, and many adult distributors of tobacco to youths are young adults aged between 18 and 20 years. Raising the tobacco sales minimum age to 21 years across the United States would decrease tobacco retailer and industry sales by approximately 2% but could contribute to a substantial reduction in the prevalence of youths’ tobacco use and dependency by limiting access.

Starting in May 2014, it will be illegal in New York City to sell tobacco products and e-cigarettes to persons younger than 21 years of age. Further dissemination of “Tobacco 21” laws represents a critical opportunity for public health law to reduce a major health risk.

Objectives The vast majority of tobacco users began before the age of 21. Raising the tobacco sales age to 21 has the potential to reduce tobacco use initiation and progression to regular smoking. Our objective was to assess the level of public support nationally for ‘Tobacco 21’ initiatives in the USA. Methods The Social Climate Survey of Tobacco Control, a cross-sectional dual-frame survey representing national probability samples of adults was administered in 2013. Respondents were asked to state their agreement level with, ‘The age to buy tobacco should be raised to 21.’ Results Of 3245 respondents, 70.5% support raising the age to buy tobacco to 21. The majority of adults in every demographic and smoking status category supported raising the tobacco sales age to 21. In multivariable analyses, support was highest among never smokers, females, African-Americans and older adults. Conclusions This national study demonstrates broad public support for raising the sales age of tobacco to 21 and will help facilitate wide dissemination of initiatives to increase the legal purchase age at national, state and local levels. Increasing public awareness about the susceptibility and rapid addiction of youth to nicotine may further increase public support for raising the tobacco sale age to 21.

Why do we know so much about physician impairment and so little about positive physician functioning? Studies exploring physician functioning in the medical literature have focused on negative behavioral indices such as divorce, suicide, mental and physical illness, marital dysfunction, drug and alcohol use, and burnout.1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16 This tendency to pathologize seems to also pervade the general psychological literature.17 The presumption in the literature seems to be that the absence of impairment is an indication of health. Indeed, in a study by St Claire and colleagues, physicians defined health simply as the absence of disease.18 This stands in stark contrast to patients, who define health much more broadly, using terms such as “being able,” “taking action,” and “physical well-being.” There is little information that delineates the specific physician practices that promote successful life adjustment. Several authors draw on personal experience or provide anecdotes of their professional work to suggest ways to prevent burnout, overcome compassion fatigue, renew the joy in practice, and create life balance.19,20,21,22 Their ideas appear to be valid, but they are generally not grounded in any specific research. Yet, many practicing physicians are able to maintain balance and meaning in their lives despite the stressors and limitations of their practices. What do they do to survive—indeed, thrive—while some of their other colleagues suffer? How is it that some are more effective at this than others? Is this something that can be promoted? Manusov discovered that specific strategies used by 14 first-year residents to positively influence their level of happiness (an affective measure of psychological well-being) were pursuing and achieving goals, being positive, being in relationships, having a religious belief system, and receiving positive feedback.23 Quill and Williamson sorted the creative solutions used by practicing internal medicine physicians to cope with the stressors of medical practice into 5 categories: self-awareness, sharing of feelings and responsibilities, self-care, developing a personal philosophy, and setting limits.24 Their 10% response rate (out of 600 surveys) suggests that it is difficult to obtain qualitative data from busy physicians, and the low response rate may limit the generalizability of their findings. A 1997 survey of primary care physicians found that psychological and emotional well-being among physicians was significantly associated with the ability to maintain individual identities in relationships with original family members, with the presence of strong social support, and with levels of practice stress.25 In that survey, qualitative data were requested from physician participants related to how they maintain their physical, emotional, and spiritual well-being. In this article, we report those qualitative results. Our goals are to shed additional light on the wellness-promotion activities used by practicing physicians, to assess the extent to which such practices are actually associated with increased well-being, and to promote further research in this area.

OBJECTIVE To determine the effectiveness of and costs associated with semiautomated rescreening of Papanicolaou smears with negative findings at a community hospital. DESIGN A prospective study of 1200 Papanicolaou smear slides with negative findings using the PAPNET screening system (Neuromedical Systems, Incorporated, Suffern, NY). SETTING Community hospital laboratory. PATIENTS Patients with negative findings on Papanicolaou smears who agreed to have their smears reviewed using PAPNET. INTERVENTIONS None. MAIN OUTCOME MEASURES Results of rescreening and resources involved in processing the PAPNET review. RESULTS Screening with PAPNET identified 8 patients with atypical squamous cells of undetermined significance (ASCUS) that were not diagnosed on initial screening, yielding a false-negative rate in our laboratory of 0.7% for ASCUS. No low- or high-grade squamous intraepithelial lesions were identified. Based on our laboratory processing 6000 Papanicolaou smears a year, at $19 per slide, it would cost our laboratory $102,600 for PAPNET review of all smears with negative findings. In contrast, the estimated cost to have another cytotechnologist review all such smears manually would cost $11,977. The rate of changed diagnoses in the PAPNET group was similar to the rate in our standard rescreening of 10% of all smears with negative findings. Mean turnaround time for a PAPNET screen was 13.9 days, compared with 3.9 days for manual review. CONCLUSIONS For a laboratory with a low percentage of smears with abnormal findings, a quality cytotechnologist and pathologist, and required quality assurance standards in place, PAPNET may not improve appreciably the pick-up rate for missed cervical lesions, and may add significantly to the cost and turnaround time of cytologic evaluation of cervical smears.

Little is known about the actual smoking intervention practices of maternity care providers. This study examines smoking intervention practices of maternity care providers in a large Midwestern city.A telephone survey was used to collect information on the care of pregnant patients who smoke (n = 73).After brief counseling during the first prenatal care visit (98 percent), 84 percent of providers readdressed smoking at follow-up visits. Family physicians were significantly more likely than obstetricians to provide further counseling (97 versus 72 percent, P0.005). Common cessation interventions included provider counseling (99 percent) and recommending smoking cessation classes (26 percent). Reasons cited by providers for patients' inability to stop smoking during pregnancy included addiction, habit, and environment or family. Methods used to encourage smoking cessation did not correlate with those known to be effective for treating addiction, modifying behavior, or responding to family or social system problems.Maternity care providers underutilize effective methods of smoking cessation for their patients who smoke and rely on less effective methods.

Fogo selvagem is an autoimmune blistering skin disease that principally occurs among rural Brazilians living in geographically clumped disease foci. Exposure to hematophagous black flies possibly is related to the cause of the disease. We compared the occurrence, proportions, and richness of simuliid species immatures and the biting activity of adult females within a recently discovered, high prevalence focus of fogo selvagem, the Limao Verde Terena Reservation, to that of neighboring regions with no reported cases of fogo selvagem. Nine black fly species were collected from 12 stream sites during 5 trips to the fogo selvagem focus. The species showed longitudinal (upstream-downstream) trends in occurrence, proportions, and richness, and the abundance of simuliid immatures was greater at downstream sites. The most prevalent species at the focus, Simulium nigrimanum (Macquart), dominated the stream sites with highly abundant simuliid assemblages, and was the most common black fly in human bait collections. This species was absent or in very low numbers in neighboring valleys and villages that did not have cases of fogo selvagem.

Article-at-a-Glance Background As primary care physicians develop ongoing relationships with their patients, each contact provides another opportunity for primary, secondary, or tertiary prevention activities. In 1991 an interdisciplinary prevention project team using continuous quality improvement (CQI) principles was established to improve family practice residents' provision of such services. Diagnostic journey For a random sample of 60 patient charts, abstractors looked for documentation of 23 clinical preventive services, including nursing screens, physician on-site and off-site implemented services, lifestyle education (diet, tobacco use), and self-screening education. After the chart review, the physicians, nurses, residents, and clinical staff used a fishbone analysis to identify physician-, clinic system–, and patient-centered factors contributing to the lack of conformance with clinical prevention guidelines. Remedial journey The residency program began a series of didactic sessions on clinical prevention and instituted a procedures rotation to teach prevention procedure skills such as flexible sigmoidoscopy, stress testing, and colposcopy. On the CQI team's recommendation, a checklist developed by physicians and staff which itemized age- and gender-specific clinical prevention services was placed at the front of all patient charts. Clinic-system and patient factors were also addressed. Holding the gains—monitoring performance The 1993 postintervention chart review showed significant improvements for 17 (81%) of the 21 targeted services. Discussion Providing educational sessions on prevention, permitting residents to select the areas of prevention on which to focus, and giving feedback on resident and staff performance through ongoing, nonpunitive monitoring resulted in increased provision of clinical prevention services in a family practice residency training center.

We studied the effect of state legislation requiring the disclosure of options for the treatment of breast cancer on the use of breast-conserving surgery in clinical practice.The National Cancer Institute's Surveillance, Epidemiology, and End Results registry provided data on women from 30 through 79 years of age who underwent breast-conserving surgery or mastectomy for local or regional breast cancer from 1983 through 1990. We examined the trend over time in use of breast-conserving surgery among patients in four sites (Connecticut, Iowa, Seattle, and Utah) where there were no state laws specifically requiring the disclosure of options for the treatment of breast cancer by physicians. For four additional sites (Detroit, Atlanta, New Mexico, and Hawaii) that had such legislation, we determined whether the rate of breast-conserving surgery after the legislation was different from the expected rate.An attorney rated the legislation as giving most direction to physicians in Michigan, followed by Hawaii, Georgia, and New Mexico. The rate of breast-conserving surgery was up to 8.7 percent higher than expected in Detroit for six months after the passage of the Michigan law (P0.01). The rate was up to 13.2 percent higher than expected in Hawaii for 12 months after that state's law was passed (P0.05) and up to 6.0 percent higher than expected in Atlanta for 3 months after the passage of the Georgia law (P0.01). After these transient increases, the surgery rates reverted to the expected levels. No significant effect was detected in New Mexico, where only a resolution without legal force was passed.Legislation requiring physicians to disclose options for the treatment of breast cancer appeared to have only a slight and transient effect on the rate of use of breast-conserving surgery.

We analyzed the adequacy of pain control for 17 trauma patients during the initial part of their stay in the intensive care unit, and assessed reasons for inadequate analgesia, if it occurred. Patients, and physicians, and nurses were interviewed. A verbal pain intensity scale was used to determine whether patients received adequate analgesia. Patients were asked if the pain hindered their activities, and whether they requested pain medication from their caregivers. Caregivers were questioned whether patients received adequate analgesia. Prescribed morphine regimens and the amount of narcotic administered were analyzed. Twenty-seven percent of patients rated pain intensity as moderate and 47% as severe. Ninety-five percent of housestaff and 81% of nurses reported the patients received adequate pain control. Forty-seven percent of the patients who had moderate or severe pain asked their physician for more pain medication, and 65% asked the nurse. Thirteen residents did not order a larger dose of morphine due to concern about respiratory depression or hypotension. Morphine dosages ranged from 1-8 mg intravenously every 1-2 hours as necessary. Nurses administered less than the maximum amount ordered 58% of the time. The mean dosing interval was 2.3 hours. Barriers to adequate pain management were disparity in the perception of pain between patients and caregivers; patients not requesting more analgesia despite despite the presence of moderate to severe pain; and physician and nurse concerns about patients' adverse physiologic response to increased dosages.

The recognition that tobacco control and human rights concerns overlap is quite recent. This commentary reflects upon tobacco control's growth through allying with other domains, and details a particular effort to build alliances between tobacco control and human rights practitioners.

OBJECTIVE: To describe the clinical presentation of narcotic overdose in hospitalized patients and to differentiate this circumstance from other conditions often misdiagnosed as overdose. DESIGN: Case series. SETTING: Two acute-care teaching hospitals. PATIENTS: Forty-three hospitalized patients who received naloxone for a clinically suspected narcotic overdose. INTERVENTIONS: Two investigators independently evaluated each incident to determine whether the patient had a narcotic overdose. The patients were judged to have had an overdose if caregivers documented an immediate improvementin mental status, respiratory rate, or blood pressure after naloxone administration. MEASUREMENTS: The clinical presentation of a narcotic overdose in hospitalized patients was defined. Conditions misdiagnosed as an overdose were determined. MAIN RESULTS: Symptoms improved rapidly with the administration of naloxone in 28 incidents (65 percent) and were designated overdose. In 15 other instances there was no improvement in symptoms; these patients were designated nonoverdose. Only half of the overdose patients had a respiratory rate CONCLUSIONS: Narcotic overdoses in hospitalized patients seldom fit the classic description. The lack of respiratory depression does not mean the absence of a narcotic overdose. Patients who receive narcotics and develop a signficant decrease in mental status should be evaluated for a possible overdose. Pulmonary, neurologic, cardiovascular, and electrolyte abnormalities often are misdiagnosed as a narcotic overdose in hospitalized patients.

Summary Prostatectomy is the standard treatment for benign prostatic hyperplasia (BPH) and non-surgical treatment of prostatism would reduce the detection of Stage A prostate cancer. We wished to identify the number of potentially undiagnosed cancers resulting if non-surgical therapy were used to treat a presenting complaint of BPH. We also sought to identify the age group which would most clearly benefit from treatment of Stage A prostate cancer. Our series of transurethral prostatectomy specimens showed 92/996 patients (9.2%) positive for incidental carcinoma; 26/92 patients (28%) received further treatment and 25 of the 26 patients had Stage A2 disease. After evaluating life-tables and survival data on untreated A2 disease, the population aged 72 years had a relative benefit of treatment ratio > 1.0, i.e. had a greater likelihood of dying from prostate cancer than from natural causes; 17/616 (2.8%) of the population aged < 72 years had their A2 disease treated and would have potentially been denied early cancer treatment if non-surgical management of BPH had been employed. The above figures assume 100% non-surgical treatment of BPH and no screening for prostate cancer pre-treatment. Stage A2 patients in this study demonstrated no significant difference in cause-specific survival rates between treated and untreated study groups (both 0%) or between treated study patients and untreated historical patients. Treated A2 patients demonstrated a significantly lower 5-year progression rate (0 vs 32%) relative to untreated patients reported in the literature, and a trend toward a significantly lower progression rate (0 vs 25%) relative to untreated study patients.

The Wisconsin Ambulatory Review Project is the most extensive study to date with the goal of describing in detail the nature of care in the ambulatory setting. To assist in the description, a detailed, electronic clinical data base was created from a random sample of nonstandard, often hand-written, ambulatory patient medical records. This paper describes the set of processes that enabled significant clinical data to be collected, organized, and made available to researchers, including the collection of a representative sample of patient medical records, the creation of a detailed clinical vocabulary, the implementation of the vocabulary as a data abstraction tool, the collection and aggregation of distributed electronic data files, and the assessment of the efficiency of the abstraction process. The integration of all of these processes has produced a working system that has successfully been deployed as a pilot study across a seven-state area.

Background: Retinal detachments are usually considered to be a surgical emergency. However, there are additional risks and costs for unnecessary emergency surgeries. The purpose of this study is to evaluate whether the conventional wisdom for treating all retinal detachments as emergencies needs to be re-examined. Methods: Forty-eight patients who had an emergency scleral buckle and 89 patients who had a scheduled procedure were randomly selected from 884 consecutive patients who had a primary scleral buckling procedure during a 4 1/2-year period. The medical records of each patient were used to obtain detailed information related to prognosis. The visual acuity measurements of each patient, taken 6 months after the procedure, were obtained from the records of the ophthalmologist following the patient. Linear regression analysis was used to compare the final visual outcome for patients who had emergency surgery with patients who had scheduled surgery after taking into account patient factors related to prognosis. Results: Patients selected for emergency surgery had better visual prognoses than scheduled patients but had the same risk of systemic complications and the same extent of detachment if the macula was not involved. None of the 18 patients with an attached macula experienced macular involvement while awaiting scheduled surgery. There were no differences between emergency and scheduled patients in ocular or systemic complications, rate of reattachment, rate of decreased visual acuity after surgery, visual outcome adjusted for prognosis, or, since 1985, length of hospital stay. A greater cost was incurred for the patients having emergency surgery due to difference in pay scales for support personnel. Conclusions: Because the study is not large and the patients were not randomized to treatment, the results are not definitive. However, they suggest that emergency surgery is unnecessary for many patients with a detached retina.

Background. In the past decade there has been an increase in the use of treatment designed to conserve the breast for women with breast cancer. The extent to which such treatment has been adopted in various regions of the country and whether characteristics of hospitals and patients predict its use are not known, however. Methods. We used national data on Medicare claims for inpatient care provided in 1986 to study 36,982 women 65 to 79 years of age, who had local or regional breast cancer and underwent either mastectomy or breast-conserving treatment (local excision, quadrantectomy, or subtotal mastectomy). Information about the hospitals at which these women were treated was obtained from an American Hospital Association survey. Results. Of the 36,982 women, 12.1 percent had breast-conserving surgery and 87.9 percent had a mastectomy. The frequency of breast-conserving surgery ranged from 3.5 percent to 21.2 percent in various states. The highest rate of use was in the Middle Atlantic states (2...

Use patterns of outpatient cardiac rehabilitation services need to be identified, not as dichotomous measures of compliance-dropout, but as measures on a compliance continuum described by different levels of attendance. The authors investigated the associations between use of outpatient cardiac reha

The potential for transmission of deadly viral diseases to health care workers exists when contaminated blood is inoculated through injury or when blood comes in contact with nonintact skin. Operating room personnel are at particularly high risk for injury and blood contamination, but data on the specifics of which personnel are at greater risk and which practices change risk in this environment are almost nonexistent. To define these risk factors, experienced operating room nurses were employed solely to observe and record the injuries and blood contaminations that occurred during 234 operations involving 1763 personnel. Overall 118 of the operations (50%) resulted in at least one person becoming contaminated with blood. Cuts or needlestick injuries occurred in 15% of the operations. Several factors were found to significantly alter the risk of blood contamination or injury: surgical specialty, role of each person, duration of the procedure, amount of blood loss, number of needles used, and volume of irrigation fluid used. Risk calculations that use average values to include all personnel in the operating room or all operations performed substantially underestimate risk for surgeons and first assistants, who accounted for 81% of all body contamination and 65% of the injuries. The area of the body contaminated also changed with the surgical specialty. These data should help define more appropriate protection for individuals in the operating room and should allow refinements of practices and techniques to decrease injury.

To determine which characteristics of hospitals may be related to a higher quality of care, the association of hospital characteristics with the outcomes of medical record review by state Peer Review Organizations (PROs) was studied. The two data sources were: 1) the AHA 1986 Annual Survey of Hospitals and 2) reviews completed between July 1987 through June 1988 from six large PROs. For each hospital the percentage of cases that failed physician review (the confirmed problem rate) was computed. Hospital characteristics evaluated included financial status, ownership, medical training, technological sophistication, and size. The following characteristics were significantly associated with a lower confirmed problem rate: a higher occupancy rate, greater payroll expenses per bed, a higher proportion of physicians who were board-certified specialists, greater technological sophistication, a higher number of beds, a higher proportion of nurses who were registered, and membership in the Council of Teaching Hospitals. Public hospitals had higher problems rates than private not-for-profit hospitals. All characteristics significantly related to higher confirmed problem rates were also related to higher adjusted mortality rates in a previous study of 3,100 U.S. hospitals. The results suggest that hospital resources, including financial status, training of medical personnel, and availability of sophisticated equipment, are related to the quality of care provided by the hospital.

This study examined the safety and pharmacokinetic profile of a potentially therapeutic and fully human anti-CMV monoclonal antibody (SDZ MSL-109) in a phase I dose escalation trial in patients receiving allogeneic bone marrow transplants. Fifteen adult marrow transplant patients, twelve with chronic myelogenous leukemia and three with acute nonlymphocytic leukemia, in cohorts of five patients each, were administered monoclonal antibody intravenously at doses of 50, 250, and 500 micrograms/kg at approximately three-week intervals for six months. Administration of the monoclonal antibody was associated with minimal side effects and no dose-related toxicity. Antibody elimination curves in all dose groups were consistent with a two-compartment model with an alpha half-life at the low, middle, and high dose groups of 1.03, 0.82, and 0.79 days, and a beta half life of 13.9, 14.0, and 16.5 days, respectively. The volume of distribution decreased with repetitive dosing to approximate the plasma volume in each patient and the pharmacokinetic profile was comparable to that of human IgG. There was no host antiidiotypic or antiallotypic antibody formation, indicating that MSL-109 was not immunogenic. Further studies are warranted to assess the potential efficacy of human monoclonal anti-CMV disease in marrow transplant recipients and other patients with immunodeficiency disorders.

The chronic effects of focused electrohydraulic shock waves were studied in a minipig model. Fifteen animals underwent a unilateral nephrectomy and compensatory renal hypertrophy was allowed to take place over a minimum of six months. Baseline studies were then carried out consisting of 1) serum creatinine, blood urea nitrogen, and plasma renin levels 2) intra-arterial blood pressure measurement and 3) 3H-inulin clearance. Ten of the animals then underwent 8 shockwave treatments (2500 shocks per treatment), alternately to the upper and lower pole of the kidney, at two weeks intervals. A total of 20,000 shock waves were administered to each minipig over the four month period. The five control pigs underwent sham procedures. The renal function and blood pressure evaluations were then repeated. No significant decrease in renal function was noted in the experimental animals when compared to the controls. In addition, renin mediated hypertension was not observed despite the excessive number of total shock waves delivered to the kidney.

PURPOSE To determine learning outcomes from the students' perspective on the clinical portion of a third-year primary care ambulatory clerkship. METHOD Over 18 months (December 1994 to June 1996), students at the Medical College of Wisconsin identified what they had learned during the clerkship in each of seven learning settings. Responses were transcribed and a coding dictionary developed. Response frequencies were compared by logistic regression analysis over time and between rural and urban sites. Course goals set by faculty were compared to learning outcomes reported by students. RESULTS The authors coded 3,030 student outcomes into 48 categories. The top ten learning outcomes by frequency are reported. Logistic regression analysis revealed no significant difference by time of year or by rural versus urban clerkship experiences. Twenty-six of 29 original course goals were congruent with the student-generated outcomes. CONCLUSION Basic professional knowledge, skills, and attitudes were the learning outcomes most valued throughout the year. Being alone with patients and working with their preceptors were the students' most valued learning settings.

We prospectively studied 194 patients undergoing vitrectomy between July 1988 and April 1989 to determine the incidence of postvitrectomy intraocular fibrin formation and the association of a variety of preoperative and intraoperative variables with the formation of severe postvitrectomy fibrin. Overall, 62 (32%) patients developed postvitrectomy fibrin; 25 (13%) had mild fibrin formation, 13 (6.5%) had moderate fibrin formation, and 24 (12.4%) had severe fibrin formation. By logistic multivariate analysis, preoperative factors that were independently predictive of severe fibrin formation included severe flare (P = .004), the presence of a previously placed scleral buckle (P = .001), and poor preoperative visual acuity (P = .007). Anterior epiretinal membrane dissection was the only intraoperative factor that was independently associated with an increased fibrin risk (P = .0003). A risk score derived from the multivariate analysis effectively categorized patients according to their likelihood of developing severe postvitrectomy fibrin. Results of this study may be useful in designing prophylactic interventions to decrease postvitrectomy fibrin formation.

Continually changing health threats, technologies, science, and demographics require that public health professionals have an understanding of law sufficient to address complex new problems as they come into being. This book provides a review of the legal basis and authorities for the core elements of public health practice and solid discussions of existing and emerging high-priority areas where law and public health intersect. Each chapter is authored jointly by experts in law and public health. This second edition features three new chapters, with several others revised and updated. New chapters address such topics as the statutory bases for US public health systems and practice, the judiciary role in public health, and chronic disease prevention and control. The book begins with a section on the legal basis for public health practice, including foundations and structure of the law, discussions of the judiciary, ethics and practice of public health, and criminal law and international considerations. The second section focuses on core public health applications and the law, and includes chapters on legal counsel for public health practitioners, legal authorities for interventions in public health emergencies, and considerations for special populations. The third section discusses the law in controlling and preventing diseases, injuries, and disabilities. This section includes chapters on genomics, vaccinations, foodborne illness, STDs, reproductive health, chronic disease control, tobacco use, and occupational and environmental health.

Multivariate analysis has been applied as support to proteome analysis in order to implement an easier and faster way of data handling based on separation by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. The characterisation phase in proteome analysis by means of simple visual inspection is a demanding process and also insecure because subjectivity is the controlling element. Multivariate analysis offers, to a considerable extent, objectivity and must therefore be regarded as a neutral way to evaluate results obtained by proteome analysis. Proteome analysis of storage proteins from the wheat gluten complex based on two-dimensional electrophoresis and analysis of the N-terminal sequence has revealed a protein homologous to gamma-gliadins, tentatively associated with quality and within the molecular weight range 27-35 kDa. Further examinations of gliadin data based on mass spectrometry revealed that quality among wheat varieties could be determined by means of principal component analysis. Further examinations by interval partial least squares made it possible to encircle an overall optimal molecular weight interval from 31.5 to 33.7 kDa. The use of multivariate analysis on data from mass spectrometry has thus shown to be a promising technique to minimize the number of two-dimensional gels within the field of proteome analysis.

This study evaluated predictors of dropout among men who began and attended at least 1 session of a cognitive-behavioral, skills training oriented spouse abuse abatement counseling program. Based on prior research, a number of demographic, criminal justice, partner violence pattern, and personality characteristics were studied. Dropout prediction was assessed at 2 phases of program participation, during assessment (early drop) and during intervention (late drop). Overall, few of the variables studied predicted dropout. Early dropout was predicted by high rates of police contact for violent crimes, failure to self-report an alcohol problem, and paranoid personality characteristics. Late dropout was predicted by both high and moderate levels of police contact for violent crimes, and borderline personality characteristics. An Age X Violent Crime interaction suggested that young violent offenders are more likely to complete treatment. The overall model accounted for only 7.15% of the variance. Clinical and research implications are discussed.

Background Health-related quality of life (HRQL) instruments provide valid and responsive outcome measures to assess the impact of disease and the response to interventions. However, they have not been applied widely to studies of rehabilitation after myocardial infarction. Purpose To examine the extent to which baseline sociodemographic and clinical characteristics predict baseline and change in generic and specific HRQL. Methods A randomized controlled trial of an 8-week cardiac rehabilitation intervention or usual care, with follow-up for 12 months, in 201 patients with acute myocardial infarction (MI). Multiple regression analysis was used to identify predictors of HRQL. Results Specific HRQL scores and exercise tolerance improved significantly more in rehabilitation patients than usual care patients by the end of the 8-week intervention. All HRQL measures and exercise tolerance in both groups improved significantly during the 12 month follow-up period but the differences between the groups were trivial. A poor baseline HRQL was the predominant predictor of improved generic and specific HRQL. Furthermore, greater improvement in HRQL consistently was associated with lower levels of cardiovascular risks such as absence of a previous MI or coronary artery bypass surgery, absence of angina, less smoking, and higher exercise tolerance. Conclusions Improved generic and specific HRQL was associated with poorer baseline HRQL and less baseline cardiovascular risk. This reinforces the importance of addressing health behavior changes as soon as possible after MI and the usefulness of assessing both generic and specific HRQL in evaluating treatment effectiveness.

Substantial geographic and hospital-based variations have been documented in the use of breast-conserving surgery (BCS) in 1986. The authors studied the patterns of adoption of this procedure from 1986 to 1990. National Medicare inpatient claims were used to study women aged 65 to 79 who underwent an operation for local or regional breast cancer in 1986 (38,679 patients) or 1990 (43,083 patients). Breast-conserving surgery was used for 5,509 (14.1%) of the Medicare patients in 1986 and 6,476 (15.0%) in 1990. The only region with an increase in BCS use from 1986 to 1990 was New England. Many hospitals had low volumes of operations, with a median of six to seven patients annually. Ten percent of the hospitals performed 55% of the conservative operations. Large hospitals, urban hospitals, and those with higher patient volumes or a cancer center were somewhat more likely to have increased use of BCS by 1990. Despite the substantial evidence supporting BCS as an alternative to mastectomy, the overall use of BCS in Medicare inpatients increased minimally from 1986 to 1990. Many patients are treated in hospitals with little experience with BCS. Hospitals using more BCS in 1986 were somewhat more likely to increase the use of BCS by 1990.

To determine whether posttraumatic hypothermia is associated with hemorrhage or with resuscitation.We used a sequential hemorrhage-resuscitation rat model. Rats were subjected to hemorrhage (30 mL/kg), then 1 hour of shock, followed by 2:1 crystalloid/blood resuscitation (60 mL/kg) at ambient temperature. A control group underwent neither hemorrhage nor resuscitation.We recorded core temperature and blood pressure every 10 minutes. Temperature drop averaged 3.4 degrees C and was fastest during hypotensive shock. Rate of temperature change correlated with blood pressure (beta = .0102, P.001), shock phase (beta = .4504, P = .041), and blood pressure during shock phase (beta = .0116, P.001), but not with resuscitation phase or with duration of shock or resuscitation. Three of 14 rats died during shock, none during resuscitation. An increase in temperature was noted in 1 of 14 rats during shock and in 7 of 11 rats during resuscitation.Hemorrhage-associated hypothermia occurs during hypotensive shock, not during fluid resuscitation.

Whereas fractures related to osteoporosis have become a pressing public health concern, relatively few epidemiologic studies have focused on vertebral fractures. To shed further light on the occurrence of this injury, we collected data from the Health Care Financing Administration on 151,986 discharges listing a diagnosis of vertebral fracture over a 4-year period. After adjusting for age, white women experienced the highest rates of discharge, at 17.1 per 10,000 per year, followed by white men (9.9 per 10,000), black women (3.7 per 10,000), and black men (2.5 per 10,000). Among white women, discharge rates rose exponentially from 5.3 discharges per 10,000 population at age 65 to nearly 47.8 per 10,000 at age 90. White men, black women, and black men experienced less dramatic age-related increases in discharge rates. The similarity of these patterns to discharge rates for hip fracture suggests that the race-sex differences in vertebral fracture discharge rates may be due to differences in the incidence of vertebral fracture.

Various study designs and approaches to statistical analysis in clinical research have their own underlying rationales and limitations for interpretation. This information is presented in an intuitive and accessible manner, relying minimally on basic algebra. Epidemiologic concepts of study design and interpretation, bias and confounding, hypothesis testing, and sample size and power are explained. Statistical tests and their appropriate applications are discussed for mean comparisons (t tests and ANOVA), percentages (chi-square), survival analysis, and correlation and regression. Applicable nonparametric tests are also introduced.

• Health care workers, particularly surgeons, understand the importance of preventing contamination from blood of patients infected with deadly viruses. One of the most common areas of contamination is the hands and fingers due to the failure of glove protection. There are varying opinions regarding the frequency of glove failure, the necessity of wearing two gloves for added protection, and the ability to operate when wearing two gloves. We performed a prospective, randomized, trial of 143 procedures involving 284 persons to answer these questions for surgeons and first assistants. Overall, the glove failure rate (blood contamination of the fingers) was 51% when one glove was worn and 7% when two gloves were worn. Acceptability was 88% in the group who agreed to wear two gloves, and 88% of these did not perceive that tactile sense was significantly impaired. We believe that double gloving should be, and can be, used routinely during major surgical procedures to protect surgeons from blood contamination. ( Arch Surg. 1992;127:213-217)

purpose: Invasive Aspergillus infections cause significant morbidity and mortality in marrow transplant patients. In this study, we examined whether administration of intravenous low-dose prophylactic amphotericin B could reduce the incidence and mortality associated with invasive aspergillosis in patients undergoing allogeneic marrow transplantation. patients and methods: The subjects of this analysis were 186 consecutive patients undergoing allogeneic marrow transplantation in an adult bone marrow transplant unit between July 1, 1985, and September 30, 1990, utilizing consistent disease-specific chemoirradiation and graftversus-host disease protocols. The incidence, morbidity, and case fatality of invasive aspergillosis in the study group receiving amphotericin chemoprophylaxis were compared with that in two historic cohorts managed without prophylactic amphotericin B. Univariate and multivariate statistical analyses were performed to examine whether an apparent protective effect could be attributed to differences in patient and treatment variables among the cohorts and to determine potential toxicities of the chemoprophylaxis regimen. results: There was a significant reduction in both the incidence (p = 0.003) and mortality (p = 0.03) of invasive aspergillosis in patients receiving amphotericin B chemoprophylaxis as compared with those not receiving chemoprophylaxis. The prophylactic amphotericin B schedule, as employed here, was not associated with increased renal or hepatic toxicity as compared with that in historically managed patients. conclusion: These data suggest that the risks of invasive aspergillosis in allogeneic marrow transplant recipients can be reduced by administration of prophylactic amphotericin B during the pretransplant and peritransplant periods.

The purpose of this study was to compare the results of the Chevron osteotomy to the DuVries' modification of the McBride procedure using identical criteria in two groups of patients. Thirty-two patients (48 feet) that had a Chevron osteotomy and 10 patients (17 feet) who had a modified McBride bunionectomy without metatarsal osteotomy for treatment of mild to moderate hallux valgus were retrospectively reviewed using subjective and objective criteria. Both groups were matched according to age, severity of deformity, and length of follow-up. Ninety-two percent of patients in the Chevron group and 88% of patients in the McBride group responded that they were either totally satisfied or improved regarding pain relief and appearance of the foot following surgery. Chevron osteotomy resulted in a statistically significant greater correction of the intermetatarsal 1–2 angle than did the McBride bunionectomy. Postoperative metatarsophalangeal joint range of motion was not significantly different for the two groups. Following Chevron osteotomy, five (10%) metatarsal heads exhibited radiographic changes of cyst formation and/or increased osteodensity and three (6%) of the osteotomies healed in a malunited postion. One of the three metatarsal head malunions occurred in a patient that also had a lateral capsular release, however, none of the five cases that developed radiographic changes in the first metatarsal head was associated with a lateral capsular release. Lateral capsular release with the Chevron osteotomy did not improve the amount of correction of the hallux valgus deformity and it may be a contributing factor to instability at the osteotomy site leading to a valgus malunion.

Two articles in this edition of Tobacco Control , by Ashley and Ferrence1 and Lund et al,2address an issue that is likely to become increasingly important in the new millennium. How will children be protected from the known health threat of exposure to environmental tobacco smoke (ETS) when that exposure occurs in places, such as the home or the private automobile, that are traditionally considered off limits to governmental or other outside intervention? The overall problem is enormous. According to data collected in 1992–93 in the United States, 21.9% of children under 18 years of age are exposed to ETS at home by their parents.3 As Aligne and Stoddard recently noted: “Parental smoking is an important preventable cause of morbidity and mortality among American children; it results in annual direct medical expenditures of $4.6 billion and loss of life costs of $8.2 billion.”5 A 1998 Canadian study has found that nearly half (47%) of children in that country are exposed to ETS in the home, whether by parents, visitors, or babysitters.4 The authors concluded: “Additional efforts to reduce children’s exposure to tobacco smoke are warranted.”5 Societies will differ regarding the pace and extent of such interventions. Lund et al have begun to quantify the awareness of parents in Nordic countries of the harm to children caused by exposure to ETS. Their results are encouraging. In addition, according to a recent survey conducted in Massachusetts, …

Background: In the United States, few studies have examined important variables in physician attitudes toward the practice of euthanasia, such as the patient's underlying disease, mental capacity, and age, and the physician's specialty and religion. We administered a case-based survey to analyze the impact of such specific variables on physician attitudes toward the practice. Methods: A four-section survey solicited (1) physician responses to three hypothetical cases in which patients requested euthanasia; (2) physicians' general opinions about euthanasia and how its legalization might affect them personally and professionally; and (3) demographic information. Analysis focused on physicians' characteristics as they related to their responses to the various aspects of euthanasia elicited in the survey. Univariate and multivariate analyses, using logistic regression, were performed. Results: Completed and analyzable surveys were returned by 740 physicians. We found that physicians felt more comfortable with euthanasia requests from non-decisional, nonterminal patients who had left advance directives than they did with requests from decisional patients suffering from grave illnesses or injuries, or from decisional patients who had early signs of a progressive but nonlethal neurologic disease. We also found that physicians' specialties and religions correlated with their responses to the hypothetical cases and with their generalized attitudes toward euthanasia. Conclusions: Given the disparity in responding physicians' attitudes toward euthanasia, along with the fact that values based on religious affiliation or profession may underlie many physicians' opposition to the practice, we conclude that if euthanasia is to be legalized, safe-guards protective of patients and physicians must be incorporated. (Arch Intern Med. 1994;154:575-584)