Computer-Assisted Instruction in Probabilistic Reasoning During the Inpatient Medicine Clerkship

The acceptability and utility of computer-assisted instruction in probabilistic reasoning was assessed for medicine clerkship students. After a pretest, the experimental (n = 40), but not the control students (n = 39), completed a program that we designed. The program contained the test and its answers. After program exposure, experimental students rated their knowledge of the program’s content significantly higher (p = 10−4) than control students. On the identical posttest, experimental students also scored significantly higher than control students (p = 10−4) and improved their scores significantly more (p = 10−3). They rated ease-of-use items significantly higher than content-relevance items (p = 1CT−4). We conclude that computer-assisted instruction in probabilistic reasoning is acceptable to clerkship students, and that it may improve their knowledge and skills in this area. However, students may rate the vehicle of this instruction more highly than its content.

Effects of pelvic floor muscle training on strength and predictors of response in the treatment of urinary incontinence

AIMS

The objectives of this study were (1) to determine the effect of training on pelvic floor muscle strength; (2) to determine whether changes in pelvic floor muscle strength correlate with changes in continence; and (3) to determine whether demographic characteristics, clinical incontinence severity indices, or urodynamic measures predict response to pelvic floor muscle training.

METHODS

One hundred thirty-four women with urinary incontinence (95=genuine stress incontinence [GSI]; 19=detrusor instability [DI]; 20=mixed incontinence [GSI+DI]) were randomized to pelvic floor muscle training (n=67) or bladder training (n=67). Urinary diaries, urodynamic evaluation, and vaginal pressure measurements by using balloon manometry were performed at baseline and after 12 weeks of therapy. Primary outcome measures consisted of incontinent episodes per week and vaginal pressure measurements.

RESULTS

Both treatment groups had a reduction in incontinent episodes (P</=0.004). Vaginal pressures increased more with pelvic floor muscle training than with bladder training (P=0.0003). Other than a weak correlation between a reduction in incontinent episodes/week and an increase in maximum sustained vaginal pressure in women with GSI (r=0.32, P=0.04), there were no significant correlations between increases in pelvic floor muscle strength and improvement in continence status. There were no significant correlations between baseline demographic characteristics, clinical incontinence severity, or urodynamic measures and increases in vaginal pressure or improvement in clinical severity after pelvic floor muscle training.

CONCLUSIONS

Pelvic floor muscle training improves continence and increases vaginal pressure measurements, but the direct correlations between these alterations are weak. A woman's response to behavioral treatment does not depend on her demographic characteristics, clinical incontinence severity, urodynamic measures, or initial pelvic floor muscle strength.

Access, satisfaction, and utilization in two forms of Medicaid managed care

We determined access and satisfaction of 2,598 recipients of Virginia's Medicaid program, comparing its health maintenance organizations (HMOs) to its primary care case management (PCCM) program. Positive responses were summed as sub-domains either of access, satisfaction, or of utilization, and adjusted odds ratios were calculated for HMO (vs. PCCM) sub-domain scores. The response rate was 47 per cent. We found few significant differences in perceived access, satisfaction, and utilization. Both HMO adults and children more often perceived good geographic access (adults, OR, [CI] = 1.50, [1.04-2.16]; children, OR, [CI] = 1.773 [1.158, 2.716]). But HMO patients less often reported good after-hours access (adults, OR, [CI] = 0.527 [0.335, 0.830]; children, OR, [CI] = 0.583 [0.380, 0.894]). Among all patients reporting poorer function, HMO patients more often reported good general and preventive care (OR, [CI] = 2.735 [1.138, 6.575]). We found some differences between Medicaid HMO versus PCCM recipients' reported access, satisfaction, and utilization, but were unable to validate concerns about access and quality under more restrictive forms of Medicaid managed care.

Assessing Medicaid recipient access and satisfaction. Fee-for-service, case management, and capitation

Medicaid increasingly requires enrollment in managed care programs. This study assessed access to care, satisfaction with care, and appointment wait times during the transition from fee for service to managed care using three annual Medicaid recipient surveys. There was little evidence of dissatisfaction or poorer access among managed care recipients. Fee-for-service recipients, compared to primary care case management, reported greater general (91 vs. 78%, p < .01) and specialty care access (92 vs. 80%, p < .01). When appointments were required, adult HMO enrollees, compared to case management, had longer waits for routine care in the second (5.8 +/- 8.2 days vs. 4.0 +/- 6.6) and third surveys (5.5 +/- 6.9 days vs. 3.8 +/- 7.3); waits for other appointments did not consistently differ by program. There were no significant program differences in overall satisfaction. Findings are tempered by the potential for response bias and geographic confounding. Continued monitoring is crucial to assure that access and satisfaction remain high in Medicaid managed care.

Effect of different types of Medicaid managed care on childhood immunization rates

Medicaid managed care can improve access to prevention services, such as immunization, for low-income children. The authors studied immunization rates for 7,356 children on Medicaid in three managed care programs: primary care case management (PCCM; n = 4,605), a voluntary HMO program (n = 851), and a mandatory HMO program (n = 1,900). Immunization rates (3:3:1 series) in PCCM (78%) exceeded rates in the voluntary HMO program (71%), which in turn exceeded those in the mandatory HMO program (67%). Adjusting for race, urban residence, and gender, compared to children in PCCM, children in the voluntary HMO program were less likely to complete the 3:3:1 series (OR = 0.75, CI = 0.63, 0.90), and children in the mandatory HMO program were even less likely to complete the series (OR = 0.59, CI = 0.51, 0.68). Results differed by individual HMOs. Monitoring of outcomes for all types of managed care by Medicaid agencies is imperative to assure better disease prevention for low-income children.

Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity

BACKGROUND

The validity of outcome report cards may depend on the ways in which they are adjusted for risk.

OBJECTIVES

To compare the predictive ability of generic and disease-specific survival prediction models appropriate for use in patients with heart failure, to simulate outcome report cards by comparing survival across hospitals and adjusting for severity of illness using these models, and to assess the ways in which the results of these comparisons depend on the adjustment method.

DESIGN

Analysis of data from a prospective cohort study.

SETTING

A university hospital, a Veterans Affairs (VA) medical center, and a community hospital.

PATIENTS

Sequential patients presenting in the emergency department with acute congestive heart failure.

MEASUREMENTS

Unadjusted 30-day and 1-year mortality across hospitals and 30-day and 1-year mortality adjusted by using disease-specific survival prediction models (two sickness-at-admission models, the Cleveland Health Quality Choice model, the Congestive Heart Failure Mortality Time-Independent Predictive Instrument) and generic models (Acute Physiology and Chronic Health Evaluation [APACHE] II, APACHE III, the mortality prediction model, and the Chadson comorbidity index).

RESULTS

The community hospital's unadjusted 30-day survival rate (85.0%) and the VA medical center's unadjusted 1-year survival rate (60.9%) were significantly lower than corresponding rates at the university hospital (92.7% and 67.5%, respectively). No severity model had excellent ability to discriminate patients by survival rates (all areas under the receiver-operating characteristic curve < 0.73). Whether the VA medical center, the community hospital, both, or neither had worse survival rates on simulated report cards than the university hospital depended on the prediction model used for adjustment.

CONCLUSIONS

Results of simulated outcome report cards for survival in patients with congestive heart failure depend on the method used to adjust for severity.

Relationship between urethral and vaginal pressures during pelvic muscle contraction. The Continence Program for Women Research Group

Condensation is the performance of an effective pelvic muscle contraction increases urethral and vaginal pressures and is independent of demographic, clinical, and urodynamic factors. Our objective was to examine the relationship between urethral closure pressure and vaginal pressure during a pelvic muscle contraction in minimally trained women. Our secondary aim was to determine whether demographic, clinical, or urodynamic factors predict pelvic muscle contraction performance. Two hundred two women with urinary incontinence underwent multichannel urodynamic evaluation, including urethral profilometry and measurement of vaginal pressure during pelvic muscle contraction. One hundred forty-four women were diagnosed with genuine stress incontinence, 28 with detrusor instability, and 30 with mixed incontinence. Urethral and vaginal pressures correlated significantly during pelvic muscle contraction (P < or = 0.006). The ability to perform an adequate pelvic muscle contraction was independent of subject age, parity, hormonal or hysterectomy status, clinical severity, urethral support, and urethral profilometry measures (P > or = 0.42).

Understanding lower urinary tract function in women soon after bladder neck surgery. Continence Program for Women Research Group

The aim of this work was to correlate anatomic and urodynamic measures with function following bladder neck surgery. Eighty-seven women who underwent bladder neck surgery at two tertiary academic medical centers in the southeastern U.S. were studied in this prospective outcomes analysis. Preoperative and 6-week and 6-month postoperative status was assessed with urodynamic testing, physical examination, and condition-specific quality of life instruments. Correlations of dynamic urethral obstruction (quantified by pressure transmission ratio, PTR, determinations) and urethral support (quantified by urethral axis measurements) with functional status were determined. At 6 weeks, 50% of the subjects with inadequate dynamic obstruction (PTR < 90%) had genuine stress incontinence (GSI) compared to 5% of those with PTR >/= 90% (P = .00002). Of those with excessive obstruction (PTR > 110%), 32% had detrusor instability (DI) and 47% had emptying phase dysfunction (EPD) compared to 6% and 24%, respectively, of those with PTR </= 110% (P = .006 and P = .04). At 6 months, subjects with excessive obstruction were more likely to have EPD than other subjects (75% vs. 27%, P = .001). Those with optimal dynamic obstruction (PTR >/= 90% but </= 110%) were more likely to have normal function (no GSI, no DI, and no EPD) than those with higher or lower PTRs (59% vs. 34%, P = .04). Urethral axis measurements did not correlate with functional status at either follow-up session. The magnitude of dynamic urethral obstruction is related to function after bladder neck surgery. Excessive obstruction is associated with DI and EPD, inadequate obstruction with GSI, and optimal obstruction with normal function. Neurourol. Urodynam. 18:629-637, 1999.

The effect of bladder training, pelvic floor muscle training, or combination training on urodynamic parameters in women with urinary incontinence. Continence Program for Women Research Group

The purpose of this study was to compare the effect of three conservative interventions: pelvic floor muscle training, bladder training, or both, on urodynamic parameters in women with urinary incontinence. Two hundred four women with genuine stress incontinence (GSI) or detrusor instability with or without GSI (DI +/- GSI) participated in a two-site trial comparing pelvic floor muscle training, bladder training, or both. Patients were stratified based on severity of urinary incontinence, urodynamic diagnosis, and treatment site, then randomized to a treatment group. All women underwent a comprehensive standardized evaluation including multi-channel urodynamics at the initial assessment and at the end of 12 weeks of therapy. Analysis of covariance was used to detect differences among treatment groups on urodynamic parameters. Post-treatment evaluations were available for 181 women. No differences were found among treatments on the following measurements: maximum urethral closure pressure, mean urethral closure pressure, maximum Kegel urethral closure pressure, mean Kegel urethral closure pressure, functional urethral length, pressure transmission ratios, straining urethral axis, first sensation to void, maximum cystometric capacity, and the MCC minus FSV. The effect of treatment did not differ by urodynamic diagnosis. Behavioral therapy had no effect on commonly measured urodynamic parameters. The mechanism by which clinical improvement occurs remains unknown. Neurourol. Urodynam. 18:427-436, 1999.

Nosocomial bloodstream infections in United States hospitals: a three-year analysis

Nosocomial bloodstream infections are important causes of morbidity and mortality. In this study, concurrent surveillance for nosocomial bloodstream infections at 49 hospitals over a 3-year period detected >10,000 infections. Gram-positive organisms accounted for 64% of cases, gram-negative organisms accounted for 27%, and 8% were caused by fungi. The most common organisms were coagulase-negative staphylococci (32%), Staphylococcus aureus (16%), and enterococci (11%). Enterobacter, Serratia, coagulase-negative staphylococci, and Candida were more likely to cause infections in patients in critical care units. In patients with neutropenia, viridans streptococci were significantly more common. Coagulase-negative staphylococci were the most common pathogens on all clinical services except obstetrics, where Escherichia coli was most common. Methicillin resistance was detected in 29% of S. aureus isolates and 80% of coagulase-negative staphylococci. Vancomycin resistance in enterococci was species-dependent--3% of Enterococcus faecalis strains and 50% of Enterococcus faecium isolates displayed resistance. These data may allow clinicians to better target empirical therapy for hospital-acquired cases of bacteremia.

Predictors of Medicare costs in elderly beneficiaries with breast, colorectal, lung, or prostate cancer

BACKGROUND

Determining the apportionment of costs of cancer care and identifying factors that predict costs are important for planning ethical resource allocation for cancer care, especially in markets where managed care has grown.

DESIGN

This study linked tumor registry data with Medicare administrative claims to determine the costs of care for breast, colorectal, lung and prostate cancers during the initial year subsequent to diagnosis, and to develop models to identify factors predicting costs.

SUBJECTS

Patients with a diagnosis of breast (n = 1,952), colorectal (n = 2,563), lung (n = 3,331) or prostate cancer (n = 3,179) diagnosed from 1985 through 1988.

RESULTS

The average costs during the initial treatment period were $12,141 (s.d. = $10,434) for breast cancer, $24,910 (s.d. = $14,870) for colorectal cancer, $21,351 (s.d. = $14,813) for lung cancer, and $14,361 (s.d. = $11,216) for prostate cancer. Using least squares regression analysis, factors significantly associated with cost included comorbidity, hospital length of stay, type of therapy, and ZIP level income for all four cancer sites. Access to health care resources was variably associated with costs of care. Total R2 ranged from 38% (prostate) to 49% (breast). The prediction error for the regression models ranged from < 1% to 4%, by cancer site.

CONCLUSIONS

Linking administrative claims with state tumor registry data can accurately predict costs of cancer care during the first year subsequent to diagnosis for cancer patients. Regression models using both data sources may be useful to health plans and providers and in determining appropriate prospective reimbursement for cancer, particularly with increasing HMO penetration and decreased ability to capture complete and accurate utilization and cost data on this population.

Use and costs of incontinence pads in female study volunteers. Continence Program for Women Research Group

OBJECTIVES

We examined the use and cost of incontinence pads and the relationship to factors such as age, duration of incontinence, diurnal frequency, incontinence severity indices, urodynamic diagnosis, and quality of life.

SUBJECTS AND SETTING

Three hundred fifteen women with urinary incontinence who volunteered to participate in 1 of 3 incontinence studies (behavioral intervention, estrogen supplementation, or surgery) were analyzed. Subjects were community-dwelling women aged 45 years and older living in 3 cities in the southeastern United States.

METHODS

Pad use was recorded on a daily diary. The type of pads used was reported on the history. Average price of pad types was assessed at local stores and reported in 1995 dollars. Statistical comparisons used nonparametric methods.

MAIN OUTCOME MEASURES

The number of pads used per week and annual cost of pads in 1995 dollars.

RESULTS

Seventy-seven percent of subjects used pads at baseline. Median cost per year for the entire cohort was $46 (interquartile range $3-$138). For pad users, median annual cost was $76 (interquartile range $36-$177), with costs being greater for women with detrusor instability than those with pure genuine stress incontinence (median $135-$138 versus $63). This increased cost was likely associated with the greater use of special incontinence products among women with detrusor instability. For the entire cohort, cost and usage did not differ by urodynamic diagnosis. Cost and pad usage were significantly associated with number of incontinent episodes and quality of life, but not with age, pad weight, or duration of incontinence.

CONCLUSIONS

The majority of incontinent women who sought treatment used absorbent pads at least once per week, with menstrual pads being the most common type of pad. The annual cost of pad usage was not as high as in previous estimates.

Reliability and correlation of measurements during and after bladder neck surgery. The Continence Program for Women Research Group

OBJECTIVES

To assess the reliability of seven intraoperative measurements of the effects of bladder neck suspension and correlate these measurements with postoperative dynamic urethral obstruction, quantified as the cough-pressure transmission ratio.

PATIENTS AND METHODS

Sixty women undergoing surgery for bladder neck hypermobility had seven measurements performed in duplicate: (i) the endoscopic appearance of the bladder neck: (ii) the bladder neck-retropubic surface distance (BN-RP distance); (iii) urethral axis; (iv) slow urethral pressure profilometry (UPP); (v) fast UPP; (vi) straining UPP; and (vii) dynamic UPP. Reliabilities were assessed by computing the intraclass correlation coefficient (R) for continuous data or Kappa statistic (K) for ordinal data. Pearson correlation coefficients were used to assess the relationships between the intra-operative measures and postoperative pressure transmission.

RESULTS

The intra-operative reliabilities for maximum pressure, length and area from the three UPP techniques were high (R=0.88-0.98) as were those for urethral axis measurements (R=0.98). In contrast, reliabilities were poor for pressure transmission ratios (R=0.15-0.33), BN-RP distance (R=0.55), and endoscopic appearance (K=0.10). There were significant correlations of the pressures from the UPPs and intra-operative pressure transmission ratios with postoperative pressure transmission ratios; however, the poor intra-operative reliability of intra-operative pressure transmission limits their usefulness. None of the other measures correlated significantly with postoperative pressure transmission ratios.

CONCLUSIONS

Of the measures studied, only intra-operative UPPs had both high reliability and good postoperative correlations.

Comparative efficacy of behavioral interventions in the management of female urinary incontinence. Continence Program for Women Research Group

OBJECTIVE

We compared the efficacy of bladder training, pelvic muscle exercise with biofeedback-assisted instruction, and combination therapy, on urinary incontinence in women. The primary hypothesis was that combination therapy would be the most effective in reducing incontinent episodes.

STUDY DESIGN

A randomized clinical trial with three treatment groups was conducted in gynecologic practices at two university medical centers. Two hundred and four women diagnosed with genuine stress incontinence (n = 145) and/or detrusor instability (n = 59) received a 12-week intervention program (6 weekly office visits and 6 weeks of mail/telephone contact) with immediate and 3-month follow-up. Outcome variables included number of incontinent episodes, quality of life, perceived improvement, and satisfaction. Data analyses consisted of analysis of covariance using baseline values as covariates and chi2 tests.

RESULTS

The combination therapy group had significantly fewer incontinent episodes, better quality of life, and greater treatment satisfaction immediately after treatment. No differences among groups were observed 3 months later. Women with genuine stress incontinence had greater improvement in life impact, and those with detrusor instability had less symptom distress at the immediate follow-up; otherwise, no differences were noted by diagnosis, incontinence severity, or treatment site.

CONCLUSIONS

Combination therapy had the greatest immediate efficacy in the management of female urinary incontinence regardless of urodynamic diagnosis. However, each of the 3 interventions had similar effects 3 months after treatment. Results suggest that the specific treatment may not be as important as having a structured intervention program with education, counseling, and frequent patient contact.

An international comparison of physicians' judgments of outcome rates of cardiac procedures and attitudes toward risk, uncertainty, justifiability, and regret

OBJECTIVE

Compare U.K. and U.S. physicians' judgments of population probabilities of important outcomes of invasive cardiac procedures; and values held by them about risk, uncertainty, regret, and justifiability relevant to utilization of cardiac treatments.

DESIGN

Cross-sectional study.

SETTING

University hospital and VA medical center in the United States; two teaching hospitals in the United Kingdom.

PARTICIPANTS

171 housestaff and attendings at U.S. teaching hospitals; 51 physician trainees and consultants at U.K. hospitals.

MEASURES

Judgments of probabilities of severe complications and deaths due to Swan-Ganz catheterization, cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and coronary artery bypass grafting (CABG); judgments of malpractice risks for case vignettes; Nightingale's risk-aversion instrument; Gerrity's reaction-to-uncertainty instrument; questions about need to justify decisions; responses to case vignettes regarding regret.

RESULTS

The U.S. physicians judged rates of two bad outcomes of cardiac procedures (complications due to cardiac catheterization; death due to CABG) to be significantly higher (p < or = 0.01) than did the U.K. physicians (U.S. medians, 5 and 3.5, respectively; U.K. medians 3 and 2). The median ratio of (risk of malpractice suit I error of omission)/(risk of suit I error of commission) judged by U.K. physicians, 3, was significantly (p=0.0006) higher than that judged by U.S. physicians, 1.5. The U.K. physicians were less often risk-seeking in the context of possible losses than the U.S. physicians (odds ratio for practicing in the U.K. as a predictor of risk seeking 0.3, p=0.003). The U.K. physicians had significantly more discomfort with uncertainty than did the U.S. physicians, as reflected by higher scores on the stress scale (U.K. median 48, U.S. 42, p=0.0001) and the reluctance-to-disclose-uncertainty scale (U.K. 40, U.S. 37, p < 0.0001) of the Gerrity instrument. There was no clear international difference in perceived need to justify decisions, or in regret.

CONCLUSIONS

The results were not clearly consistent with the uncertainty hypothesis that international practice variation is due to differences in judged rates of outcomes of therapy or with the imperfect-agency hypothesis that practice variation is due to differences in physicians' personal values. The causes and implications of practice variations remain unclear.

Behavior of infants with iron-deficiency anemia

This study tested the hypothesis that infants with iron-deficiency anemia show behaviors, such as increased proximity to caregivers, increased wariness or hesitance, and decreased activity, that could contribute to "functional isolation." The behavior of 52 Costa Rican 12- to 23-month-old infants with iron-deficiency anemia was contrasted with that of 139 comparison group infants with better iron status during free play and mental and motor testing and in the home. Infants with iron-deficiency anemia maintained closer contact with caregivers; showed less pleasure and delight; were more wary, hesitant, and easily tired; made fewer attempts at test items; were less attentive to instructions and demonstrations; and were less playful. Adult behavior also differed. The results indicate that iron-deficiency anemia in infancy is associated with alterations in affect and activity, suggesting that functional isolation is a useful framework for understanding poorer developmental outcome in iron-deficiency anemia, the world's most common single nutrient deficiency.

Sample size determination for diagnostic accuracy studies involving binormal ROC curve indices

Receiver operating characteristic (ROC) curves and their associated indices are valuable tools for the assessment of the accuracy of diagnostic tests. The area under the ROC curve is a popular summary measure of the accuracy of a test. The full area under the ROC curve, however, has been criticized because it gives equal weight to all false positive error rates. Alternative indices include the area under the ROC curve in a particular range of false positive rates ('partial' area) and the sensitivity of the test for a single fixed false positive rate (FPR). We present a unified approach for computing sample size for binormal ROC curves and their indices. Our method uses Taylor series expansions to derive approximate large-sample estimates of the variance and covariance of binormal ROC curve parameters. Several examples from diagnostic radiology illustrate the proposed method.

Physicians' judgments of the risks of cardiac procedures. Differences between cardiologists and other internists

OBJECTIVES

The authors compared judgments of the population risks of invasive cardiac procedures made by cardiologists and other internal medicine physicians. Our main hypotheses were that cardiologists' judgments would differ from those made by the other physicians and that cardiologists' judgments would be more accurate than those of other physicians.

METHODS

This was a cross-sectional survey of senior staff and physician-trainees at two teaching hospitals affiliated with a US medical school, Emergency Department physicians at a community hospital in the same metropolitan area, and senior staff and trainees at two teaching hospitals affiliated with a UK school. Judgments of the risks of severe morbidity and death due to Swan-Ganz catheterization, cardiac catheterization, percutaneous coronary angioplasty, and coronary artery bypass grafting were assessed.

RESULTS

Nineteen cardiologists judged the risks of severe morbidity due to all procedures and the risks of death due to all procedures except coronary artery bypass grafting to be significantly lower than did the 78 other internists. Cardiologists more frequently made accurate judgments of the rates of morbidity and death due to cardiac catheterization than did the other internists; other internists more frequently made accurate judgments for the rates of morbidity due to Swan-Ganz catheterization.

CONCLUSIONS

Disagreements about the risks of procedures may arise from a paucity of published data, or from an over-supply of confusing data.

Physicians' survival predictions for patients with acute congestive heart failure

BACKGROUND

Current guidelines suggest that patients with low likelihoods of survival may be excluded from intensive care. Patients with new or exacerbated congestive heart failure are frequently but not inevitably admitted to critical care units.

OBJECTIVE

To assess how well physicians could predict the probability of survival for acutely ill patients with congestive heart failure, and in particular how well they could identify patients with small chances of survival.

METHODS

This was a prospective cohort study done in the emergency departments of a university hospital, a Veterans Affairs medical center, and a community hospital. The study population was consecutive adults for whom new or exacerbated congestive heart failure, diagnosed clinically, was a major reason for the emergency department visit. Physicians caring for the study patients in the emergency departments recorded their judgments of the numeric probability that each patient would survive for 90 days and for 1 year. The patients vital status at 90 days and 1 year was ascertained by multiple means, including interview, chart review, and review of hospital and state databases.

RESULTS

By calibration curve analysis, the physicians underestimated survival probability at both 90 days and 1 year, particularly for patients they judged to have the lowest probabilities of survival. Their predictions had modest discriminating ability (receiver operating characteristic curve areas, 0.66 [SE = 0.020] for 90 days; 0.63 [SE = 0.017] for 1 year). The physicians identified only 15 patients they judged to have a 90-day survival probability of 10% or less, whose survival rate was actually 33.3%.

CONCLUSIONS

Physicians have great difficulty predicting survival for patients with acute congestive heart failure and cannot identify patients with poor chances of survival. Current triage guidelines that suggest patients with poor chances of survival may be excluded from critical care may be impractical or harmful.

Ability of Medicare claims data and cancer registries to identify cancer cases and treatment

The objective of this study is to compare the ability of Medicare and cancer registry data to identify incident cancer cases and initial surgical therapy both singly and in combination. Data from the Virginia Cancer Registry (VCR) were linked to Medicare claims files (Medical Provider Analysis and Review File (MEDPAR)) for Virginia residents aged 65 years and over with breast, colorectal, lung, or prostate cancer diagnosed between 1986 and 1989. MEDPAR found 73-83% of cancer cases identified by VCR. Factors significantly associated with MEDPAR missing a case that was reported to VCR included younger age, male gender, living in an urban area, higher social class, in situ disease, and lack of cancer treatment. A total of 70-82% of cancer cases identified through Medicare claims were reported to the VCR. Older age, female gender, nonwhite race, comorbid conditions, no surgical procedures, multiple cancer admissions, and the position of the cancer diagnostic code on the MEDPAR record were factors significantly related to being missed by the VCR. The rate of capturing initial surgical therapies was similar to that of identifying cases. Combining information from VCR and MEDPAR resulted in increasing sensitivity for identifying incident cases to 92-97%. Using combined data from independent sources may improve reporting, increase the accuracy of cancer incidence estimates, and provide an opportunity to identify reasons for missing data.

Quality of life following bladder training in older women with urinary incontinence

This study investigated the changes in quality of life following a randomized controlled 6-week trial of bladder training in 123 older women with urinary incontinence. Both clinical (diary, pad test) and quality of life measures (Incontinence Impact Questionnaire (IIQ), Center for Epidemiological Studies-Depression Scale (CES-D)) and visual analog scales on symptom burden were obtained at baseline, 6 weeks and 6 months following treatment. All subscales and the composite scale of the IIQ and the visual analog scales were significantly improved following bladder training, with effects maintained 6 months later. No changes were observed in CES-D scores. Women with genuine stress incontinence and those with detrusor instability with or without concomitant stress incontinence had similar improvements. We conclude that bladder training is effective in improving the quality of life of incontinent women regardless of urodynamic diagnosis.

Bacteremia in young urban women admitted with pyelonephritis

The objective of this study was to determine the rate of bacteremia in young women admitted to the hospital with presumed pyelonephritis and compare it with other published rates. The study design was a retrospective, structured chart review and a review of published reports of bacteremic pyelonephritis. An urban county teaching hospital provided the setting for the study. The patients were nonpregnant women (n = 98) 44 years of age or younger who were without bladder dysfunction and who had not been admitted to an intensive care unit. Further criteria for participation included discharge with the diagnosis of acute pyelonephritis. Blood cultures were ordered for 69 women; the results of 64 were noted in the chart. Twenty-three women (35.9% of those cultured; 23.4% of all patients) were diagnosed with bacteremia. In patients for whom blood culture results were obtained, trends developed between those patients with bacteremia and those with complicated pyelonephritis, defined as a known or newly discovered genitourinary abnormality or a risk factor (P = 0.044), those who were black (P = .044), those with higher pulses on admission (P = .050), those with more white blood cells per high-powered field after urinalysis (P = 0.007), and those whose fever lasted longer (P = 0.033). Blood culture results were positive in two patients whose urine cultures were negative. This comparatively high bacteremia rate supports routine ordering of blood cultures for urban women suspected of having pyelonephritis.

Efficacy of estrogen supplementation in the treatment of urinary incontinence. The Continence Program for Women Research Group

OBJECTIVE

To assess the efficacy of cyclic postmenopausal hormone replacement in treating urinary incontinence in hypoestrogenic women.

METHODS

Eighty-three hypoestrogenic women complaining of urinary incontinence were included. All patients were community-dwelling, age 45 years or older, with involuntary loss of urine occurring at least once a week and urodynamic evidence of genuine stress incontinence and/or detrusor instability. Evaluation consisted of a comprehensive clinical and urodynamic research protocol. The hypoestrogenic entry criterion was a plasma estradiol level of 30 pg/mL or less. Parabasal cells on vaginal smears were also monitored. The primary outcome was the number of incontinent episodes per week, as documented on a standardized urinary diary. Secondary outcomes were the quantity of fluid loss, voluntary diurnal and nocturnal micturition frequency, generic and condition-specific health-related quality of life measurements, and patient satisfaction. A randomized, placebo-controlled, double-blind design was used. Subjects in the treatment group were given conjugated equine estrogens (0.625 mg) and medroxyprogesterone (10 mg) cyclically for 3 months. Controls received placebo tablets.

RESULTS

(All results are presented as mean +/- standard deviation.) Subjects were 67 +/- 9 years old. The menopause duration was 18 +/- 11 years. The duration of incontinence was 9 +/- 9 years. Estradiol level at baseline was 9 +/- 9 pg/mL, and the parabasal cell count was 42 +/- 44%. The number of incontinent episodes at baseline was 13 +/- 10 for the treatment group and 16 +/- 4 for controls. No significant changes occurred in the number of incontinent episodes after treatment: 10 +/- 10 for the treatment group, and 13 +/- 14 for the controls (P = .7). Also, fluid loss was not changed: 176 +/- 106 g for the treatment group and 64 +/- 88 g for the control group at baseline, and 101 +/- 150 and 51 +/- 69 g after treatment, respectively (P = .7). There were no significant differences for either diurnal or nocturnal voluntary micturition, quality of life measures, or patient's perception of improvement.

CONCLUSION

Three-month cyclic hormone replacement therapy did not affect either clinical or quality of life variables of incontinent, hypoestrogenic women. Long-term effects are unlikely to be substantially different. The use of estrogen supplementation as preventive or adjuvant therapy was not evaluated in this study.

Randomized prospective comparison of needle colposuspension versus endopelvic fascia plication for potential stress incontinence prophylaxis in women undergoing vaginal reconstruction for stage III or IV pelvic organ prolapse. The Continence Program for Women Research Group

OBJECTIVE

Severe prolapse may mask potential genuine stress urinary incontinence in women. Some have suggested that a suspending urethropexy be performed in women who have potential genuine stress incontinence demonstrated by barrier reduction of the prolapse preoperatively. Our aim was to compare outcomes after prolapse surgery that included a formal bladder neck suspension with those operations that did not.

STUDY DESIGN

This prospective randomized clinical trial assigned 32 women with bladder neck hypermobility and stage III or IV pelvic organ prolapse to receive either a needle colposuspension or bladder neck endopelvic fascia plication as part of the vaginal reconstructive surgery. Twenty-nine subjects underwent detailed clinical, anatomic, urodynamic, and quality-of-life evaluations before and 6 weeks and 6 months after surgery; 23 completed urinary diary and quality-of-life evaluations after a mean of 2.9 years.

RESULTS

Needle colposuspension increased short-term complications without providing additional protection from de novo stress incontinence. Barrier testing before surgery predicted urethral sphincteric resistance after surgery; however, such testing neither predicted a patient's function after surgery nor indicated the need for a suspending urethropexy. The combination of a needle colposuspension with a sacrospinous ligament suspension predisposed to the early development of support defects of the upper anterior vaginal segment and to failure of bladder neck support.

CONCLUSIONS

Preoperative barrier testing in women with severe prolapse is not useful in identifying individuals who require a suspending urethropexy. Needle colposuspension increases short-term complications, lacks durability, and may predispose to early and severe recurrent anterior prolapse when performed with a sacrospinous ligament vault suspension.

Prediction of survival of critically ill patients by admission comorbidity

The objective of this study was to determine how well the Charlson index of comorbidity would predict mortality of critically ill patients; and how the predictive ability of the index would compare with that of the comorbidity component (Chronic Health Points) of the APACHE II system. This prospective cohort study included in its setting an intensive care unit (ICU) and intermediate ICU (IICU) in a teaching hospital. Patients included a previously assembled inception cohort of 201 patients consecutively admitted to either unit, followed until death or discharge from the hospital, excluding patients admitted after coronary artery bypass grafting, for planned dialysis, or transferred to the IICU from another intensive care unit. Main outcome measures were recorded as death in hospital versus survival at discharge. For each patient we had prospectively obtained all data necessary to predict the probability of in-hospital death using the APACHE II system, and to classify comorbidity using the Charlson index. The Charlson index had significant ability to discriminate between patients who would live and who would die (ROC curve area = 0.67, SE = 0.05). The Chronic Health Points component of APACHE II had no significant discriminating ability (ROC area = 0.57, SE = 0.05), although the full APACHE II system was an excellent predictor (area = 0.87, SE = 0.04). Logistic regression analyses suggested that the Charlson index could contribute significant (p = 0.03) prognostic information to that obtained from the components of APACHE II other than Chronic Health, i.e., acute physiological derangement, age, and reason for admission, but the Chronic Health Points component of APACHE II could not so contribute to the rest of APACHE II (p = 0.19). Our conclusion is that use of the detailed information about comorbidity captured by the Charlson index could improve prognostic predictions even for critically ill patients.

Comparison between urinary diaries completed with and without intensive patient instructions

The evaluation of the incontinent patient relies on accurate assessment of urinary symptoms. Although the 7 day urinary diary is a reproducible method of data collection, the optimal means of implementing this diary is unknown. The urinary diary is usually employed after the initial clinical pathophysiologic evaluation has been performed and the patient has received intensive instructions on the correct method of diary completion. This study aims to determine if a urinary diary provided to the patient prior to the initial clinical evaluation along with minimal instructions will provide symptom data comparable with that obtained by conventional methods. Two hundred seventy-eight women were recruited to participate in one of three clinical trials for urinary incontinence treatment. All subjects completed a diary prior to the initial clinical evaluation, the Minimal Instruction Diary, and a second diary after clinical evaluation, the Intensive Instruction Diary. The Minimal and the Intensive Instruction Diaries were compared for number of episodes of diurnal and nocturnal voluntary micturition and incontinence. Pearsons' correlation coefficients ranged from 0.67 to 0.78 for each of the urinary symptoms. Intra-subject comparison indicated a decline in reports of nocturnal voluntary micturitions from the Minimal to the Intensive Instruction Diary. No demographic or urodynamic parameters could account for the difference. The 7 day urinary diary is a reliable tool to asses urinary symptoms, which can be utilized prior to the initial clinical evaluation. Its case of use and practicality make this diary promising for use in a wider patient population.

Correlation of urodynamic measures of urethral resistance with clinical measures of incontinence severity in women with pure genuine stress incontinence. The Continence Program for Women Research Group

OBJECTIVE

Our aim was to correlate multiple measures of urethral resistance with five clinical measures of incontinence severity in women with pure genuine stress incontinence.

STUDY DESIGN

Seventy-five women with pure genuine stress incontinence underwent passive and dynamic urethral pressure profilometry and Valsalva leak point pressure determinations. The standardized and validated measures of incontinence severity included (1) the number of incontinent episodes, (2) the number of continence pads used recorded in a prospective 1-week urinary dairy, (3) grams of fluid loss on a pad quantitation test, and (4) two condition-specific quality-of-life scales, the urogenital distress inventory and the incontinence impact questionnaire. The urodynamic and severity measures were compared with Pearson product-moment correlation analysis.

RESULTS

There were no significant correlations between dynamic urethral pressure profile pressure transmission ratios and any measure of incontinence severity. Passive urethral pressure profile variables correlated significantly with incontinence episodes and pad use. Valsalva leak point pressures correlated significantly with pad use and quantitation testing. None of the urodynamic measurements was significantly correlated with either of the quality-of-life scales, but our power to demonstrate a correlation was limited.

CONCLUSIONS

Both passive urethral pressure profile measures and Valsalva leak point pressures correlate with some severity measures of genuine stress incontinence. Although inefficient pressure transmission during stress is critical to the pathogenesis of genuine stress incontinence, the severity of the pressure transmission defect is not related to clinical severity. Conversely, impairment of intrinsic urethral resistance is not essential to the pathogenesis of genuine stress incontinence, but the degree of sphincteric impairment is related to severity once the condition exists.

Valsalva leak point pressures in women with genuine stress incontinence: reproducibility, effect of catheter caliber, and correlations with other measures of urethral resistance. Continence Program for Women Research Group

OBJECTIVES

The Valsalva leak point pressure has been promoted as an alternative to urethral pressure profilometry as a measure of urethral resistance in women with genuine stress incontinence. Our aims were to evaluate the reproducibility of the Valsalva leak point pressure, to assess the effect of catheter caliber on the Valsalva leak point pressure, and to compare vesical Valsalva leak point pressure to other measures of urethral resistance.

STUDY DESIGN

Sixty consecutive women with genuine stress incontinence underwent duplicate Valsalva leak point pressure determinations by use of 8F and 3F vesical and 8F vaginal catheters. Subjects also underwent a standard resting urethral pressure profilometry, cough leak point pressure determinations, and pressure-flow micturition studies.

RESULTS

Leakage was demonstrated on both Valsalva maneuvers in approximately 80% of subjects with both catheters. In subjects who leaked with both strains there was an extremely high correlation between the test-retest Valsalva leak point pressure within both catheters. The intercatheter correlation between the 8F and 3F Valsalva leak point pressures was significant but much weaker than the intracatheter correlations; 8F Valsalva leak point pressures were significantly higher than 3F Valsalva leak point pressures, although there were individual exceptions to this observation. Urethral pressure profilometry measures and micturition opening pressures were poorly correlated with Valsalva leak point pressure. Cough and vaginal Valsalva leak point pressures were significantly correlated with vesical Valsalva leak point pressure, but cough leak point pressures were significantly higher and vaginal Valsalva leak point pressures were significantly lower than the vesical Valsalva leak point pressure.

CONCLUSIONS

Valsalva leak point pressure is a simple and reproducible technique for evaluating urethral resistance in women with genuine stress incontinence. However, variations in Valsalva leak point pressure measurement must be precisely described, standardized, and validated before a technique can be advocated for clinical use.

Controlling for confounding by indication for treatment. Are administrative data equivalent to clinical data?

There has been controversy about whether confounding by indication for treatment--that is, owing to physicians' conscious efforts to base treatment decisions on patients' pretreatment prognoses--makes nonrandomized, observational comparisons of treatments invalid. Some now believe evidence from studies of practice variation means that physicians' treatment decisions have little relationship to patients' prognostic clinical characteristics. They therefore believe that patients who receive different treatments should vary little in their baseline prognoses, and multivariable statistical methods should easily be able to adjust for any resultant confounding, even when analyses are restricted to administrative rather than clinical data. The objective of this study is to determine whether adjusting for variables found in administrative data sets produces the same results as does adjusting for clinical variables. Data were reanalyzed from a previously enrolled prospective sequential cohort of 227 hospitalized patients with suspected bacteremia who had blood cultures. The treatment under study was aminoglycoside therapy given empirically, that is, before blood culture results were known. The outcome of interest was death during hospitalization. Univariable analyses suggest that empiric aminoglycoside therapy had a positive association with mortality, by univarible logistic regression, odds ratio (OR = 3.1 (95% confidence interval = [1.6, 5.8]). Few administrative variables had univariable associations with aminoglycoside use or death. Multivariable analyses that controlled for them still suggest that aminoglycosides increased mortality; for example, in one model, adjusted OR = 3.2 (1.6, 6.5). Many clinical variables were strongly associated with aminoglycoside use or death. Analyses that controlled for them suggested that empiric aminoglycosides did not increase mortality; for example, in one model, adjusted OR = 1.2 (0.55, 2.7.) Results of adjustment for confounding using administrative data disagreed with the results of adjustment using clinical data. It is concluded that nonrandomized, observational outcome studies that fail to control for prognostic differences between patients receiving different treatments may not always be valid.

Short forms to assess life quality and symptom distress for urinary incontinence in women: the Incontinence Impact Questionnaire and the Urogenital Distress Inventory. Continence Program for Women Research Group

This article describes short form versions of the Incontinence Impact Questionnaire (IIQ) and the Urogenital Distress Inventory (UDI). These instruments assess life impact and symptom distress, respectively, of urinary incontinence and related conditions for women. All subsets regression analysis was used to find item subsets that best approximated scores of the long form versions. The approach succeeded in reducing the 30-item IIQ and the 19-item UDI to 7- and 6-item short forms, respectively. The short form versions may be more useful than the long form versions in many clinical and research applications.

Comparison of "subjective" and "objective" measures of severity of urinary incontinence in women. Program for Women Research Group

The aims of this study were to compare "subjective" measures of severity of urinary incontinence to similar "objective" measures, establish their statistical correlation, and determine the effect of specific urodynamic diagnosis on such correlations. Baseline data was available from 265 women entered into a clinical trial studying pharmacologic and behavioral interventions for urinary incontinence. The "subjective" measures of incontinence were obtained by patient recall during history taking and included: the number of incontinent episodes in 1 week, the number of perineal pads used during 1 week, and the number of clothing changes required due to wetness. The "objective" measures of severity included: the number of incontinent episodes per week as recorded on a 7-day diary, the number of perineal pads used per week, also recorded on a diary, and the amount of fluid lost during a standardized pad test. Analysis consisted of Pearson correlations and linear regressions to determine equations for the prediction of objective measurement on the basis of the corresponding subjective measure. Significant positive correlations were seen between "subjective" and "objective" measurements for the comparisons of number of weekly incontinent episodes (R = 0.63), and for the weekly number of pads used (R = 0.81). The comparison between the number of clothing changes and the amount of fluid lost during pad testing was also significantly but less strongly correlated (R = 0.24). For the correlations between subjective and objective determinations of urinary incontinent episodes and for those between clothing changes and pad testing, the urodynamic diagnosis had no effect on the correlation coefficients, but did have a statistically significant effect on the intercept.(ABSTRACT TRUNCATED AT 250 WORDS)

Postoperative radiotherapy improves survival in squamous cell carcinoma of the hypopharynx

BACKGROUND

Postoperative radiation is considered to be "standard of care" therapy for advanced, resectable squamous cell carcinoma of the head and neck. This approach has been supported by retrospective data but has not been validated in randomized clinical trials.

PATIENTS AND METHODS

The present analysis examined the clinical course of 110 patients with squamous cell cancer of the hypopharynx treated with surgery alone (n = 65) and postoperative radiotherapy alone (n = 45) between 1966 and 1990. Staging of patients was performed using the 1988 American Joint Committee on Cancer criteria. Cox regression analyses identified clinical and pathologic factors that were significant for disease-free and overall survival. Crude and adjusted cancer-specific survival rates were calculated.

RESULTS

The postoperative radiotherapy group presented with more advanced disease than the surgery alone group (stage III and IV combined, 96% versus 77%, P = 0.015). Crude 5-year cancer-specific survival probabilities were 43% for the postoperative therapy group and 27% for the surgery alone group (P = NS). Adjusted 5-year survival rates, correcting for differences in significant prognostic variables between groups, were 18% and 48%, respectively, for the surgery and postoperative radiotherapy groups (P = 0.029).

CONCLUSIONS

The addition of postoperative radiotherapy was associated with improved disease-free and adjusted overall cancer-specific survival in patients with advanced hypopharyngeal squamous cancer. The potential survival benefit of postoperative radiotherapy should be addressed in a randomized clinical trial.

Estrogen therapy in the management of urinary incontinence in postmenopausal women: a meta-analysis. First report of the Hormones and Urogenital Therapy Committee

OBJECTIVE

To apply a meta-analysis to available data to evaluate the efficacy of estrogen therapy in the management of postmenopausal women with urinary incontinence.

METHODS

The literature review incorporated English language articles based on a search of EXCERPTA MEDICA, BIOSIS, and MEDLINE from January 1969 to June 1992. Criteria included: peer-reviewed original article, confirmed diagnosis of urinary incontinence, an estrogen-treated group, and outcome data on subjective improvement, quantitation of fluid loss, or maximum urethral closure pressure. In addition, the data had to allow comparison between treated and control groups in controlled trials or an estimated change in uncontrolled series. meta-analytic methods were applied only to studies considered to be controlled clinical trials.

RESULTS

Of 166 articles reviewed, 143 did not meet the entry criteria; six were considered controlled clinical trials and 17 were uncontrolled series. Meta-analysis found an overall significant effect of estrogen therapy on subjective improvement for all subjects (P < .01) and for subjects with genuine stress incontinence alone (P < .05). The results showed no significant effect on quantity of fluid loss but a significant effect (P < .05) on maximum urethral closure pressure. However, the latter result was influenced by only one study showing a large effect.

CONCLUSION

It appears from this analysis that estrogen subjectively improves urinary incontinence in postmenopausal women. However, the studies included nonhomogeneous groups, and the diagnostic criteria, therapeutic interventions, and outcome assessments varied considerably.

Computer-assisted instruction in probabilistic reasoning during the inpatient medicine clerkship

The acceptability and utility of computer-assisted instruction in probabilistic reasoning was assessed for medicine clerkship students. After a pretest, the experimental (n = 40), but not the control students (n = 39), completed a program that we designed. The program contained the test and its answers. After program exposure, experimental students rated their knowledge of the program's content significantly higher (p = 10(-4)) than control students. On the identical posttest, experimental students also scored significantly higher than control students (p = 10(-4)) and improved their scores significantly more (p = 10(-3)). They rated ease-of-use items significantly higher than content-relevance items (p = 10(-4)). We conclude that computer-assisted instruction in probabilistic reasoning is acceptable to clerkship students, and that it may improve their knowledge and skills in this area. However, students may rate the vehicle of this instruction more highly than its content.

Cigarette smoking and urinary incontinence in women

OBJECTIVE

The goal of this case control study was to evaluate the relationship between smoking and female urinary incontinence.

STUDY DESIGN

The study included 606 women whose smoking histories were known; 322 were incontinent and 284 were continent. The condition(s) causing each subject's incontinence was determined by urodynamic testing; 40% of the continent subjects had the same testing.

RESULTS

There were highly significant overall differences (p = 0.000009) in the distribution of current, former, and never smokers between incontinent (35%, 16%, 49%) and continent (24%, 8%, 68%) groups. The odds ratio for genuine stress incontinence was 2.20 for former (95% confidence interval 1.18 to 4.11) and 2.48 for current smokers (95% confidence interval 1.60 to 3.84); for motor incontinence it was 2.92 for former (95% confidence interval 1.58 to 5.39) and 1.89 (95% confidence interval 1.19 to 3.02) for current smokers. Increasing daily and lifetime cigarette consumption was associated with an increasing odds ratio for genuine stress incontinence but not for motor incontinence. The increased risk for incontinence was not due to differences in age, parity, weight, or hypoestrogenic status.

CONCLUSION

The data establish a strong statistical relationship between current and former cigarette smoking and both stress and motor urinary incontinence in women.

Combining and comparing area estimates across studies or strata

A method for combining and comparing medical tests across studies or strata is presented. The area under the receiver operating characteristic (ROC) curve is the parameter of interest to be used for comparison. The combined area is a weighted average of the areas under the curve in each study or stratum. A chi-square test for equality of areas across strata can be used to compare the areas. The power of the test is also explored. The methods presented are simple and require only knowledge of estimates of area and their standard errors. Either parametric or nonparametric estimates of the area can be used.

Obesity and lower urinary tract function in women: effect of surgically induced weight loss

OBJECTIVE

The subjective and objective effects of massive weight loss on lower urinary tract function in morbidly obese women were examined.

STUDY DESIGN

Thirteen subjects underwent a comprehensive evaluation of lower urinary tract function before and 1 year after surgically induced weight loss.

RESULTS

We demonstrated significant improvements in lower urinary tract function after weight loss. Of 12 subjects who complained of incontinence before surgery only three complained of incontinence (p = 0.004) and only one requested treatment after weight loss. Objective and subjective resolution of both stress and urge incontinence was documented. Statistically significant changes were seen in measures of vesical pressure, the magnitude of bladder pressure increases with coughing, bladder-to-urethra pressure transmission with cough, urethral axial mobility, number of incontinence episodes, and the need to use absorptive pads.

CONCLUSION

Weight reduction is desirable for obese women complaining of urinary incontinence and may obviate the need for further incontinence therapy.

Stage III breast cancer: is neoadjuvant chemotherapy always necessary?

Optimal management of locally advanced breast cancer is controversial. Claims of superiority for neoadjuvant systemic therapy are based on comparisons with outdated historical control groups who received no chemotherapy. Between 1978 and 1987, 118 patients with locally advanced breast cancer underwent treatment and follow-up at the Medical College of Virginia. Median follow-up was 44 months (range 3-119 months). Actuarial 5-year survival for the entire group was 54%. This compares favorably with recent series using neoadjuvant chemotherapy in which 5-year survival rates of 40-65% have been reported. Primary tumor size larger than 9 cm, metastases to more than 50% of regional lymph nodes, and the presence of inflammatory disease were significant prognostic indicators. This series represents a contemporary control group of patients with locally advanced breast cancer in whom conventionally accepted guidelines for local and postoperative systemic adjuvant therapy were used. Until the optimal sequence of therapy is determined by prospective randomized trials, series such as this may serve as more appropriate controls to which the results of new therapies could be compared.

Ego bias, reverse ego bias, and physicians' prognostic

OBJECTIVE

To evaluate the effects of "ego bias" on physicians' prognostic judgments. Ego bias is defined as systematic overestimation of the prognosis of one's own patients compared with the expected outcome of a population of similar patients.

DESIGN

A prospective study of an inception cohort of critically ill patients followed until death or discharge from the hospital.

PATIENTS

Consecutive patients admitted to either an ICU or an intermediate ICU at a teaching hospital during January and February 1987, excluding patients admitted after coronary artery bypass grafting, for elective dialysis, or transferred to the intermediate ICU from another critical care unit. MAIN OUTCOME MEASURES AND COMPARISONS: House officers' and critical care attending physicians' assessments of the likelihood of inhospital survival for each patient, and their assessments of the overall survival rate of ICU and intermediate ICU patients were compared with each other and with actual survival rates.

RESULTS

The attending physicians' predictions for individual patients were significantly lower than their judgments of the overall survival rate, 79.8% vs. 88.0%, p = .0067, suggesting the presence of a "reverse ego bias." The house officers' predictions for individual patients were significantly higher than their judgments of the overall survival rate, 73.5% vs. 68.9%, p = .018, suggesting the presence of ego bias. The magnitude and directions of these differences varied significantly among the attending physicians (F = 4.3, degrees of freedom = 3, p = .0062 by repeated-measures analysis of variance) and the house officers (F = 6.3, degrees of freedom = 5, p = .0001).

CONCLUSIONS

The critical care attending physicians exhibited reverse ego bias that was mainly a function of their optimism about the overall survival rate for critically ill patients. The house officers exhibited ego bias that was mainly a function of their pessimism about the overall survival rate for critically ill patients.

Altered membrane anisotropy gradients of plasma membranes of living peripheral blood leukocytes in aging and Alzheimer's disease

Several reports have suggested that membrane rigidity, a term that refers to the relative motion of membrane constituents, is decreased in Alzheimer's Disease. Accordingly, a series of fluorescent membrane probes was used to evaluate the rigidity from the surface to the center of the outer hemi-leaflet of the plasma membrane of living neutrophils, monocytes and lymphocytes. Anisotropy, a parameter which increases with increasing membrane rigidity, was calculated from flow cytometric measurements of vertically and horizontally polarized components of the fluorescence emission of the probes. These preliminary experiments suggest that whereas membrane rigidity in certain regions of the plasma membrane of peripheral blood leukocytes is increased as expected in elderly controls, it is decreased in Alzheimer's disease.

Efficacy of bladder training in older women with urinary incontinence

The efficacy of bladder training was evaluated in a randomized clinical trial involving 123 noninstitutionalized women 55 years and older with urinary incontinence. Subjects were urodynamically categorized as those with urethral sphincteric incompetence (N = 88) and those with detrusor instability with or without concomitant sphincteric incompetence (N = 35). Bladder training reduced the number of incontinent episodes by 57%; the effect was similar for both urodynamic diagnostic groups. The quantity of fluid loss was reduced by 54%. This was greater for patients with detrusor instability than for those without it. Diurnal and nocturnal voluntary micturitions were also reduced. The effect on nocturnal micturition, however, was not observed in subjects with unstable detrusor function. It is recommended that bladder training be considered as an initial step in treatment of women with urinary incontinence. Provided prior comprehensive clinical evaluation is done, it can be prescribed without the need for urodynamic characterization.

Determining a range of false-positive rates for which ROC curves differ

Many indices have been proposed for summarizing the information contained in the ROC curve. When comparing two ROC curves, though, there are times when global summary measures are either not optimal or not appropriate. The author presents a method for directly comparing true-positive rates for two diagnostic, screening or prognostic tools, determining over what range of false-positive values the tests differ. The method is applicable for independent or dependent samples. An example concerning gallium citrate imaging is presented, as well as an example using a prognostic index for severity of illness in the ICU. The range of false-positive rates for which the ROC curves differ is determined for each example.

Urinary incontinence in community-dwelling women: clinical, urodynamic, and severity characteristics

Descriptive data on 145 community-dwelling older women with urinary incontinence are presented. Assessment included history, physical and functional examinations, and urodynamic and severity evaluations. Patients were 67 +/- 8 years old, mentally and functionally intact, predominantly white, and of middle-to-upper socioeconomic strata. Specific urodynamic criteria were used to establish the diagnosis of sphincteric incompetence and detrusor instability. Fifteen (10%) did not fulfill either criteria, 90 (62%) had sphincteric incompetence, 17 (12%) had detrusor instability, and 23 (16%) had both. Detrusor and urethral function variables showed some impairment in all patients. Impairment was least in subjects without demonstrable diagnosis and worst in those with both disorders (p less than 0.01). The findings suggest that detrusor and urethral functions are impaired in all incontinent women and that the degree of impairment varies. The impairment seems worse when both urodynamic diagnoses are demonstrable. The data support the pathophysiologic association of urethral and detrusor dysfunctions.

Analyzing a portion of the ROC curve

The area under the ROC curve is a common index summarizing the information contained in the curve. When comparing two ROC curves, though, problems arise when interest does not lie in the entire range of false-positive rates (and hence the entire area). Numerical integration is suggested for evaluating the area under a portion of the ROC curve. Variance estimates are derived. The method is applicable for either continuous or rating scale binormal data, from independent or dependent samples. An example is presented which looks at rating scale data of computed tomographic scans of the head with and without concomitant use of clinical history. The areas under the two ROC curves over an a priori range of false-positive rates are examined, as well as the areas under the two curves at a specific point.

How well can physicians estimate mortality in a medical intensive care unit?

The accuracies of physicians' predictions of mortality for 523 patients in a medical intensive care unit were compared with estimates derived from a logistic model. The model utilized a popular severity-of-illness measure, the APACHE II. Accuracy was assessed through its components resolution (discrimination) and calibration. Physicians could better discriminate survivors from nonsurvivors, as measured by the area under the receiver operating characteristic curve (0.89 for physicians vs 0.83 for APACHE II model, p less than 0.001) and by resolution (0.103 for physicians vs 0.130 for APACHE II model, p less than 0.001). Overall, the APACHE II model was better calibrated (0.003 for APACHE II vs 0.021 for physicians, p less than 0.001). While the APACHE II model was better calibrated in the central probability ranges, physicians could more accurately identify those most likely to die. Decisions on withholding or withdrawing treatment are being made daily in intensive care units based on physicians' subjective prognostic estimates. At least for experienced physicians at a major medical center, these estimates are comparable in accuracy to quantitative models.

The impact of age on utilization of intensive care resources

The impact of age on admission practices and pattern of care were examined in 599 admissions to a medical intensive care unit (MICU) and 290 patients on the conventional medical care divisions of the same hospital. Four age groups were compared: under 55, 55 to 64, 65 to 74, and 75 years of age and over. Severity of illness and prior health were assessed using the Acute Physiology Score (APS) and the Chronic Health Evaluation (CHE) instruments. Resource utilization was assessed using the Therapeutic Intervention Scoring System (TISS) and hospital charges. Patients 65 years of age and over comprised 48% of the MICU sample. The distribution of CHE was different among the four groups. Twenty-one percent of patients under 55 years of age had no prior chronic illness, as compared to less than 8% of older patients. The APS at admission was similar for all age groups, as was admission, daily, and total TISS. Hospital survival declined with age from 85% to 70%, while the likelihood of being designated do not resuscitate (DNR) increased from 10% to 24%. Differences in hospital survival disappeared when controlling for severity of illness and prior health, but differences in DNR status did not. Still, elderly DNR patients received as much resources as younger DNR patients and this was more than non-DNR patients. The sample of patients treated on conventional medical divisions had age distribution similar to the MICU sample. There was some evidence that admission APS (median, 5, 5, 6, 6, respectively, P = .055) and maximum APS (median, 5, 5, 7, 8, respectively, P = .023) differed slightly across age groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparing the areas under more than two independent ROC curves

For a diagnostic test, the area under the associated receiver operating characteristic (ROC) curve is considered a measure of the efficacy of the test. Statistical methodology for the comparison of the areas under more than two independent ROC curves is developed. The jackknife is used to devise an F test using the pseudovalues as data. A Studentized range (SR) test is also considered using the original area estimates. A Monte Carlo study is performed to evaluate the significance level and power of the two test statistics. Both statistics conform well to the 0.10, 0.05, and 0.01 significance levels when the sampling design is balanced between cases with and without the disease. Power is also comparable. For unbalanced designs, the SR test on the original area estimates is very conservative while the F test on pseudovalues performs well. The F test is recommended as the method of choice for comparing the areas, although for balanced designs the SR test, with its computational simplicity, may be preferred.

Iron deficiency anemia and iron therapy effects on infant developmental test performance

The behavioral effects of iron deficiency and its treatment were evaluated in a double-blind randomized controlled community-based study of 191 Costa Rican infants, 12 to 23 months of age, with various degrees of iron deficiency. The Bayley Scales of Infant Development were administered before and both 1 week and 3 months after IM or oral administration of iron. Appropriate placebo-treated control infants were also tested. Infants with iron deficiency anemia showed significantly lower mental and motor test scores, even after considering factors relating to birth, nutrition, family background, parental IQ, and the home environment. After 1 week, neither IM nor oral iron treatments differed from placebo treatment in effects on scores. After 3 months, lower mental and motor test scores were no longer observed among iron-deficient anemic infants whose anemia and iron deficiency were both corrected (36%). However, significantly lower mental and motor test scores persisted among the majority of initially anemic infants (64%) who had more severe or chronic iron deficiency. Although no longer anemic, they still showed biochemical evidence of iron deficiency after 3 months of treatment. These persistent lower scores suggest either that iron therapy adequate for correcting anemia is insufficient to reverse behavioral and developmental disturbances in many infants or that certain ill effects are long-lasting, depending on the timing, severity, or chronicity of iron deficiency anemia in infancy.

Profile of medical ICU vs. ward patients in an acute care hospital

Demographic characteristics, severity of illness, resource utilization, and outcome were compared for 351 medical ICU (MICU) and 329 ward patients of a large, urban, tertiary care hospital. Patients were similar in age, race, sex, and insurance coverage. Both MICU and ward patients had similar health status distributions 3 to 6 months before hospitalization. Severity of illness, as measured by the Acute Physiology Score was significantly higher in the MICU patients, although there was considerable overlap in the distributions. Resource utilization, as measured by the Therapeutic Intervention Scoring System (TISS), was also significantly higher in the MICU; again, the distributions of the two groups overlapped, although mostly for low values of TISS. Of the MICU sample, 28% to 30% never required active therapeutic interventions; 11% of the ward sample received active treatment. The significant overlap between MICU and ward distributions of severity of illness and resource utilization has implications for admission and discharge policies.