Abstract PD4-05: Survivorship care planning is associated with breast cancer survivors' reported quality and coordination of care

Primary goals of cancer survivorship care planning (SCP) include the assessment of ongoing risks for late effects and the coordination of health care. SCP strives to improve communication and coordination between survivors, health-care, and supportive care providers. Results on the effectiveness of SCP have been mixed. We report on the relationship between self-reported indicators of care with two essential elements of SCP: receipt of a written treatment summary and written instructions for routine cancer check-ups.

Methods: The Greater Plains Collaborative Clinical Data Research Network conducted the Share Thoughts on Breast Cancer survey across 8 cancer-care delivery sites across the Midwest. Participants were women age 18 years and older who had completed treatment for noninvasive or invasive (but not metastatic) breast cancer diagnosed from 1/1/2013 to 5/1/2014. Women were excluded if diagnosed with lobular carcinoma in situ, had previously been diagnosed with cancer per tumor registry records, did not report having cancer-directed surgery, or did not respond to questions about survivorship care planning. Logistic regression was used to examine characteristics and outcomes associated with a three-category SCP summary variable: (a) received both a written treatment summary and instructions for follow-up care; (b) received only one of these elements; or (c) received neither element. Adjustment variables included age at diagnosis, race, marital status at diagnosis, education, history of smoking, number of comorbidities, self-report that one health professional coordinated cancer care, type of surgery, and treatment with chemotherapy, radiation or hormones, and practice site.

Results: Of the 1148 survivors meeting study criteria, 485 (42.2%), 420 (36.6%), and 243 (21.2%) reporting receiving both SCP elements, one element, or no element, respectively. Several factors were associated with receiving elements of SCP: Those who reported having a single health professional who coordinated their cancer care were twice as likely to receive both elements of the SCP vs neither element (OR=2.3; 95% CI 1.6-3.2). Of patients who received both SCP elements, 88% reported excellent/very good quality of care compared to 73% who received neither element (p = .001). Respondents who reported always knowing who to ask questions about their cancer were far more likely to have received both elements vs neither element (OR=10.1; 95% CI 5.2-19.4). No association was observed between SCP and cancer care delivery site.

Conclusions: Breast cancer survivors who reported receiving a written summary of treatment and instructions for follow-up care reported better quality of cancer care, and they were also more confident about how to find answers to cancer related questions. Survivors who receive SCP were also more likely to have a single health professional coordinating their cancer care, potentially illustrating how SCP may fit into overall care processes.

Citation Format: McDowell BD, Klemp J, Blaes A, Cohee AA, Trentham-Dietz A, Kamaraju S, Otte JL, Rock JL, Rubenstein L, Chrischilles EA. Survivorship care planning is associated with breast cancer survivors' reported quality and coordination of care [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr PD4-05.

The primary care physician and Alzheimer's disease: an international position paper

This paper aims to define the role of the primary care physician (PCP) in the management of Alzheimer's disease (AD) and to propose a model for a work plan. The proposals in this position paper stem from a collaborative work of experts involved in the care of AD patients. It combines evidence from a literature review and expert's opinions who met in Paris, France, on July 2009 during the International Association of Geriatrics and Gerontology (IAGG) World Congress. The PCP's intervention appears essential at many levels: detection of the onset of dementia, diagnostic management, treatment and follow-up. The key role of the PCP in the management of AD, as care providers and care planners, is consolidated by the family caregiver's confidence in their skills. In primary care practice the first step is to identify dementia. The group proposes a "case finding" strategy, in target situations in which dementia should be detected to allow, secondarily, a diagnosis of AD, in certain cases. We propose that the PCP identifies 'typical' cases. In typical cases, among older subjects, the diagnosis of "probable AD" can be done by the PCP and then confirm by the specialist. While under-diagnosis of AD exists, so does under-disclosure. Disclosure to patient and family should be done by both specialist and PCP. Then, the PCP has a central role in management of the disease with the general objectives to detect, prevent and treat, when possible, the complications of the disease (falls, malnutrition, behavioural and psychological symptoms of dementia). The PCP needs to give basic information to the caregiver on respite care and home support services in order to prevent crisis situations such as unplanned institutionalisation and "emergency" hospital admission. Finally, therapeutic research must be integrated in the daily practice of PCP. It is a matter of patients' right to benefit from access to innovation and clinical research whatever his age or diseases, while of course fully respecting the rules and protective measures that are in force.

Psychological screening of children for participation in nontherapeutic invasive research

BACKGROUND

The need for children to participate in research has raised concerns about ethical issues surrounding their participation.

OBJECTIVES

To describe a protocol of preresearch psychological screening and postresearch outcomes and to present the results of the screening process for a nontherapeutic, invasive research study.

DESIGN AND SETTING

Descriptive study carried out at The University of Iowa Hospitals and Clinics, Iowa City.

PARTICIPANTS

Twenty-eight children (mean age, 10.6 years) were screened, with 4 not completing the research study and another 4 unavailable for psychological follow-up.

MAIN OUTCOME MEASURES

Prescreening interviews with parent and child and screening measures of appropriate child cognitive abilities and behavior; postscreening parent and child questionnaires.

RESULTS

Of the 4 children who did not complete the research study, 3 were identified with increased anxiety during the screening and were advised to not participate in the study. The primary motivator for participation was monetary reimbursement (14 parents [82%]; 15 children [75%]), followed by altruistic reasons (10 parents [59%]; 4 children [20%]). Before participating, none of the children reported concerns related to participating in the study. However, on follow-up, 9 (45%) of the children reported that they had had concerns before participating. Follow-up assessment showed that parents underestimated their children's concerns related to sexual development assessment and intravenous insertion.

CONCLUSIONS

Children with increased anxiety may not be appropriate participants in potentially anxiety-provoking research. Children's reports of concerns may change from preparticipation to postparticipation, and discrepancies may exist between parent and child reports of concerns with research participation. Further research is needed to ensure children's safe participation in research.

Two-year effects of quality improvement programs on medication management for depression

BACKGROUND

Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression.

METHODS

A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists.

RESULTS

Participants enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group.

CONCLUSIONS

Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.

Initiation of nonselective alpha1-antagonist therapy and occurrence of hypotension-related adverse events among men with benign prostatic hyperplasia: a retrospective cohort study

BACKGROUND

Treatment of benign prostatic hyperplasia (BPH) with nonselective alpha1 antagonists such as terazosin, doxazosin, and prazosin results in blood pressure reduction due to vasodilation.

OBJECTIVE

Using claims data from a large Medigap plan, we examined the effect of initiating nonselective alpha1-antagonist therapy on the incidence of hypotension-related adverse events likely to be associated with vascular alpha-adrenoreceptor antagonism in patients with BPH.

METHODS

Medical and prescription claims data were obtained from the MEDSTAT Group for 53,824 men with a diagnosis code for BPH during the study period (January 1995-December 1997). We examined the rate of possible hypotension-related adverse events (diagnosis codes for hypotension, syncope, dizziness, fractures, and other injuries) per 10,000 person-days for men who began therapy with alpha1 antagonists and for a random sample of nonusers, stratified by prior use of other antihypertensive agents.

RESULTS

After adjusting for baseline differences in event rates, those who initiated alpha1-antagonist therapy (n = 1564) had a significantly greater increase in hypotension-related adverse-event rates in the 4 months after initiation (vs the 4 months before initiation) than randomly selected nonusers (n = 8641) (increase of 1.82 vs decrease of 0.02 events per 10,000 person-days among those not taking antihypertensive agents; increase of 0.94 vs 0.69 events per 10,000 person-days among those taking other antihypertensive agents; P < 0.01). This increase began earlier and lasted longer among patients taking other antihypertensive agents. Those who discontinued their alpha1 antagonist had a higher rate of hypotensive events at baseline than those who did not (5.09 vs 3.19 events per 10,000 person-days among those using other antihypertensive agents; 3.62 vs 2.27 events per 10,000 person-days among those not using other antihypertensive agents; P < 0.05).

CONCLUSIONS

Initiation of nonselective alpha1-antagonist therapy for the treatment of BPH increases the risk of a cluster of clinical events consistent with vascular alpha-adrenoreceptor antagonism. This effect is seen during a 4-month period around the initiation date. Prior initiation of other antihypertensive medication increases this effect. Urologists should consult with a patient's primary care physician about use of other antihypertensive agents before initiating nonselective alpha1-antagonist therapy for BPH.

Quality Enhancement Research Initiative in Mental Health

The Veterans Administration (VA) recently introduced its Quality Enhancement Research Initiative (QUERI) to facilitate the translation of best practices into usual clinical care. The Mental Health QUERI (MHQ) was charged with developing strategic plans for major depressive disorder (MDD) and schizophrenia. Twenty percent or more of VA service users are affected by 1 of these 2 disorders, disorders that often have a devastating impact on affected individuals. Despite the increasing availability of efficacious treatments for each disorder, substantial gaps remain between best practices and routine care. In this context, the MHQ identified steps critical to the success of a sustained process of rapid-cycle health care improvement for MDD and schizophrenia, including research initiatives to close gaps in knowledge of best treatment practices, demonstration projects to close gaps in practice and to expand understanding of effective strategies for implementing clinical guidelines, targeted enhancements of the VA information system, and research and dissemination initiatives to increase the availability of resources to support the accelerated incorporation of best practices into routine care. This article presents an overview of the elements in the initial MHQ strategic plans and the rationale behind them.

The role of competing demands in the treatment provided primary care patients with major depression

OBJECTIVE

To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit.

DESIGN

A cross-sectional patient survey.

PARTICIPANTS AND SETTING

Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders.

MAIN OUTCOME MEASURES

In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients.

RESULTS

Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05).

CONCLUSIONS

The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.

Appropriateness of the decision to transfer nursing facility residents to the hospital

OBJECTIVES

To develop and test a standardized instrument, the purpose of which is to assess (1) whether skilled nursing facilities (SNFs) transfer residents to emergency departments (ED) inappropriately, (2) whether residents are admitted to hospitals inappropriately, (3) and factors associated with inappropriate transfers.

DESIGN

A structured implicit review (SIR) of medical records.

SETTING AND PARTICIPANTS

Using nested random sampling in eight community SNFs, we identified SNF and hospital records of 100 unscheduled transfers to one of 10 hospitals.

MEASUREMENTS

Seven trained physician reviewers assessed appropriateness using a SIR form designed for this study (2 independent reviews per record, 200 total reviews). We measured interrater reliability with kappa statistics and used bivariate analysis to identify factors associated with assessment that transfer was inappropriate.

RESULTS

In 36% of ED transfers and 40% of hospital admissions, both reviewers agreed that transfer/admit was inappropriate, meaning the resident could have been cared for safely at a lower level of care. Agreement was high for both ED (percent agreement 84%, kappa .678) and hospital (percent agreement 89%, kappa .779). When advance directives were considered, both reviewers rated 44% of ED transfers and 45% of admissions inappropriate. Factors associated with inappropriateness included the perceptions that: (1) poor quality of care contributed to transfer need, (2) needed services would typically be available in outpatient settings, and (3) the chief complaint did not warrant hospitalization.

CONCLUSIONS

Inappropriate transfers are a potentially large problem. Some inappropriate transfers may be associated with poor quality of care in SNFs. This study demonstrates that structured implicit review meets criteria for reliable assessment of inappropriate transfer rates. Structured implicit review may be a valuable tool for identifying inappropriate transfers from SNFs to EDs and hospitals.

Rehabilitation after hip fracture--equal opportunity for all?

OBJECTIVES

To determine whether factors unrelated to clinical appropriateness affect use of physical and occupational therapy (PT/OT) in elderly Medicare patients with acute hip fracture.

DESIGN

Bivariate and multivariate analysis of detailed clinical data retrospectively gathered from medical records and of nonclinical variables obtained through linkage with the American Hospital Association data base.

SETTING

297 randomly selected hospitals from 5 states.

PATIENTS

2,762 elderly Medicare patients hospitalized with a primary diagnosis of acute hip fracture who were hospitalized during 1981-1982 or 1985-1986.

INTERVENTION

Observational study.

MAIN OUTCOME MEASURES

Initiation and intensity of PT/OT while in the acute hospital.

RESULTS

We found evidence that factors not relevant to clinical appropriateness, such as race, hospital size, and state, significantly affect whether patients receive any PT/OT after acute fracture, as well as the intensity of PT/OT. For example, after controlling for patient clinical characteristics, we found that 63% of African-American patients received low-intensity PT/OT in comparison to 43% among non-African-American, and we found threefold differences among states both in initiation of PT/OT and in the intensity of its use. Overall, clinical characteristics had relatively greater influence on whether patients started PT/OT, whereas factors not relevant to clinical appropriateness had relatively greater influence on how much rehabilitation was provided.

CONCLUSION

There are significant disparities in use of rehabilitation after hip fracture, only partially explained by patient clinical characteristics. Factors without obvious relevance to the clinical appropriateness of PT/OT exert a significant influence on use of rehabilitation services, particularly on the intensity of their use.

Strategies to overcome barriers to early detection of cancer among older adults

If health professionals wish to help increase the number of older adults who get screened regularly to detect cancer at an early stage, they must first understand the barriers to screening that older people experience. This paper discusses the barriers older women face regarding mammography screening. Data from American Association of Retired Persons research are presented, and strategies being implemented across the country are discussed. Barriers that older men face in terms of screening for prostate cancer and preventive health in general are also addressed. Finally, specific recommendations for health providers to use to educate seniors are offered.

Who pays for published research?

OBJECTIVE

To determine the extent of unfunded research published in major medical journals.

DESIGN

Review of original research completed in the United States and published in 23 official journals of internal medicine and neurology during 1 month in 1991. Investigators were contacted to confirm lack of funding.

MAIN OUTCOME MEASURE

Percentage of unfunded, published original research.

RESULTS

One hundred ninety-six articles were evaluated. There was at least one unfunded study in 78% of journals. Forty-five published studies (23%) were unfunded. Among those 45 studies, 7% were clinical trials, 9% were cohort studies, 18% were cross-sectional or case-control studies, 53% were case series, and 13% were surveys. Thirteen unfunded studies involved procedures that presumably were performed for research purposes and not as part of routine patient care.

CONCLUSIONS

Nearly one quarter of original research published in major medical journals was unfunded. Seven percent of published research involved direct clinical costs that were not accounted for by the investigators. These costs may have been passed on to study participants or third-party payers.

Argon laser scatter photocoagulation in treatment of branch retinal vein occlusion. A prospective clinical trial

The objective of this prospective study was to ascertain whether scatter argon laser photocoagulation to the involved sector in major branch retinal vein occlusion and ischemic hemicentral retinal vein occlusion (a) prevents development of retinal and/or optic disk neovascularization and vitreous hemorrhage, and (b) affects visual acuity, visual fields and macular retinal lesions. The study was done in 271 eyes allocated to either treated (n = 61 eyes) or untreated (n = 210) groups. In this study, on an average follow-up of 3.6 years, the laser treatment (1) significantly reduced the risk of development of retinal neovascularization and vitreous hemorrhage, (2) did not affect the visual acuity and macular retinal lesions, and (3) produced a significant worsening in the peripheral visual fields compared to the untreated eyes. In view of our findings, we recommend that argon laser photocoagulation treatment should be given only when neovascularization is seen and not otherwise, because in the latter case, its detrimental effects may outweigh its beneficial ones.

Arch length considerations due to the curve of Spee: a mathematical model

Arch length analysis should consider discrepancies not only within the sagittal plane but also within the vertical and transverse planes. The vertical deviation of the occlusal plane from a flat plane is known as the curve of Spee. The purpose of this study was to produce a mathematical model of the mandibular arch form in three planes of space and to determine the effect that the curve of Spee has on arch circumference. Two mandibular arch forms, the catenary and the Bonwill-Hawley, were examined. The curve of Spee was modeled as a cylinder perpendicular to the midsagittal plane centered on the arch anteroposteriorly. A mathematical distance formula was used to calculate arch circumferences from the central fossa of the first molars for 10 arches with curves of Spee ranging from 0 to 10 mm. This procedure was repeated for arch circumferences extending from the central fossa of the second molars. Plots for the difference in arch circumferences verses depth of the curve of Spee showed that the relationship between these two variables is not linear and is less than one to one. This model showed that clinical practice of allowing 1 mm of arch circumference for leveling each millimeter of curve of Spee overestimates the amount of arch circumference needed to flatten the curve of Spee.

Benefits and obstacles of health status assessment in ambulatory settings. The clinician's point of view. The Dartmouth Primary Care COOP Project

In the past decade physicians have identified the need to expand patient assessment to include global function and quality of life. During the same period, the busy clinic has evolved into the location where this assessment seems most appropriate. Integrating functional health assessment into a busy clinical practice is difficult because the necessary steps require time, thought, recording, and follow-up. Attention to the office ecosystem is very important before any patient care management method is introduced. The clinician must transform the results of health status screening into a specific functional diagnosis. The clinician has to understand the sensitivity, specificity, and predictive value of the measure for a preliminary diagnosis to be made. Often, additional measurements must be taken to establish a specific diagnosis. These steps encompass assessment linkage. Once the specific cause for the dysfunction is recognized, the clinician then has to determine the need for special resources. This is called the resource linkage. By following the steps outlined in this paper, the clinician should be able to overcome many obstacles for functional health status assessment in busy ambulatory settings.

The short-term effect of patient health status assessment in a health maintenance organization

This study was designed to test the short-term effects of health assessment on the process of care and patient satisfaction. The 29 Chart physicians used the Dartmouth COOP Charts to measure their adult patients' health status during a single clinical encounter; the 27 control clinicians used no measure of health status. We compared the change between baseline and post-intervention information for a sample of all study clinicians' patients. Most of the patients were female (67%), well educated (70% had at least a college education) and young (approximately 90% were aged 59 years or younger). We found that the ordering of tests and procedures for women was increased by exposure to the COOP Charts (52% vs. 35%; p < 0.01); the effect in men was not as significant (37% vs. 23%: p = 0.06). Although women reported no change in satisfaction with care, men claimed that the clinician helped in the management of pain (p = 0.02). We conclude that the use of health status measures during a single clinical encounter in an HMO changes clinician test ordering behaviour and may improve the help male patients receive for pain conditions. The long-term impact of these management changes is not known.

The ambulatory care of HIV-infected persons: a survey of physician practice patterns

OBJECTIVE

To describe the use of various counseling practices, examinations, and laboratory tests used by general internists in the primary care of HIV-infected persons.

DESIGN

Mailed questionnaire survey.

SUBJECTS

Random sampling of members of the Society of General Internal Medicine.

RESULTS

Based on a 64% response rate (131/205), there are many areas of physician agreement in the ambulatory care of HIV-infected persons. Greatest physician consensus was seen in the use of viral serologic testing, vaccinations, and Pap tests. Most (70-80%) primary care physicians do not use surrogate markers such as beta 2-microglobulin and p24 antigen to follow disease progression; instead, they rely mostly on CD4 lymphocyte counts. Sixty percent of physicians continue to order CD4 lymphocyte counts when a baseline count is under 200 cells/mm3. All studies are ordered more frequently for patients with more advanced disease. As a group, those physicians following the largest number of patients do not manage patients significantly differently from the less HIV-experienced physicians.

CONCLUSIONS

Despite some variation, there is substantial consensus on the "routine" management of HIV-infected persons. Clinical guidelines would be one mechanism for defining appropriate care of HIV-infected patients. The majority judgments of the practitioners studied here could be one component among various sources of information used by expert panels to define guidelines except where studies clearly indicate a different and more effective approach. Such incorporation might increase guideline acceptance by practicing clinicians.

Targeting health advocacy efforts toward the older population

Three American Association of Retired Persons health education programs addressing the prevention, detection, and treatment of cancer illustrate successful strategies for mobilizing older adults to be advocates for their own health. Programs include a national initiative to decrease smoking among adults older than 50 years of age, community education efforts to increase mammography use among older women, and peer education workshops designed to teach older patients consumer skills that will enable them to make informed treatment decisions.

Explaining variations in hospital death rates. Randomness, severity of illness, quality of care

We used administrative (Part A Medicare) data to identify a representative sample of 1126 patients with congestive heart failure and 1150 with acute myocardial infarction in hospitals with significant unexpectedly high inpatient, age-sex-race-disease-specific death rates ("targeted") vs all other ("untargeted") hospitals in four states. Although death rates in targeted hospitals were 5.0 to 10.9 higher per 100 admissions than in untargeted hospitals, 56% to 82% of the excess could result from purely random variation. Differences in the quality of the process of care (based on a medical record review) could not explain the remaining statistically significant differences in mortality. Comparing targeted hospitals with subsets of untargeted ones, eg, those with lower than expected death rates, did not affect this conclusion. Severity of illness explained up to 2.8 excess deaths per 100 admissions for patients with myocardial infarction. Identifying hospitals that provide poor-quality care based on administrative data and single-year death rates is unlikely; targeting based on time periods greater than 1 year may be better.

Evaluating humanistic attributes of internal medicine residents

OBJECTIVE

Methods of assessing humanism in internal medicine residents have not been completely designed or evaluated. This study used patient satisfaction as a measure of humanism, and assessed the validity of using faculty physicians to evaluate residents' humanistic behavior. Residents' ability to assess themselves was also evaluated.

SETTING

A university-affiliated internal medicine training program.

SUBJECTS

Forty-seven internal medicine residents were evaluated by patients, faculty, and themselves.

DESIGN

Faculty physicians were given standard faculty evaluation and patient satisfaction forms, and were asked to evaluate residents. These evaluations were compared with the patients' responses on the same satisfaction forms. Residents performed self-assessment using identical forms; these responses were compared with those of the faculty and patients.

RESULTS

There was no correlation between patients' responses and those of the faculty or residents. There was a significant inverse correlation between resident and faculty responses, especially for the female residents (r = 0.71).

CONCLUSION

These findings suggest the need for further study of the evaluation process, including what factors influence individuals to respond as they do. It appears that the use of one rating group is not sufficient to achieve an accurate assessment of residents' humanistic skills. The present status of the process of evaluating humanism is discussed.

The effects of forceps delivery on facial growth

Postnatal growth of the face is a composite function of genetic and environmental factors. A sudden traumatic insult due to the use of forceps at birth could have long-term effects which could detrimentally influence growth and development. This study examines the development of the skeletal and dental components of forceps vs. non-forceps-delivered patients. The association between delivery methods as related to TMJ problems, bruxism, posterior crossbites, and molar arch width differences was evaluated in 16 forceps-delivered and 29 naturally delivered patients. Results showed no statistically significant difference between delivery method and TMJ problems, posterior crossbites, bruxism, or molar arch width. It was noted that the non-forceps group had a higher incidence of posterior crossbite and narrower molar arch width. The forceps-delivered group had a higher percentage of bruxism and TMJ pain and/or noise. It was also noted that the small sample size may have influenced the statistical relationships.

Improving children's oral hygiene through parental involvement

This study evaluated whether preschool children's oral hygiene would improve, if the parent, after receiving professional instruction, could demonstrate proficient toothbrushing. In the experimental group, twenty-four parents received a clinical demonstration and verbal instruction in the scrub-brush technique. They were asked to demonstrate proficiency in brushing their children's teeth using this technique. In the control group, twenty-six parents received the same brushing instructions, but did not clean their children's teeth. Baseline and four-week follow-up plaque and gingival scores showed improvement only in the plaque score (p less than .05) for the experimental group. Gingival scores were unchanged. These results indicate the advantage of parental participation in their child's dental care, especially in the case of new patients.

A molecular model for activation of a 5-hydroxytryptamine receptor

The extension of a model proposed previously for molecular recognition at a serotonin (5-hydroxytryptamine (5-HT) ) receptor makes possible the formulation of a molecular mechanism of receptor activation. The activation mechanism proposed here is based on the changes induced in the drug and in a model receptor by the interaction mimicking the formation of a drug-receptor complex. This mechanism was simulated by quantum mechanical calculations of molecular interactions between 5-HT and a model for a receptor represented by an imidazolium-ammonia complex that serves as a proton transfer model (PTM). The movement of the proton in the PTM is promoted by the interaction with 5-HT, suggesting a process by which 5-HT can trigger the activation of the receptor. The elements of the activation mechanism revealed by the results of the simulation are: (a) the electrostatic alignment between the PTM and 5-HT, which guides the recognition of 5-HT by the PTM; (b) the contraction of the distance between the hydrogen bonded components of the PTM, induced by the interaction of 5-HT with the PTM, which leads to a decrease in the barrier to proton transfer in the PTM; (c) an additional decrease of the barrier to proton transfer produced by the negative electrostatic potential of 5-HT, which stabilizes the transition state; and (d) the increased preference for product over reactant in the interaction complex between 5-HT and the PTM, which constitutes a driving force for the proton transfer process. According to this model, compounds that activate the 5-HT receptor should bind in a mode that induces the changes described above in the PTM and thus triggers the proton transfer.

Combined modality therapy for stage IIIMO non-oat cell bronchogenic carcinoma

Thirty-nine patients with stage IIIMO non-cell bronchogenic carcinoma (NOBC) were treated with combined modality therapy: radiation therapy and chemotherapy with cyclophosphamide, adriamycin, methotrexate, and procarbazine. The median survival for all patients treated was 9.6 months compared to 6.4 months for historical controls (P = 0.015). Patients who responded to the treatment program had a significantly longer survival (median, 15.2 months) compared to nonresponders and historical controls (P less than 0.005). It is concluded that combined modality therapy is moderately effective therapy in stage IIIMO NOBC.

Quality-of-care assessment by process and outcome scoring. Use of weighted algorithmic assessment criteria for evaluation of emergency room care of women with symptoms of urinary tract infection

Weighted process criteria based on chart review using an algorithmic method, and weighted outcome criteria based on a telephone interview with the patient, were used to assess the quality of emergency room care of women with symptoms of acute urinary tract infection. Outcomes at a municipal hospital were significantly better than those at an affiliated voluntary hospital. Process and outcome scores were positively correlated at both hospitals; the data suggest, but do not themselves adequately test, the hypothesis that the correlation is curvilinear and that there is a threshold process score below which a poor outcome is extremely likely. Our findings suggest that weighted algorithmic assessment criteria are a useful method for quality assessment and are consistent with the testable hypothesis that the greatest improvements in outcome may result from raising the quality of care from a poor to an adequate level rather than from an adequate to an optimal level.

Cyclophosphamide, adriamycin, methotrexate, and procarbazine (CAMP)--effective four-drug combination chemotherapy for metastatic non-oat cell bronchogenic carcinoma

Twenty-three patients with metastatic non-oat cell bronchogenic carcinoma (MNOBC) were treated with cyclophosphamide, adriamycin, methotrexate, and procarbazine (CAMP) after radiation therapy. Objective responses were seen in 11 of 23 patients (48%) with a projected median survival time of 12.5 months for responding patients and patients with stable disease. Lung, liver, and cutaneous sites of involvement proved to be highly responsive; bone involvement was less responsive. CAMP is an effective combination in the treatment of MNOBC and its use in patients with less advanced disease should be explored.