Larry Sachs

Cervical competence as a continuum: A study of ultrasonographic cervical length and obstetric performance

OBJECTIVE Our purpose was to investigate the hypothesis that cervical competence is a continuum that is related to cervical length and is reflected by pregnancy history. STUDY DESIGN A cross-sectional study was performed of cervical length measured by transvaginal ultrasonography in women with prior preterm delivery at < or = 26 weeks, 27 to 32 weeks, and 33 to 35 weeks compared with women with cervical incompetence and normal controls delivered at term. RESULTS Transvaginal cervical length was measured during pregnancy in 32 subjects with cervical incompetence, 98 with previous preterm birth < or = 26 weeks, 98 with previous preterm birth at 27 to 32 weeks, 127 with previous preterm birth at 33 to 35 weeks, and 106 normal controls. The relationship between obstetric history and cervical length was evaluated by analysis of variance. The gestational age at the first preterm delivery was significantly correlated with cervical length in the current pregnancy at each gestational interval between 20 and 30 weeks in a continuous manner. CONCLUSION Cervical competence is a continuous rather than categoric variable and is indicated indirectly by measurement of the length of the cervix.

Effects of ethnicity on treatment attendance, stimulant response/dose, and 14-month outcome in ADHD.

From the Multimodal Treatment Study of Children with Attention-Deficit/Hyperactivity Disorder--a randomized clinical trial of 579 children ages 7-9 years receiving 14 months of medication management, behavioral treatment, combination, or community care--the authors matched each African American and Latino participant with randomly selected Caucasian participants of same sex, treatment group, and site. Although Caucasian children were significantly less symptomatic than African American and Latino children on some ratings, response to treatment did not differ significantly by ethnicity after controlling for public assistance. Ethnic minority families cooperated with and benefited significantly from combination (multimodal) treatment (d = 0.36, compared with medication). This incremental gain withstood statistical control for mothers education, single-parent status, and public assistance. Treatment for lower socioeconomic status minority children, especially if comorbid, should combine medication and behavioral treatment.

The Infant Feeding Decision in Low and Upper Income Women

Few studies have described the woman who chooses breast-feeding by more than simple demographics. The purpose of our study was to characterize new mothers by their infant feeding decisions, by demographic and obstetrical data, and by sources of personal support they received during their pregnancies and in making their infant feeding decisions. To this end, 220 were interviewed, including 116 who chose to breastfeed. Breast-feeding women were more likely to be older, more educated, married, more affluent, experienced with breast-feeding, to have demonstrated good prenatal habits, and to have received support from other sources than those who chose bottle feeding. Participation in Lamaze classes, previous successful breast-feeding, and maternal education were significant predictors of feeding choice, and mode of delivery predicted duration of breastfeeding. Low income women who chose breastfeeding resembled low income bottle feeders in certain medical/social factors, but they showed support patterns similar to middle to upper income women.

Brain Tumors in Childhood

A review of the pathology of 689 neuroectodermal tumors occurring over a 30-year period at The Hospital for Sick Children in Toronto has underlined the importance of examining the tissue from each tumor in order to insure consistency and accuracy in histological diagnosis. The age, sex, histology and topographical distribution of this series of tumors is compared with other series and discussed in detail. The high proportion of tumors occurring in early childhood, the striking male preponderance, and the high incidence of astrocytomas, medulloblastomas and ependymomas is emphasized.

Multiple primary gynecologic neoplasms

Some patients may be predisposed to the development of more than one gynecologic neoplasm. We evaluated 130 cases of synchronous or metachronous tumors among 5967 patients followed up by The Ohio State University Gynecologic Tumor Registry for the past 44 years from 1939 to 1983. Based on primary tumor site and invasive behavior, expected incidences for a specific second malignancy were calculated by the person-years method. A second malignancy of the lower genital tract occurred in patients with cervical, vulvar, and vaginal cancers, 1.6%, 4.3%, and 9.6%, respectively, which supports the theory of multicentric cancer of the lower genital tract. Prior radiation therapy was rarely associated with increased second gynecologic malignancies (two of 41 patients, 4.9%). Four patients had three gynecologic tumors.

Management of preterm prematurely ruptured membranes: A retrospective comparison of observation versus use of steroids and timed delivery

A retrospective study of 38 women with preterm prematurely ruptured membranes was performed. Twenty were treated with intravenous hydrocortisone followed by timed delivery between 48 and 72 hours after initiation of steroid therapy. Eighteen were managed expectantly, with observation for labor and infection. There were no significant differences between steroid-treated patients and observed patients in the incidence of neonatal respiratory distress syndrome, perinatal mortality, or maternal or neonatal infections.

Adjuvant therapy for Stage I uterine sarcoma

A retrospective evaluation of adjuvant therapy in 64 patients with Stage I sarcoma was undertaken. A combination of operation and adjuvant radiation was compared with operation alone. A decreased recurrence of both pelvic and distant tumor was noted for endometrial sarcoma but not for leiomyosarcoma treated with adjuvant radiation. A Cox regression analysis showed a trend for improved survival, but the results were not statistically significant. Survival after vaginal cuff recurrence and treatment with radiation therapy (two patients) or combined radiation and chemotherapy (one patient) is reported. Seven patients received adjuvant chemotherapy with Adriamycin-based regimens. Chemotherapy alone did not statistically decrease recurrence in this small sample.

Demographic variables in medical school admission

Admission committees report that demographic variables, although accurate, reliable, and easily obtained from applicants to medical schools, are only moderately important in their decision making. This may be because the committees are concerned about the validity and legality of using such data as admissions criteria. This essay discusses the research on the validity of demographic variables and the recommendations for their legal use in selecting students for medical school. The relationships of age, gender, size of hometown, parental education, parental occupation, parental income, and marital status to medical school outcomes of preclinical performances, clinical performance, attrition, specialty choice, and practice location are summarized. [Race or ethnic group is discussed in a separate essay in this issue.] Although the authors focus on the predictive value of demographic variables, these variables play a more important role as the moderator variables for other predictors of medical school outcomes. The full value of using demographic variables derives from data obtained in local validity studies. To comply with the equal-protection and due-process requirements, admission officers must assure that the use of demographic information in the admission process is explicit in bulletins given to applicants and is uniformly applied in the evaluation of all applicants.

Health Care Team Training in U.S. and Canadian Medical Schools.

This paper reports the results of a survey to determine the extent to which interdisciplinary health team concepts are being taught as part of the undergraduate curriculum in U.S. and Canadian medical schools. Less than a third (29 percent) of the respondents indicated the existence of a formal program or program component designed to teach health care team skills. Although the total number of reported programs is small, 53 percent of these programs were required for all students. Three overall categories of content taught within the programs included group process skills, role and function of the team and its members, and content related to the health care context. Although the team approach is a process orientation, fewer than half of the programs reported using direct application of the process, that is, building groups of students into teams.

Successful Use of an Expert System to Teach Diagnostic Reasoning for Antibody Identification

A previously reported study indicated that, when used by an instructor as a tool to assist with tutoring in a class laboratory setting, use of the Transfusion Medicine Tutor (TMT) resulted in improvements in antibody identification performance of 87-93% (p<.001). Based on input from teachers requesting that TMT be designed for use without the presence of an instructor, a new study on the use of TMT without instructor assistance found that performance improved by 64-66% (p<.001). Finally, based on the results of these two studies, TMT was mailed to 7 sites for beta-testing. In exchange for a free copy of the kit, the instructors (and their students) were asked to fill out questionnaires. Results of these questionnaires are summarized.