Robert G. Wones

Relationship between breast cancer risk factors and mammographic breast density in the Fernald Community Cohort

Background:We investigated associations of known breast cancer risk factors with breast density, a well-established and very strong predictor of breast cancer risk.Methods:This nested case–control study included breast cancer-free women, 265 with high and 860 with low breast density. Women were required to be 40–80 years old and should have a body mass index (BMI) <35 at the time of the index mammogram. Information on covariates was obtained from annual questionnaires.Results:In the overall analysis, breast density was inversely associated with BMI at mammogram (P for trend<0.001), and parity (P for trend=0.02) and positively associated with alcohol consumption (ever vs never: odds ratio 2.0, 95% confidence interval 1.4–2.8). Alcohol consumption was positively associated with density, and the association was stronger in women with a family history of breast cancer (P<0.001) and in women with hormone replacement therapy (HRT) history (P<0.001). Parity was inversely associated with density in all subsets, except premenopausal women and women without a family history. The association of parity with density was stronger in women with HRT history (P<0.001).Conclusion:The associations of alcohol and parity with breast density appear to be in reverse direction, but stronger in women with a family history of breast cancer and women who ever used HRT.

Rewarding Teaching Faculty with a Reimbursement Plan

OBJECTIVE: To develop a system for measuring the teaching effort of medical school faculty and to implement a payment system that is based on it.DESIGN: An interventional study with outcomes measured before and after the intervention.SETTING: A department of internal medicine with a university hospital and an affiliated Veterans Administration hospital.INTERVENTION: We assigned a value in teaching units to each teaching activity in proportion to the time expended by the faculty and the intensity of their effort. We then calculated total teaching units for each faculty member in the Division of General Internal Medicine and for combined faculty effort in each subspecialty division in the Department of Medicine. After determining the dollar value for a teaching unit, we distributed discretionary teaching dollars to each faculty member in the Division of General Internal Medicine and to each subspecialty division according to total teaching units.MEASUREMENTS AND MAIN RESULTS: The distribution of discretionary teaching dollars was determined. In the year after the intervention, there was a substantial redistribution of discretionary teaching dollars among divisions. Compared with an increase in total discretionary dollars of 11.4%, the change in allocation for individual divisions ranged from an increase of 78.2% to a decrease of −28.5%. Further changes in the second year after the intervention were modest. The distribution of teaching units among divisions was similar to the distribution of questions across subspecialties on the American College of Physicians In-Training Examination (r=.67) and the American Board of Internal Medicine Certifying Examination (r=.88).CONCLUSIONS: It is possible to measure the value of teaching effort by medical school faculty and to distribute discretionary teaching funds among divisions according to the value of teaching effort. When this intervention was used at our institution, there were substantial changes in the amounts received by some divisions. We believe that the new distribution more closely approximates the desired distribution because it reflects the desired emphasis on knowledge as measured by two of the most experienced professional groups in internal medicine. We also believe that our method is flexible and adaptable to the needs of most clinical teaching departments.

Should physicians perform their own quality assurance audits

Quality assurance is required of all hospital outpatient clinics although there is little evidence documenting its value. The purposes of this study were to assess the impact of quality assurance audits on physicians’ ordering behavior and to learn whether doctors who actually performed audits behaved differently from physicians who passively received audit results. Baseline influenza vaccination and screening mammography ordering rates were established for the authors’ residents’ clinic in 1985. In 1986, residents were assigned randomly to three groups. Residents in one group audited their own charts for 1985 influenza vaccination ordering; the second group audited its own charts for 1985 screening mammography ordering; and the third group performed no audit but received the other groups’ results. Passive receipt of results improved ordering of vaccination from 40% to 59% and ordering of mammography from 8% to 16%. Actual performance of audits improved ordering of mammography from 16% to 26% but did not improve vaccination ordering. These quality assurance audits were effective in improving the performance of selected preventive health measures in a residents’ clinic.

Medical monitoring: a beneficial remedy for residents living near an environmental hazard site.

Objective: People living close to an environmental hazard site may suffer health harms from real or perceived contaminant exposures. In class-action litigation, medical monitoring is a potential remedy that has been allowed in some jurisdictions but not others. From 1952 to 1989, a US Department of Energy uranium metal plant near Fernald, Ohio, released ionizing radiation and uranium particulates into the surrounding community. Methods: Settlement of litigation between nearby residents and the Department of Energy resulted in an 18-year medical monitoring program (N = 9775), which focused on general health promotion rather than effects of uranium. Results: Participation was higher than projected; decreases in common risk factors (cholesterol and blood pressure) and deaths from cancer have been observed. Conclusions: These data support the appropriateness of comprehensive medical monitoring as a remedy for people affected by defined sources of environmental contaminants.

Intercorrelations and sources of variability in three mutagenicity assays : a population-based study

The purpose of this study was to evaluate the intercorrelation between three genetic assays in 112 subjects. The group was pooled from two originally separate but homogeneous subgroups of 56 persons each. Procedures included assays for hprt mutant frequencies, micronuclei in human lymphocytes, and mutations at the glycophorin A (gpa) loci. We found no statistically significant or biologically important intercorrelations among the three biomarkers. We did, however, observe significant correlations between log(e) hprt mutant frequency and cloning efficiency (inverse correlation for these 2 variables), age and log(e) hprt mutant frequency, an inverse relationship between cloning efficiency and age, and an important differential sex effect favoring a greater micronuclei frequency in females than males. No significant correlations between the covariates of interest and glycophorin A variant frequencies NN or NO were observed. Using multivariable linear regression, age was found to account for the majority of the variability in hprt mutant frequency (greater than sex and/or smoking); for micronuclei data, only sex contributed a statistically significant and biologically important proportion to the total variation. We conclude that despite observing no significant intercorrelations between the three assays performed simultaneously from the same individuals in a large population database, a significant correlation between age and hprt mutant frequency and an inverse association between cloning efficiency and hprt do exist; furthermore, we verified the strong differential sex-specific effect on micronucleus frequencies.