Terrell W. Zollinger

TOCOLYTIC THERAPY: A META-ANALYSIS AND DECISION ANALYSIS

OBJECTIVE: To determine the optimal first-line tocolytic agent for treatment of premature labor. METHODS: We performed a quantitative analysis of randomized controlled trials of tocolysis, extracting data on maternal and neonatal outcomes, and pooling rates for each outcome across trials by treatment. Outcomes were delay of delivery for 48 hours, 7 days, and until 37 weeks; adverse effects causing discontinuation of therapy; absence of respiratory distress syndrome; and neonatal survival. We used weighted proportions from a random-effects meta-analysis in a decision model to determine the optimal first-line tocolytic therapy. Sensitivity analysis was performed using the standard errors of the weighted proportions. RESULTS: Fifty-eight studies satisfied the inclusion criteria. A random-effects meta-analysis showed that all tocolytic agents were superior to placebo or control groups at delaying delivery both for at least 48 hours (53% for placebo compared with 75–93% for tocolytics) and 7 days (39% for placebo compared with 61–78% for tocolytics). No statistically significant differences were found for the other outcomes, including the neonatal outcomes of respiratory distress and neonatal survival. The decision model demonstrated that prostaglandin inhibitors provided the best combination of tolerance and delayed delivery. In a hypothetical cohort of 1,000 women receiving prostaglandin inhibitors, only 80 would deliver within 48 hours, compared with 182 for the next-best treatment. CONCLUSION: Although all current tocolytic agents were superior to no treatment at delaying delivery for both 48 hours and 7 days, prostaglandin inhibitors were superior to the other agents and may be considered the optimal first-line agent before 32 weeks of gestation to delay delivery.

Sociocultural context of mammography screening use.

PURPOSE/OBJECTIVES To examine variations in cultural and health beliefs about mammography screening among a socioeconomically diverse sample of African American and Caucasian women and to identify which set of beliefs predicted mammography screening adherence. DESIGN Descriptive, retrospective, cross-sectional study. SETTING Community-based organizations and public housing. SAMPLE 111 African American women and 64 Caucasian women, aged 40 years or older, with no history of breast cancer. METHODS Telephone and in-person structured interviews were conducted. Items used previously validated scales based on the Cultural Assessment Model for Health and the Health Belief Model. MAIN RESEARCH VARIABLES Race or ethnicity, education, income, personal space, health temporal orientation, personal control, fatalism, susceptibility, benefits, barriers, self-efficacy, and mammography screening adherence. FINDINGS African American women were more fatalistic about breast cancer and perceived fewer benefits to screening. Mammography screening-adherent women were more future oriented, believed that they had less control over finding health problems early, had fewer barriers to screening, and experienced more physical spatial discomfort during the screening procedure than nonadherent women. CONCLUSIONS Several of the cultural beliefs were not significantly different by race or ethnicity. However, cultural and health beliefs were significant predictors of mammography screening. IMPLICATIONS FOR NURSING Theoretically based cultural beliefs are important to consider for behavioral interventions to increase mammography screening in African American and Caucasian women.

Measuring Mammography and Breast Cancer Beliefs in African American Women

Although intervention trials have demonstrated significant improvement in mammography adherence for African American women, many of the current measurement tools used in these interventions have not been assessed for validity and reliability in ethnic minorities. This study assessed the validity and reliability of Health Belief Model (HBM) variables that are often the target of mammography interventions. Scale validity and reliability was assessed for HBM scales in a sample of 344 low-income African American women. Validity was supported through exploratory factor analysis and theoretical prediction of relationships. Internal consistency reliability was .73 or above for all scales.

Beliefs Associated With Fecal Occult Blood Test and Colonoscopy Use at a Worksite Colon Cancer Screening Program

Colorectal cancer (CRC) is the second leading cause of cancer death in the United States. Although regular screening can decrease morbidity and mortality from CRC, screening rates nationwide are very low. This descriptive study assessed beliefs associated with fecal occult blood test and colonoscopy use among participants of a worksite colon cancer screening program. Randomly selected employees, aged 40 and older, were mailed a survey on CRC screening-related beliefs. Instruments were tested for reliability and validity. Results indicated that fecal occult blood test use was significantly associated with being female, Caucasian, having low perceived barriers, and provider recommendation. Colonoscopy use was significantly associated with higher knowledge, lower barriers, higher benefits, higher self-efficacy, and provider recommendation. Findings may be used to develop interventions designed to improve CRC screening rates.

Lesser curvature gastrostomy reduces the incidence of postoperative gastroesophageal reflux

Gastrostomy is frequently required in children with neurological impairment and feeding disability. In some centers, concomitant (prophylactic) antireflux procedures are often performed due to the increased risk of occurrence of significant gastroesophageal reflux (GER) after isolated operative or percutaneous endoscopic gastrostomy placement. This has been documented in both experimental and clinical settings. A recent clinical study suggests that placement of a gastrostomy in a lesser curvature location rather than on the greater curvature of the stomach may decrease the incidence of postoperative GER. The purpose of this study is to evaluate this clinical impression. Under ketamine anesthesia and sterile technique, 30 cats underwent laparotomy and placement of a Stamm gastrostomy tube; 15 (group A) were located on the greater curvature of the stomach. Each animal was evaluated postoperatively for the occurrence of GER using upper gastrointestinal contrast study, nuclear medicine gastric scintigraphy (technetium 99m), pH probe/Tuttle test, and lower esophageal sphincter (LES) manometrics. Contrast esophagram with barium demonstrated GER in 3 animals in group A and none in group B (P less than .05). The pH/Tuttle test was positive in 4 animals in group and none in group B (P less than .05). 99mTc gastric scintigraphy (over a 30-minute period) demonstrated GER in 7 cats in group A and in only 1 cat in group B (P less than .05). LES manometric pressures were similar among both groups. This study suggests that a gastrostomy placed in the lesser curvature may reduce the incidence of postgastrostomy GER and obviate the need for a concomitant antireflux procedure in patients with a severe feeding disability but without demonstrable GER during preoperative assessment.

Patterns of child sexual abuse knowledge among professionals

To better understand knowledge and perceptions of child sexual abuse, a survey was conducted of 902 professionals attending child sexual abuse educational programs during 1986-1987. About half (50.8%) of the group reported seeing at least two child sexual abuse cases a month, while 20.5% reported seeing five or more. Almost half (48.9%) of the respondents reported previous formal training regarding child sexual abuse. Professionals were generally knowledgeable about child sexual abuse; however, at least 20% of the professionals were not knowledgeable about some items that are important in the identification of child sexual abuse and that might hamper the legal and medical investigation of a case. Those with formal training, more years of professional practice, and who see five or more victims per month answered more questions correctly, but the differences were not always statistically significant. Further training for both medical and non-medical professionals is needed to ensure appropriate care of child sexual abuse victims and to improve communication and coordination of efforts between professions.

An empirical analysis of cash flow, working capital, and the stability of financial ratio groups in the hospital industry

Abstract Hospitals are facing stringent financial constraints as well as proposed changes in their financial reporting. Three issues were explored: (a) whether hospital financial ratio groups differed from industrial firm financial ratio groups found in previous studies; (b) whether hospital financial ratio groups remained stable over a five-year period 1983–1987; and (c) whether there was a difference between working capital flow, cash flow, and net income plus depreciation as alternative hospital asset flow measures. The results of our study confirmed the existence of five hospital ratio groups that were identical to industrial ratio groups. A separate Cash Flow group emerged for some years but not for the entire study period. And unlike studies on industrial firms, Return On Equity and Working Capital Flow emerged as two distinctly independent financial ratio groups. Furthermore, the Cash Flow ratios did not differ consistently from their surrogate measures—the Net Income Plus Depreciation ratios. Our study provided evidence to suggest that analysts should pay closer attention to two aspects of hospital financial performance: (a) hospital equity in relationship to total assets, net income, working capital flow, and cash flow; and (b) hospital working capital flow as a separate aspect of hospital asset flow rather than just cash flow and/or net income plus depreciation. In fact, hospital cash flow did not differ consistently from net income adjusted for depreciation.

Risk of mesh erosion after abdominal sacral colpoperineopexy with concomitant hysterectomy.

OBJECTIVE The purpose of this study was to evaluate the effect of concomitant hysterectomy at the time of abdominal sacral colpoperineopexy on the risk of mesh erosion with the use of type 1 polypropylene mesh. STUDY DESIGN This was a retrospective case control study. All cases of vaginal mesh erosion (n = 31) were compared with matched control cases (n = 93) in a 3:1 ratio. Demographic data, concomitant procedures, and postoperative complications were compared between groups with the use of 2-sample Student t test and Pearson chi(2) test. RESULTS The odds ratio of a vaginal mesh erosion was no different for those who underwent a hysterectomy at the time of abdominal sacral colpoperineopexy (odds ratio, 0.95; 95% confidence interval, 0.41-2.18; P = .899) when potential confounders were similar between groups. CONCLUSION Hysterectomy at the time of abdominal sacral colpoperineopexy is not a risk factor for vaginal mesh erosion with the use of type 1 polypropylene mesh.

The effect of pregnancy intention on important maternal behaviors and satisfaction with care in a socially and economically at-risk population

This study examined the association of pregnancy intention with maternal behaviors and the woman’s perceived satisfaction with her prenatal and delivery care. Face-to-face interviews with 478 primarily Medicaid eligible women in Indianapolis, Indiana during their postpartum hospital stay were conducted to assess their degree of satisfaction with prenatal care and pregnancy intention, stratified into wanting to be pregnant now, later or never. Behaviors and characteristics influencing utilization of prenatal care were obtained from linked birth certificate data. A greater proportion of younger women (15–29) wanted to be pregnant later, a greater proportion of African-Americans never wanted to be pregnant, a greater proportion of divorced and never married women wanted to be pregnant later or never, and as parity increased the percentage of women never wanting to be pregnant increased. Multivariate analyses found that women never wanting to be pregnant were twice as likely to underutilize prenatal care, twice as likely to smoke while pregnant, half as likely to utilize WIC services and half as likely to recommend their providers to pregnant friends or relatives compared to women with a planned pregnancy, controlling for confounding variables. Finally, women wanting to be pregnant later were half as likely to rate their overall hospital care and prenatal care provider as high. Providers assessing their patients’ pregnancy intention could better identify those women needing additional support services to adopt healthier behaviors and improve satisfaction with care. This study also demonstrated the value of more specific definitions of pregnancy intention.

Medical students' experience with musculoskeletal diagnoses in a family medicine clerkship

Many US medical schools require a family medicine clerkship, yet little is known about the quantity and diversity of the diagnoses the students experience. This study examines patients encountered with musculoskeletal diagnoses using quantitative data collected by family practice clerkship students. Over a two-year period, 445 students completed 7202 patient encounter forms for patients with a musculoskeletal diagnosis, noting their confidence level and responsibilities. Of the 78 854 diagnoses presented, 7850 were for musculoskeletal conditions. Students reported a lower level of confidence in diagnosing and treating musculoskeletal patients when compared with their confidence level in dealing with non-musculoskeletal patients. They are generally more actively involved with musculoskeletal patients by observing, seeing the patient before the preceptor, taking a history, suggesting treatment and discussing the case with the preceptor. At the study school, this fact may reflect that formal curricular teaching in orthopedics occurs in the fourth year, after students have completed their family medicine clerkship. It is concluded that by using a relatively simple computerized database, areas of need for curricular change can be identified. Our study verifies that additional training is needed in the area of musculoskeletal diagnoses.