Assessing the health of future physicians: an opportunity for preventive education

INTRODUCTION: Research shows that physicians who model prevention are more likely to encourage preventive behaviors in their patients. Therefore, understanding the health of medical students ought to provide insight into the development of health promotion programs that influence the way these future physicians practice medicine. A university-based General Clinical Research Center (GCRC) provides a venue well suited to the health assessment and education of medical students. This research explores the utility of a GCRC in a program measuring the prevalence of clinical risk factors and related health behaviors in first-year medical students. METHODS: A 6-year cross-sectional study of first-year medical students measured clinical and behavioral variables associated with metabolic syndrome. Statistical testing was used to determine the prevalence of risk factors and the influence of gender in these variables. RESULTS: This group of medical students displayed better health indicators than did the general young adult population; however a small proportion of medical students exhibited early risk factors for chronic disease. There were significant gender differences in mean values for clinical risk factors, with males displaying higher cardiovascular risk overall. Males and females demonstrated significant differences in dietary intake and exercise programs. DISCUSSION: A GCRC can be used to provide a health assessment of medical students. Moreover, some students may benefit from health promotion programs incorporated into medical school curricula. This study provides a foundation for further research on the health of future physicians and the development of health promotion programs for this population. It also begins to explore the use of a GCRC as a teaching resource for medical students.     

Improving the effectiveness of adjuvant psychological treatment for women with breast cancer: the feasibility of providing online support

Many well-designed studies have shown psychosocial treatments for cancer to be efficacious for improving patients' quality of life, but the actual impact of these treatments may be limited by low rates of participation. Web-based treatment formats could improve effectiveness by increasing availability and accessibility. Two phases of a feasibility study are reported in this article. In the first phase, we sought to assess internet access and perceived interest in online support among 136 women with breast cancer (June-October, 1999). Levels of interest in participating in an online psychosocial treatment were associated with age, outcome expectancy, and barriers to using the internet but not stage or time since diagnosis. In the second phase, we document accrual rates among several methods of recruitment during a randomized trial (February-December, 2001) and report changes over time in internet access. Recruitment rates were substantially higher when a study representative was available in clinic to provide information about the treatment than for all other methods of recruitment. Access to the internet increased between 1999 (63%) and 2001 (70%) and varied across age groups. These results suggest that internet-based psychosocial treatments, with notable limitations, are feasible for increasing the impact of psychosocial care.     

Early versus delayed insertion of tympanostomy tubes for persistent otitis media: developmental outcomes at the age of three years in relation to prerandomization illness patterns and hearing levels

BACKGROUND: Whether prompt insertion of tympanostomy tubes in children with persistent early life otitis media prevents or minimizes subsequent developmental impairment has been the subject of conflicting opinions and differing approaches to management. METHODS: We randomly assigned 429 children with persistent middle ear effusion (MEE) before the age of 3 years to have tympanostomy tubes inserted either as soon as possible or up to 9 months later if MEE persisted. In 402 of these children, we found no significant differences at age 3 years between the 2 treatment groups in mean scores on any measure of speech, language and cognition and in 401 of the children no significant differences in measures of psychosocial development. We then examined outcomes within subgroups of children who might have been the most severely affected, namely those who had been randomized on the basis of bilateral, continuous MEE rather than unilateral and/or discontinuous MEE and those who had the greatest degrees of hearing loss. RESULTS: In none of the subgroups we considered were scores on any outcome measure significantly more favorable in children in the early treatment group than in children in the late treatment group. CONCLUSIONS: In otherwise normal children who have MEE, during the first 3 years of life within the durations we studied, prompt insertion of tympanostomy tubes does not measurably improve developmental outcomes at age 3 years, irrespective of whether MEE has been continuous or discontinuous and unilateral or bilateral and whether or not MEE has been accompanied by mild to moderate hearing loss.     

Improving participation in Chlamydia screening programs: perspectives of high-risk youth

BACKGROUND: Many young people at highest risk for chlamydial infection do not use chlamydia screening services. OBJECTIVES: To describe young people's beliefs and opinions about obstacles to and motivators for obtaining testing and to provide recommendations for how to improve youth participation in chlamydia screening programs. METHODS: Eight focus group interviews (4 male and 4 female groups) were conducted with young people using a semistructured interview guide. Thirty-two male and 23 female volunteers (mean age, 18.2 years; age range, 15-24 years) were recruited from Job Corps and Department of Youth Services sites. The main outcome measure was categorization of textual data using content analysis techniques. Data were coded by 2 investigators into categories of responses based on research questions and spontaneously offered comments. Satisfactory intercoder agreement was achieved. RESULTS: Participants described many obstacles to testing, including concern that someone will know they were tested or tested positive, fear about discovering they have a sexually transmitted disease, and fear of acquired immunodeficiency syndrome. Many participants were unsure what physical effects chlamydia produced or thought it was possible to die of a chlamydial infection. Participants recommended providing more information about the effects of chlamydia, availability of urine testing, and ease of treatment to motivate more young people to seek testing. They also emphasized the need to make sexually transmitted disease screening services more private and confidential. There was an overwhelming interest in using a home Chlamydia test (much like a home pregnancy test) if one were available. CONCLUSIONS: To increase youth participation in screening programs, it will be necessary to address their concerns, dispel misconceptions, and provide more information about chlamydia. A home Chlamydia test might be one way to increase screening.     

Infectivity of<Emphasis Type="Italic"> Cryptosporidium parvum</Emphasis> genotype I in conventionally reared piglets and lambs

Parasites of the genus Cryptosporidium are intracellular parasites that occur throughout the animal kingdom and have been reported in many species of mammals, including human. Most infections in humans are caused by two C. parvum genotypes, genotype I and genotype II; these are the human and the bovine (zoonotic) genotypes, respectively. Successful experimental infection of Cryptosporidium parvum genotype I "human genotype" is described in four conventionally reared piglets and in a lamb. The inoculum was originally obtained from two diarrheic children, and the Cryptosporidium genotypes were determined by PCR and rDNA sequencing. The infective dose was between 10(6) and 2 x 10(6) oocysts. No clinical signs were observed in the infected animals, except in a piglet that showed watery diarrhea. The oocyst shedding period in positive animals ranged between 4 and 10 days. Histopathologic examination of the gastrointestinal tract of two positive piglets revealed shortening of the villi and denudation of the villous tips of the jejunum. In one piglet, the colon mucosa revealed numerous Cryptosporidium oocysts. The storage time of the inocula (< or =3 weeks in PBS at 4 degrees C) and the age of the animal (newborn) were important for the successful induction of infection.     

Groin recurrence in patients with vulvar cancer with negative nodes on superficial inguinal lymphadenectomy

OBJECTIVE: The objective of this study was to investigate the cause of groin recurrence in patients with vulvar cancer who had negative nodes in their superficial inguinal lymphadenectomy (SIL) specimens. METHODS: The records of patients with vulvar cancer treated at M. D. Anderson Cancer Center between 1986 and 1997 were reviewed to identify patients with squamous histology, clinical and surgical stage I or II, depth of invasion greater than 1 mm, and primary treatment consisting of radical wide excision and SIL. One hundred four patients met these criteria. Among these, nine experienced recurrent disease that involved one or both of the groins. All of the original hematoxylin and eosin (H&E)-stained slides were reviewed by one pathologist (AM). Then, each paraffin block containing nodal tissue was recut at 40 microm intervals to obtain five sections for H&E staining and two unstained sections to be used for cytokeratin immunostaining if necessary. RESULTS: The median age at diagnosis and primary surgery was 65 years and the median depth of invasion was 4 mm. Seven patients underwent bilateral, and two underwent unilateral, groin dissections. The median number of lymph nodes removed per groin was seven. The median time to recurrence was 22 months. A total of 785 additional H&E-stained slides were prepared and examined at 100x and 400x magnification. No micrometastases were identified, and there were no other suspicious findings. Therefore, immunohistochemical staining was not performed. At recurrence, one patient had a biopsy only, and eight had attempted surgical resection. In two patients, tumor was identified in fibroadipose tissue only; no lymph nodes were identified. Among the other six patients, the median number of lymph nodes resected at the time of the recurrence was five (range 1 to 10). At last report, six patients had died and three were alive and free of disease. Median follow-up for survivors was 63 months (range 42 to 71). CONCLUSION: These data strongly suggest that groin relapse in patients with negative nodes on SIL is caused by metastatic disease in unresected inguinal nodes. SIL as performed on the patients in this study did not eliminate all sites of nodal metastasis.     

Aae,an autotransporter involved in adhesion of Actinobacillus actinomycetemcomitans to epithelial cells

The periodontal pathogen Actinobacillus actinomycetemcomitans possesses myriad virulence factors, among them the ability to adhere to and invade epithelial cells. Recent advances in the molecular manipulation of this pathogen and the sequencing of strain HK 1651 (http://www.genome.ou.edu/act.html) have facilitated examination of the genetics of its interaction with epithelial cells. The related gram-negative organism, Haemophilus influenzae, possesses autotransporter adhesins. A search of the sequence database of strain HK 1651 revealed a homologue with similarity in the pore-forming domain to that of the H. influenzae autotransporter, Hap. A. actinomycetemcomitans mutants deficient in the homologue, Aae, showed reduced binding to epithelial cells. A method for making A. actinomycetemcomitans SUNY 465 transiently resistant to spectinomycin was used with conjugation to generate an isogenic aae mutant. An allelic replacement mutant was created in the naturally transformable A. actinomycetemcomitans strain ATCC 29523. Lactoferrin, an important part of the innate host defense system, protects against bacterial infection by bactericidal and antiadhesion mechanisms. Lactoferrin in human milk removes or cleaves Hap and another autotransporter, an immunoglobulin A1 protease, from the surface of H. influenzae, thereby reducing their binding to epithelial cells. Human milk whey had similar effects on Aae from A. actinomycetemcomitans ATCC 29523 and its binding to epithelial cells; however, there was little effect on the binding of SUNY 465. A difference in the genetic structure of aae in the two strains, apparently due to the copy number of a 135-base repeated sequence, may be the cause of the differential action of lactoferrin. aae is the first A. actinomycetemcomitans gene involved in adhesion to epithelial cells to be identified.     

Prospective follow-up suggests similar risk of subsequent cervical intraepithelial neoplasia grade 2 or 3 among women with cervical intraepithelial neoplasia grade 1 or negative colposcopy and directed biopsy

OBJECTIVE: The purpose of this study was to determine the risk of cumulative cervical intraepithelial neoplasia (CIN) grade 2 or 3 according to initial colposcopy and directed biopsy results among women with low-grade squamous intraepithelial lesions (LSIL) or human papillomavirus (HPV) DNA positive atypical squamous cells of undetermined significance (ASCUS). STUDY DESIGN: A 2-year follow-up of 897 cases of LSIL and 1193 cases of HPV DNA positive ASCUS from the ASCUS/LSIL Triage Study was used to simulate American Society for Colposcopy and Cervical Pathology Consensus Conference recommendations. Women with CIN grade 1 or less were followed up for 2 years by semiannual cytologic examination, with universal exit colposcopy. The clinical end point was a cumulative clinical center histologic diagnosis of CIN grade 2 or 3. RESULTS: The cumulative risk of CIN grade 2 or 3 was equivalent for LSIL (27.6%) and HPV positive ASCUS (26.7%). After excluding the women with a diagnosis of CIN grade 2 or 3 at initial colposcopy and directed biopsy (17.9%), the remaining women were at nearly identical risk for subsequent CIN grade 2 or 3 regardless of initial colposcopy result (completely negative colposcopy-11.3%; negative colposcopically directed biopsy-11.7%; and CIN grade 1 biopsy-13.0%). CONCLUSION: LSIL and HPV positive ASCUS are clinically equivalent. Initial colposcopic detection of obviously prevalent CIN grade 2 or 3 reduces risk. However, for the remaining women who have CIN grade 1 or less on colposcopy and directed biopsy, the risk for subsequent CIN grade 2 or 3 (whether missed, prevalent, or truly incident) is approximately 12% over 2 years. This risk does not vary meaningfully by initial distinction of histologic CIN grade 1 from negative colposcopy and biopsy.