Cross-cultural validity of the Miami Structured Interview--1 for type A in children: the American-Hellenic Heart Study

The Miami Structured Interview--1 was developed (1) to assess Type A behaviour in a broader age range of children than tested with previous interviews, and (2) for cross-cultural studies. This study examined the validity of the Miami Structured Interview--1 for assessing Type A behavior in 507 American and Greek preadolescent (ages 7-11) and adolescent (ages 12-16) boys. The interview was scored on voice stylistics such as speed of speech, word emphasis, and latency of response. Validity was tested using the Matthews Youth Test for Health (MYTH), a teacher rating scale of Type A behaviors. Interview determined Type A's received significantly higher MYTH scores than non Type A's for American adolescents (p less than 0.05), Greek preadolescents (p less than 0.01), and Greek adolescents (p less than 0.05). The interview also identified extreme groups of Type A's and Type B's for American adolescents (p less than 0.01) and Greek preadolescents (p less than 0.05). The findings support the cross-cultural validity of the Miami Structured Interview--1 and the Type A construct for children. Limitations of the Miami Structured Interview--1 are discussed.     

The Limits of Science in On-The-Job Drug Screening

Mass drug screening offers a deceptively simple solution to the problem of drug use among workers. Even a very effective test is subject to error. In any given group of tested individuals, some will unavoidably be falsely accused. Even though scientific tests appear to provide efficient solutions to social and legal problems, these tests should not be accepted unless they also meet our standards for fair dealing.     

Making the Rounds: The Ethical Development of Medical Students in the Context of Clinical Rotations

Medical students newly arrived on the wards encounter frustrating ethical predicaments that are complicated by students' place in the hospital hierarchy. A careful scrutiny of medical social structure and culture may enable medical schools to offer their students a more effective ethics education.     

Ethics are local: engaging cross-cultural variation in the ethics for clinical research.

Relatively little consideration has heretofore been given to the interaction between Western clinical research ethics and non-Western ethical expectations. How should any conflict that might arise when a biomedical investigator and a research subject come from different cultural settings and have different ethical expectations be addressed? Which ethics should govern such trans-cultural clinical research? The answers to these questions are of increasing importance because many countries of the developing world are presently sites of field testing of biomedical agents sponsored and administered by countries of the developed world, especially in the context of the AIDS pandemic. Drawing mainly on examples from Asian medical systems and settings, I elucidate four possible ethical models to guide the conduct of transcultural biomedical research. Two assume that research ethics are culturally relative and two assume that a unified, universalistic conceptualization of research ethics is possible. All four, however, are problematic and are to a large extent deficient. The cause of the deficiencies of these models lies, I argue, in the way that ethics are ordinarily conceived. The proper approach to ethical conflict recognizes that culture shapes (1) the content of ethical precepts, (2) the form of ethical precepts, and (3) the way ethical conflict is handled. Medical ethics may be viewed in cross-cultural perspective as a form of 'local knowledge', and any differences in such knowledge between cultures--since such differences will not conveniently disappear--must be engaged and negotiated.     

Coronary artery bypass grafting in patients with poor ventricular function. Cardiovascular Surgeons of the University of Toronto.

Although patients with severe ventricular dysfunction have improved long-term survival times after coronary bypass procedures, operative morbidity and mortality rates remain high. This study was designed to identify the contemporary risk factors for isolated coronary artery bypass grafting in this high-risk subgroup. Between January 1982 and December 1990, a total of 12,471 patients underwent isolated coronary artery bypass grafting. The 9445 patients with preoperative ejection fractions greater than 40% had a lower operative mortality rate (2.3%) than that of the 2539 patients with ejection fractions between 20% and 40% (4.8%) and that of the 487 patients with ejection fractions less than 20% (9.8%; p less than 0.001). However, patients with ejection fractions of less than 20% were demographically distinct from those with higher ejection fractions. This group was older, with fewer women, a higher frequency of left main stenosis, and more frequent requirement of urgent operation for unstable angina. The risk factors for operative death also varied with preoperative ejection fraction. The traditionally accepted risk factors--urgency of operation, left main coronary artery stenosis, reoperation, sex, and age--were predictive of risk of operative death for patients with ejection fractions greater than 40%. The risk of operative death for patients with ejection fractions between 20% and 40% was predicted by urgency of operation, reoperation, sex, myocardial protection, and age. The only predictor of risk of operative death for patients with ejection fractions less than 20% was urgency of operation. Patients undergoing isolated coronary artery bypass grafting who have severe ventricular dysfunction are therefore a highly selected, high-risk subgroup of patients who risk depends on the urgency of operation. Strategies to improve the results in these patients should be focused on patient selection, improvement of myocardial protection, and more aggressive preoperative treatment of myocardial ischemia.     

The influence of gender on the outcome of coronary artery bypass surgery

BACKGROUND: To assess the impact of gender as an independent risk factor for early and late morbidity and mortality following coronary artery bypass surgery. METHODS: Perioperative and long-term data on all 4,823 patients undergoing isolated coronary bypass operations from November 1989 to July 1998 were analyzed. Of these patients, 932 (19.3%) were females. RESULTS: During the years 1989 to 1998 there was a progressive increase in the percentage of women undergoing coronary artery bypass surgery. The following preoperative risk factors were more prevalent among women than men: age above 70, angina class 3 or 4, urgent operation, preoperative intraaortic balloon pump usage, congestive heart failure, previous percutaneous transluminal coronary angioplasty, diabetes, hypertension, and peripheral vascular disease (all p < 0.05). Men were more likely to have an ejection fraction less than 35%, three-vessel disease, repeat operations, and a recent history of smoking. Women had a statistically significant smaller mean body surface area than men (1.72+/-0.18 versus 1.96%+/-0.26% m2). On average, women had fewer bypass grafts constructed than men (2.9%+/-0.8% versus 3.2%+/-0.9%) and were less likely to have internal mammary artery grafting (76.2% versus 86.1%), multiple arterial conduits (10.1% versus 19.8%), or coronary endarterectomy performed (4.9% versus 8.6%). The early mortality rate in women was 2.7% versus 1.8% in men (p = 0.09). Women were more prone to perioperative myocardial infarction (4.5% versus 3.1% p < 0.05). After adjustment for other risk variables, female gender was not an independent predictor of early mortality but was a weak independent predictor for the prespecified composite endpoint of death, perioperative myocardial infarction, intraaortic balloon counterpulsation pump insertion, or stroke (8.55 versus 5.9%; odds ratio, 1.30; 95% confidence interval, 0.99 to 1.68; p = 0.05) Recurrent angina class 3 or 4 was more frequent in female patients (15.2%+/-4.0% versus 8.5%+/-2.0% at 60 months, p = 0.001) but not repeat revascularization procedures (percutaneous transluminal coronary angioplasty, redo) (0.6%+/-0.3% versus 4.1%+/-0.8% at 60 months). Actuarial survival at 60 months was greater in women then men (93.1%+/-1.7% versus 90.0%+/-1.0%), and after adjustment for other risk variables, female gender was protective for late survival (risk ratio, 0.40; 95% confidence interval, 0.16-0.74; p < 0.005). CONCLUSIONS: Perioperative complications were increased and recurrent angina more frequent in women. Despite this, late survival was increased in women compared with men after adjustment for other risk variables     

Attitude and self-reported practice regarding hospice referral in a national sample of internists

Systematic, nationally representative information about physicians' attitudes and behavior with respect to hospice care is not available. We sought to describe these previously unexamined attitudes and practices. We conducted a mail survey of a random national sample of 1311 internists, of whom 697 responded (an unadjusted response rate of 53%). We elicited physician's attitudes and self-reported practice with respect to hospice. Most internists (89%) felt that hospice care was a good form of terminal care. Physicians with longer definitions of what constitutes "terminal" illness and those whose patients were more accepting of their prognoses were more likely to hold this opinion. Over the course of a year, the median internist referred five patients to hospice. Specialists and those with longer definitions of "terminal" were more likely to have done so. When asked "If you knew exactly how long a patient had to live, how long before death would you refer them to hospice?" the average response was 12.1 +/- 8.5 weeks, but responses varied from 1 to 52 weeks, and the pattern of responses was bimodal, with one peak at about 13 weeks (73% of internists) and one at about 25 weeks (27%). Moreover, the distribution of hospice enrollment times implied by physician reports about ideal practice is significantly more compact than the distribution of survival that is actually observed; physicians support far fewer very short (<2 weeks) and very long (>6 months) stays in hospice than are observed. We conclude that internists show significant support for, and utilization of, hospice and they endorse a length of stay that is longer than currently observed. These findings suggest that it may be possible to increase both the number of patients using hospice and their duration of use of hospice.     

Spousal illness burden is associated with delayed use of hospice care in terminally ill patients

Patients' families are important in hospice not only because they themselves might benefit from it, but also because they influence whether and how hospice is used to begin with. We hypothesized that, among the married, people with less capable spouses (in this case, those who are less healthy) should be less able to use home hospice care and should enroll in hospice later in the course of their illness, closer to death. We tested this hypothesis by evaluating the impact of spousal health on the timing of patients' use of hospice in a select group of 517 couples, a total of 1034 patients, for whom we have health data for both partners from Medicare claims records. We evaluated cohort survival using the Kaplan-Meier method and Cox regression, and we measured illness burden using the Charlson comorbidity score. Among the probands, 45.6% had a primary cancer diagnosis, 44.5% were female, 7.5% were nonwhite, their mean age was 80.0 years (+/-7.6 SD), and their mean Charlson score was 3.1 +/- 3.0. The probands' median survival after hospice enrollment was 55 days. Spouses were similarly composed demographically, but were less likely to have a cancer primary diagnosis (35.4% had cancer) and were slightly younger than the probands; their mean Charlson score was 2.9 +/- 2.9. Each additional point in the Charlson score of the spouse, controlling for measured characteristics of the proband, is associated with a 5.1% increase in the risk of death after enrollment. That is, after controlling for the characteristics of hospice patients themselves, those with sicker spouses are enrolled later. Compared with patients with the healthiest spouses, those with moderately sick and very sick spouses had considerably later enrollment into hospice, with the median survival decreasing from 111 to 49 to 22 days across the groups. Our data suggest that there may be a separate role of spousal health in affecting the time of hospice enrollment, and that patients' social support may affect not just their health status to begin with, but also their use of health care in general.     

Factors considered important at the end of life by patients, family, physicians, and other care providers

CONTEXT: A clear understanding of what patients, families, and health care practitioners view as important at the end of life is integral to the success of improving care of dying patients. Empirical evidence defining such factors, however, is lacking. OBJECTIVE: To determine the factors considered important at the end of life by patients, their families, physicians, and other care providers. DESIGN AND SETTING: Cross-sectional, stratified random national survey conducted in March-August 1999. PARTICIPANTS: Seriously ill patients (n = 340), recently bereaved family (n = 332), physicians (n = 361), and other care providers (nurses, social workers, chaplains, and hospice volunteers; n = 429). MAIN OUTCOME MEASURES: Importance of 44 attributes of quality at the end of life (5-point scale) and rankings of 9 major attributes, compared in the 4 groups. RESULTS: Twenty-six items consistently were rated as being important (>70% responding that item is important) across all 4 groups, including pain and symptom management, preparation for death, achieving a sense of completion, decisions about treatment preferences, and being treated as a "whole person." Eight items received strong importance ratings from patients but less from physicians (P<.001), including being mentally aware, having funeral arrangements planned, not being a burden, helping others, and coming to peace with God. Ten items had broad variation within as well as among the 4 groups, including decisions about life-sustaining treatments, dying at home, and talking about the meaning of death. Participants ranked freedom from pain most important and dying at home least important among 9 major attributes. CONCLUSIONS: Although pain and symptom management, communication with one's physician, preparation for death, and the opportunity to achieve a sense of completion are important to most, other factors important to quality at the end of life differ by role and by individual. Efforts to evaluate and improve patients' and families' experiences at the end of life must account for diverse perceptions of quality. JAMA. 2000;284:2476-2482.