A paradigm for understanding trust and mistrust in medical research: The Community VOICES study.

BACKGROUND: To promote justice in research practice and rectify health disparities, greater diversity in research participation is needed. Lack of trust in medical research is one of the most significant obstacles to research participation. Multiple variables have been identified as factors associated with research participant trust/mistrust. A conceptual model that provides meaningful insight into the interplay of factors impacting trust may promote more ethical research practice and provide an enhanced, actionable understanding of participant mistrust. METHODS: A structured survey was developed to capture attitudes toward research conducted in emergency situations; this article focuses on items designed to assess respondents' level of trust or mistrust in medical research in general. Community-based interviews were conducted in English or Spanish with 355 New York City residents (white 42%, African American 29%, Latino 22%). RESULTS: Generally favorable attitudes toward research were expressed by a majority (85.3%), but many respondents expressed mistrust. Factor analysis yielded four specific domains of trust/mistrust, each of which was associated with different demographic variables: general trustworthiness (older age, not disabled); perceptions of discrimination (African American, Latino, Spanish language preference); perceptions of deception (prior research experience, African American); and perceptions of exploitation (less education). CONCLUSIONS: The four domains identified in the analysis provide a framework for understanding specific areas of research trust/mistrust among disparate study populations. This model offers a conceptual basis for the design of tailored interventions that target specific groups to promote trust of individual researchers and research institutions as well as to facilitate broader research participation.

Localization of human prealbumin in choroid plexus epithelium.

Cerebrospinal fluid (CSF) is generally considered to be derived from plasma through a combined process of ultrafiltration and secretion by the choroid plexus. However, the mechanisms ultimately responsible for achieving the final protein composition of CSF are uncertain. Some proteins, in particular prealbumin, are present in quantities not easily explained by usual physicochemical considerations. To investigate the possibility of de novo synthesis by choroid epithelium, we have examined human choroid plexus an ependyma for the presence of prealbumin. Using the peroxidase-antiperoxidase method at the light and electron microscopic level, as well as immunofluorescence, we localized prealbumin in choroid epithelial cytoplasm on the endoplasmic reticulum and in association with the Golgi apparatus. Ependymal cells and stroma did not reveal immunocytochemical labeling. These findings indicate that the choroid plexus epithelium contributes to the final CSF composition by de novo protein synthesis.

The histologic and biologic spectrum of tubular carcinoma of the breast.

The authors performed a retrospective study, with a mean 7.5-year follow-up period, of 66 patients with tubular carcinoma of the breast. There were ten patients with sclerosing types of tubular carcinoma, 17 with pure forms, and 39 with tubular carcinoma mixed with another histologic type. Although all tumors had tubular formations, the nuclear grades of the mixed forms were less well differentiated than those of the other two subtypes. The mixed tubular carcinomas were also associated with axillary metastases more frequently than was either the sclerosing or the pure type. Of the five patients who died of breast carcinoma, three had mixed tubular carcinomas. The authors conclude that tubular carcinomas have a histologic and biologic spectrum of features and that the mixed form has a less favorable prognosis than the sclerosing or the pure type.

Computer-assisted interpretive reporting with trend analysis of creatine kinase and lactate dehydrogenase isoenzyme determinations.

A program has been developed for a central laboratory computer that provides rapid, comprehensive interpretation of CK and LDH isoenzyme determinations. The laboratory computer can receive data on line from a densitometer or by manual result entry from a cathode ray tube. The program algorithm is based on extensive literature references and yields combinations of narrative comments selected from a file of statements. The algorithm is flexible and easily modified; it permits result correlation of simultaneously ordered CK and LDH studies as well as stand-alone interpretation of these tests requested separately. Trend analysis permits identification of changes from previous results and detection of asynchronous appearances of CK-MB and LD-1 as diagnostic of myocardial injury. The output can be formatted to suggest a strategy for further laboratory evaluation of a patient with suspected myocardial injury. Blind sample analysis of 1,500 sets of patient isoenzyme data, comparing human and computer results, has shown that the program is accurate, consistent, and reliable in a variety of clinical circumstances.

Access to care: a review of the emergency medicine literature.

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.

America's Health Care Safety Net: intact or unraveling?

In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.

Assessing research methodology training needs in emergency medicine.

OBJECTIVE: To determine the perceptions of emergency medicine (EM) academic faculty leaders and other academic emergency physicians regarding importance and knowledge of specific research methodology content areas and training priorities. METHODS: The authors conducted a confidential mail survey of 52 EM academic chairs, 112 residency directors, 116 research directors, and 400 randomly selected other members of the Society for Academic Emergency Medicine (SAEM). Respondents rated the importance of knowledge about each of 12 content areas for enhancing research productivity, rated their own knowledge of these areas, and identified training priorities. Standard descriptive statistics were used to characterize the study population; subgroup differences were examined by nonparametric statistics. RESULTS: 551 (81%) of those sampled returned surveys. Most (90%) respondents thought that knowledge about all selected content areas was important for enhancing research productivity; however, 7-37% (depending on the topic) reported little knowledge or experience in specific areas. Research directors reported highest overall knowledge levels (p < 0.001), followed by chairs, residency directors, and other SAEM members. Top training priorities (identified by all subgroups) included study planning (70%), problem identification/hypothesis construction (41%), and proposal writing (38%). CONCLUSIONS: These data support the continued need to offer broad training in research methodology, but suggest that greater emphasis be given to concepts involved in initiating and planning a study and to strengthening research proposal writing skills. These results should be of interest to academic departments who must address their own training needs, and help support the development of research methodology curricula on regional and national levels to advance the state of research in the specialty of EM.

EMCyberSchool: an evaluation of computer-assisted instruction on the Internet.

OBJECTIVES: To test the hypothesis that integration of the EMCyberSchool, a computer-assisted instruction (CAI) tool available on the Internet, into the curriculum of a senior medical student subinternship in emergency medicine (EM) would improve exam scores and course satisfaction. METHODS: Students were prospectively randomized, by four-week blocks, into a CAI group and a no-CAI group. All students were surveyed on previous computer experience and their use and opinion of the EMCyberSchool. RESULTS: Completed data were obtained from 100 of 120 students. Sixty-five percent of the students said they wanted CAI as an adjunct to their course curricula; only 28% actually used the educational tool. The students who used the site rated it useful (4.2/5), easy to use (4.4/5), and easy to access (4.1/5). Of the students who had access, and chose not to use the EMCyberSchool, 77.8% reported not having enough time as the reason for not using the site. The mean exam scores were 72.8% for the students in the CAI group and 68.2% for those in the no-CAI group (p = 0.058). In the CAI group, 77.5% (31/40) of the students rated the course as outstanding or excellent; compared with 66% (33/50) in the no-CAI group (p = 0.23). CONCLUSIONS: Although desired, it remains unclear whether CAI on the Internet is a useful adjunct for teaching EM to medical students.

Patients' rights and professional responsibilities: the moral case for cultural competence.

A right to health care can be derived from basic ethical principles. The empirical evidence revealing significant racial inequities in health status, access to health services, quality of care received and outcomes of health services is reviewed. The need for health care providers to acquire cultural competence in order to fulfill their professional responsibilities is discussed; the insight, knowledge and discipline required to function effectively in the context of cultural differences are described. The broader implications of cultural competence for institutional and public policy, research and professional education are outlined.

Value of flow cytometry in the evaluation of head and neck fine-needle lymphoid aspirates: a 3-year retrospective review of a community-based practice.

OBJECTIVE: To study the clinical efficacy of flow cytometry in patients suspected of having a lymphoma with head and neck pathology. STUDY DESIGN: Retrospective review of 49 patients with lymphoid aspirates having concurrent flow cytometry studies. SETTING: Private practice office-based study. CONCLUSION: Fine-needle aspiration with concurrent flow cytometry is a useful, convenient adjunct to the diagnosis of head and neck non-Hodgkins lymphomas. SIGNIFICANCE: Flow cytometry is a significant improvement over fine-needle aspiration derived cytologic diagnosis alone. Tissue open biopsy may be avoided altogether in some patients with non-Hodgkins lymphoma.

Quantitative evaluation of fine-needle aspiration.

A protocol was developed to obtain mature lymphocytes from freshly harvested tonsils by a combination of 5-, 10-, and 20-cm3 syringes and 21-, 23-, and 27-gauge needles. The cells were then suspended in Earle's balanced salt solution and counted with an automated cell counter. Cell counts for each study group was compared as a function of needle and syringe size. The range of harvested cells was 900 to 2800 cells per cubic millimeter, allowing adequate cellular material for diagnostic purposes. The amount of negative pressure for each syringe/needle combination was measured with a manometer. Pressures ranged from -500 to -700 cm of H2O pressure. In this particular study, fine-needle aspiration with a 20-cm3 syringe and 21-gauge needle yielded the best results.

Stroke syndromes.

Emergency physicians must stay cognizant of the rapid and dramatic changes underway in the management of patients with acute stroke syndrome. The future clearly points towards a time when emergency physicians will be called upon to treat "brain attacks" in a manner similar to heart attacks, with early recognition and treatment. As effective interventions are developed, we will be able to alter the course, increase the survival, and decrease the morbidity and long-term disability of stroke patients.

Diplopia in the emergency department.

Normal binocular vision requires that all involved structures; ocular, muscular, and neuronal; be intact and all of the intricate processes controlling conjugate gaze and cortical fusion be functioning. Diplopia may represent pathology at any point in this complex system. A careful history and physical examination may reveal a relatively benign etiology or may compel rapid diagnostic studies to evaluate the patient for neurological catastrophe.

Genetic and lifestyle causal beliefs about obesity and associated diseases among ethnically diverse patients: a structured interview study.

BACKGROUND: New genetic associations with obesity are rapidly being discovered. People's causal beliefs about obesity may influence their obesity-related behaviors. Little is known about genetic compared to lifestyle causal beliefs regarding obesity, and obesity-related diseases, among minority populations. This study examined genetic and lifestyle causal beliefs about obesity and 3 obesity-related diseases among a low-income, ethnically diverse patient sample. METHODS: Structured interviews were conducted with patients attending an inner-city hospital outpatient clinic. Participants (n=205) were asked how much they agreed that genetics influence the risk of obesity, type 2 diabetes, heart disease, and cancer. Similar questions were asked regarding lifestyle causal beliefs (overeating, eating certain types of food, chemicals in food, not exercising, smoking). In this study, 48% of participants were non-Hispanic Black, 29% Hispanic and 10% non-Hispanic White. RESULTS: Over two-thirds (69%) of participants believed genetics cause obesity 'some' or 'a lot', compared to 82% for type 2 diabetes, 79% for heart disease and 75% for cancer. Participants who held genetic causal beliefs about obesity held more lifestyle causal beliefs in total than those who did not hold genetic causal beliefs about obesity (4.0 vs. 3.7 lifestyle causal beliefs, respectively, possible range 0-5, p=0.025). There were few associations between causal beliefs and sociodemographic characteristics. CONCLUSIONS: Higher beliefs in genetic causation of obesity and related diseases are not automatically associated with decreased lifestyle beliefs. Future research efforts are needed to determine whether public health messages aimed at reducing obesity and its consequences in racially and ethnically diverse urban communities may benefit from incorporating an acknowledgement of the role of genetics in these conditions.

Healthscapes: the role of the facility and physical environment on consumer attitudes, satisfaction, quality assessments, and behaviors.

The role of the health care physical or tangible environment, including the facility, is essentially an unstudied area. This article identifies and defines components of "atmospherics" concerning health care (Healthscapes), to assess their strengths and predictiveness in the relationship between patient and other customer outcomes, satisfaction, quality assessments, intention to return, and willingness to recommend a health care provider to others and to propose much needed research in the area.

Clinical applications of the altered iron kinetics of toxemia of pregnancy.

The previously reported elevation of serum iron in association with toxemia of pregnancy was evaluated to determine if this chemical test could be clinically useful. When patients with toxemia and pregnant women with chronic hypertension were compared, a serum iron value greater than 100 micrograms/dl or an increase greater than 70% above baseline was a sensitive and specific indicator of toxemia. The predictive value is high and exceeds that of other commonly available tests. The clinical value of this model is discussed.

Altered ferrokinetics in toxemia of pregnancy: a possible indicator of decreased red cell survival.

Serum iron concentration was increased in women with toxemia of pregnancy (mean 135 mcg/dl) compared to normotensive parturients (62 mcg/dl) and chronic hypertensive parturients (72 mcg/dl). Mean iron for eclamptics was 203 mcg/dl; for severe preeclamptics, 137 mcg/dl, independent of hepatic or renal function. Recovery to normal postpartum levels occurred in 1-3 days. Concomitant increase in serum ferritin (mean: 59 ng/ml vs. 19 ng/ml for normals) persisted longer. When hepatocellular injury occurred, mean ferritin increased to 421 ng/ml. Increased iron was independent of transferrin concentration. Serum hemoglobin was detectable in 15 of 25 toxemic patients who had elevated serum iron; only 3 of these patients had clinically significant levels. Serum haptoglobin was significantly decreased in 4 of 25 patients. Reticulocyte count averaged 2.5%, with an average hematocrit of 38%. It is hypothesized that serum iron and ferritin increase in response to catabolism of released hemoglobin. The magnitude of iron increase is greater than could be derived from intravascular hemolysis and suggests an extravascular locus.

Elevated serum ferritin in the altered ferrokinetics of toxemia of pregnancy.

The serum concentration of ferritin in 11 patients with toxemia of pregnancy was compared to that of normal women in the early third trimester of pregnancy and in labor at term. The mean concentration of ferritin for toxemic patients was 91.8 ng/ml compared to 18.4 ng/ml and 19.4 ng/ml for the two control groups, respectively. The biochemical and physiologic features of ferritin are reviewed, and the relationship between iron and ferritin is discussed. Despite elevated serum levels of ferritin in toxemia, it is noted to be less reflective of the clinical course of the syndrome than serum ion.

The effects of a three-month exercise programme on neuropsychological function in elderly institutionalized women: a randomized controlled trial.

This randomized controlled trial examined the effect of a 3-month exercise programme on neuropsychological function in a population of very elderly institutionalized women. Baseline neuropsychological testing was performed, and following 3 months of exercise or control intervention, subjects were retested 3-7 days after the completion of the study period. Apart from the Word Fluency Test, there was no significant improvement in any of the neuropsychological test scores. This study may not have shown any significant improvement in neuropsychological function because our exercise programme was too light to improve aerobic fitness, or because neuropsychological tests were repeated 3-7 days after exercise was completed and any acute effects of exercise may have disappeared by that time.