Sources of child maltreatment information in Canada.

AIM: Interest in understanding the problem of child maltreatment is widely shared by governments, organizations of physicians, and others. Our objective was to describe and discuss sources of information in Canada that could be used to help understand the nature and scope of the problem, either within any province or territory, or across all of Canada. METHODS: A series of web searches and a focused literature review were conducted to identify sources of child maltreatment information. Government departments responsible for child welfare were also contacted on an as-needed basis in order to identify additional sources. RESULTS: Identified sources included: child welfare administrative provincial/territorial data and reports based on those data, other child welfare information, surveys of child protection workers and shelter workers, mortality/morbidity data, police data, direct surveys of children and their parents, and the 2011 Canadian census. Each type of source had strengths and limitations in terms of how it could describe the nature and scope of the problem of child maltreatment. CONCLUSION: Increased use of morbidity and mortality data, data linking, expanding existing databases, and increasing the use of general population surveys could expand understanding of child maltreatment in Canada.

Ovipositional preferences of the Japanese beetle (Coleoptera: Scarabaeidae) among warm- and cool-season turfgrass species.

Japanese beetles, Popillia japonica Newman (Coleoptera: Scarabaeidae), were evaluated for ovipositional preferences among four turfgrasses common in northwestern Arkansas. Choice assays revealed females preferred to oviposit in tall fescue (Festuca arundinacea Schreb.) and zoysiagrass (Zoysia japonica Steud.), and that they avoided oviposition in common bermudagrass (Cynodon dactylon [L.] Pers.) and hybrid bermudagrass (C. dactylon x C. transvaalensis Pers.). Significantly fewer eggs were oviposited in hybrid bermudagrass in a no-choice assay, suggesting that chemical and/or physical plant characteristics deter oviposition in that grass. The percentage of turfgrass cores with evidence of female activity (presence of female or eggs, or signs of female digging) in choice assays revealed no differences among treatments, yet significantly fewer hybrid bermudagrass cores had eggs. These results suggest that many females did not initially reject hybrid bermudagrass based on aboveground plant characteristics, but rather they left without ovipositing. Therefore, resistance in hybrid bermudagrass is likely expressed below ground. Our results suggest that the use of hybrid bermudagrass as a means of cultural control in an integrated pest management program may discourage Japanese beetle oviposition and subsequent grub infestations in lawns, golf courses, or sports fields.

Life history and natural enemy associations of calico scale (Homoptera: Coccidae) in Kentucky.

Seasonal phenology of calico scale, Eulecanium cerasorum (Cockerell), was monitored for 3 yr on various deciduous tree species in central Kentucky. Infestations were found on 16 host species in six plant families. Calico scale is a univoltine parthenogenic species that overwinters as second instars on bark. Nymphs molted to adult females around mid-April and began producing eggs in late April. Mean fecundity ranged from 3,728 to 4,654 eggs per female, depending on host plant species. Date of first crawler hatch in 2001-2003 ranged from 21 to 26 May, corresponding to a mean accumulation of 818 +/- 2 Celsius degree-days (DDC), calculated from 1 January and a base of 4.4 degrees C. This value predicted crawler hatch within 2 d in Lexington, KY, in 2004. Crawler dispersal lasted 2 to 3 wk. Upon hatching, crawlers move to leaves where they feed during summer. Crawlers primarily settled on the abaxial side of leaves and their within-leaf distribution varied between different tree species. Settled crawlers molted in mid-July and second instars remained on leaves until late September through mid-October, when they returned to bark to overwinter. On hackberry, Celtis occidentalis L., they were concentrated toward the basal end of shoots, primarily because leaf flush continued beyond the end of the crawler dispersal period. Crawler distribution did not differ between upper and lower canopy zones. Fourteen species of parasitoids and a coccinellid beetle were reared from individual scales. Monitoring with sticky traps in tree canopies confirmed that targeting crawlers with insecticides during late May or June would not coincide with peak flight activity of the scale's primary parasitoids.

Epidermal growth factor activates m-calpain (calpain II), at least in part, by extracellular signal-regulated kinase-mediated phosphorylation.

How m-calpain is activated in cells has challenged investigators because in vitro activation requires near-millimolar calcium. Previously, we demonstrated that m-calpain activation by growth factors requires extracellular signal-regulated kinase (ERK); this enables tail deadhesion and allows productive motility. We now show that ERK directly phosphorylates and activates m-calpain both in vitro and in vivo. We identified serine 50 as required for epidermal growth factor (EGF)-induced calpain activation in vitro and in vivo. Replacing the serine with alanine limits activation by EGF and subsequent cell deadhesion and motility. A construct with the serine converted to glutamic acid displays constitutive activity in vivo; expression of an estrogen receptor fusion construct produces a tamoxifen-sensitive enzyme. Interestingly, EGF-induced m-calpain activation occurs in the absence of increased intracellular calcium levels; EGF triggers calpain even in the presence of intracellular calcium chelators and in calcium-free media. These data provide evidence that m-calpain can be activated through the ERK cascade via direct phosphorylation and that this activation may occur in the absence of cytosolic calcium fluxes.

Evaluating companion planting and non-host masking odors for protecting roses from the Japanese beetle (Coleoptera: Scarabaeidae).

Effectiveness of companion planting, and use of nonhost masking odors were evaluated under field conditions for protecting roses against the Japanese beetle, Popillia japonica Newman. Three reputedly effective companion species, rue (Ruta graveolens L.), zonal geranium (Pelargonium x hortorum Bailey), and garlic chives (Allium scheonparum L.) were interplanted with roses in replicated garden plots. Numbers of beetles on these roses were compared with rose-only control plots on 6 d during beetle flight. The masking odor hypothesis was tested by hanging mesh bags of aromatic herbs or other sources of reputedly repellent nonhost volatiles around potted roses in the field. Treatments included crushed red pepper (Capsicum frutescens L.), fennel seeds (Foeniculm vulgare Miller), crushed spearmint (Mentha picata L.), cedar shavings (Juniperus sp.), osage orange fruits (Maclura pomifera (Raif) Schneid.), and fleshy gingko seeds (Gingko biloba L.). No treatment significantly reduced numbers of beetles relative to the controls. Interplanting with geraniums significantly increased numbers of Japanese beetles on roses. Similarly, roses surrounded by sachets with fennel seeds, cedar shavings, crushed red pepper, or osage orange fruits had significantly more beetles than the control plants on two or more sample dates. Our results suggest that the use of companion or reputedly repellent plants or plant odors probably will be ineffective for protecting roses or other highly-susceptible ornamentals from P. japonica. Use of such tactics in an effort to discourage other garden pests might even increase Japanese beetle damage in those plantings.

v-Src-induced modulation of the calpain-calpastatin proteolytic system regulates transformation.

v-Src-induced oncogenic transformation is characterized by alterations in cell morphology, adhesion, motility, survival, and proliferation. To further elucidate some of the signaling pathways downstream of v-Src that are responsible for the transformed cell phenotype, we have investigated the role that the calpain-calpastatin proteolytic system plays during oncogenic transformation induced by v-Src. We recently reported that v-Src-induced transformation of chicken embryo fibroblasts is accompanied by calpain-mediated proteolytic cleavage of the focal adhesion kinase (FAK) and disassembly of the focal adhesion complex. In this study we have characterized a positive feedback loop whereby activation of v-Src increases protein synthesis of calpain II, resulting in degradation of its endogenous inhibitor calpastatin. Reconstitution of calpastatin levels by overexpression of exogenous calpastatin suppresses proteolytic cleavage of FAK, morphological transformation, and anchorage-independent growth. Furthermore, calpastatin overexpression represses progression of v-Src-transformed cells through the G(1) stage of the cell cycle, which correlates with decreased pRb phosphorylation and decreased levels of cyclins A and D and cyclin-dependent kinase 2. Calpain 4 knockout fibroblasts also exhibit impaired v-Src-induced morphological transformation and anchorage-independent growth. Thus, modulation of the calpain-calpastatin proteolytic system plays an important role in focal adhesion disassembly, morphological transformation, and cell cycle progression during v-Src-induced cell transformation.

Modified atmosphere treatments as a potential disinfestation technique for arthropod pests in greenhouses.

Incidental transport of arthropods on plant material can be a significant mode of pest entry into greenhouses. We evaluated the use of controlled atmosphere treatments as a potential way to eliminate arthropod pests on plant propagules (i.e., cuttings or small rooted plants). Lethal exposures to CO2 or N2 were determined for common greenhouse pests including fungus gnat larvae, Bradysia sp.; green peach aphid, Myzus persicae (Sulzer); sweetpotato whitefly, Bemisia sp.; twospotted spider mite, Tetranychus urticae Koch; and western flower thrips, Frankliniella occidentalis (Pergande). We also studied the effect of pest species, life stage, and presence or absence of plants on efficacy of modified atmosphere treatments. Finally, effects of modified atmospheres on plant quality were evaluated for several bedding plant species including begonia, Begonia semperflorens-cultorum Hort. 'Cocktail Series', chrysanthemum, Dendranthema grandiflora Tzvelev., geranium, Pelargonium X hortorum L.H. Bailey, and impatiens, Impatiens wallerana Hook f., and among cultivars of geranium and chrysanthemum. Exposure for 12-18 h to >99% N2 or CO2 caused complete mortality of aphids, mites, thrips, and whiteflies. Fungus gnat larvae were more tolerant of hypoxic conditions. Adult mites and eggs were equally susceptible. For most pests, there was no difference in response to atmospheres modified by CO2 or N2. However, there was variation in response among plant species and cultivars, with effects ranging from delayed flowering to mortality. Despite the possibility of adverse effects on some plants, this work indicates that use of modified atmospheres has potential to eliminate arthropod pests on plant propagules before they are introduced into greenhouses.

Lethal and sublethal effects of bendiocarb, halofenozide, and imidacloprid on Harpalus pennsylvanicus (Coleoptera: Carabidae) following different modes of exposure in turfgrass.

Routes by which nontarget predatory insects can be exposed to turfgrass pesticides include topical, residual, and dietary exposure. We used each of these routes to evaluate potential lethal or sublethal effects of two novel turfgrass insecticides, imidacloprid and halofenozide, and a carbamate, bendiocarb, on survival, behavior, and fecundity of the ground beetle Harpalus pennsylvanicus DeGeer. Field-collected carabids were exposed to direct spray applications in turf plots, fed food contaminated by such applications, or exposed to irrigated or nonirrigated residues on turf cores. Halofenozide caused no apparent acute, adverse effects through topical, residual, or dietary exposure. Moreover, the viability of eggs laid by females fed halofenozide-treated food once, or continuously for 30 d, was not reduced. In contrast, topical or dietary exposure of carabids to bendiocarb inevitably was lethal. Exposure to imidacloprid by those routes caused high incidence of sublethal, neurotoxic effects including paralysis, impaired walking, and excessive grooming. Intoxicated beetles usually recovered within a few days in the laboratory, but in the field, they were shown to be highly vulnerable to predation by ants. One-time intoxication by imidacloprid did not reduce females' fecundity or viability of eggs. There was no apparent behavioral avoidance of insecticide residues, or of insecticide-treated food. Carabids exposed to dry residues on turfgrass cores suffered high mortality from bendiocarb, and some intoxication from imidacloprid, but these effects were greatly reduced by posttreatment irrigation. Implications for predicting hazards of insecticides to beneficial invertebrates in turfgrass are discussed.

Dogwood borer (Lepidoptera: Sesiidae) infestation of horned oak galls.

Pin oak, Quercus palustris Muenchhausen, is the primary host for the gall wasp Callirhytis cornigera (Osten Sacken). Woody stem galls formed by C. cornigera may be infested by the dogwood borer, Synanthedon scitula (Harris), an important pest of flowering dogwood, Cornus florida L. Previous research has shown that S. scitula has a bimodal seasonal flight pattern, with peaks in late spring and midsummer. We tested the hypothesis that moths emerging from dogwoods largely account for the first flight pulse, whereas emergence from stem galls contributes disproportionately to the second pulse. Seasonal flight activity of S. scitula was monitored with pheromone traps baited with Z,Z-3,13-octadecadien-1-ol acetate. Traps were hung near plantings of dogwoods in suburban landscapes or near heavily galled pin oaks. Borer emergence from dogwood was monitored by sampling infested trees for pupal exuviae, and from galls that were collected and held in outdoor rearing cages. The impact of S. scitula on C. cornigera larvae was assessed by weighing, measuring, and dissecting galls. Flight activity of S. scitula began on 5 May and ended on 13 October 1999, with peaks in late May and in late July to early August. The flight pattern was similar for the two types of trapping sites, and moths emerged from both hosts during both flight periods. Proportionately more moths emerged from dogwoods during the first flight pulse than during the second, but emergence from galls was nearly evenly divided between the two flight peaks. We therefore reject the hypothesis that emergence of borers from galls contributes disproportionately to the second flight period. Approximately 12-15% of stem galls (2-3 yr old) contained S. scitula larvae. Feeding and tunneling by borers contributed to gall desiccation and reduced horn development, but rarely killed C. cornigera larvae. This study has implications for management of S. scitula because borers emerging from horned oak galls may represent a threat to dogwood.

Impact of whole-canopy and systemic insecticidal treatments on Callirhytis cornigera (Hymenoptera: Cynipidae) and associated parasitoids on pin oak.

The gall wasp Callirhytis cornigera (Osten Sacken) is a cynipid with alternating generations that produce large, woody stem galls and tiny blister-like leaf galls on pin oak, Quercus palustris Muenchhausen, in the United States. We tested 3 approaches to control the leaf-galling generation, and determined their impact on associated parasitoids and effectiveness in reducing numbers of new stem galls. First, trees were sprayed with bifenthrin or chlorpyrifos in late March to kill females emerging from stem galls before they oviposited into buds. Second, concentrated solutions of abamectin, imidacloprid, or bidrin were injected from pressurized containers into tree sapwood to control larvae developing in young leaf galls. Finally, systemic insecticides (acephate, abamectin, dimethoate, or imidacloprid) were sprayed at early leaf expansion (2 May) or to young, expanded leaves (17 May) to target larvae in leaf galls. Parasitoids, mostly eulophids, accounted for approximately 70% mortality of leaf-galling C. cornigera larvae on untreated trees. Whole-canopy sprays during C. cornigera emergence from stem galls reduced overall numbers of galled leaves and leaf galls. Trunk injections of bidrin or abamectin resulted in significant mortality of gall inhabitants, including parasitoids. However, neither of the aforementioned approaches significantly reduced numbers of new stem galls. Sprays of abamectin, dimethoate, or imidacloprid applied on 2 May caused high mortality of all gall inhabitants. There was no net benefit, however, because parasitism caused a similar reduction in C. cornigera survival on unsprayed shoots. Sprays applied later in leaf expansion had little impact on gall inhabitants. Of the treatments tested, bifenthrin sprays at bud break provided the greatest reduction in new leaf galls, whereas bidrin injections provided the greatest reduction in gall wasps emerging from galled leaves. This study suggests that gall wasp outbreaks are unlikely to be controlled by a single treatment, regardless of application method.

Inhibition of calpain blocks platelet secretion, aggregation, and spreading.

Previous studies have indicated that the Ca(2+)-dependent protease, calpain, is activated in platelets within 30-60 s of thrombin stimulation, but specific roles of calpain in platelets remain to be identified. To directly test the functions of calpain during platelet activation, a novel strategy was developed for introducing calpain's specific biological inhibitor, calpastatin, into platelets prior to activation. This method involves treatment of platelets with a fusion peptide, calpastat, consisting of the cell-penetrating signal sequence from Kaposi's fibroblast growth factor connected to a calpain-inhibiting consensus sequence derived from calpastatin. Calpastat specifically inhibits thrombin peptide (SFLLR)-induced alpha-granule secretion (IC(50) = 20 microM) during the first 30 s of activation, thrombin-induced platelet aggregation (IC(50) = 50 microM), and platelet spreading on glass surfaces (IC(50) = 34 microM). Calpastat-Ala, a mutant peptide in which alanine is substituted at conserved calpastatin residues, lacks calpain inhibitory activity and fails to inhibit secretion, aggregation, or spreading. The peptidyl calpain inhibitors calpeptin, MDL 28,170 (MDL) and E64d also inhibit secretion, aggregation and spreading, but require 3-10-fold higher concentrations than calpastat for biological activity. Together, these findings demonstrate that calpain regulates platelet secretion, aggregation, and spreading and indicate that calpain plays an earlier role in platelet activation following thrombin receptor stimulation than had been previously detected.

Low-dose follicular-phase cocaine administration disrupts menstrual and ovarian cyclicity in rhesus monkeys.

OBJECTIVE: To evaluate the effects of daily low-dose follicular-phase cocaine administration on menstrual cyclicity, ovulation rates, corpus luteum function, and hormone levels in rhesus monkeys. METHOD: Normally cycling, drug-naive, adult rhesus monkeys were randomized to receive either 1 mg/kg of cocaine (n = 7), 2 mg/kg of cocaine (n = 7), or normal saline (n = 7) daily on cycle days 2 to 14. Daily blood samples were obtained through indwelling catheters for measurement of serum gonadotropins and ovarian steroids. Daily vaginal swabs were obtained to determine onset of menses. Laparoscopy was performed 2 days after the midcycle estrogen peak to document ovulation. Daily caloric intakes as well as pretreatment and posttreatment weights were recorded. RESULTS: Two of seven monkeys receiving 1 mg/kg per day and two of seven monkeys receiving 2 mg/kg per day of cocaine had timely ovulation and normal menstrual cycle lengths. One monkey receiving the 2-mg/kg dose ovulated on cycle day 24 and had a short luteal phase (7 days) with a mean progesterone level of 2.4 ng/mL. All seven saline-treated control monkeys ovulated normally; the mean cycle length was 29 days and all had adequate luteal phases. The difference in ovulation rates between cocaine-treated and control monkeys was statistically significant (P = .003). There were no differences in basal levels of LH or FSH between treatment groups. There were no significant differences in weight change or caloric intake among groups. One third of the subsequent menstrual cycles in cocaine-treated monkeys were of abnormal duration. CONCLUSION: Daily low-dose follicular-phase cocaine administration disrupts menstrual cyclicity and folliculogenesis. This effect is independent of weight loss, caloric intake, and basal gonadotropin levels. Cocaine exposure may have a persistent effect on menstrual and ovarian cyclicity in some monkeys.

Noncommunicating accessory uterine cavity.

OBJECTIVE: To report a case of a noncommunicating accessory uterine cavity. DESIGN: Case report. SETTING: University-affiliated reproductive endocrinology practice. PATIENT(S): A 15-year-old nulligravida with increasing dysmenorrhea. INTERVENTION(S): Pelvic ultrasound, intravenous pyelogram, hysterosalpingogram, laparoscopy, laparotomy, and resection of noncommunicating accessory uterine cavity. MAIN OUTCOME MEASURE(S): Results of imaging studies, surgical examination, and resection of anomaly. RESULT(S): Complete resection of accessory cavity and resolution of dysmenorrhea. CONCLUSION(S): The patient had a müllerian anomaly in which the uterus contained two uterine cavities. One normal uterine cavity with communication to both fallopian tubes was present along with a noncommunicating, accessory uterine cavity.

Endometrial biopsy during hormone replacement cycle in donor oocyte recipients before in vitro fertilization-embryo transfer.

OBJECTIVE: To examine the usefulness of a trial cycle of hormone replacement therapy (HRT) and endometrial biopsy before the actual ET cycle in recipients of donated oocytes. DESIGN: Retrospective review. SETTING: Clinical practice at the South Texas Fertility Center, San Antonio, Texas. PATIENT(S): Thirty-six concurrent patients who underwent a trial cycle of HRT with endometrial biopsy before the ET cycle with donated oocytes fertilized in vitro. INTERVENTION(S): Patients > or =40 years of age received 100 mg of i.m. progesterone in oil daily; patients <40 years of age received 50 mg daily. Endometrial biopsies were performed during the late luteal phase of the trial cycle. MAIN OUTCOME MEASURE(S): Histologic dating of the biopsy specimens was correlated with the chronologic date of the biopsy. RESULT(S): Five of 20 patients > or =40 years of age had out-of-phase biopsies. All 16 patients <40 years of age had in-phase biopsies. All out-of-phase biopsies subsequently were corrected with higher doses of progesterone. Pregnancy rates after fresh and frozen ETs were not significantly different between the two age groups. CONCLUSION(S): Patients > or =40 years of age are at risk of having out-of-phase endometrial biopsies while they are receiving standard HRT despite receiving higher doses of progesterone. Trial HRT cycles with endometrial biopsies are recommended.

Calpain regulates actin remodeling during cell spreading.

Previous studies suggest that the Ca2+-dependent proteases, calpains, participate in remodeling of the actin cytoskeleton during wound healing and are active during cell migration. To directly test the role that calpains play in cell spreading, several NIH-3T3- derived clonal cell lines were isolated that overexpress the biological inhibitor of calpains, calpastatin. These cells stably overexpress calpastatin two- to eightfold relative to controls and differ from both parental and control cell lines in morphology, spreading, cytoskeletal structure, and biochemical characteristics. Morphologic characteristics of the mutant cells include failure to extend lamellipodia, as well as abnormal filopodia, extensions, and retractions. Whereas wild-type cells extend lamellae within 30 min after plating, all of the calpastatin-overexpressing cell lines fail to spread and assemble actin-rich processes. The cells genetically altered to overexpress calpastatin display decreased calpain activity as measured in situ or in vitro. The ERM protein ezrin, but not radixin or moesin, is markedly increased due to calpain inhibition. To confirm that inhibition of calpain activity is related to the defect in spreading, pharmacological inhibitors of calpain were also analyzed. The cell permeant inhibitors calpeptin and MDL 28, 170 cause immediate inhibition of spreading. Failure of the intimately related processes of filopodia formation and lamellar extension indicate that calpain is intimately involved in actin remodeling and cell spreading.

Physician variability and uncertainty in the management of breast cancer. Results from a factorial experiment.

OBJECTIVES: The purpose of this research was to determine the influence of patient and physician characteristics on physicians' level of variability and certainty in breast cancer care. METHODS: One hundred twenty-eight physicians viewed a videotape of a simulated physician-patient interaction in which the patient has an "atypical" breast lump. Six patient characteristics (age, race, socioeconomic status, physical mobility, comorbidity, presentation style) were manipulated experimentally, resulting in a balanced set of 32 different "patients." Physician subjects were recruited to fill four equal strata defined by specialty (surgeons versus nonsurgeons) and experience (< or = 15 or > 15 years since graduation from medical school). RESULTS: More than half of the physicians offered a diagnosis of benign breast disease, a third offered a diagnosis of breast cancer, and the rest believed that the patient had a normal breast or something "other." Results also indicated that physicians' level of certainty and test ordering behavior varied with the diagnosis that was offered. Of the six patient characteristics, only socioeconomic status influenced physician certainty; physicians were more certain of their diagnosis when the patient was of a higher socioeconomic status. Surgeons were found to be more certain of their diagnosis compared with nonsurgeons. However, surgeons were less likely to order radiologic tests or a tissue sample for metastatic evaluation than were nonsurgeons. CONCLUSIONS: Overall, physicians displayed considerable variability and uncertainty when diagnosing and managing possible breast cancer.

Effects of follicular-phase cocaine administration on menstrual and ovarian cyclicity in rhesus monkeys.

OBJECTIVE: The purpose of this study was to evaluate the effects of daily follicular-phase cocaine administration on menstrual cyclicity, gonadotropin and ovarian steroid levels, ovulation rates, and corpus luteum function in cycling rhesus monkeys. STUDY DESIGN: Thirteen normally cycling, drug-naive adult rhesus monkeys were randomized to receive daily intravenous injections of either 4 mg/kg cocaine or an equal volume of saline solution. Treated animals were yoked to pair-fed controls to minimize differences in caloric intake. Daily blood samples were obtained through indwelling catheters for measurement of serum gonadotropin and ovarian steroid levels. Daily vaginal swabs were obtained to determine the onset of menses. Laparoscopy was performed 2 days after the midcycle estrogen peak to check for ovulation. Daily caloric intakes and pretreatment and posttreatment weights were recorded. RESULTS: All six of the control monkeys had laparoscopically confirmed ovulation compared with one of seven in the cocaine-treated group (p < 0.004). Cycle length was normal in five of six controls versus one of seven cocaine-treated monkeys. Estradiol levels were significantly higher in the controls versus the cocaine-treated monkeys (p = 0.01) during the first 14 days of the treatment cycle. There were no differences in basal plasma gonadotropin levels between groups. Luteal-phase lengths and luteal-phase plasma progesterone levels were similar in the controls and the single ovulatory cocaine-treated monkey. There were no significant differences in weight change or caloric intake between the two groups. CONCLUSIONS: Daily follicular-phase cocaine administration disrupts menstrual cyclicity and folliculogenesis independent of weight loss, caloric intake, and basal gonadotropin levels.

Nonmedical influences on medical decision making: an experimental technique using videotapes, factorial design, and survey sampling.

OBJECTIVE: To study nonmedical influences on the doctor-patient interaction. A technique using simulated patients and "real" doctors is described. DATA SOURCES: A random sample of physicians, stratified on such characteristics as demographics, specialty, or experience, and selected from commercial and professional listings. STUDY DESIGN: A medical appointment is depicted on videotape by professional actors. The patient's presenting complaint (e.g., chest pain) allows a range of valid interpretation. Several alternative versions are taped, featuring the same script with patient-actors of different age, sex, race, or other characteristics. Fractional factorial design is used to select a balanced subset of patient characteristics, reducing costs without biasing the outcome. DATA COLLECTION: Each physician is shown one version of the videotape appointment and is asked to describe how he or she would diagnose or treat such a patient. PRINCIPAL FINDINGS: Two studies using this technique have been completed to date, one involving chest pain and dyspnea and the other involving breast cancer. The factorial design provided sufficient power, despite limited sample size, to demonstrate with statistical significance various influences of the experimental and stratification variables, including the patient's gender and age and the physician's experience. Persistent recruitment produced a high response rate, minimizing selection bias and enhancing validity. CONCLUSION: These techniques permit us to determine, with a degree of control unattainable in observational studies, whether medical decisions as described by actual physicians and drawn from a demographic or professional group of interest, are influenced by a prescribed set of nonmedical factors.

The influences of patient characteristics and physician experience on case recall.

The study focused on the influences of both patient characteristics and physician experience on the recall of two breast cancer cases. Two general research questions were addressed: 1) whether patient characteristics such as age, race, and assertiveness affect a physician's initial problem representation, and 2) whether the recall advantage for physicians of intermediate levels of experience extends to physicians who have been out of medical school for at least six years, 128 physicians with a minimum of six years' experience were presented with two videotapes of a doctor-patient encounter. In the first videotape (the pre-workup scenario), the patient had just discovered a lump; in the second (the post-workup scenario), she had recently had a biopsy. Following the presentation of each videotape, the physicians were instructed to record a synopsis of the case prior to making diagnoses, ordering tests, and providing treatment recommendations. The synopses were coded to capture information from the cases that the physicians were able to recall and inferences that they generated based on this information. Two critical findings were obtained. First, none of the patient characteristics investigated consistently produced differences in recall or inference generation across the two scenarios. Second, physician recall was a monotonically decreasing function of years of experience. The latter result is interpreted using a theoretical framework from Schmidt and Boshuizen.

Non-medical influences on medical decision-making.

BACKGROUND: The influence of non-medical factors on physicians' decision-making has been documented in many observational studies, but rarely in an experimental setting capable of demonstrating cause and effect. We conducted a controlled factorial experiment to assess the influence of non-medical factors on the diagnostic and treatment decisions made by practitioners of internal medicine in two common medical situations. METHOD: One hundred and ninety-two white male internists individually viewed professionally produced video scenarios in which the actor-patient, presenting with either chest pain or dyspnea, possessed various balanced combinations of sex, race, age, socioeconomic status, and health insurance coverage. Physician subjects were randomly drawn from lists of internists in private practice, hospital-based practice, and HMO's, at two levels of experience. RESULTS: The most frequent diagnoses for both chest pain and dyspnea were psychogenic origin and cardiac problems. Smoking cessation was the most frequent treatment recommendation for both conditions. Younger patients (all other factors being the same) were significantly more likely to receive the psychogenic diagnosis. Older patients were more likely to receive the cardiac diagnosis for chest pain, particularly if they were insured. HMO-based physicians were more likely to recommend a follow-up visit for chest pain. Several interactions of patient and physician factors were significant in addition to the main effects. CONCLUSIONS: The variability in decision-making evidenced by physicians in this experiment was not entirely accounted for by strictly rational Bayesian inference (the common prescriptive model for medical decision-making), in-as-much as non-medical factors significantly affected the decisions that they made. There is a need to supplement idealized medical schemata with considerations of social behavior in any comprehensive theory of medical decision-making.