Frequent video-game playing in young males is associated with central adiposity and high-sugar, low-fibre dietary consumption.

PURPOSE: Video-game playing is associated with an increased obesity risk. The association of video-game playing with body composition, physical activity and eating behaviour was investigated. METHODS: A total of 45 young males (age range 18-27 years, BMI range 18.5-35.1 kg/m(2)) were recruited. Measurements of body composition and blood pressure were performed. The EPIC-FFQ questionnaire was used to assess dietary intake. A questionnaire battery was administered to assess physical activity, eating behaviour, sleep quality and frequency of video-game playing (hours/week). Subjects were categorised into frequent (>7 h/week) and non-frequent (≤7 h/week) players. RESULTS: Frequent video-game players had greater waist circumference and fat mass. Video-game playing was significantly associated with high added sugar and low fibre consumption. A higher level of dietary restraint was observed in non-frequent video-game users. CONCLUSIONS: These preliminary results identify frequent video-game playing as an important lifestyle behaviour which may have important implications for understanding obesity risk in young male adults.

Presenting manifestations, cigarette smoking, and detection bias in age at diagnosis of lung cancer.

PURPOSE: To examine the possible role of detection bias in the association between amount of cigarette smoking and age at diagnosis of lung cancer. The bias can occur because primary lung cancer can often escape detection during life and will be found (if at all) as a "necropsy surprise" unless a diagnostic workup is provoked by such presenting manifestations as hemoptysis and a localized chest lesion. The necropsy surprises will be reduced and the reported rates of pre-mortem incidence will be raised if a cigarette smoking history also acts as a diagnostic incentive. METHODS: This possibility was examined in a case series of 1266 patients whose primary lung cancer had been carefully classified according to diverse features at the time of presentation. For the total case group and for pertinent clinical, anatomic, and demographic subgroups, we then examined the trends for age at diagnosis in relation to amount of cigarette smoking. RESULTS: The overall age at diagnosis (median = 63 years; mean = 61.2) remained essentially similar in five ordinal groups of Tumor, Nodes, Metastases (TNM) and four of five Clinical Severity stages, but had an inverse monotonic gradient in six ordinal groups of customary cigarette smoking [from none to >2 packs per day (ppd)]. Because an earlier age of discovery can be explained by either etiologic or detection-bias roles for heavier smoking, its impact was checked in subgroups with and without diagnostically provocative manifestations. In localized lesions, the smoking-age gradient vanished if suspicious "indicator" symptoms were present, but persisted if they were absent. Regardless of symptoms, the age gradient was strengthened in non-localized cancer lesions where smoking might particularly point to a primary diagnostic source in the lung. CONCLUSIONS: Detection bias may play a distinctive, although often overlooked, role in the work-up decisions that precede and lead to a diagnosis of lung cancer.

A quality-of-life instrument for young hemorrhagic stroke patients.

BACKGROUND AND PURPOSE: Hemorrhagic stroke has a high initial mortality rate. While survivors often recover motor function, many experience significant changes in their quality of life (QOL). Available outcome measures assess neurological impairment, disability, or handicap, yet often inadequately characterize the full impact of a stroke on patients' lives. In this study, we develop and validate a QOL instrument specific for young patients with hemorrhagic strokes. METHODS: Methodological guidelines for instrument development were initially established. Based on the content of 40 open-ended patient interviews, a 54-item instrument (HSQuale) was developed. The reliability (test-retest and internal consistency) and validity (content and construct) of HSQuale were assessed in another 71 patients (18 to 49 years of age, 63% women, 77% white), at 1 year after their hemorrhagic stroke. Comparisons were made between HSQuale and other commonly used outcome measures. RESULTS: HSQuale demonstrated reproducibility (test-retest kappa, 0.40 to 0.96) and internal consistency (Cronbach alpha >/=0.80 for 5 of 7 domains). HSQuale scores had broad frequency distributions (

Prediction of bile duct stones and complications in gallstone pancreatitis using early laboratory trends.

OBJECTIVES: We aimed to determine whether early trends in the serum pancreatic enzymes and liver tests of patients with gallstone pancreatitis predict persistent common bile duct (CBD) stones and complications. METHODS: Medical records of patients with gallstone pancreatitis were reviewed retrospectively. Serial serum pancreatic enzymes and liver tests were recorded until the time of cholangiography. Laboratory trends were analyzed by comparing initial results obtained in the emergency department to subsequent results obtained 8-24 h, 24-48 h, and 48-72 h after presentation. RESULTS: Of 154 patients with gallstone pancreatitis, 28 (18%) had persistent CBD stones at cholangiography. Complications and death were more frequent in patients with persistent CBD stones than in those without CBD stones (29% and 11% vs 12% and 1%, respectively; p < 0.05). Laboratory trends predicted both persistent CBD stones and complications of pancreatitis. When any laboratory value rose between admission and 24-48 h of hospitalization, persistent CBD stones were present in 31% of cases, versus 8% of those in whom all laboratory values remained constant or fell (p = 0.001). Likewise, complications occurred in 21% of those with any rising laboratory value, versus 8% of those in whom all values remained constant or fell (p < 0.05). CONCLUSIONS: Patients with gallstone pancreatitis and rising serum chemistries had a 4-fold risk of persistent CBD stones and a nearly 3-fold risk of complications compared to patients in whom all chemistry values remained constant or fell. This simple prediction rule may identify patients with biliary pancreatitis who are most likely to benefit from early interventions to diagnose and remove persistent CBD stones.

"Benign" tumors and "early detection" in mammography-screened patients of a natural cohort with breast cancer.

BACKGROUND: Although the cure of breast cancer by "early detection" and prompt treatment rests on the belief that all breast cancers grow at the same rate, many cancers have been shown to grow rapidly and others slowly. In particular, mammography screening may often detect the slow-growing, nonaggressive tumors that might not be found until much later, if at all. METHODS: We reviewed the medical records of a natural cohort of 233 patients. The cohort comprised all women who received their first antineoplastic treatment for breast cancer at Yale-New Haven Hospital during the period from January 1 through December 31, 1988, and had a median follow-up thereafter of 82.4 months. RESULTS: The mammography screen-detected group (MSDG) contained 97 (42%) of the 233 breast cancers. The rates of subsequent freedom from cancer deaths or recurrences were 95% (92 patients) in the MSDG and 79% (107 patients) in all other patients (log-rank 2P<.001). This superiority occurred partly because 90 (93%) of the MSDG were in the good prognosis TNM stages 0, I, and IIA, compared with 92 (68%) of the non-MSDG (chi2 2P = .001). Of the 31 patients with stage 0 (carcinoma in situ), all of whom had disease-free survival, 24 (77%) were found by mammography screening. Even within similar TNM stages, however, the MSDG had distinctly better disease-free survival results than the non-MSDG. For patients in TNM stages I and IIA, the "failure events" had respective rates of 2% and 13% (log-rank 2P = .02). CONCLUSIONS: The results suggest that many of the breast cancers found by mammography screening have excellent prognosis not just because of early detection, but also because many of the cancers are relatively benign, requiring minimal therapy.

The International Health Program: the fifteen-year experience with Yale University's Internal Medicine Residency Program.

The purpose of this study was to assess the impact of international health electives on physicians-in-training. A retrospective study was conducted using an anonymous, self-administered mailed survey to internal medicine residents who trained at Yale from 1982 to 1996 based on their experience with our International Health Program (IHP). The response rate was 61%, with 96 completed surveys in the participant group and 96 completed surveys in the nonparticipant group. Participants were more likely than nonparticipants to care for patients on public assistance (77 versus 49; P < 0.001) and immigrant patients (41 versus 23; P = 0.006). Among residents who changed their career plans, participants (22) were more likely than nonparticipants (14) to switch from subspecialty medicine to general medicine (P = 0.02). Participants were significantly more likely to have a positive view of health care delivery in developing countries. Compared with nonparticipants (64), IHP participants (74) believed that the physical examination is under-used by physicians from the United States as a diagnostic skill (P = 0.03). International health experiences appeared to have an important impact on the decisions and attitudes of residents.

Does diagnostic accuracy in mammography depend on radiologists' experience?

This study was designed to determine if radiologists' experience in mammography is associated with their performance in correctly interpreting mammograms. Study mammograms (n = 150) were chosen by stratified random sampling from those interpreted as normal, abnormal-benign or abnormal-suspicious for cancer, with oversampling of cancer cases. Ten radiologists who had varying amounts of experience were asked to read the mammograms. Associations between the levels of the radiologists' experience and their accuracy in reading mammograms were assessed. Significant associations (p < 0.05) were found between the frequency of immediate workup recommendations in cancer patients and obtaining feedback, total lifetime mammograms read, number of mammography continuing medical education (CME) credits, and practice type. Radiologists with more experience also noted smaller cancer lesions. However, these experience variables were also associated with increased workup recommendations in the noncancer patients (p < 0.10). In multivariable analysis, obtaining regular feedback and the total lifetime number of mammograms read were independently associate with the number of times immediate workup was recommended in the cancer cases. The most experienced radiologist had the highest sensitivity in diagnosing breast cancer. Further studies are needed to assess whether the current requirements of the U.S. Food and Drug Administration for radiologists who read mammograms ensure acceptable levels of accuracy.

Clinical utility of endoscopic retrograde cholangiopancreatography.

BACKGROUND: ERCP is a frequently performed procedure, but its necessity for diagnosis and ability to change management plans are unclear in many cases. METHODS: We prospectively evaluated diagnosis, certainty of diagnosis, and management recommendations, both before and after ERCP, as well as therapeutic maneuvers performed during ERCP, in unselected patients undergoing this procedure. RESULTS: ERCP procedures (1341) were studied at a university hospital, an ERCP referral center, and two community hospitals. Among patients undergoing first-time ERCP, the preceding clinical diagnosis was correct for 64% of those predicted to have bile duct stones, 86% to 89% of those given other biliary diagnoses, and 88% predicted to be normal. In 35% of cases, diagnostic confidence improved substantially after ERCP. Endoscopic therapy was successfully completed in 51%. After ERCP, plans for other invasive procedures changed in 82%: percutaneous biliary studies and open surgical procedures were recommended less often and laparoscopic cholecystectomy more often. Endoscopic therapy and overall clinical utility were most common in patients with cholangitis, jaundice, or bile leaks. CONCLUSIONS: ERCP is particularly helpful for diagnosis of bile duct stones but is less likely to change other diagnoses. The endoscopic therapy commonly carried out during ERCP often changes the treatment plan, leading to fewer surgical and percutaneous interventions in general, but more laparoscopic cholecystectomies.

The impact of clinical history on mammographic interpretations.

OBJECTIVE: To determine whether mammographic interpretations are biased by the patient's clinical history. DESIGN: On 2 occasions, separated by a 5-month wash-out period, 10 radiologists read mammograms for the same 100 women, randomly divided into 2 groups of 50. For 1 group, the clinical history was supplied for the first reading and omitted (except for age) for the second reading. This sequence was reversed in the other group. In addition, 5 cases were shown a third time with a deliberately leading sham history. PATIENTS: Selected with stratified random sampling from 3 categories of diagnostic findings (64 had mammographic abnormalities) and from the definitive designation of breast cancer or no breast cancer (18 had breast cancer). MAIN OUTCOME MEASURES: Radiologists' diagnostic accuracy and directional changes in interpretations and recommendations between the 2 readings. RESULTS: The direction suggested by the history led to small but consistent changes in the interpretations. Overall diagnostic accuracy was not altered, but recommendations were affected for appropriate further diagnostic workup: an alerting history (eg, breast symptoms or family history of breast cancer) increased the number of workups recommended in patients without cancer (P=.01); and a nonalerting history led to fewer recommended workups in the cancer patients (P=.02). The direction of the sham histories led an average of 4 of the 10 radiologists to change previous diagnoses and an average of 1 radiologist to change a previous biopsy recommendation. CONCLUSIONS: Knowledge of the clinical history may alter a radiologist's level of diagnostic suspicion without improving performance in either diagnosis or management recommendations.

Variability in radiologists' interpretations of mammograms.

BACKGROUND: Despite the proved value of mammography in screening for breast cancer, its efficacy depends on radiologists' interpretations. The variability in such interpretations is not well understood. METHODS: Using a technique of stratified random sampling, we selected 150 mammograms obtained in 1987: 27 from women with histopathologically confirmed breast cancer and 123 from women with no evidence of breast cancer after three years of follow-up examinations. Ten radiologists, who were unaware of the diagnoses and research hypothesis, each interpreted the 150 mammograms. Disagreement was analyzed within pairs of the 10 radiologists, as well as for the group of 150 women as a whole. RESULTS: The diagnostic consistency between pairs of radiologists was moderate, with a median weighted percentage of agreement of 78 percent (weighted kappa, 0.47). The frequency of the radiologists' recommendations for an immediate workup ranged from 74 to 96 percent for mammograms from the women with cancer and from 11 to 65 percent for films from the women without cancer. A substantial disagreement in management recommendations--in which one radiologist recommended routine follow-up and another recommended a biopsy for the same patient--occurred in 3 percent of the pairwise comparisons but in 25 percent of the comparisons for the group of women as a whole. When two or more radiologists recommended a biopsy for the same patient, a disagreement in the stated location (right or left breast) occurred in 2 percent of the pairwise comparisons among the radiologists but in 9 percent of comparisons for the group of women as a whole. Because some disagreement was likely, given that 10 radiologists read each film, the pairwise comparison is a more conservative estimate of disagreement. CONCLUSIONS: Although mammography is of value in screening women for breast cancer, radiologists can differ, sometimes substantially, in their interpretations of mammograms and in their recommendations for management. Efforts to improve accuracy and reduce variability in interpretation may increase the effectiveness of mammography in detecting early breast cancers.

Prognostic value of clinical variables in invasive cervical cancer.

OBJECTIVE: To test the hypothesis that clinical variables, such as patients' symptoms, symptom severity, and co-morbidity, affect the survival rate of patients with invasive cervical cancer. METHODS: From the medical records of 251 cases of invasive cervical cancer treated at Yale-New Haven Hospital between 1984 and 1988, information was extracted for patients' demographic characteristics, symptoms, symptom severity, comorbidity, physical findings, laboratory data, treatment, and subsequent course. RESULTS: Three-year survival data were available for 250 (99%) of the 251 cases. For a composite clinical predictive system based on symptom status and co-morbidity, the 3-year survival rates were as follows: 85% (64 of 75) for the patients who were asymptomatic without co-morbidity; 63% (58 of 92) for the group that was either symptomatic or co-morbid, but not both; and 40% (33 of 83) for symptomatic patients with co-morbidity or patients with systemic, metastatic, or severe symptoms (P < .0001, chi 2 for linear trend). When entered into a Cox proportional hazards model along with other variables that might affect prognosis, including International Federation of Gynecology and Obstetrics stage, the composite symptom-co-morbidity stage remained statistically significant. CONCLUSIONS: Our findings demonstrate the importance of clinical variables, such as symptoms and co-morbidity, in estimating prognosis in cervical cancer, even after stage and other factors are controlled. Unless the clinical variables are suitably analyzed, prognostic estimates based on morphology alone will be imprecise and therapeutic evaluations may be misleading.

New clinical severity staging system for cancer of the larynx. Five-year survival rates.

Although statistics for cancer of the larynx are reported according to the tumor, node, metastasis (TNM) morphological staging system, functional clinical distinctions can identify major prognostic differences within the same morphological stage. This study was done to improve the staging system by incorporating pertinent clinical variables. In 193 patients with cancer of the larynx first treated between 1973 and 1985, the total 5-year survival was 66% (127/193). By TNM stage it was I, 78% (60/77); II, 67% (32/48); III, 60% (27/45); and IV, 35% (8/23). In three new functional severity stages that combined symptom severity and comorbidity, the corresponding rates were alpha, 83% (89/107); beta, 58% (34/59); and gamma, 15% (4/27). The functional severity stages could be combined with TNM stages to create a powerful new clinical severity staging system, in which the survival results were A, 88% (53/60); B, 80% (24/30); C, 63% (38/60); and D, 28% (12/43). These results demonstrate that inclusion of clinical variables in a formal staging system can strikingly improve prognostic estimations and classification of patients.

The impact of symptoms and comorbidity on prognosis in stage IB cervical cancer.

OBJECTIVE: Like other gynecologic malignancies, cervical cancer is classified by the anatomic location and extent of the tumor. Because clinical variables such as patients' symptoms, symptom severity, and comorbidity may indicate a cancer's biologic virulence and the host-tumor interaction, this study was performed to test the hypothesis that clinical variables will also affect survival of patients with stage IB cervical cancer. STUDY DESIGN: From medical records of 251 cases of invasive cervical cancer treated at Yale-New Haven Hospital between 1984 and 1988, information was extracted for patients' demographic characteristics, symptoms, symptom severity, comorbidity, physical findings, laboratory data, treatment, and subsequent course. RESULTS: In the 122 available cases of stage IB cervical cancer the overall 3-year survival rate was 79%. For a composite clinical predictive system on the basis of symptom status and comorbidity, the 3-year survival rates were as follows: symptomatic patients with comorbidity 58% (seven of 12), either symptomatic or comorbid but not both 77% (46/60), and asymptomatic patients without comorbidity 86% (43/50) (p = 0.02 for linear trend chi 2). When entered into a Cox proportional-hazard model along with other variables that might have an impact on prognosis, the composite symptom-comorbidity stage was the only variable that remained statistically significant. CONCLUSION: These findings demonstrate the importance of clinical variables in estimating prognosis in stage IB cervical cancer. Unless these variables are suitably analyzed, prognostic estimates based only on morphologic studies will be imprecise and therapeutic evaluations may be misleading.

A new clinical prognostic staging system for acute pancreatitis.

PURPOSE: (1) To test the hypothesis that the clinical features of patients with acute pancreatitis could be used to construct a new prognostic staging system, and (2) to compare the new system with the results of the existing Ranson system based on age and laboratory data. PATIENTS AND METHODS: We obtained an inception cohort of 162 persons with 176 episodes of acute pancreatitis admitted to Yale-New Haven Hospital from January 1, 1987, to March 31, 1989. RESULTS: The main adverse outcome events, death and/or complications, occurred in 22% of episodes. Acute pancreatitis severity was classified in three stages, reflecting the presence of only primary features (no ileus or peritonitis), or the occurrence of secondary features that could be mild (mild ileus) or severe (severe ileus and/or peritonitis). In these 3 stages, the respective rates for outcome events were 13% (17 of 133), 43% (13 of 30), and 62% (8 of 13). The severity of comorbidity was classified according to Charlson's comorbidity index. For the 3 comorbidity stages, the outcome event rates were: minimal: 13% (12 of 92); intermediate: 22% (11 of 49); and severe: 43% (15 of 35). When the acute pancreatitis severity stages and comorbidity stages were conjoined to form the composite staging system, the corresponding outcome event rates were stage I: 8 of 107 (7%); stage II: 24 of 60 (40%); and stage III: 6 of 9 (67%). The composite staging system produced sharper gradients for the outcome events than Ranson's system, and was more readily applicable to all patients, particularly when the requisite special laboratory tests had not been ordered. CONCLUSIONS: The clinical and comorbid features of patients with acute pancreatitis can be used to construct a clinically "sensible" composite staging system. The stages are easy to use, require no additional or special laboratory tests, and predict more accurately than Ranson's system.

In-vivo and post-mortem gallstones: support for validity of the "epidemiologic necropsy" screening technique.

This research was done to evaluate the "epidemiologic necropsy" procedure as a "screening" technique for disease that has been clinically unsuspected or inactive during life. The post-mortem occurrence rates of gallstones in necropsies at Yale-New Haven Hospital were compared and found reasonably similar to the analogous rates of gallstones detected in-vivo via ultrasonographic screening of large general populations. Because the authors could not find an appropriate in-vivo screening study done in the United States, they used data mainly from screening studies in Copenhagen, Denmark, and Rome and Sirmione, Italy. Two additional ultrasonographic screening studies have been done in Norway and in populations of Hispanic Americans. Previous disparities between post-mortem and in-vivo screening results probably arose because of failure to stratify for age and sex, to remove patients with cholecystectomy from the analysis, or to account for small-size stones that would be detected at necropsy but not with ultrasonography. The current results help confirm the value of the epidemiologic necropsy procedure in estimating the size of the substantial reservoir of undetected disease that does not appear in the customary tabulations of "vital statistics."

Classifying clinical severity to help solve problems of stage migration in nonconcurrent comparisons of lung cancer therapy.

To compare the effects of stage migration in the "traditional" 3-stage TNM (tumor, node, metastasis) system with those in a new "expanded" 5-stage system, which has two additional stages for the poor prognostic groups, we used both systems to classify a cohort of 178 patients with primary lung cancer. To check for migrations, the stages in both systems were first assigned using only "old" technological information and were then reassigned using all the available "new" as well as old technological data. Although the 5-stage system had more migrations than the 3-stage system, survival rates were relatively unaffected for patients in the two new stages with poor prognosis. In both TNM staging patterns, the effects of stage migration on survival statistics were most impressive in the prognostically better (TNM I and II) stages. A solution to the migration problem is offered by the "clinical severity" (CS) staging system. Like the expanded TNM system, the CS system has 5 stages and a sharp prognostic gradient among stages. The CS system, however, had fewer technology-induced stage migrations than either TNM system, and the migrations had no substantial impact on stage-specific survival results. The excellent prognostic discrimination and secular stability of the CS system make it superior to the TNM system for comparing treatment results from different eras, especially for patients with stage I and II disease.

Diagnostic criteria and technology as sources for changing incidences of pulmonary diseases.

PURPOSE: To investigate the impact of changes in diagnostic criteria and technology on the rates of occurrence of pulmonary diseases during each of four different calendar years: 1921, 1941, 1961, and 1982. PATIENTS AND METHODS: The medical records were obtained for all patients discharged from Yale-New Haven Hospital during 1921, 1941, 1961, and 1982 with a diagnosis of either pulmonary tuberculosis or primary lung cancer. Each patient's entire clinical course was then thoroughly reviewed, including all available data obtained in the six-month intervals before and after the patient's hospitalization. Critical diagnostic information obtained during life at any time during this one-year period was acceptable as evidence for the diagnosis. RESULTS: According to modern diagnostic criteria, the existing evidence of pulmonary tuberculosis or primary lung cancer often did not justify those diagnoses in patients hospitalized during each of the four survey years. The proportions of justified diagnoses showed a consistent increase over time: 16%, 42%, 53%, and 86%, respectively, for tuberculosis, and 0%, 54%, 93%, and 93%, respectively, for lung cancer. CONCLUSION: The results suggest that some of the statistical changes in occurrence rates for these two pulmonary diseases may be due to temporal improvements in diagnostic precision, not just to environmental changes or therapeutic advances.

A comparison of multivariable mathematical methods for predicting survival--I. Introduction, rationale, and general strategy.

This paper and the two following papers (Parts I-III) report an investigation of performance variability for four multivariable methods: discriminant function analysis, and linear, logistic, and Cox regression. Each method was examined for its performance in using the same independent variables to develop predictive models for survival of a large cohort of patients with lung cancer. The cogent biologic attributes of the patients had previously been divided into five ordinal stages having a strong prognostic gradient. With stratified random sampling, we prepared seven "generating" sets of data in which the five biologic stages were arranged in proportional, uniform, symmetrical unimodal, decreasing exponential, increasing exponential, U-shaped, or bi-modal distributions. Each of the multivariable methods was applied to each of the seven generating distributions, and the results were tested in a separate "challenge" set, which had not been included in any of the generating sets. The research was intended not merely to compare the performance of the multivariable methods, but also to see how their performance would be affected by different statistical distributions of the same cogent biologic attributes. The results, which are presented in the second and third papers, were compared for selection of independent variables and coefficients, and for accuracy in fitting the generating sets and the challenge set.