The effect of demographic characteristics, Country of birth and country of medical training on the peer evaluations of internal medicine resident physicians.

Background: Peer review by resident physicians, a standard evaluation technique, has rarely been studied for potential biases related to demographic and cultural characteristics of trainees. Objective: The study sought to determine whether peer evaluations were favorably biased toward trainees of similar background. Methods: This observational study was conducted in the Internal Medicine residency of a large, metropolitan, community hospital, and included all 91 Internal Medicine residents who had entered the program from 1 July 2009 thru 30 June 2017. Of 3,445 Peer Evaluation Forms (PEF)s offered, 2,922 (84%) were completed and studied. Multivariate statistical analysis was completed. The primary dependent variable was the Peer Evaluation Score (PES). Independent variables included age, gender, race, birth country and country of medical school training. Confounding variables included United States Medical Licensing Examination (USMLE) and In-Training Examination (ITE) scores, and the American Board of Internal Medicine (ABIM) yearly assessment. Results: Confounding factors accounted for most of the variation. Among the independent variables, only age difference and medical school country were statistically associated with PES. Race and Gender were not significant. Conclusions: Peer evaluations were not significantly biased by race or gender similarities and only minimally biased by age and medical school country similarities.

Nonconcurrence in abstracted diagnoses of non-Hodgkin's lymphoma.

The availability of two independent sets of abstracted diagnoses on 289 cases of non-Hodgkin's lymphoma (NHL), one from the Iowa Surveillance, Epidemiology, and End Results (SEER) Program and the other from an epidemiologic study in Iowa of factors affecting rural males (FARM), allowed us to determine the disagreement between abstracted diagnoses. For both sets the reported diagnosis was translated to International Classification of Disease for Oncology terminology and then to the Working Formulation (WF). Comparison of the WF diagnoses between the FARM study and the SEER Program showed disagreement in 68 of 290 cases (23.4%). Apparent causes of disagreement were as follows: coding errors-9 cases, unconventional or ambiguous terminology on reports resulting in different interpretation of the NHL subtype--30 cases, differences in coding rules for the FARM study and SEER Program--9 cases, acquisition of different reports with different diagnoses on the same case by the FARM study and SEER Program--20 cases. Several corrective measures that might successfully decrease the incidence of disagreement include: education of pathologists in the use of conventional terminology, and use of the category "unclassifiable" when abstracting reports with unconventional or ambiguous terminology. This 23.4% disagreement rate in the abstracting method adds to the known problem of nonconcurrence in the pathologic diagnosis of subtypes of NHL.

Pesticide exposures and other agricultural risk factors for leukemia among men in Iowa and Minnesota.

Mortality surveys and death certificate studies have suggested an association between leukemia and farming. To investigate whether exposure to carcinogens in an agricultural setting is related to risk of leukemia, the authors conducted a population-based case-control interview study of 578 white men with leukemia and 1245 controls living in Iowa and Minnesota. Consistent with recent mortality studies, there were slight, but significant, elevations in risk for all leukemia [odds ratio (OR) 1.2] and chronic lymphocytic leukemia (OR 1.4) for farmers compared to nonfarmers. There were no significant associations with leukemia for exposure to specific fungicides, herbicides (including 2,4-D and 2,4,5-T), or crop insecticides. However, significantly elevated risks for leukemia of greater than or equal to 2.0 were seen for exposure to specific animal insecticides including the organophosphates crotoxyphos (OR 11.1), dichlorvos (OR 2.0), and famphur (OR 2.2) and the natural product pyrethrins (OR 3.7) and the chlorinated hydrocarbon methoxychlor (OR 2.2). There were also smaller, but significant, risks associated with exposure to nicotine (OR 1.6) and DDT (OR 1.3). This finding of elevated risks for insecticides used on animals deserves further evaluation.

Effect of cost education, cost audits, and faculty chart review on the use of laboratory services.

A randomized controlled trial of several strategies designed to reduce the use of laboratory tests by house staff was performed in two parts. Part 1 compared cost education, cost audits, and both methods combined, all after a baseline observation period. Significant reductions were achieved only in the combination group for the categories of total tests (9.4%) and Sequential Multiple Analysis (SMA)-12 (10.8%), but not for charges, SMA-6, or complete blood cell counts (CBCs). Part 2 compared a group subjected to faculty chart review with a control group. Significant reductions in total charges (9.8%), total tests (15.1%), SMA-12s (20.6%), SMA-6s (12.5%), and CBCs (18.5%) were observed in the intervention group, as compared with the control group. Among the methods examined, faculty chart review seems to be the most effective method of reducing the amount of laboratory testing performed by house staff.

Hypothalamic-hypopituitarism due to temporal arteritis.

Hypothalamic hypopituitarism developed in a 74-year-old woman who was in the active phase of temporal arteritis. Hypopituitarism was established by low basal gonadotrophin, thyroxine, and thyroid-stimulating hormone levels. The failure of growth hormone and prolactin to respond to insulin hypoglycemia and an inadequate prolactin response to the administration of chlorpromazine provided further evidence of hypopituitarism. The hypothalamic origin of the hypopituitarism was suggested by quantitatively normal prolactin and gonadotrophin responses to the administration of gonadorelin (gonadotrophin-releasing hormone) and protirelin (thyrotrophin-releasing hormones). Despite the frequency of other intracranial neurological lesions, injury to the hypothalamus and pituitary gland is rare in temporal arteritis. This apparent protection may be due to the abundant blood supply to the hypothalamic-pituitary region.

Alcohol consumption and risk of leukemia, non-Hodgkin's lymphoma, and multiple myeloma.

Population-based case-control interview studies of white men, 578 with leukemia, 622 with non-Hodgkin's lymphoma, and 820 controls from Iowa and Minnesota and 173 with multiple myeloma and 452 controls from Iowa, offered the opportunity to investigate the relationship of these cancers with alcohol consumption. Although drinkers had non-significantly elevated risks for specific subtypes of leukemia (acute lymphocytic leukemia (OR = 3.0), myelodysplasia (OR = 1.6), and other leukemia (OR = 1.5)) and multiple myeloma (OR = 1.3), there were no statistically significant findings and no dose-response gradients with amount of alcohol consumed. Thus, these data suggest that alcohol is not an important contributor to the etiology of lymphatic and hematopoietic tumors.

Impact of supervision by medical teachers and in-patient test control programmes on the out-patient test utilization of residents.

The expense of clinical laboratory services and the broad variation in use of these services by doctors has led to several successful programmes to reduce the expense, particularly for in-patients. The applicability of the programmes to the care of out-patients of residents and the contribution of the interaction of the attending physician with the resident have not been formally studied. To address these issues, out-patient test utilization by first-year residents was studied both during and after an in-patient test control programme. Test utilization means how much the tests are used. It is another question whether the investigation makes any difference to patient care. The residents in the intervention group significantly reduced test utilization compared to the control group and the reductions were sustained for the duration of the study for the use of chemistry panels. Studies of the interaction of attending physicians with residents suggested that the residents' style of test utilization was the predominant one but that this style was magnified when working with an attending physician of similar or more extreme style.

Eosinophilic gastroenteritis with hepatic eosinophilic granulomas. Report of a case with 30-year follow-up.

A patient with eosinophilic gastroenteritis of 30 years' duration is presented. During the course of the illness, anemia, hepatosplenomegaly, diarrhea and hepatic giant cell granulomas with surrounding eosinophilia were noted. The differential diagnosis of the granulomatous lesion is discussed. The patient's initially serious but subsequently benign illness illustrates the diverse manifestations of eosinophilic gastroenteritis. The need for a cautious therapeutic approach to the disorders of eosinophilia and organ infiltration is emphasized.

Educational influences on consultation rates of house staff physicians in a primary care clinic.

Consultation rates of medical house staff physicians were examined in a primary care setting in order to determine the factors that lead to the use of consultants. The factors that were studied in the regression analysis were clinical experience and teaching in medical school, intensity of use of services, residency year, Alpha Omega Alpha (AOA) membership, and future practice plans. The factors were marginally useful in predicting surgical consultations but were helpful in explaining the use of other consultations. House staff physicians with a pattern of intense ancillary service utilization also requested more consultations. Senior house staff physicians requested fewer consultations than junior house staff members. AOA members and future academic physicians used more consultations than other physicians. Consultation rates were highest for specialties requiring the lowest quantity of education in medical school. Consultation patterns reflect past educational experiences and future practice plans of medical house staff physicians and may be useful in the formulation of the curriculum of medical schools and residencies.

Villous tumors of the duodenum. Report of two cases.

Two cases of duodenal villous adenoma are reported, bringing the total reported in the world literature to 51. The tumors are of importance despite their rarity because of the frequency of focal or occult malignant changes in the tumors, the nonspecific symptoms and radiographic findings and the potential surgical complications. Therefore, atypical lesions of the duodenum should be investigated endoscopically and all duodenal villous tumors should be surgically resected. Local excision is usually adequate treatment even when microinvasive cancer or carcinoma in situ are present.

Pesticide exposures and multiple myeloma in Iowa men.

A population-based case-control study of 173 White men with multiple myeloma (MM) and 650 controls was conducted in Iowa (United States), an area with a large farming population, to evaluate the association between MM, agricultural risk factors, and exposure to individual pesticides. A slight nonsignificantly elevated risk for MM was seen among farmers (odds ratio [OR] = 1.2, 95 percent confidence interval [CI] = 0.8-1.7). Although slight excesses were observed, there were no significant associations between MM and handling either classes of pesticides or specific pesticides. Thus, this study found little evidence to suggest an association between risk of MM and farming or pesticides.

Hair dye use and multiple myeloma in white men.

In recent reports, multiple myeloma has been linked to use of hair coloring products containing mutagenic and carcinogenic chemicals. A population-based case-control study in Iowa of 173 White men with multiple myeloma and 650 controls obtained information on hair dye use. Risk of multiple myeloma was significantly elevated (OR = 1.9) among hair dye users and was greatest among those using hair dyes at least once a month for a year or more (OR = 4.3). These data, along with results from other studies, suggest that use of hair dyes contributes to the development of multiple myeloma.

A comparative study of laboratory utilization behavior of "on-service" and "off-service" housestaff physicians.

Highly specialized housestaff programs often call for training in another specialty area, especially internal medicine. Because of differences in training background and experience with internal medicine, laboratory utilization patterns might differ. Hence, laboratory test comparisons between medical ("on-service") and nonmedical ("off-service") housestaff were carried out on the general medicine service. On-service and off-service housestaff were found to have similarly ill patients and similar workloads. Off-service housestaff generally used less laboratory services than on-service housestaff, although both groups used large numbers of tests. Despite differences in experience and training, off-service housestaff appeared to deliver less costly and apparently equal quality medical care, compared with on-service housestaff.

Selected cancer mortality and farm practices in Iowa.

Death certificate analyses of white male Iowans over age 30 who died of multiple myeloma, non-Hodgkin's lymphoma, prostate cancer or stomach cancer between 1964 and 1978 were completed. Each case was matched to two controls on age (within two years) at death, county of residence, and year of death. Consideration of usual occupation, as recorded on the death certificate, resulted in the following odds ratios for mortality due to the specified cancers among farmers: multiple myeloma, 1.48; non-Hodgkin's lymphoma, 1.26; prostate cancer, 1.19; and stomach cancer, 1.32. Each is statistically significant (p less than 0.05). Odds ratios were computed separately for three birth cohorts according to counties stratified by crop and livestock production. Multiple myeloma was elevated in those born after 1890 and was associated with number of egg-laying chickens, hog production, insecticide use, and herbicide use. Non-Hodgkin's lymphoma was elevated in those born before 1901 and was associated with egg-laying chickens, milk products sold, hog production, and herbicide use. Although prostate cancer was elevated in those born before 1901, it was not associated with any agricultural practice. Stomach cancer was elevated in each birth cohort. It was associated with milk products sold, cattle production, and corn per acre.

Data management of a case-control study with a large number of variables.

The description is presented of the system design and implementation experience obtained while providing the data management for a case-control study involving a large number of variables. Topics concerning questionnaire design, data collection, data coding, data entry, data edit, and data storage and retrieval are discussed. Designing and implementing the data-processing system for such a study provides diversified data management experience. This experience results in the investigation of existing and the development of new procedures and documents that can be applied to other studies in medical research. Emphasis is placed on the presentation of system details that can be tailored to specifications for a variety of studies.

Smoking and risk of non-Hodgkin's lymphoma and multiple myeloma.

Population-based case-control interview studies of 622 White men with non-Hodgkin's lymphoma and 820 controls from Iowa and Minnesota (United States) and 173 White men with multiple myeloma and 452 controls from Iowa offered the opportunity to investigate the relationship of these cancers with smoking. Risks were significantly elevated for all lymphoma (odds ratio [OR] = 1.4), high-grade lymphoma (OR = 2.3), and unclassified lymphoma (OR = 2.8) for cigarette smokers. Dose-response gradients were not seen with intensity of cigarette use, but risks for these subtypes were greatest for cigarette smokers of longest duration. Similar elevations in risks were seen for tobacco users. The risk of multiple myeloma was not significantly elevated for either tobacco users or cigarette smokers. The findings from this study confirm the lack of an association between smoking and multiple myeloma and provide some support for an association between tobacco use and certain subtypes of non-Hodgkin's lymphoma.