Florida Experience Research Articles

Medical liability crisis in mammography: The Florida experience

Medical liability crisis in mammography: The Florida experience

The Wrong Man is President! Overvotes in the 2000 Presidential Election in Florida

Using ballot-level data from the NORC Florida ballots project and ballot-image files, I argue that overvoted ballots in the 2000 presidential election in Florida included more than 50,000 votes that were intended to go to either Bush or Gore but instead were discarded. This was primarily due to defective election administration in the state, especially the failure to use a system to warn each voter when too many marks were on a ballot and allow the voter to make corrections. If the best type of vote tabulation system used in Florida in 2000—precinct-tabulated optical scan ballots—had been used everywhere in the state, Gore would have won by more than 30,000 votes. Florida's election experience points to the need to gather ballot-level data to evaluate the success of election reform efforts now underway in much of the United States.Walter R. Mebane Jr. has published numerous articles concerning topics in American politics, especially elections, and political methodology. An early version of this work was presented at a seminar at the University of Minnesota in April 2003. The author thanks Jason Conn, Anthony Keeney, and Mike Rosenberg for assistance, and Jasjeet Sekhon for helpful discussion.

The Florida manatee and eco-tourism: toward a safe minimum standard

Development of a safe minimum standard (SMS) is proposed for the Florida manatee. Analysis was conducted to determine if preservation benefits of its recovery exceeded forgone development benefits. The manatee is a long-term endangered marine mammal that has brought millions of dollars to many coastal Florida communities. Its population has increased significantly in recent years. However, in part due to frequent motorboat collisions related injuries and deaths, the mammal continues to need protection and its long-term prospects are highly uncertain. Measurable protection benefits include local tourism revenues, as coastal Florida experiences significant manatee-related tourism, and ecological services performed by manatees through consumption of hydra in waterways, which otherwise have to be dredged. To account for the more difficult to measure preservation benefits, a contingent valuation method (CVM) survey was sent to a random sample of Citrus County, Florida residents. This county contains important winter habitat and receives significant manatee-related tourism. The CVM survey described a hypothetical market to measure household willingness to pay to protect manatees. Statistical analysis was performed on the determinants of the value of manatee preservation. Forgone net development benefits were proxied only on the cost of law enforcement of boating speed limits. The study found that the benefits of manatee protection in Citrus County greatly exceeded the development benefits foregone by approximately $8.2–$9 million, primarily related to eco-tourism. These results support an SMS policy at current population levels or higher.

Current opinions and understandings of menopausal women about hormone replacement therapy (HRT)—The University of Florida experience

This study was designed to assess the opinions and understanding of patients about hormone replacement therapy (HRT) since the release of the Women's Health Initiative (WHI) HRT trial data, which was widely publicized in the lay press. All patients between the ages of 45 and 65 years seen in the last 3 years in the University of Florida Women's Clinics were mailed a survey asking about their attitudes and perceptions of HRT. A total of 6468 surveys were mailed with the return of 1076 completed surveys (16.6%); 78% of the respondents were menopausal and 65% had taken HRT. Of the women taking HRT, 70% stated it was for symptom relief and 30% for long-term benefits, including protection from heart disease (10%), Alzheimer's (4%), and osteoporosis (16%). Attitude changes about HRT since the release of WHI results were reported in 42% of respondents. Women currently on HRT had a more positive view of therapy (88%) compared with respondents overall (58%). Despite a great deal of media attention given to the topic of HRT, many women dramatically overestimated the risks of HRT, with 31% believing HRT increases the risk of heart disease 10% to 30% per year and 53% believing HRT increases the risk of breast cancer 10% to 30% per year. Despite this overestimation of risks, only 35% of respondents would not recommend HRT to a friend. This study suggests that WHI results did not impact attitudes about HRT in the majority of women taking HRT, as they were usually on therapy for relief of menopausal symptoms. However, there is a great need for consumer education about the attributable risks of HRT, approximately 1 per 1000 per year for heart disease, stroke, DVT, and breast cancer, so they can better weigh the benefits of HRT versus the risks.

Agroforestry as an approach to minimizing nutrient loss from heavily fertilized soils: The Florida experience

Nutrient buildup in the soil caused by increased animal manure and fertilizer use in agricultural and forestry practices may increase the potential for their loss from the soil, leading to groundwater contamination and nonpoint source pollution. Studies in the tropics have suggested that agroforestry practices can reduce such nutrient (especially nitrogen) losses because of enhanced nutrient uptake by tree and crop roots from varying soil depths, compared to more localized and shallow rooting depths of sole crop stands. In temperate systems, such benefits have been well documented for riparian forest buffer practices. Currently, other temperate agroforestry practices are also being considered for their potential to reduce runoff and leaching of chemicals and thereby improve environmental quality within the agricultural landscape. In this regard, the ‘Florida P-Index,’ which considers both phosphorus transport characteristics and management practices, may be a useful tool in the evaluation of nutrient management practices and environmental benefits of agroforestry. Preliminary results from an alleycropping site and a silvopastoral site on two different soil types in Florida suggest that both of these agroforestry practices will likely reduce nutrient loss compared to conventional agricultural practices. The primary aspects of P-Index include consideration of transport factors such as soil erosion, soil runoff class, leaching potential, and distance from a water body along with management factors such as soil test P, P application method, and source and rate of P application. P-Index evaluation of these studies indicates that both agroforestry sites can be on a nitrogen-based nutrient management program. The relevance of some management practices such as application of manure vs. inorganic fertilizer is also discussed in light of the P-Index and the two agroforestry practices.

Medical malpractice crisis: Florida's recent experience.

As summarized in several previous Circulation Mini-Reviews1–3 and elsewhere,4 the United States is experiencing a growing deficit in cardiovascular physicians that is made worse as cardiovascular diseases become more prevalent. Important contributors to this deficit in the cardiovascular workforce and other specialty workforces are the high and rising costs of malpractice premiums in the majority of our states.5 As cardiovascular specialists in Florida (cardiothoracic surgery and cardiology), we are at the center of this crisis. In the present review, we will examine the problem along with recent activities related to this crisis in Florida and discuss their implications. The American Medical Association stated in June 2002, that the majority (>40) of our states had major problems in that members of high-risk specialties were leaving or considering leaving their practices. Then–AMA President, Richard F. Corlin, MD, stated, “doctors are disappearing from American communities on a regular basis because of skyrocketing medical liability insurance premiums and an out-of-control legal system. As insurance becomes unaffordable or unavailable, and the legal system produces multi-million dollar jury awards on a regular basis, physicians are forced to limit services, leave practices, or relocate—all of which seriously impede patient access to high quality health care.” Florida (along with Georgia, Mississippi, Nevada, New Jersey, New York, Ohio, Oregon, Pennsylvania, Texas, Washington, and West Virginia) was among the 12 states considered to be at crisis level. According to the Department of Insurance in Florida, in 1975, total indemnity payments for professional liability cases were $10 271 090. By 2001, this had increased 3074% to a total indemnity payout of $326 052 228. A survey of comparative 2002 malpractice insurance premiums revealed that an invasive cardiologist in Los Angeles paid $16 148 for $1 000 000 coverage, whereas the same specialist in Miami paid $106 497, highest …

The Role of Education and Experience in Developing Site Investigation Skills

A computer simulation program was developed to teach site investigation skills. It includes an open-ended assessment test to gauge an individual9s abilities and effectiveness at site investigation. The test consists of a series of educational and experience questions followed by 14 investigation strategy questions, which were designed to measure the ability to apply geological knowledge to characterize sites and improve investigation plans. The individual scores on the test were compared statistically with the educational and experience elements to assess the critical components of an engineering geologist9s background that improved his or her site investigation skills. The most important college courses contributing to site investigation skills include geomorphology, field camp, regional geology, and a strong introductory geology course. Secondary but helpful courses include case histories, stratigraphy, structural geology, engineering geology, sedimentation, rock mechanics, and hydrogeology. The total number of geology background courses is not statistically significant, nor is the terminal degree earned, although individuals with certain post-baccalaureate degrees showed higher scores than average. The number of years of experience is statistically significant, although after 20 years statistical improvements do not continue. Professional registration is correlated with improved scores, with the Certified Engineering Geologist and Geotechnical Engineer registration being the most important. Those who have only Engineer-in-Training or Geologist-in-Training registration showed significantly lower than average scores, reflecting their short record of experience. Finally, the number of geographic regions in which an individual had work experience was significant, although those who had worked in more than five regions did not follow the overall trend. Those with experience in the Rockies, California, the Piedmont, New England, and the Gulf Coast scored better than average. Those with experience in Florida, the Appalachians, or the Midwest scored worse than average, which may be a reflection of the relatively homogeneous geology and limited opportunities for breadth of experience in parts of those regions.

Preoperative chemoradiation for locally advanced rectal adenocarcinoma-the University of Florida experience.

To evaluate the efficacy of preoperative radiotherapy alone or combine with chemotherapy. Between 1975 to 1997, 318 patients with locally advanced rectal adenocarcinomas were treated with preoperative radiation therapy. Between 1991 and 1997, approximately 60% of patients received fluorouracil (5-FU)-based adjuvant chemotherapy. Patients treated since 1991 had improved downstaging compared with those treated prior to 1991. Patients treated between 1991 and 1997 were also more likely to undergo a sphincter preserving surgical procedure. Preoperative chemoradiation probably results in improved downstaging and survival compared with preoperative irradiation alone.

Florida's universities tackle the IT curriculum

Employers complain that their new IT workers graduate from college without real-world know-how. But what is IT, and how do you teach it? There are no signs that the information technology field will ever stop changing. Consequently, every IT program in Florida's public universities is truly a work in progress. What is new in these degree programs is the realization that their transformation is inevitable, and that it must be closely and continually coordinated with the local community's needs. Will these programs' practical, real-world orientation prompt more traditional programs, such as computer science, to become more employer-oriented? Or, instead, will those traditional programs become more theoretical, freed by the IT programs from vocational concerns'? If Florida's diverse experience so far is any indication, we will most likely see both outcomes, and perhaps some others as well.

Radiation therapy for esthesioneuroblastoma: Rationale for elective neck irradiation

Esthesioneuroblastoma is an uncommon malignancy of neural crest origin arising in the upper nasal cavity. We describe the University of Florida experience using radiation therapy (RT) in the treatment of this neoplasm, particularly the use of elective nodal irradiation. Between May 1972 and August 1998, 22 patients received RT for esthesioneuroblastoma. Two additional patients were treated with palliative intent and were excluded from analysis. Equal numbers of male and female patients were treated, with a median age of 54 years (range, 3-82). The modified Kadish stage was A in 1 patient, B in 4 patients, C in 15 patients, and D in 2 patients. Treatment modalities included primary RT in 6 patients, preoperative RT in 1 patient, postoperative RT after craniofacial resection in 12 patients, and salvage RT in 3 patients treated for recurrence after surgery. Elective neck RT was performed in 11 of 20 patients; 2 patients had cervical metastases at presentation for RT. Rates of local control, cause-specific survival, and absolute survival at 5 years were 59%, 54%, and 48%, respectively. The cause-specific survival rate at 5 years was lower after primary RT (17%) than after craniofacial resection and postoperative RT (56%). Cervical metastases occurred in 6 of 22 patients (27%). No neck recurrences occurred in 11 patients treated with elective neck RT compared with 4 neck recurrences in 9 patients (44%) not receiving elective neck RT (p =.02). Combined modality therapy is preferred over RT alone in advanced-stage esthesioneuroblastoma. Our data and review of the current literature suggest a higher cervical failure rate than previously recognized. Elective neck RT seems to correlate with improved nodal control and should be considered in the treatment of esthesioneuroblastoma.

Oligodendroglioma: does deferring treatment compromise outcome?

This study reports the University of Florida experience treating oligodendrogliomas with the goal of identifying the factors that predict favorable outcome. Between 1958 and June 1998, 51 patients (aged 5-75 years) were diagnosed with pure oligodendroglioma at the University of Florida. Histologic grade was anaplastic in 19 patients, low-grade in 30 patients, and unknown in one patient. Twelve patients were treated with surgery alone (10 with low-grade tumors). Thirty-nine patients underwent postoperative radiotherapy after surgery (plus chemotherapy in four patients). A biopsy was performed in 10 patients, 40 underwent subtotal or gross total resection, and one had surgery of unknown extent. Thirteen patients with a radiographic abnormality consistent with a low-grade glioma had the initiation of definitive treatment (i.e., surgery with or without radiotherapy) deferred for a median of 4.5 years before undergoing treatment for worsening symptoms or radiographic progression. Absolute survival for the entire group (51 patients) at 5, 10, and 20 years from the date of initial treatment was 61%, 37%, and 31%, respectively, and at 5, 10, and 20 years from the date of initial diagnosis was 65%, 43%, and 34%, respectively. No patient died of intercurrent disease. Multivariate analysis for absolute survival from the time of initial treatment demonstrated young age (young patients fared better than older patients) and size (<5 cm better than > or =5 cm) to be significant variables. No patient under the age of 21 years (n = 8) at the time of diagnosis has died in this series. Deferring aggressive treatment did not alter survival. Multivariate analysis for favorable absolute survival based on the time from initial diagnosis demonstrated young age and presentation with seizures alone to be statistically significant for favorable outcomes. Approximately one third of patients with oligodendroglioma appear to be cured with aggressive treatment. Age is the most important predictor of long-term progression-free and absolute survival with young patients (especially aged <21 years) doing much better than older patients. Deferring aggressive treatment (surgery and/or radiation) until symptoms clearly indicate tumor progression does not compromise outcome for a select group of patients who are diagnosed at a young age with a nonenhancing mass on MR and seizures as the lone presenting symptom.

Radiation therapy for esthesioneuroblastoma: rationale for elective neck irradiation

Purpose/Objective: Esthesioneuroblastoma is an uncommon malignancy of neural crest origin arising in the upper nasal cavity. We describe the University of Florida experience using radiation therapy (RT) in the treatment of this neoplasm.

Sequential Dermal-Peritumoral Radiocolloid Injection for Sentinel Node Biopsy for Breast Cancer: The University of Florida Experience

Although sentinel lymph node (SLN) biopsy is rapidly becoming the standard of care for small breast cancers the optimal radiocolloid injection technique remains controversial. We report our experience with sequential dermal-peritumoral radiocolloid injection that takes advantage of both techniques. One hundred eighteen patients with clinical stage T(is), T1, T2 and N0 breast cancer underwent SLN biopsy at the University of Florida. Twelve to 18 hours before surgery patients received either an injection of 0.5 to 1.0 mCi 50:50 filtered:unfiltered technetium sulfur colloid into the dermis overlying the tumor and/or a peritumoral injection of a 3 to 4-mCi of radiocolloid 30 minutes later. Dynamic lymphoscintigraphy was performed and the topographical location of all imaged lymph nodes was marked on the skin. The next morning the surgeon utilized a hand-held gamma probe to remove all SLN(s) defined as any lymph node with radioactive counts 10 per cent or more of the ex vivo counts of the most radioactive SLN [internal mammary (IM) nodes were not removed]. The SLN identification rate was 98.5 per cent (3 IM nodes) for dermal injection (d.), 83.3 per cent (1 IM node) for peritumoral injection (p.), and 100 per cent (14 IM nodes) for sequential dermal-peritumoral injection (d.p.) (p < 0.05 DP versus D). Sequential d.p. 50:50 filtered:unfiltered technetium sulfur colloid injection results in a rapid, high SLN identification rate that persists until surgery the next morning. Delineation of nonaxillary SLNs may lead to more accurate breast cancer staging and may also influence the delivery of IM node radiation.

Rubblization over Soft Soils. The Florida Experience

Rubblization over Soft Soils. The Florida Experience

SYSTEMWIDE CHALLENGES TO INTELLIGENT TRANSPORTATION SYSTEMS DEPLOYMENT: An Analysis of the Central Florida Experience

This paper highlights major aspects of Intelligent Transportation Systems (ITS) deployment, and briefly defines the key components of ITS. A general analysis of barriers that must be overcome before ITS integration can occur is next presented. The Central Florida experience is assessed as an example of a system that has begun to implement ITS components but faces numerous challenges before it is fully deployed.

Evaluation and treatment of velopharyngeal insufficiency: the University of Florida experience.

This retrospective study spans the years 1988 to 2000 and looks specifically at the treatment procedures and outcomes for the correction of velopharyngeal insufficiency (VPI). Ninety-eight patients underwent preoperative assessment by speech pathologists that included perceptual speech evaluation, videofluoroscopy, and, for some, nasendoscopy. Based on this evaluation protocol, a specific surgical procedure was chosen to serve the patients' needs. The four procedures of choice were the palatal pushback with a pharyngeal flap lining, sphincter pharyngoplasty, a superiorly based obturating pharyngeal flap, and Furlow palatoplasty. The criteria for selecting these procedures are reviewed. The results revealed VPI resolution and the establishment of normal nonnasal speech in more than 95% of the 75 patients for whom outcomes were determined. This study reiterates the importance of thorough preoperative evaluation and the individualization of the secondary corrective procedure.

José Martí in the United States: The Florida Experience

José Martí in the United States: The Florida Experience

Abstracts

Background Perineural invasion is observed in a small subset of patients with carcinomas of the skin of the head and neck. Methods Review of the patient literature highlighting the University of Florida experience. Results Patients with early perineural invasion are asymptomatic, and the phenomenon is discovered only on pathologic examination of the excised lesion. These patients are defined as having “incidental” perineural invasion, and treatment with surgery followed by postoperative irradiation results in a cure rate of approximately 80%. Undiagnosed, the perineural carcinoma slowly progresses and eventually results in symptoms, usually facial weakness or numbness. The disease eventually extends to the skull base and becomes incompletely resectable. Symptomatic patients are defined as having “clinical” perineural invasion, and aggressive treatment results in a cure rate of approximately 45%. Conclusions Perineural invasion is an uncommon spread pattern observed in patients with skin cancer and is associated with a relatively poor prognosis. The likelihood of cure is inversely related to the proximal extent of the cancer and is lower for symptomatic compared with asymptomatic patients. © 2002 John Wiley & Sons, Inc. Head Neck 24: 78–83, 2002.

Subdiaphragmatic Hodgkin’s disease: The University of Florida experience

Purpose : To assess the long-term outcomes and late effects of patients with subdiaphragmatic Hodgkin’s disease. Methods and Materials : Twenty-one patients with Stage I and II subdiaphragmatic Hodgkin’s disease were treated with curative intent between February 1966 and February 1998 at the University of Florida. Patient characteristics were as follows: mean age, 38.7 years (range, 3–75 years); 20 males and 1 female; 33% lymphocyte predominant, 43% nodular sclerosing, 14% mixed cellularity, 5% lymphocyte depletion, and 5% unclassified Hodgkin’s disease. Treatment included inverted Y irradiation (InY) (8 patients), total nodal irradiation (TNI) (7 patients), and combined modality irradiation and chemotherapy (CMT) (6 patients). Median follow-up was 12.3 years (range, 3.1–33.6 years). Results : Progression-free survival and overall survival were 80% and 70%, respectively, at 10 years. There were no deaths from Hodgkin’s disease. Treatment failures occurred in 1 of 8 patients after InY, 1 of 7 after TNI, and 1 of 6 after CMT. Two of 3 recurrences were in patients with 3 or more sites of involvement and/or splenic involvement; 1 was in-field. There were 5 second malignant neoplasms and 3 cardiac events, including 4 second malignant neoplasms and 2 cardiac events in the 9 patients ≥40 years old at diagnosis and 1 second malignant neoplasm and 1 cardiac event in the 12 patients <40 years old. All 3 second solid malignancies in this study occurred 7–14 years after treatment in areas receiving 10–20 Gy. Conclusions : Subdiaphragmatic Hodgkin’s disease is an uncommon manifestation with excellent disease control achieved with InY, TNI, and CMT. This subgroup of patients with Hodgkin’s disease is predominantly male and older than subgroups with other presentations, which may predispose the group to a higher risk for serious adverse events after treatment. We recommend InY with spleen for clinical Stages IA and nodular sclerosis or lymphocyte-predominant clinical Stage IIA, InY alone for pathologic Stages IA and IIA, and CMT for all Stage I/II patients with greater than three involved sites, B symptoms, bulky disease (>6 cm), central (para-aortic) presentation, or splenic involvement.

Carcinoma of the skin of the head and neck with perineural invasion.

Perineural invasion is observed in a small subset of patients with carcinomas of the skin of the head and neck. Review of the patient literature highlighting the University of Florida experience. Patients with early perineural invasion are asymptomatic, and the phenomenon is discovered only on pathologic examination of the excised lesion. These patients are defined as having "incidental" perineural invasion, and treatment with surgery followed by postoperative irradiation results in a cure rate of approximately 80%. Undiagnosed, the perineural carcinoma slowly progresses and eventually results in symptoms, usually facial weakness or numbness. The disease eventually extends to the skull base and becomes incompletely resectable. Symptomatic patients are defined as having "clinical" perineural invasion, and aggressive treatment results in a cure rate of approximately 45%. Perineural invasion is an uncommon spread pattern observed in patients with skin cancer and is associated with a relatively poor prognosis. The likelihood of cure is inversely related to the proximal extent of the cancer and is lower for symptomatic compared with asymptomatic patients.