Unsatisfactory Research Articles

Early Pre-clerkship Clinical Skills Assessments Predict Clerkship Performance.

IntroductionAssessment of medical students’ clinical skills (CS) remains a challenge. Little is known about early predictors of future CS performance. This study examines the relationship between students’ pre-clerkship clinical skills (PCCS) performance and year 3 clerkship performance measures.MethodsThe authors performed a retrospective analysis of four medical student cohorts who matriculated between 2014 and 2017 and participated in a longitudinal pre-clerkship CS curriculum. A total of 440 students were included in the analyses. Students’ clinical skills were assessed through a series of PCCS exams, each consisting of a single standardized patient encounter. First-year PCCS exams assessed history taking, physical examination, professionalism, and communication skills; second-year PCCS exams also assessed clinical documentation and clinical reasoning skills. Evaluators assigned a grade of “satisfactory,” “borderline,” or “unsatisfactory” for each skill set. Regression analyses compared year 3 performance outcomes between students with one or more “unsatisfactory” or “borderline” PCCS skill set grades and students assessed as “satisfactory” for all PCCS skill set assessments.ResultsThirty-two percent (n = 140) of the 440 students had at least one borderline or unsatisfactory (US) PCCS skill set grade. These students performed significantly worse on year 3 National Board of Medical Examiner subject exams, workplace-based clinical performance evaluations, and overall year 3 performance compared to students who passed all PCCS exam components. In addition, a higher percentage of students with PCCS performance deficiencies failed the United States Medical Licensing Examination Step 2 CS exam on the first attempt versus students who passed all PCCS exam components.ConclusionsPCCS exam performance at our institution aligned with future student performance on multiple year 3 clerkship outcome measures. This pre-clerkship performance data can be used to identify at-risk students who would benefit from additional resources to achieve competency in the clerkship environment and future medical training.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40670-022-01519-8.

Outcome analysis and negative predictive value of the “unsatisfactory/nondiagnostic” category of The Paris System for Reporting Urinary Cytology

The Paris System (TPS) for Reporting Urinary Cytology (UCyto) was published in 2016, but to date, no study addressing the unsatisfactory (UNSAT) category has been published. We aimed to identify the negative predictive value (NPV) for UNSAT UCyto after the implementation of TPS at our institution. For the period from January 1, 2017, to December 31, 2019, we identified all cases with UNSAT diagnosis on UCyto specimens and available cytologic and/or surgical pathology follow-up within 6 months from the UNSAT diagnosis. Cases were deemed true negative (TN) if the follow-up was "negative for high-grade urothelial carcinoma" (NHGUC). Information regarding previous medical history, clinical indications, and specimen type were tabulated and analyzed. From 6348 UCyto specimens, there were 230 (3.6%) UNSAT diagnoses made on 209 patients (112 [53.6%] men and 97 [46.4%] women) with a median age of 64 years. Of these, 116 UCyto specimens from 106 patients, which had cytologic and/or surgical pathology follow-up within 6 months, were further studied. Most UNSAT UCyto specimens were bladder washing/barbotage (BW/BB), and the most common indication for UCyto was cancer surveillance. The main cause of UNSAT UCyto was low cellularity. There were 5 false-negative (FN) results for high-grade urothelial carcinoma (HGUC), which corresponds to an overall NPV of 84.4%. NPV was highest for patients with UCyto for hematuria, and for patients with BW/BB as UCyto specimen type. Our results show that UNSAT diagnoses have a lower NPV than that typical of NHGUC diagnoses, and should be managed accordingly.

Prognostic significance of rate of tumor marker (TM) decline during high-dose chemotherapy (HDCT) for relapsed germ cell tumors (rGCT).

403 Background: Rate of serum TM decline is prognostic in patients (pts) with GCT receiving first-line chemotherapy. We investigated the prognostic value of TM decline in rGCT treated with HDCT+peripheral-blood stem-cell transplant (PBSCT). Methods: 462 consecutive pts with rGCT treated with HDCT+PBSCT at Indiana University between 1/2004-1/2019. All pts were planned for 2 consecutive HDCT courses with carboplatin+etoposide per protocol (N Engl J Med 2007;357:340-8). Pts with elevated AFP and/or hCG were included (N=347). Slope and half-life (T1/2) were calculated for weekly AFP+hCG during HDCT starting with peak value at days 1-7 to avoid interference from lysis. T1/2 AFP≤7 days and hCG≤3 days were categorized satisfactory (SAT). Progression-free (PFS) and overall survival (OS) were compared for SAT vs unsatisfactory (UNSAT) using log-rank test and analyzed using Kaplan-Meier. Uni- and multivariable analysis using Cox regression model was performed. Results: 347 pts had elevated TM: 312 had non-seminoma and 35 had seminoma. Median age was 31 (range, 17-58). Primary site: testis (292), mediastinum (26), retroperitoneum/other (29). Metastatic sites included retroperitoneum (277), lung (233), liver (83), brain (77), and bone (21). At initiation of HDCT, 77 pts had elevated AFP, 222 elevated hCG, and 48 elevated both AFP+hCG. Median AFP 9 (1-21,347) and hCG 113 (1-178,140). 314 pts (91%) completed 2 planned cycles of HDCT. Overall, 46/347 pts had SAT decline (13 for AFP; 30 for hCG; 3 for both). Pts with SAT TM decline had superior outcomes compared to UNSAT: 2-yr PFS 69% vs 45% (p=0.006) and 2-yr OS 75% vs 51% (p=0.006). When evaluating each TM separately, SAT decline in hCG had superior outcomes vs UNSAT: 2-yr PFS 74% vs 47% (p=0.002). There was statistically non-significant difference for AFP: 2-yr PFS 48% vs 42% (p=0.65). In univariable analysis, UNSAT decline of hCG, but not AFP, was an adverse prognostic factor for PFS: HR=2.51 (95% CI, 1.40-4.51); p=0.002. Multivariable analysis will be presented. Conclusions: SAT rate of TM decline, particularly in hCG, predicts superior outcomes in rGCT undergoing HDCT+PBSCT. Pts with UNSAT TM decline are at higher risk for relapse and death.

Estimation of Relationships Between Demographic Characteristics and Consumers’ Willingness to Pay for Beef

ObjectivesThe objective of this study was to determine the relationship between consumer demographic characteristics and willingness to pay for beef.Materials and MethodsData were collected from consumers (n = 4080) from April to December 2018 in conjunction with consumer eating quality assessments in Lubbock, TX. All beef samples were prepared and demographics and willingness to pay (WTP) questionnaires were administered in accordance with Meat Standards Australia protocols. The following demographic characteristics were collected: age, gender (GEN), occupation (OCC), consumption (CONS), number of adults in household (NOA), number of children (NOC), beef preferences (PREF), preferred degree of doneness (DOD), income (INC), education (EDU), and heritage (HER). At the conclusion of a tasting session, which consisted of 7 beef samples prepared and served as steaks, smoked brisket, or fajita strips, consumers were asked how much they would pay for each of the four quality levels [Unsatisfactory (UNS), Good everyday (GOOD), Better than everyday (BTE), and Premium (PREM)], using line scales anchored from $0/lb. to $40/lb. Data were analyzed using the STEPWISE option of PROC REG of SAS. Variables had to meet a 0.15 significance level for entry and to remain in the model. Willingness to pay data were analyzed using PROC GLIMMIX of SAS with fixed effects of quality level, cook method, and their interaction (α = 0.05).ResultsRegression analysis revealed that demographic characteristics accounted for 6, 7, 6, and 7% of the variation in willingness to pay for UNS, GOOD, BTE, and PREM quality beef, respectively (P < 0.01). For UNS, increasing AGE, CONS, NOA, PREF, and DOD were positively linked with WTP, while GEN, NOC, INC, and EDU were negatively linked with WTP (P < 0.15). Increasing CONS, NOA, and PREF elevated WTP for GOOD quality, while AGE and EDU had a negative impact (P < 0.15). For BTE quality, NOA, PREF, INC, and GEN positively influenced WTP, while AGE, NOC, and EDU reduced WTP (P < 0.15). Finally, increasing CONS, NOA, PREF, and INC resulted in greater WTP of PREM quality beef, but AGE and NOC were negatively linked (P < 0.15).An interaction between quality level and cook method was observed for WTP (P < 0.01). Consumers were willing to pay the most for PREM quality with significant differentiation between each quality level (PREM > BTE > GOOD > UNS). Overall, consumers were willing to pay $17.84, $12.96, $8.65, and $3.80 for PREM, BTE, GOOD, and UNS, respectively. However, within quality level, consumer WTP varied due to cook method. For PREM and UNS WTP, consumers were willing to pay more (P < 0.05) for samples cooked as steaks and fajitas than as brisket. For BTE and GOOD WTP, consumers were willing to pay more (P < 0.05) for samples cooked as steaks than as brisket, but WTP of fajita samples was similar (P > 0.05) to the other cook methods.ConclusionDemographic characteristics can account for a small proportion of the variation in consumer WTP for beef products. Increasing age, number of children, and education consistently had negative impacts on WTP, regardless of quality level. Conversely, increasing beef consumption and preferences, along with number of adults lifted WTP across all quality levels. Cook method also influenced consumer WTP within each quality level.

Prognostic value of serum tumor marker (STM) rate of decline during high-dose chemotherapy (HDCT) and peripheral-blood stem-cell transplant (PBSCT) for relapsed germ-cell tumors (rGCT).

e16044 Background: Rate of STM decline is prognostic in patients (pts) with metastatic GCT receiving first-line chemotherapy. We investigated the prognostic value of STM decline in pts with rGCT treated with HDCT and PBSCT. Methods: 444 consecutive pts with rGCT were treated with HDCT and PBSCT at Indiana University between 2004-2018. All pts were planned for 2 consecutive HDCT courses. Pts with elevated STM (AFP > 25 and/or hCG > 4.9) were included in this analysis. Slope and half-life (T1/2) were calculated for weekly AFP and hCG values during HDCT starting with peak value during days 1-7 to avoid interference from lysis. T1/2 AFP≤7 days and hCG≤3 days were categorized as satisfactory (SAT); normalization within 7 days was also considered SAT regardless of T1/2. Pts with elevated AFP and hCG must have adequate decline in both to be SAT. Progression-free (PFS) and overall survival (OS) were compared for SAT vs unsatisfactory (UNSAT) using log-rank test and analyzed using Kaplan-Meier methods. Results: 2-yr PFS for pts with elevated STM at initiation of HDCT (N = 335) was inferior to pts with normal STM (N = 109) [49% vs. 89%; p < 0.001]. Among the 335 pts with elevated STM, 300 had non-seminoma and 35 had seminoma. Median age was 31 (range, 17-58). Primary site: testis (285), mediastinum (25), and retroperitoneum/other (25). Metastatic sites included retroperitoneum (267), lung (226), liver (81), brain (76), and bone (21). At initiation of HDCT, 73 pts had elevated AFP only, 215 had elevated hCG only, and 47 had elevated both AFP and hCG. Median AFP 9 (1-21,347) and hCG 115 (1-178,140). 307 pts (92%) completed 2 planned cycles of HDCT. Overall, 45/335 pts had SAT decline (13 for AFP; 29 for hCG; 3 for both). Pts with SAT STM decline had superior outcomes compared to UNSAT: 2-yr PFS 71% vs 46% (p = 0.004) and 2-yr OS 77% vs 52% (p = 0.004). When evaluating each STM separately, SAT decline in hCG had superior outcomes vs UNSAT: 2-yr PFS 76% vs 47% (p = 0.002). There was statistically non-significant difference in outcomes for AFP: 2-yr PFS 50% vs 43% (p = 0.55). Conclusions: SAT rate of STM decline predicts superior outcomes in pts with rGCT undergoing HDCT and PBSCT. Although UNSAT STM decline does not preclude long-term remissions, these pts are at higher risk of relapse and death.

Estimation of Relationships Between Demographic Characteristics and Consumers’ Willingness to Pay for Beef

ObjectivesThe objective of this study was to determine the relationship between consumer demographic characteristics and willingness to pay for beef.Materials and MethodsData were collected from consumers (n = 4080) from April to December 2018 in conjunction with consumer eating quality assessments in Lubbock, TX. All beef samples were prepared and demographics and willingness to pay (WTP) questionnaires were administered in accordance with Meat Standards Australia protocols. The following demographic characteristics were collected: age, gender (GEN), occupation (OCC), consumption (CONS), number of adults in household (NOA), number of children (NOC), beef preferences (PREF), preferred degree of doneness (DOD), income (INC), education (EDU), and heritage (HER). At the conclusion of a tasting session, which consisted of 7 beef samples prepared and served as steaks, smoked brisket, or fajita strips, consumers were asked how much they would pay for each of the four quality levels [Unsatisfactory (UNS), Good everyday (GOOD), Better than everyday (BTE), and Premium (PREM)], using line scales anchored from $0/lb. to $40/lb. Data were analyzed using the STEPWISE option of PROC REG of SAS. Variables had to meet a 0.15 significance level for entry and to remain in the model. Willingness to pay data were analyzed using PROC GLIMMIX of SAS with fixed effects of quality level, cook method, and their interaction (α = 0.05).ResultsRegression analysis revealed that demographic characteristics accounted for 6, 7, 6, and 7% of the variation in willingness to pay for UNS, GOOD, BTE, and PREM quality beef, respectively (P BTE > GOOD > UNS). Overall, consumers were willing to pay $17.84, $12.96, $8.65, and $3.80 for PREM, BTE, GOOD, and UNS, respectively. However, within quality level, consumer WTP varied due to cook method. For PREM and UNS WTP, consumers were willing to pay more (P 0.05) to the other cook methods.ConclusionDemographic characteristics can account for a small proportion of the variation in consumer WTP for beef products. Increasing age, number of children, and education consistently had negative impacts on WTP, regardless of quality level. Conversely, increasing beef consumption and preferences, along with number of adults lifted WTP across all quality levels. Cook method also influenced consumer WTP within each quality level.

Application of the Milan System for Risk Stratification and Its Comparison with a Previous Reporting System of Parotid Gland Cytopathology in a Tertiary Care Centre

Objective: To compare the recently proposed Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) with the four-tiered reporting system (FTRS) followed at our institute. Methods: Parotid gland fine-needle aspirates reported over a period of 5 years were analysed. These aspirates had been placed into 4 categories according to the FTRS: unsatisfactory (UNS), no evidence of malignancy/negative (NEG), inconclusive for malignancy (INC), and diagnostic for malignancy/positive (POS). Aspirates with follow-up histopathology were then categorized according to the MSRSGC as follows: non-diagnostic, non-neoplastic, atypia of unde­termined significance (AUS), neoplasm, suspicious for malignancy, and malignant. The risk of malignancy (ROM) was calculated. Results: A total of 893 parotid region aspirates were evaluated and histopathology was available for 190 cases (21%). ROM in MSRSGC groups, namely non-diagnostic, non-neoplastic, AUS, neoplasm, suspicious for malignant neoplasm, and malignant, was 44, 8, 0, 12, 81 and 100%, respectively. ROM in FTRS groups, namely UNS, NEG, INC, and POS, was 45, 13, 67 and 100%, respectively. Conclusions: MSRGC and FTRS are comparable with respect to the ROM across groups. Compared to FTRS, the further subcategorisation of the non-malignant group, the use of specific nomenclature, and the reproducibility of MSRGC provide proper risk stratification, thereby guiding better management and resulting in improved patient care.

A systematic review of clinical application of Percu Twist tracheostomy in intensive care unit

To evaluate the effectiveness of Percu Twist (PT) tracheostomy comparing with that of operative tracheostomy (OT) in intensive care unit (ICU). Related data were retrieved from CBM, CNKI, Wanfang Data, VIP, PubMed, EMBASE, CENTRAL, and Web of Science from the time of their establishment to May 15th 2014, and the data of randomized controlled trials (RCTs) concerning PT and OT were selected. The risk of bias assessment and data extraction were performed by two independent reviewers. Meta analysis was conducted using RevMan 5.2 software. A total of 12 RCTs were identified, and 893 patients in ICU were involved. The results of Meta-analysis showed that PT could significantly shorten the operation time [mean difference (MD)=-15.11, 95% confidence interval (95% CI)=-17.14 to -13.07, P<0.000 01], reduce the volume of blood loss (MD=-17.59, 95% CI=-21.90 to -13.28, P<0.000 01), reduce the size of incision (MD=-2.20, 95% CI=-2.57 to -1.82, P<0.000 01), shor ten the time of healing (MD=-3.60, 95% CI=-4.15 to -3.05, P<0.000 01), and reduce complications such as infection of the wound [odds ratio (OR)=0.20, 95%CI=0.10-0.44, P<0.000 1] and cutaneous emphysema/mediastinal emphysema (OR=0.22, 95% CI=0.10-0.47, P<0.000 1) compared with OT group. The funnel plot suggested that publication bias might be found among 12 researches. PT was shown to be more effective than OT in ICU with lower incidence of complications. As number of RCT cases is still small with unsatis factory quality, further clinical use is warranted for a better assessment.

Evaluation of endobronchial ultrasound‐guided fine‐needle aspirations (EBUS‐FNA): Correlation with adequacy and histologic follow‐up

Endobronchial ultrasound-guided fine-needle aspiration (EBUS-FNA) is a minimally invasive modality for diagnosing mediastinal lesions. When determining adequacy, EBUS-FNAs are evaluated for diagnostic material or sufficient lymphoid tissue. In this study, the authors evaluated their experience with EBUS-FNAs and correlated the findings with adequacy and histologic follow-up. EBUS-FNAs were retrospectively reviewed over a 3-year period and correlated with the clinicopathologic findings, adequacy, and histologic follow-up. In total, 593 EBUS-FNAs were obtained from 356 patients, including 420 (71%) satisfactory (SAT) cases, 107 (18%) less than optimal (LTO) cases, and 66 (11%) unsatisfactory (UNSAT) cases. The overall diagnostic yield was 71%, and the mediastinal (N2) lymph nodes had better yield (72%) than the peripheral intrapulmonary and hilar (N1) lymph nodes (64%). Histologic follow-up was available in 203 cases (34%), and malignancy was identified in 7 UNSAT cases (23%), 6 LTO-negative cases (11%), and 4 SAT cases (3%) with a negative cytologic diagnosis. In the suboptimal cases with follow-up, 79% were benign and 21% were malignant on follow-up, including 25 (14%) with fibrosis or hyalinization. The sensitivity, specificity, and positive and negative predictive values in the study were 80%, 100%, 100%, and 95%, respectively. The current data demonstrated that EBUS-FNA has good sensitivity, high specificity, and a higher diagnostic yield for N2 lymph nodes compared with N1 lymph nodes. The data also illustrate the finding that suboptimal cases have a greater risk of false-negative diagnoses and a 21% chance of malignancy, including processes with fibrosis or hyalinization.

PS1-53: Effects of Transitioning from Conventional Methods to Liquid-Based Methods on Unsatisfactory Pap Tests: Results from a Multicenter US Study

Background/Aims Pap testing has transitioned from conventional preparations (CP) to liquid-based preparations (LBP) due to perceived superiority of LBPs. Many studies conclude LBPs reduce unsatisfactory (UNSAT) tests, however some believe the evidence to substantiate this claim is weak. We studied the effect of the transition from CPs to LBPs on the proportion of UNSAT Pap tests (PT) in four health care systems in the United States.

Serum tumor marker (STM) decline rates during high-dose chemotherapy (HDCT) to predict outcome for germ cell tumor (GCT) patients (pts).

4532 Background: STM decline rates predict outcome for GCT pts during 1st-line conventional-dose chemotherapy. We investigated the importance of STM decline rates during salvage HDCT. Methods: HDCT included an initial low dose (LD) portion (1-2 cycles of paclitaxel plus ifosfamide [TI] + G-CSF) for stem cell collection followed by a high-dose (HD) portion (3 cycles of carboplatin + etoposide or TI + carboplatin). Eligible pts had elevated STM (AFP &gt;15 and/or HCG &gt;2.2) at the start of LD and completed ≥1 HD cycle. Slope and t1/2 were calculated for HCG and AFP for cycles 1-2 of LD and HD starting with the peak value during days (d) 1-6 of LD and HD to avoid interference from lysis. T1/2 for AFP ≤7d and HCG ≤3.5d were categorized as satisfactory (SAT); normalization within 7d was also considered SAT, regardless of t1/2. Pts with elevated AFP and HCG had to have adequate decline in both to be considered SAT. Progression-free (PFS) and overall survival (OS) were compared for SAT vs. unsatisfactory (UNSAT) pts using the log-rank test. Results: Of 117 pts (115 male, 105 nonseminoma), the most common primary sites were testis (81) and mediastinum (26). 93, 19, and 5 pts completed 3, 2, and 1 HD cycles, respectively. Overall, 19/117 had SAT decline during LD (19/77 for HCG; 7/57 for AFP). For LD, there was no significant difference in PFS or OS for SAT vs. UNSAT decline. For HD, 17/96 had SAT decline (11/59 for HCG; 9/47 for AFP). SAT overall decline (HCG and AFP) during HD predicted superior PFS (p=0.0025) and OS (p=0.0046) with 2-year (yr) PFS 0.88 (0.59, 0.97) vs. 0.37 (0.26, 0.47) and 3yr OS 0.82 (0.55, 0.94) vs. 0.37 (0.26, 0.48). SAT HCG decline alone also predicted superior PFS (p=0.0018) and OS (p=0.004) with 2yr PFS 0.91 (0.51, 0.99) vs. 0.32 (0.19, 0.46) and 3yr OS 0.91 (0.51, 0.99) vs. 0.35 (0.22, 0.50) whereas only a non-significant trend for improved PFS (p=0.14) and OS (p=0.16) was seen for AFP alone. Conclusions: STM decline rates during the HD portion of salvage HDCT predicts favorable PFS and OS, mostly driven by HCG. However, UNSAT STM decline does not exclude long-term PFS/OS. STM decline rates during the initial LD portion of HDCT programs do not predict outcome; thus, UNSAT LD decline should not prohibit subsequent HDCT.

Keloids: current prophylactic and therapeutic methods

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Bienias W, Kaszuba A. Review paperKeloids: current prophylactic and therapeutic methods. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2012;29(6):446-450. doi:10.5114/pdia.2012.32392. APA Bienias, W., & Kaszuba, A. (2012). Review paperKeloids: current prophylactic and therapeutic methods. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 29(6), 446-450. https://doi.org/10.5114/pdia.2012.32392 Chicago Bienias, Wojciech, and Andrzej Kaszuba. 2012. "Review paperKeloids: current prophylactic and therapeutic methods". Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii 29 (6): 446-450. doi:10.5114/pdia.2012.32392. Harvard Bienias, W., and Kaszuba, A. (2012). Review paperKeloids: current prophylactic and therapeutic methods. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, 29(6), pp.446-450. https://doi.org/10.5114/pdia.2012.32392 MLA Bienias, Wojciech et al. "Review paperKeloids: current prophylactic and therapeutic methods." Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii, vol. 29, no. 6, 2012, pp. 446-450. doi:10.5114/pdia.2012.32392. Vancouver Bienias W, Kaszuba A. Review paperKeloids: current prophylactic and therapeutic methods. Advances in Dermatology and Allergology/Postępy Dermatologii i Alergologii. 2012;29(6):446-450. doi:10.5114/pdia.2012.32392.

Samson's Moment of Truth

Samson gives away the secret of his strength, the story says, because Delilah nags him. Since only an incredibly stupid person could have failed to recognize her plan to betray him, Samson has been tagged as a musclebound lamebrain ever since. But nothing else in the story suggests that he is stupid—quite the opposite, in fact. The problem, then, is not Samson's intelligence but the narrator's weak explanation for Samson's moment of truth. Elevating Samson's complex characterization—and bracketing the nagging—reveals a Samson who has powerful reasons for allowing Delilah to cut his hair. Moreover, two retellings of the Samson tale, Milton's Samson Agonistes and DeMille's film Samson and Delilah , diminish or eliminate the nagging explanation and find far more satisfying alternative explanations for Samson's actions. The biblical nar rator, we may conclude, has misread the story or attempted to engineer an unsatis factory interpretation and is thus unreliable, though in a way rather different from the modern critical understanding of the unreliable narrator.

Pancreatic Fine Needle Aspiration

To compare the sensitivity and specificity of pancreatic fine needle aspiration (FNA) with computed tomography (CT) and endoscopic ultrasound (EUS) guidance. A 6-year retrospective review included 137 pancreatic FNAs (CT 51, magnetic resonance imaging 2 or EUS 84). Clinical or histologic follow-up was available for 110 patients. Positive (POS), suspicious (SUS), atypical, negative and unsatisfactory (UNSAT) results represented 25.5%, 7.3%, 7.3%, 40.1% and 19.1% of reported diagnoses, respectively. In detecting malignancy, the sensitivities of POS/SUS results were 71% and 42% for CT and EUS, respectively, with negative predictive value (NPV) of 41% and 45%. Also, 35% of UNSAT results were found to have malignancy. However, EUS was used on more difficult lesions, including 82% of small, cystic ones and 75% of small, solid ones. Although the apparent performance of percutaneous CT-guided biopsies surpasses that of EUS, this is due to the choice of endoscopy for more difficult lesions. The specificity and negative predictive value of EUS and CT are similar.

Evaluation of functional outcome of the floating knee injury using multivariate analysis.

The objective of this study is to evaluate significant contributing factors affecting the functional prognosis of floating knee injuries using multivariate analysis. A total of 68 floating knee injuries (67 patients) were treated at Kitasato University Hospital from 1986 to 1999. Both the femoral fractures and the tibial fractures were managed surgically by various methods. The functional results of these injuries were evaluated using the grading system of Karlström and Olerud. Follow-up periods ranged from 2 to 19 years (mean 50.2 months) after the original injury. We defined satisfactory (S) outcomes as those cases with excellent or good results and unsatisfactory (US) outcomes as those cases with acceptable or poor results. Logistic regression analysis was used as a multivariate analysis, and the dependent variables were defined as a satisfactory outcome or as an unsatisfactory outcome. The explanatory variables were predicting factors influencing the functional outcome such as age at trauma, gender, severity of soft-tissue injury in the femur and the tibia, AO fracture grade in the femur and the tibia, Fraser type (type I or type II), Injury Severity Score (ISS), and fixation time after injury (less than 1 week or more than 1 week) in the femur and the tibia. The final functional results were as follows: 25 cases had excellent results, 15 cases good results, 16 cases acceptable results, and 12 cases poor results. The predictive logistic regression equation was as follows: Log 1-p/p = 3.12-1.52 x Fraser type - 1.65 x severity of soft-tissue injury in the tibia - 1.31 x fixation time after injury in the tibia - 0.821 x AO fracture grade in the tibia + 1.025 x fixation time after injury in the femur - 0.687 x AO fracture grade in the femur ( p=0.01). Among the variables, Fraser type and the severity of soft-tissue injury in the tibia were significantly related to the final result. The multivariate analysis showed that both the involvement of the knee joint and the severity grade of soft-tissue injury in the tibia represented significant risk factors of poor outcome in floating knee injuries in this study.

Reproducibility of cervicovaginal ThinPrep cellularity assessment.

Criteria for judging the squamous cellularity adequacy of cervicovaginal ThinPreps using cell counts in representative fields have been proposed. We compared the interobserver reproducibility in the designation of ThinPreps as satisfactory (SAT), satisfactory but limited by (SBLB), or unsatisfactory (UNS) for interpretation. Three reviewers independently assessed 145 cervicovaginal ThinPreps accessioned from 1997-1999 at the University of Kentucky cytopathology laboratory. Scant specimens were retrieved by computer search and more cellular specimens were added to make 145. Adjacent fields on a diameter including center at 10x and 40x were counted for sufficiently preserved and unobscured cells. A specimen was designated UNS if four or more fields at 10x had less than 10 squamous cells, and SBLB if four or more fields at 40x had less than five squamous cells. All three observers agreed on the adequacy designation in 76% of cases and the overall kappa was 0.73 (near excellent). Complete interobserver agreement was present in 86% (63/73) of UNS cases, 79% (33/42) of SAT, but only 47% (14/30) of SBLB slides. When SBLB and UNS categories were combined, the discrimination from the SAT category was excellent (kappa = 0.87) with pairwise k-values of 0.94-0.97. In conclusion, adjacent field cell count methods to judge ThinPrep cellularity provide near excellent interobserver reproducibility. While we have designated both UNS and SBLB adequacy categories, criteria could easily be revised to set one threshold to separate SAT and UNS ThinPreps.

Some considerations on the validity of evidence-based practice in social work

Summary This paper considers the validity of evidence-based practice in social work. It critically examines various underlying presuppositions and assumptions entailed in evidence based practice and draws out their implications for social work. The paper is divided into three main parts. Following a consideration of the background to the develop ment of evidence-based practice and a discussion of its key organizing concepts, the paper goes on to examine its underlying scientific assumptions. It shows that evidence based practice proposes a particular deterministic version of rationality which is unsatis factory. Evidence-based practice is derived from ideas based on optimal behaviour in a planned and systematically organized environment. By concentrating on 'epistemic processes' involved in planning and psychological inference it is claimed that cognitive heuristic devices are the determinants of decision making and not evidence. The heur istic model suggests that decision making is indeterminate, reflexive, locally optimal at best and based on a limited rationality. It is argued that social workers engage in a reflexive understanding and not a determinate or certainty based decision-making pro cess based on objective evidence. Complex phenomena such as decision making are not rationally determined or subject to 'control'. The paper goes on to suggest that the tendency to separate processes into 'facts' and 'values' implicit in evidence-based procedures undermines professional judgement and discretion in social work. The third part of the paper focuses on the connection between method and ideology in evid ence-based practice. It examines how the evidence-based preoccupation with positiv istic methods and determinate judgement entraps social workers within a mechanistic form of technical rationality. This framework restricts social work to a narrow ends means rationality such that only certain forms of action are considered legitimate. This feeds into the rhetoric of new managerialist strategies aimed at developing a perform

‘Knitting Progress Unsatis Factory’ Gender and Special Issues in Education, Gwyned Lloyd (ed.) (Moray House Publications, 1996), pp. 176, pb. £12.50.

‘Knitting Progress Unsatis Factory’ Gender and Special Issues in Education, Gwyned Lloyd (ed.) (Moray House Publications, 1996), pp. 176, pb. £12.50.

Human sacrifice at Prambanan

While the discovery of a human skeleton is nothing extraordinary in Indo nesian archaeology, that of one in the central area of the famous Hindu temple complex of Candi Prambanan in Central Java, which dates from the first half of the ninth century A.D., does call for an explanation. Such explanations as have been put forward up to now have all been unsatis factory. Although an explanation in terms of human sacrifice was sug gested at the time, the idea received scant recognition in the archaeological literature. Only after another human skeleton was found in a neighbouring Buddhist temple complex could the possibility of the practice of human sacrifice in ancient Central Java no longer be ignored. The phenomenon remained a difficult topic among archaeologists, however. The problem that hampered scholarly progress was the choice of the appropriate ideological framework in which to place such sacrificial practices: Hindu-Buddhist religious ideas or Javanese folklore. It is this problem that we want to discuss and try to find a solution for in this article.

THE CHANGE IN ACUTE PHASE PROTEIN AS SELF-DEFESE MECHANISM IN DIABETIC PATIENT AFTER ABDOMINAL OPERATION

Acute phase protein, which are produced after operation or various insulants, play an important role as a self-defense mechanism of the body. It can be supposed that diabetic patients after surgery may differ from non-diabetic patients in the production of acute phase proteins in the liver, because of their severe postoperative catabolic condition and not an uncommon presence of latent liver dysfunction.In this study we compared for post-operative changes in acute phase reactants (CRP, α1-antitripsin, haptoglobin, α1-acid glycoprotein, fibronectine, complement) between 6 daibetic and 24 non-diabetic patients, who were operated on for tumorous leisions in the stomach and colon. Diabetic patients differed from non-diabetic in the protease inhibitor, such as α1-antitrypsin, pancreatic trypsin-inhibitor, and α1-acid glycoprotein, complement C3. It is assumed that these differences are related to the unsat isfactory repairing faculty and the high infectivity of diabetic patients. And the abnomality of acute phase protein and surgical complications will be reduced if diabetes are appropriately managed before operation.