Clinical outcomes following inpatient penicillin allergy testing: A systematic review and meta-analysis.

BACKGROUND: A documented penicillin allergy is associated with increased morbidity including length of hospital stay and an increased incidence of resistant infections attributed to use of broader-spectrum antibiotics. The aim of the systematic review was to identify whether inpatient penicillin allergy testing affected clinical outcomes during hospitalization. METHODS: We performed an electronic search of Ovid MEDLINE/PubMed, Embase, Web of Science, Scopus, and the Cochrane Library over the past 20 years. Inpatients having a documented penicillin allergy that underwent penicillin allergy testing were included. RESULTS: Twenty-four studies met eligibility criteria. Study sample size was between 24 and 252 patients in exclusively inpatient cohorts. Penicillin skin testing (PST) with or without oral amoxicillin challenge was the main intervention described (18 studies). The population-weighted mean for a negative PST was 95.1% [CI 93.8-96.1]. Inpatient penicillin allergy testing led to a change in antibiotic selection that was greater in the intensive care unit (77.97% [CI 72.0-83.1] vs 54.73% [CI 51.2-58.2], P<.01). An increased prescription of penicillin (range 9.9%-49%) and cephalosporin (range 10.7%-48%) antibiotics was reported. Vancomycin and fluoroquinolone use was decreased. Inpatient penicillin allergy testing was associated with decreased healthcare cost in four studies. CONCLUSIONS: Inpatient penicillin allergy testing is safe and effective in ruling out penicillin allergy. The rate of negative tests is comparable to outpatient and perioperative data. Patients with a documented penicillin allergy who require penicillin should be tested during hospitalization given its benefit for individual patient outcomes and antibiotic stewardship.

Complete diagnostic evaluation in colorectal cancer screening: research design and baseline findings.

BACKGROUND: While indicated by guidelines, complete diagnostic evaluation, or CDE (i.e., colonoscopy or combined flexible sigmoidoscopy plus barium enema X ray), is often not recommended and performed for persons with an abnormal screening fecal occult blood test (FOBT) result. We initiated a randomized trial to assess the impact of a physician-oriented intervention on CDE rates in primary care practices. METHODS: In 1998, we identified 1,184 primary care physicians (PCPs) in 584 practices whose patients received FOBTs that are mailed annually by a managed care organization screening program. A total of 470 PCPs in 318 practices completed a baseline survey. Practices were randomly assigned either to a Control Group (N = 198) or to an Intervention Group (N = 120). Control Group practices received the screening program. Intervention Group practices received the screening program and the intervention (i.e., CDE reminder-feedback plus educational outreach). Practice CDE recommendation and performance rates are the primary outcomes to be measured in the study. RESULTS: Baseline CDE recommendation and performance rates were low and were comparable in Control and Intervention Group practices (54 to 57% and 39 to 40%, respectively). PCPs in the practices tended to view FOBT screening and CDE favorably, but had concerns about screening efficacy, time involved in CDE, and patient discomfort and adherence. Control Group physicians were more likely than Intervention Group physicians to believe that a mail-out FOBT screening program helps in the practice of medicine. CONCLUSIONS: We were able to enroll a high proportion of targeted primary care practices, measure practice characteristics and CDE rates at baseline, and develop and implement the intervention. Study outcome analyses will take into account baseline differences in practice characteristics.

Factors associated with changing levels of interest in primary care during medical school.

PURPOSE: To examine changing levels of interest in primary care as related to clinical experiences during medical school, and to other variables. METHOD: A total of 1,911 (74%) allopathic medical school graduates responded to a national survey in early 1993. Respondents' reported changes of interest in primary care during medical school were cross-tabulated with their clinical experiences in medical school, their demographics, their interests prior to medical school, and their future practice plans. RESULTS: Increased interest in primary care during medical school was strongly associated with the electives taken in primary care. This positive change of interest in primary care was found to be associated with interest prior to medical school and with primary care career plans. CONCLUSION: Schools wishing to graduate more students who enter primary care specialties may want to raise the number of primary care elective courses to increase students' interests, and to help them choose to enter and remain in primary care specialties.

Assessing emergency medicine resident communication skills using videotaped patient encounters: gaps in inter-rater reliability.

We report on a process for assessing the communication skills of emergency medicine residents that includes 1) a faculty development initiative; 2) videotaping of actual resident-patient encounters in the emergency department; and 3) creation of an observation instrument for evaluating communication behaviors. We tested this observation instrument for inter-rater reliability, finding moderate-to-high agreement for only 11 of 32 items. These related to personal introductions, conflict management, nonverbal communication, and overall performance. There was poor or no agreement for behaviors related to establishing rapport, gathering information, and contracting or informing. Challenges of assessing interpersonal skills of emergency medicine residents are discussed.

Medical students' personal values and their career choices a quarter-century later.

A longitudinal study of 391 physicians tested two hypotheses regarding personal values and career choices: that higher preference for social values would be associated with physicians' being more interested in "people-oriented" rather than "technology-oriented" specialties and that higher preference for economic values would be associated with expectations of high income. The physicians (344 men, 47 women) were graduates of Jefferson Medical College in 1974 and 1975 who completed the Allport-Vernon-Lindzey Study of Values during medical school. Analysis showed that physicians currently in the "people-oriented" specialties scored significantly higher on the Social Value scale than their peers in "technology-oriented" specialties. A moderate but statistically significant correlation was found between scores on the Economic Value scale and expectations of higher income. The findings suggest that physicians' personal values are relevant to their career decisions such as specialty choice and expectations of income. The findings have implications with regard to two major issues in the evolving health care system, namely, the distribution of physicians by specialty and cost containment.

Students' satisfaction and perceptions of attending physicians' and residents' teaching role.

BACKGROUND: Changes in the health care system imply that fewer patients will be admitted to hospitals and attending physicians will be devoting more time to clinical activities with less time for student education. METHODS: Surveys of third-year students were conducted for 5 consecutive years at Jefferson Medical College at the end of the required 6-week surgical clerkship at the university hospital or at one of the eight affiliates. RESULTS: The numbers of new inpatients and outpatients encountered by students were not significantly related to students' overall satisfaction. The ratings of teaching rounds and conferences were significant predictors of satisfaction with the clerkship, as were the ratings of residents' teaching. CONCLUSIONS: As medical education shifts to ambulatory settings, didactic teaching such as rounds and conferences should be maintained and efforts to enhance the teaching skills of residents should be encouraged.

Effects of blood alcohol concentrations on negative punishment: implications for decision making.

OBJECTIVE: A series of studies examined how various blood ethanol concentrations influenced the effectiveness of a negative punishment procedure in a risk-taking/decision-making task. Based on the animal punishment literature plus the impression that ethanol diminishes the effects of punishment and impairs decision making, it was predicted that individuals receiving alcohol would increase their risk- taking behavior despite the presence of a negative punishment stimulus (point loss) given on a variable schedule. METHODS: In Experiment 1, a within-subjects design with repeated measures was used where 10 male subjects played a modified computer-generated choice game under three levels of punishment certainty, three levels of punishment severity and four ranges of blood ethanol (0.00%, 0.01-0.049%, 0.050-0.099%, 0.10-0.15%) RESULTS: Results indicated significant decreases in risk taking as either punishment certainty or severity was increased. However, no significant effects were found for ethanol, or interactions of ethanol with punishment certainty or punishment severity. Two additional studies examining aspects of the experimental procedure produced similar results CONCLUSIONS: Overall, the results of these studies do not support the hypothesis that high concentrations of blood alcohol are sufficient in and of themselves to eliminate the suppression function of negative punishment contingencies leading to increased risk-taking behavior. The implications of these results for understanding blood alcohol effects are discussed.

Increasing designated driving with a program of prompts and incentives.

Designated driving (DD) is a potentially viable but underutilized component of efforts to reduce driving while intoxicated. A reversal design was used to evaluate the effects of prompts and incentives in a bar on the frequency of DD. The results showed an approximate doubling of the number of designated drivers during the two intervention periods.

Primary care and nonprimary care physicians' concerns in practice and perceptions of medical school curriculum.

The purpose of the present study is to address the issue of physicians' concerns in practice and their perception of a medical school's curriculum with an emphasis on comparisons between primary and nonprimary care physicians. The sample consisted of 663 physicians who graduated from Jefferson Medical College (JMC) between 1982 and 1986, and also responded to a mailed questionnaire. Comparisons were made between physicians in primary care (n=234) and in nonprimary care (n=429) specialties on their responses regarding concerns in medical practice and evaluation of the medical school curriculum. Primary care physicians were more concerned about the time for their professional development whereas nonprimary care physicians were more concerned about an oversupply of physicians in their specialties, prospective hospital payment, and malpractice litigation. Regardless of the specialties, the physicians overall seemed very concerned about their personal time. Interpersonal skills were regarded by all respondents as an important aspect of the medical school's curriculum. The importance of psychological, social, and cultural factors in the curriculum was strongly supported by these physicians' responses, particularly among primary care and women physicians.

Perceptions of practice problems encountered by family physicians, pediatricians, and orthopedic surgeons.

Information about physicians' practice problems was solicited through a structured questionnaire mailed to a group of family physicians, pediatricians, and orthopedic surgeons. Overall, a lack of personal time was the major concern across the three groups of physicians. Comparisons among the three types of physicians revealed two patterns: Family physicians reported more concerns in the "interpersonal" dimension, whereas orthopedic surgeons had more concerns in the "legal-economic" dimension. These patterns of differences persisted with two variables controlled: gender and time period in which they completed their residency program. These findings indicate that physicians' concerns in their practice vary among the specialties, and they imply that the changed economy and reimbursement system might have more impact on one than the other. Thus the effectiveness of residency training and continuing education might be improved by emphasizing the specialty-related problems in practice.

Attendings' and residents' teaching role and students' overall rating of clinical clerkships.

The study was conducted with a sample of third-year students (n = 584) at Jefferson Medical College to explore students' perception of patterns of differences between attending physicians and residents in their teaching behaviors during clinical clerkships. Attending physicians' teaching behaviors were perceived more in a mentorship mode whereas residents' teaching behaviors were equally divided between mentorship and preceptorship modes. Attending physicians and residents' teaching behaviors varied among clerkships. Results were discussed in terms of difference of teaching roles played by attending physicians and residents and relationship of the teaching behaviors to students' overall rating of clerkship.

Modifying hypnotizability with the Carleton Skills Training program: a partial replication and analysis of components.

3 standard components of the Carleton Skills Training (CST) program--information, modeling, and instructions--were administered in 1 of 3 sequences to 12 low-hypnotizable Ss. Hypnotizability measures were obtained after each component was given, as well as before and after training. Although objective scores showed significant gains from screening to testing, subjective scores did not, suggesting that while training encouraged behavioral compliance, few Ss learned to have the subjective experiences traditionally associated with hypnosis. Results from the component analysis were clear and consistent: whether instructions were presented first, second, or third in the training sequence, no significant changes occurred until this component was provided.

Effects of clozapine on ketamine-induced linguopharyngeal events in rats.

We tested the effects of clozapine (0.02-20 mg/kg i.p.) on ketamine-induced linguopharyngeal events in rats anesthetized with i.m. injections of ketamine hydrochloride (100 mg/kg) and mounted on a stereotaxic with the tip of the tongue tied to a force displacement transducer monitoring tongue protrusions, retrusions and swallows. Reduction began at the 0.04 mg/kg dose. At 4.8 mg/kg there was total suppression of events. At 20 mg/kg, suppression lasted for 1 h. Notably clozapine doses causing total suppression of events in our model were much lower than those usually reported to alter dopamine turnover.

Ketamine-induced tongue protrusions in rats.

1. The purpose of this study was to demonstrate that ketamine anesthesia (100 mg/kg) induces tongue protrusions (P) in addition to retrusions (R) and swallows (S) in adult rats. 2. These linguo-pharyngeal events occur alone or combined in various sequential patterns. 3. The SPR sequence is not the predominant pattern in all preparations suggesting profound disruption of physiological linkages by ketamine. 4. Haloperidol administration suppresses these events for 1-120 min depending on the dose (0.75-2.5 mg/kg). 5. Swallows are the least vulnerable to haloperidol. 6. This and previous findings provide further evidence that ketamine induced linguo-pharyngeal activity can serve as a model for acute or tardive dyskinesia better than stereotypies.

Modifying hypnotic suggestibility with the Carleton Skills Training program.

The Carleton Skills Training (CST) program was used to investigate (a) whether increases in hypnotic responsiveness obtained at Carleton University could be replicated at a different laboratory, (b) the influence of demand characteristics on suggestibility gains, and (c) whether initial gains are maintained over time. After two screening sessions, a replication and experimental group received the CST program, while a control group was allowed to practice hypnotic responding. All groups were then tested twice. Whereas the replication group was told that training and testing were part of the same experiment, the experimental group was told that training and testing were unrelated. Trained subjects returned after 4 months for a final session. Results indicated that (a) the CST program does increase hypnotic responsiveness, (b) suggestibility gains found in this study were relatively modest, (c) demand characteristics may influence suggestibility gains, and (d) suggestibility gains were not maintained at follow-up.

Accuracy of drinkers' recall of alcohol consumption in a field setting.

In a previous field study of how feedback on intoxication might affect an individual's decision to drive, it was found that a small sample of people were quite accurate in their recall of alcohol consumption. The accurate estimation of alcohol consumption clearly is of potential value in driving while intoxicated (DWI) prevention programs. However, because the finding of accurate recall is inconsistent with other reports in the literature, it was decided to replicate the testing with a larger sample. Randomly selected patrons leaving taverns and bars were asked to participate in a study, and individuals agreed to answer a consumption questionnaire and have their blood alcohol level (BAL) measured. Results indicated that subjects were very accurate in their estimates of consumption when self-reports were compared with Breathalyzer readings (r = .70, p less than .01). An additional trend of some interest was that men were apparently more accurate in their estimates of consumption than women even though they generally had higher BALs. The present study replicates and extends the earlier findings concerning the ability of college-age drinkers to estimate alcohol consumption in field settings accurately.

Tolerance of aversive stimuli in relation to life change.

This study investigated the relation between an individual's tendency to tolerate and/or report discomfort and the amount of life change experienced by that individual. The role of attention in this relation was also examined and manipulated through instruction. Eighty college freshman were selected and divided into three groups (high, medium, low) as a function of scores obtained on the College Schedule of Recent Experience (CSRE). Participants were asked to experience two known discomforting stimuli, the cold pressor and loud broad-band noise. Dependent measures included participant's tolerance time, report of discomfort, and amount of attention paid to each of the stimuli. Results indicated that "high"-life change groups tolerated the two discomforting stimuli significantly less than either the "low"- or the "medium"-life change groups. Neither discomfort ratings nor attention was significantly different across groups. Findings are discussed in relation to epidemiological studies of the life change and illness relation.

Effects of feedback on legally intoxicated drivers.

College-aged patrons leaving a drinking establishment were given feedback about their blood alcohol level (BAL): 24 were administered a Breathalyzer and were then read a statement on the consequences of driving with their BAL; 21 were shown a large chart and had to determine their own BAL from their weight and number of drinks consumed; and 21 were given no feedback. The two feedback groups were later collapsed. The subjects were also followed unobtrusively to determine whether they drove away from the premises. A total of 24 of the feedback subjects (47%) were legally intoxicated, but 83% of this group nonetheless drove after learning that they were legally intoxicated. In addition, when self-reports of consumption were compared with Breathalyzer BALs, a correlation of .82 was obtained.

Self-control revisited: Or why doesn't anyone actually read Skinner anymore?

Self-control continues to develop as a major source of explanatory concepts within cognitive behavior therapy. The recent history of self-control is reviewed, and three related areas of disagreement between radical behaviorists and cognitive behaviorists are discussed. The logical status of self-reinforcement, reciprocity, and private events is examined and evaluated. This review suggests that a radical behavioral approach continues to offer psychology the most effective program for the analysis of behavior.

A comparison of self-delivered consequences and desensitization in the treatment of fear of rats.

Exposed 52 rat phobic Ss to either group desensitization, self-delivered consequences imagined exposure, self-delivered consequences in-vivo exposure, or no treatment. Self-delivered consequences Ss conducted the treatment on their own and self-delivered preselected reinforcers contingent upon performance of the treatment exercises. All treatment groups improved significantly more than the no-treatment control group. The self-delivered consequences imagined exposure and the group desensitization treatments were equally effective. The self-delivered consequences in-vivo exposure treatment was significantly more effective than the self-delivered consequences imagined exposure and group desensitization treatments. The applicability of self-management techniques to the treatment of fear responses to specific stimuli and an extinction explanation of the effectiveness of systematic desensitization are discussed.