Reliability of the history and physical assessment (HAPA) form.

BACKGROUND: Medical student assessment on core clerkship rotations is notoriously difficult. Most evaluation is subjective and may include significant bias. This study aims to determine the inter-rater reliability of an objective, standardised history and physical examination write-up assessment (HAPA) form. METHODS: The HAPA form was used by two paediatrician evaluators to assess 10 student history and physical examination write-ups (H&Ps). Kappa scores were determined to assess agreement between evaluators for each HAPA form item, for the total HAPA form score and for an additional 'overall assessment' score. RESULTS: The kappa scores were relatively high, indicating good agreement between evaluators for the major HAPA form sections: 0.59 for data collection; 0.66 for critical reasoning; and 0.36 for communication skills. The kappa score for the total HAPA form score was 0.58, which was higher than the agreement derived from an 'overall assessment' score (0.30) that the evaluators provided for the H&P. CONCLUSIONS: A standardised form for H&P assessment (the HAPA form) provides superior reliability to the 'overall assessment' of H&Ps that is often used in clerkships for evaluation. Criterion-based evaluation of the student write-up can provide reliable evaluation and feedback to students on a clerkship.

Neighborhood and individual factors in marijuana and other illicit drug use in a sample of low-income women.

Few studies have systematically evaluated whether contextual variables differ in their ability to explain the use of different drugs in the same sample. Our objective was to examine correlates of use for different illicit drugs at the individual and neighborhood level in a tri-ethnic sample of low-income women, an underrepresented sample in drug research. Women 18-31 were recruited from a low-cost family planning clinic in southeast Texas from December 2001 to May 2003. Neighborhood level indicators of disadvantage, family structure, and nativity status from U.S. Census 2000 were linked with individual survey data. Multilevel logistic regression was used to examine the effect of individual and neighborhood level measures on lifetime use of marijuana only and of other illicit drugs in 594 women. Only individual level variables (younger age, non-Hispanic White ethnicity, not being married, greater peer acceptance of substance use) increased odds of exclusive marijuana use, controlling for neighborhood level factors. However, both neighborhood and individual level variables significantly predicted other illicit drug use. Residence in less disadvantaged neighborhoods, non-Hispanic White ethnicity, higher levels of education, greater acceptance of substance use by peers, and a larger number of perceived neighborhood problems increased odds of illicit drug use. Use of other illicit drugs with or without marijuana may be more closely tied to area level factors whereas factors driving exclusive marijuana use may not rely on localized structures to the same extent. Thus, community-level interventions may need to customize their approaches according to the type of drug use targeted. The implication of using neighborhood level variables in substance use research is also discussed.

Clinical stage after preoperative chemoradiation is a better predictor of patient outcome than the baseline stage for localized gastric cancer.

BACKGROUND: For patients with localized gastric cancer (LGC) who are receiving preoperative chemoradiation (CTRT), the postsurgical pathologic stage predicts overall survival (OS) better than the baseline stage. The authors hypothesized that presurgical (postCTRT) stage would also correlate better with patient outcome than the baseline stage. METHODS: The authors analyzed 74 LGC patients treated with preoperative CTRT receiving similar treatment. Patients were staged with baseline endoscopic ultrasonography (EUS) and laparoscopy. Patients received induction chemotherapy, then CTRT (45 Gy), and had an attempted surgery. After CTRT, patients had complete preoperative staging including EUS in 35 patients. RESULTS: Thirty-five had all 3 sets of staging, baseline, presurgical, and postsurgical. Baseline stage did not associate with OS (P = .16) nor disease-free survival (DFS; P = .13). However, presurgical stage was associated with OS (P = .01), and DFS (P = .05). OS was also associated with postsurgical stage and was longer for stages 0 and I than for stages III and IV (P = .01 and .04, respectively). Similarly, DFS was longer in postsurgical pathologic stages 0, I, and II than in stage III or IV (P < .001, <.001, and <.01, respectively). Baseline staging did not correlate with the proportion of patients alive at 4 years; however, presurgical staging did. Patients with stage I or II survived longer than those with stage III or IV (81% vs 25%; P < .01). CONCLUSIONS: Heterogeneity in clinical biology of LGC is best reflected after CTRT in presurgical and postsurgical pathologic stages rather than by the baseline stage. Correlation of outcome with presurgical staging may facilitate strategies to individualize therapy for LGC.

Adolescent girls' communication with "mothers" about topical microbicides.

STUDY OBJECTIVE: Topical microbicides, a female-initiated method to protect against sexually transmitted infections (STI) and pregnancy, will only be effective if found acceptable. Mothers may have an influence on acceptability and use among adolescent girls. The current study examined the communication between girls and mothers to understand the potential predictors and nature of conversations regarding surrogate microbicide products. DESIGN: Sexually experienced girls, 14 to 21 years, were recruited for a 6-month study examining microbicide acceptability. During face-to-face interviews, qualitative data were collected regarding communication between girls and mothers. Two independent raters coded the responses, which were organized into themes. Themes were interpreted according to the conceptual understanding of mother-daughter communication. RESULTS: Fifty percent of the 171 girls with codable responses had a conversation with their mother. Higher levels of indirect parental monitoring were related to being more likely to have a conversation. Concrete events related to the study (i.e. receiving phone call from the researcher, having an appointment, or seeing the product) or inquiries by mothers appeared to promote conversation. Barriers to conversation included the private nature of the information and relationship issues between the mother and daughter. Conversations often addressed issues related to girls' participation in the study, although some conversations included global issues related to sexuality. CONCLUSIONS: Girls may talk to their mothers about new products for STI prevention, and such conversations may provide opportunities to promote use.

Surgical pathology stage by American Joint Commission on Cancer criteria predicts patient survival after preoperative chemoradiation for localized gastric carcinoma.

BACKGROUND: Preoperative chemoradiation for localized gastric cancer can modify baseline stage, as determined by surgical pathology stage. Therefore, the authors hypothesized that surgical pathology stage would be a better prognosticator of overall survival (OS) than baseline stage. METHODS: Patient populations were combined from 2 prospectively conducted, preoperative chemoradiation trials that used the same therapeutic strategy. Patients must have had localized gastric adenocarcinoma and were staged extensively, including endoscopic ultrasonography and laparoscopy. Patients had to be fit for surgery medically with a technically resectable cancer. All patients provided written informed consent. Patients first received induction chemotherapy for up to 2 months followed by chemoradiation (45 grays) and an attempted surgery. OS was correlated with pretreatment and posttreatment parameters, including surgical pathology stage according to American Joint Commission on Cancer criteria. RESULTS: Of 74 patients who were registered, 69 patients (93%) had undergone surgery. Nineteen patients (26%) had a pathologic complete response (pathCR), and 55 patients (81%) had a curative (R0) resection. None of the pretreatment parameters correlated with OS; however, longer OS correlated with lower pathologic stage (P < .0001), R0 resection (P < .001), clinical response noted prior to surgery (P = .002), pathCR (P = .004), lower pathologic lymph node classification (P = .006), and lower pathologic tumor classification (P = .03). Pathologic stage and R0 resection were independent prognostic factors for OS (multivariate Cox model; both P = .05). CONCLUSIONS: When preoperative chemoradiation strategy was employed for gastric cancer, the surgical pathology stage, a reflection of cancer's biologic heterogeneity, was a better prognosticator of OS than the baseline clinical stage. Surgical pathology stage, in this setting, may serve as an intermediate endpoint for Phase II/III trials.