A genetic history of the Balkans from Roman frontier to Slavic migrations

The rise and fall of the Roman Empire was a socio-political process with enormous ramifications for human history. The Middle Danube was a crucial frontier and a crossroads for population and cultural movement. Here, we present genome-wide data from 136 Balkan individuals dated to the 1st millennium CE. Despite extensive militarization and cultural influence, we find little ancestry contribution from peoples of Italic descent. However, we trace a large-scale influx of people of Anatolian ancestry during the Imperial period. Between ∼250 and 550 CE, we detect migrants with ancestry from Central/Northern Europe and the Steppe, confirming that "barbarian" migrations were propelled by ethnically diverse confederations. Following the end of Roman control, we detect the large-scale arrival of individuals who were genetically similar to modern Eastern European Slavic-speaking populations, who contributed 30%-60% of the ancestry of Balkan people, representing one of the largest permanent demographic changes anywhere in Europe during the Migration Period.

Sagittal suture morphological variation in human archaeological populations

Cranial sutures join the many bones of the skull. They are therefore points of weakness and consequently subjected to the many mechanical stresses affecting the cranium. However, the way in which this impacts their morphological complexity remains unclear. We examine the intrinsic and extrinsic mechanisms of human sagittal sutures by quantifying the morphology from 107 individuals from archaeological populations spanning the Mesolithic to Middle ages, using standardized two‐dimensional photographs. Results show that the most important factor determining sutural complexity appears to be the position along the cranial vault from the junction with the coronal suture at its anterior‐most point to the junction with the lambdoid suture at its posterior‐most point. Conversely, factors such as age and lifeways show few trends in complexity, the most significant of which is a lower complexity in the sutures of Mesolithic individuals who consumed a tougher diet. The simple technique used in this study therefore allowed us to identify that, taken together, structural aspects play a more important role in defining the complexity of the human sagittal suture than extrinsic factors such as the mechanical forces imposed on the cranium by individuals' diet.

Letter to the editor

"Inside the word emerging is emerge, from an emergency new things come forth. The old certainties are crumbling first, but danger and possibility are sisters."

Molecular epidemiology of Giardia and Cryptosporidium infections - What's new?

New information generated since 2016 from the application of molecular tools to infections with Giardia and Cryptosporidium is critically summarised. In the context of molecular epidemiology, nomenclature, taxonomy, in vitro culture, detection, zoonoses, population genetics and pathogenicity, are covered. Whole genome sequencing has had the greatest impact in the last three years. Future advances will provide a much better understanding of the zoonotic potential of both parasites, their diversity and how this is linked to pathogenesis in different hosts.

The genomic history of southeastern Europe

Farming was first introduced to Europe in the mid-7^th millennium BCE–associated with migrants from Anatolia who settled in the Southeast before spreading throughout Europe. To understand the dynamics of this process, we analyzed genome-wide ancient DNA data from 225 individuals who lived in southeastern Europe and surrounding regions between 12,000 and 500 BCE. We document a West-East cline of ancestry in indigenous hunter-gatherers and–in far-eastern Europe–early stages in the formation of Bronze Age Steppe ancestry. We show that the first farmers of northern and western Europe passed through southeastern Europe with limited hunter-gatherer admixture, but that some groups that remained mixed extensively, without the male-biased hunter-gatherer admixture that prevailed later in the North and West. Southeastern Europe continued to be a nexus between East and West, with intermittent genetic contact with the Steppe up to 2000 years before the migrations that replaced much of northern Europe’s population.

Regional differences in health, diet and weaning patterns amongst the first Neolithic farmers of central Europe

Across much of central Europe, the Linearbandkeramik (LBK) represents the first Neolithic communities. Arising in Transdanubia around 5500 cal. BC the LBK spread west to the Rhine within two to three hundred years, carrying elements of a mixed agricultural economy and a relatively homogeneous material culture. Colonisation of new regions during this progress would have required economic adaptations to varied ecological conditions within the landscape. This paper investigates whether such adaptation at a local scale affected health patterns and altered the dietary habits of populations that otherwise shared a common cultural and biological origin. Analysis of non-specific stress (linear enamel hypoplasia, porotic hyperostosis, cribra orbitalia) within five LBK populations from across central Europe in conjunction with published carbon and nitrogen stable isotope data from each site revealed a high prevalence of porotic hyperostosis and cribra orbitalia in western populations that was associated with a lower animal protein intake. Hypoplastic enamel was more frequently observed in eastern populations however, and may reflect geographic differences in childhood morbidity and mortality as a result of variation in social practices relating to weaning. Local socio-economic adaptations within the LBK were therefore an important factor in the exposure of populations to non-specific stress.

Structural modifications of the salivary conditioning film upon exposure to sodium bicarbonate: implications for oral lubrication and mouthfeel

The salivary conditioning film (SCF) that forms on all surfaces in the mouth plays a key role in lubricating the oral cavity. As this film acts as an interface between tongue, enamel and oral mucosa, it is likely that any perturbations to its structure could potentially lead to a change in mouthfeel perception. This is often experienced after exposure to oral hygiene products. For example, consumers that use dentifrice that contain a high concentration of sodium bicarbonate (SB) often report a clean mouth feel after use; an attribute that is clearly desirable for oral hygiene products. However, the mechanisms by which SB interacts with the SCF to alter lubrication in the mouth is unknown. Therefore, saliva and the SCF was exposed to high ionic strength and alkaline solutions to elucidate whether the interactions observed were a direct result of SB, its high alkalinity or its ionic strength. Characteristics including bulk viscosity of saliva and the viscoelasticity of the interfacial salivary films that form at both the air/saliva and hydroxyapatite/saliva interfaces were tested. It was hypothesised that SB interacts with the SCF in two ways. Firstly, the ionic strength of SB shields electrostatic charges of salivary proteins, thus preventing protein crosslinking within the film and secondly; the alkaline pH (≈8.3) of SB reduces the gel-like structure of mucins present in the pellicle by disrupting disulphide bridging of the mucins via the ionization of their cysteine's thiol group, which has an isoelectric point of ≈8.3.

Accidental overdose in the deep shade of night: a warning on the assumed safety of 'natural substances'

There is an increasing use of herbal remedies and medicines, with a commonly held belief that natural substances are safe. We present the case of a 50-year-old woman who was a trained herbalist and had purchased an 'Atropa belladonna (deadly nightshade) preparation'. Attempting to combat her insomnia, late one evening she deliberately ingested a small portion of this, approximately 50 mL. Unintentionally, this was equivalent to a very large (15 mg) dose of atropine and she presented in an acute anticholinergic syndrome (confused, tachycardic and hypertensive) to our accident and emergency department. She received supportive management in our intensive treatment unit including mechanical ventilation. Fortunately, there were no long-term sequelae from this episode. However, this dramatic clinical presentation does highlight the potential dangers posed by herbal remedies. Furthermore, this case provides clinicians with an important insight into potentially dangerous products available legally within the UK. To help clinicians' understanding of this our discussion explains the manufacture and 'dosing' of the A. belladonna preparation.

Social disparity and intrauterine death: from politics to policies

Correlation between intrauterine demise (IUD) and social disparity, based on maternal post-code of residence, is assessed in this study in order to find out if there is any correlation between IUD and geographical area. A total of 190 IUD cases from September 2002 to August 2004 were collected retrospectively from the IUD register. The maternity computer health record programme (Terranova-Healthware) was used for the assessment of area of residence of the patient and GP, patient demography and pregnancy details. Data were then entered onto a MS Excel spreadsheet and analysed by a public health statistician and a consultant obstetrician using the IMD-Index of Multiple Deprivation and then on to a graph. The results of this study show that there was a strong correlation between the IMD and the distribution of IUDs. Disparities come at a personal, midwifery and obstetric price. Differential access may lead to disparities in quality.

Molecular epidemiology of Giardia duodenalis in an endangered carnivore--the African painted dog

The African painted dog (Lycaon pictus) is an endangered carnivore of sub-Saharan Africa. To assist in conservation efforts a parasitological survey was conducted on wild and captive populations. Faecal samples were collected and examined for the presence of parasites using traditional microscopy techniques. The protozoan Giardia duodenalis was identified at a prevalence of approximately 26% in the wild populations and 62% in the captive population. Molecular characterisation of these isolates using three loci, 18S rRNA, β-giardin and the glutamate dehydrogenase gene revealed the zoonotic assemblages A and B existed in high proportions in both populations. The dog assemblages C and D were rarely observed. The identification of the zoonotic genotype suggests this species has the potential to act as a reservoir for human infections. Zoonotic transmission may be possible in captive populations due to the close interaction with humans however, in wild populations anthropozoonotic transmission seems more likely. This study is the first to observe G. duodenalis in the African painted dog and to identify a possible emerging disease in this wild carnivore.

Caesarean scar pregnancy

Caesarean scar pregnancy is one of the rarest forms of ectopic pregnancy. Little is known about its incidence and natural history. With increasing incidence of caesarean section worldwide, more and more cases are diagnosed and reported. Transvaginal ultrasound and colour flow Doppler provides a high diagnostic accuracy with very few false positives. A delay in diagnosis and/or treatment can lead to uterine rupture, major haemorrhage, hysterectomy and serious maternal morbidity. Early diagnosis can offer treatment options of avoiding uterine rupture and haemorrhage, thus preserving the uterus and future fertility. Management plan should be individually tailored. Available data suggest that termination of pregnancy is the treatment of choice in the first trimester soon after the diagnosis. Expectant treatment has a poor prognosis because of risk of rupture. There are no reliable scientific data on the risk of recurrence of the condition in future pregnancy, role of the interval between the previous caesarean delivery and occurrence of caesarean scar pregnancy, and effect of caesarean wound closure technique on caesarean scar pregnancy. In this article, we aim to find the demography, pathophysiology, clinical presentation, most appropriate methods of diagnosis and management, with their implications in clinical practice for this condition.

Acute pseudo-obstruction of the colon (Ogilvie's syndrome) following instrumental vaginal delivery

Acute pseudo-obstruction of the colon (Ogilvie's syndrome) is an adynamic ileus without mechanical obstruction of the bowel. Predisposing factors include: abdominal and pelvic surgery, or trauma, or severe pre-existing systemic illness. In obstetrics, many cases have been reported after caesarean delivery, but none following a vaginal delivery. Conservative and pharmacological therapies are effective in many patients, but surgical intervention may be required. Early diagnosis and appropriate treatment is imperative to avoid caecal rupture, faecal peritonitis and the associated high maternal mortality. High index of clinical suspicion and proper assessment of the gastrointestinal system in the post-surgical patient are vital to the management of this uncommon but potentially serious condition met with in obstetrics practice.

Risk selection in the Massachusetts State employee health insurance program

Using the Diagnostic Cost Group (DCG) model developed from a national sample, we examine biased selection among one fee-for-service (FFS) plan, one preferred provider organization, and several health maintenance organizations (HMOs) in Massachusetts. The proportions of enrollees in low-risk groups are higher in the HMO plans and lower in the FFS plan. The average age in the FFS plan is 9 years greater than that in the HMO plans. Actual premiums are not consistent with risk levels among HMO plans, resulting in gains in some HMO plans and losses in others as high as 20% compared to expected expenses as computed by the DCG model.

Influence of age on Medicare expenditures and medical care in the last year of life

CONTEXT

Expenditures for Medicare beneficiaries in the last year of life decrease with increasing age. The cause of this phenomenon is uncertain.

OBJECTIVES

To examine this pattern in detail and evaluate whether decreases in aggressiveness of medical care explain the phenomenon.

DESIGN, SETTING, AND PATIENTS

Analysis of sample Medicare data for beneficiaries aged 65 years or older from Massachusetts (n = 34 131) and California (n = 19 064) who died in 1996.

MAIN OUTCOME MEASURE

Medical expenditures during the last year of life, analyzed by age group, sex, race, place and cause of death, comorbidity, and use of hospital services.

RESULTS

For Massachusetts and California, respectively, Medicare expenditures per beneficiary were $35 300 and $27 800 among those aged 65 through 74 years vs $22 000 and $21 600 for those aged 85 years or older. The pattern of decreasing Medicare expenditures with age is pervasive, persisting throughout the last year of life in both states for both sexes, for black and white beneficiaries, for persons with varying levels of comorbidity, and for those receiving hospice vs conventional care, regardless of cause and site of death. The aggressiveness of medical care in both Massachusetts and California also decreased with age, as judged by less frequent hospital and intensive care unit admissions and by markedly decreasing use of cardiac catheterization, dialysis, ventilators, and pulmonary artery monitors, regardless of cause of death. Decrease in the cost of hospital services accounts for approximately 80% of the decrease in Medicare expenditures with age in both states.

CONCLUSIONS

Medicare expenditures in the last year of life decrease with age, especially for those aged 85 years or older. This is in large part because the aggressiveness of medical care in the last year of life decreases with increasing age.

Risk adjustment for measuring health outcomes: an application in VA long-term care

An empirically derived risk adjustment model is useful in distinguishing among facilities in their quality of care. We used Veterans Affairs (VA) administrative databases to develop and validate a risk adjustment model to predict decline in functional status, an important outcome measure in long-term care, among patients residing in VA long-term care facilities. This model was used to compare facilities on adjusted and unadjusted rates of decline. Predictors of decline included age, time between assessments, baseline functional status, terminal illness, pressure ulcers, pulmonary disease, cancer, arthritis, congestive heart failure, substance-related disorders, and various neurologic disorders. The model performed well in the development and validation databases (c statistics, 0.70 and 0.68, respectively). Risk-adjusted rates and rankings of facilities differed from unadjusted ratings. We conclude that judgments of facility performance depend on whether risk-adjusted or unadjusted decline rates are used. Valid risk adjustment models are therefore necessary when comparing facilities on outcomes.

Survival analysis using Medicare data: example and methods

OBJECTIVE

To describe key methods and issues in conducting survival analyses, especially using Medicare (and other) administrative data.

PRINCIPAL FINDINGS

Survival analyses are rich , informative, and underutilized methods for examining out comes whose timing is important . Medicare files contain the necessary information for conducting such analyses, including identification of cohorts, definition of events, censoring of observations, and adjustment for covariates.

CONCLUSION

Survival analyses can readily be conducted using the information contained in administrative data files.

Gender differences in the treatment of cerebrovascular disease

OBJECTIVE

Previous studies have shown that women receive fewer invasive procedures for the treatment of coronary artery disease than men, but gender differences in cerebrovascular disease have not been well studied. Our objective was to explore differences in the treatment of stroke between men and women.

DESIGN

Secondary database analyses.

STUDY PARTICIPANTS

We examined the use of carotid endarterectomy in a nationally representative sample of Medicare enrollees aged 65 to 84, hospitalized for a principal diagnosis of stroke in 1992, the "all strokes group". We also studied a subgroup of patients, the "carotid disease subgroup", admitted with a principal diagnosis of precerebral arterial occlusion and stenosis or transient cerebral ischemia.

MEASUREMENTS

We determined rates of carotid endarterectomy for the all strokes group within gender and age groups and calculated corresponding female-to-male relative risks (RR) and 95% confidence intervals (CI). We also performed similar analyses for the carotid disease subgroup. We then used logistic regression to estimate the relative risk of use of carotid endarterectomy for women, controlling for age and comorbidity.

RESULTS

The all-strokes group consisted of 3,356 women and 2,927 men, of whom 1,009 women and 990 men were in the carotid disease subgroup. The overall age-adjusted female-to-male relative risk of undergoing carotid endarterectomy for those aged 65 to 84 was 0.69 (95% CI, 0.64-0.74) in the all strokes group and 0.77 (95% CI, 0.72-0.82) in the carotid disease subgroup. In both analyses, the RR became more pronounced with increasing age. In the all strokes group, for example, the RR was 0.80 (0.70-0.92) for those aged 65 to 69 and 0.39 (0.32-0.48) for those aged 80 to 84. The RR for the all strokes group remained similar in magnitude even after controlling for comorbidity (RR, 0.63 and 95% CI, 0.59-0.70).

CONCLUSION

We conclude that women hospitalized for strokes undergo fewer carotid endarterectomies than men. Further studies are needed to examine the reasons for and implications of this gender difference.

Does diagnostic information contribute to predicting functional decline in long-term care?

BACKGROUND

Compared with the acute-care setting, use of risk-adjusted outcomes in long-term care is relatively new. With the recent development of administrative databases in long-term care, such uses are likely to increase.

OBJECTIVES

The objective of this study was to determine the contribution of ICD-9-CM diagnosis codes from administrative data in predicting functional decline in long-term care.

RESEARCH DESIGN

We used a retrospective sample of 15,693 long-term care residents in VA facilities in 1996.

METHODS

We defined functional decline as an increase of > or =2 in the activities of daily living (ADL) summary score from baseline to semiannual assessment. A base regression model was compared to a full model enhanced with ICD-9-CM codes. We calculated validated measures of model performance in an independent cohort.

RESULTS

The full model fit the data significantly better than the base model as indicated by the likelihood ratio test (chi2 = 179, df = 11, P <0.001). The full model predicted decline more accurately than the base model (R2 = 0.06 and 0.05, respectively) and discriminated better (c statistics were 0.70 and 0.68). Observed and predicted risks of decline were similar within deciles between the 2 models, suggesting good calibration. Validated R2 statistics were 0.05 and 0.04 for the full and base models; validated c statistics were 0.68 and 0.66.

CONCLUSIONS

Adding specific diagnostic variables to administrative data modestly improves the prediction of functional decline in long-term care residents. Diagnostic information from administrative databases may present a cost-effective alternative to chart abstraction in providing the data necessary for accurate risk adjustment.

Methods for analyzing health care utilization and costs

Important questions about health care are often addressed by studying health care utilization. Utilization data have several characteristics that make them a challenge to analyze. In this paper we discuss sources of information, the statistical properties of utilization data, common analytic methods including the two-part model, and some newly available statistical methods including the generalized linear model. We also address issues of study design and new methods for dealing with censored data. Examples are presented.

Using utilization review information to improve hospital efficiency

Hospitals are currently under great pressure to improve the efficiency of internal operations without sacrificing quality of care. In the rush to do this, they often overlook an extremely useful source of information that already exists--data routinely collected as part of the utilization review (UR) process. This article describes a system using UR data for management purposes that was developed in a large urban teaching hospital. The components described are: (1) data collected systematically by trained reviewers applying the Appropriateness Evaluation Protocol; (2) software for data collection using inexpensive, highly portable computers; and (3) formats for reporting UR findings to hospital administrators and physicians. Information derived from UR in the study hospital is discussed, as well as factors to be considered in adapting some or all of the system's components in other hospitals.

Do hip replacements improve outcomes for hip fracture patients?

BACKGROUND

Hip fracture is a common problem among older Americans. Two types of procedures are available for repairing hip fractures: hip replacement and open or closed reduction with or without internal fixation. The assumption has been that hip replacement produces better functional outcomes. Although that is the common wisdom, outcome studies evaluating hip replacement for treatment of hip fracture are few and have not clearly documented its superiority.

OBJECTIVES

To compare outcomes of hip fracture patients who receive hip replacement versus another stabilizing procedure (open or closed reduction with or without internal fixation).

DESIGN

Prospective cohort study.

PARTICIPANTS

We studied 332 patients (age, > 65) who were hospitalized for a femoral neck fracture and discharged alive.

MEASUREMENTS

We examined 2 treatment groups, hip replacement versus another procedure, on 6 outcomes [Activities of Daily Living (ADLs), walking, living situation (institutionalized or not), perceived health (excellent/good vs. fair/poor), rehospitalization, and mortality] at 3 postdischarge times (6 weeks, 6 months and 1 year).

RESULTS

Mean age was 80, 80% were female, 96% White, 28% married, and 71% had a hip replacement. The treatment groups were similar at baseline (3 months before admission as reported at discharge) on ADLs, walking, living situation, and perceived health (all P > 0.24). After adjusting for demographics, clinical characteristics, fracture characteristics, and prior ADLs, walking ability, living situation, and perceived health, patients with a hip replacement did not do better at 6 weeks, 6 months, or 1 year post-discharge on any of the 6 outcome measures (all 18 P > 0.10). A global test of all 6 outcomes finds hip replacement patients doing less well at one year (P = 0.02).

CONCLUSIONS

Despite the commonly held belief that hip replacement is a superior treatment for hip fracture, we found no suggestion of better outcomes for hip replacement on any of 6 key outcomes.

R2: a useful measure of model performance when predicting a dichotomous outcome

R2 has been criticized as a measure of model performance when predicting a dichotomous outcome, both because its value is often low and because it is sensitive to the prevalence of the event of interest. The C statistic is more widely used to measure model performance in a 0/1 setting. We use a simple parametric family of models to illustrate the potential usefulness of models with low R2 values, to clarify the effect of prevalence on both C and R2, and to demonstrate how R2 captures information not picked up by C. We also show that C is subject to a 'random mixing' problem that does not affect R2. Finally, we report both R2 and C values for different risk-adjustment models in situations with different prevalences and show the relationship between the measures and decile death rates, thereby providing a context for interpreting R2 values in a 0/1 setting.

Problems in assessing diabetes control in an ambulatory setting

Problems in using medical records to assess outcomes of diabetes care have not been well defined. We reviewed the medical records of 288 patients with diabetes receiving ambulatory care over a 2-year period. We determined the availability of different tests of glycemic control and described site performance as the percentage of patients with a blood glucose exceeding either 180 or 240 mg/dl. Glycosylated hemoglobin determinations were performed in only 26.7% of patients. A blood glucose was available in 208 patients (72.2%) during a 6-month outcome period. For almost 50% of the sample, the glucose was greater than 180 mg/dl, whereas in 20% it exceeded 240 mg/dl. Judgments of whether sites differed in performance depended on how control was defined. Using a single glucose determination and a threshold of 180 mg/dl, similar fractions of patients were poorly controlled at each site (51.2 versus 45.0 versus 47.0%) (P = 0.75). At 240 mg/dl, although, one site performed much worse than the other two (14.6 versus 16.7 versus 31.8%) (P = 0.02). These results highlight difficulties in defining the outcome measure when using medical records to evaluate quality of care.

Mammography use helps to explain differences in breast cancer stage at diagnosis between older black and white women

BACKGROUND

Older black women are less likely to undergo mammography and are more often given a diagnosis of advanced-stage breast cancer than older white women.

OBJECTIVE

To investigate the extent to which previous mammography explains observed differences in cancer stage at diagnosis between older black and white women with breast cancer.

DESIGN

Retrospective cohort study using the Linked Medicare-Tumor Registry Database.

SETTING

Population-based data from three geographic areas of the United States included in the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program (Connecticut; metropolitan Atlanta, Georgia; and Seattle-Puget Sound, Washington).

PARTICIPANTS

Black and white women 67 years of age and older in whom breast cancer was diagnosed between 1987 and 1989.

MEASUREMENTS

Medicare claims were used to classify women according to mammography use in the 2 years before diagnosis as nonusers (no previous mammography), regular users (> or =2 mammographies done at least 10 months apart), or peri-diagnosis users (mammography done only within 3 months before diagnosis). Information on mammography use was linked with SEER data to determine cancer stage at diagnosis. Stage was classified as early (in situ or local) or late (regional or distant).

RESULTS

Black women were more likely to not undergo mammography (odds ratio [OR], 3.00 [95% CI, 2.41 to 3.75]) and to be given a diagnosis of late-stage disease (OR, 2.49 [CI, 1.59 to 3.92]) than white women. When women were stratified by previous mammography use, the black-white difference in cancer stage occurred only among nonusers (adjusted OR, 2.54 [CI, 1.37 to 4.71]). Among regular users, cancer was diagnosed in black and white women at similar stages (adjusted OR, 1.34 [CI, 0.40 to 4.51]). In logistic modeling, previous mammography alone explained about 30% of the excess late-stage disease in black women. In a separate model, previous mammography explained 12% of the excess late-stage disease among black women after adjustment for sociodemographic and comorbidity information.

CONCLUSION

Differences in breast cancer stage at diagnosis between older black and white women are related to previous mammography use. Increased regular use of mammography may result in a shift toward earlier-stage disease at diagnosis and narrow the observed differences in stage at diagnosis between older black and white women.

Relationships of gender and career motivation to medical faculty members' production of academic publications

PURPOSE

To evaluate the relationships between both internal and external career-motivating factors and academic productivity (as measured by the total numbers of publications) among full-time medical faculty, and whether these relationships differ for men and women.

METHOD

In 1995 a 177-item survey was mailed to 3,013 full-time faculty at 24 randomly selected U.S. medical schools stratified on area of medical specialization, length of service, and gender. Two-tailed t-tests and regression analyses were used to study the data.

RESULTS

A total of 1,764 faculty were used in the final analyses. The women had published two thirds as many articles as had the men (mean, 24.2 vs. 37.8). Intrinsic and extrinsic career motivation were rated similarly (on a three-point scale) by the women and the men: intrinsic career motivation was rated higher (women's mean rating: 2.8, men's mean rating: 2.9) than was extrinsic career motivation (mean rating: 2.1 for both). The main findings of the regression analyses were (1) intrinsic career motivation was positively associated, and extrinsic career motivation was negatively associated, with the number of publications; (2) publication rates were higher for the men than for the women after controlling for career motivation; and (3) there was no significant effect of gender on these relationships.

CONCLUSION

The women faculty published less than did their men colleagues, but this difference cannot be accounted for by gender differences in career motivation. Further research on institutional support, family obligations, harassment, and other factors that could affect academic productivity is necessary to understand the gender difference in numbers of publications.

Variations in the performance of hip fracture procedures

OBJECTIVES

Hip replacement is the preferred treatment for displaced femoral neck fractures, whereas other less expensive procedures are preferred for nondisplaced fractures. The authors determined whether there was geographic variation in the use of hip replacement to treat displaced and nondisplaced fractures.

METHODS

The authors studied 332 patients, age 65 years or older, hospitalized with a femoral neck fracture in three cities.

RESULTS

The population was 55% over age 80, 80% female, and lived in Houston (17%), Pittsburgh (29%), and Minneapolis (54%). Rates of hip replacement varied by city (Houston-84%, Pittsburgh-77%, Minneapolis-63%; P = 0.002), with great variability among patients with nondisplaced fractures (Houston-88%, Pittsburgh-77%, and Minneapolis-56%; P = 0.0001), and no variation among those with displaced fractures (P = 0.72). Other factors associated with hip replacement are history of hip fracture (P = 0.003) and cerebrovascular disease (P < or = 0.10), APACHE II-APS score (P = 0.09), and impacted fracture (P = 0.001). Sociodemographic and functional status (perceived health; activities of daily living and instrumental activities of daily living dependencies) were not associated with hip replacement (P > 0.10). In a logistic model controlling for prior history, APACHE II-APS, and fracture characteristics, city remained a significant predictor of hip replacement (P < 0.001).

CONCLUSIONS

Despite an absence of evidence supporting its appropriateness and a much higher cost, hip replacement is used to treat nondisplaced fractures much more frequently in Houston and Pittsburgh than in Minneapolis.

Outcomes for older men and women with congestive heart failure

OBJECTIVES

To describe and compare outcomes for men and women discharged alive following a hospitalization for congestive heart failure (CHF).

DESIGN

Prospective cohort study.

PARTICIPANTS

A total of 519 patients, aged > or = 65, who were discharged alive after a hospitalization for CHF (DRG = 127).

MEASUREMENTS

Outcomes (Activities of Daily Living (ADLs), shortness of breath when walking, perceived health, living situation, rehospitalization, and mortality) were measured at 3 times (6 weeks, 6 months, and 1 year) post-discharge.

RESULTS

The 205 men were, on average, younger (77 +/- 7 vs 80 +/- 8, P < .001), wealthier (46% vs 21% earned > or = $10,000, P < .001), and more often married (50% vs 19%, P < .001). Men were more likely than women to have a previous history of CHF (71% vs 63%, P = .052). Men also had higher 1-year mortality than women (48% vs 35%, P = .009), even after adjusting for age, comorbidity, physiological severity (APACHE II APS and RAND discharge instability), radiological evidence of CHF, prior ADLs, walking ability, living situation, and perceived health. Men and women survivors at 1-year had similar and substantial impairment for all non-fatal outcomes considered (all P values > or = .489). Their adjusted mean ADL scores were consistent with complete dependence on one essential activity (range 0-6 dependencies); 35% were short of breath walking less than 1 block; 62% had fair or poor perceived health; 32% received some formal care; and 46% were rehospitalized within 1 year of discharge.

CONCLUSIONS

Men with CHF have a higher mortality than women with CHF. Men and women who survive have similar and substantial impairment for all non-fatal outcomes (ADLs, shortness of breath upon walking, perceived health, living situation, and rehospitalization).

Underdetection of clinical benign prostatic hyperplasia in a general medical practice

OBJECTIVE

To measure detection of clinical benign prostatic hyperplasia (BPH) in a general medicine practice.

DESIGN

Self-administered questionnaire and retrospective ambulatory medical record review.

SETTING

Hospital-based general medicine practice.

PATIENTS

Two hundred and four men aged 50 years and older.

MEASUREMENTS AND MAIN RESULTS

Clinical information was obtained from a self-administered questionnaire containing the American Urological Association symptom index and the BPH Impact Index bother scale, and from retrospective review of ambulatory medical records for the previous 24 months. Thirty percent of patients had moderate to severe urinary tract symptoms, and 67% of these individuals were bothered by the symptoms. Only 52% with moderate to severe symptoms recalled any discussion with their primary care physician about their symptoms. There was medical record documentation of a review of urinary tract symptoms in only 18% and a prostate examination in only 64%. Patients with more symptoms and bother tended to recall a discussion of urinary tract symptoms with their physician. However, moderate to severe symptoms and bother were not associated with increased documentation of a history of urinary tract symptoms or prostate examination.

CONCLUSIONS

Clinical BPH was underdetected in a general medicine practice. Because many men do not complain to their physicians about urinary tract symptoms and reduced quality of life, perhaps primary care physicians should pay more attention to recognizing this common condition of older men.