Search is not available for this dataset
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Finally, we concur that qualitative studies are invaluable in understanding domestic violence. Such research has provided insight into the complex process that women undertake to address the violence in their lives. Until there is evidence that universal screening actually helps with this process, the focus should be on developing evidence-based approaches to assist women when they do disclose abuse and on training health professionals to respond appropriately to such disclosures.
|
15526052_p24
|
15526052
|
Wathen and MacMillan's Response to Taket's Viewpoint
| 1.486119 |
other
|
Other
|
[
0.028022687882184982,
0.001774379750713706,
0.9702028632164001
] |
[
0.0062432787381112576,
0.9815385341644287,
0.011724455282092094,
0.0004938265192322433
] |
en
| 0.999999 |
Microarray experiments produce vast amounts of data. The resulting datasets are highly complex and contain large matrices of expression measurements as well as sequence and experiment annotations that provide biological context to the data. To organize these different types of data in a way that allows intuitive exploration of the data, and provides the ability to gain important insights into relationships within a given dataset requires sophisticated visualization tools. Such visualization tools are of benefit not only to researchers analyzing and presenting or publishing their own data, but also to Model Organism Databases (MODs) for compiling and displaying microarray data for a given model organism.
|
15458579_p0
|
15458579
|
Background
| 3.822579 |
biomedical
|
Other
|
[
0.997469425201416,
0.0005949743208475411,
0.0019355274271219969
] |
[
0.09812398999929428,
0.850240170955658,
0.05104656517505646,
0.0005892541958019137
] |
en
| 0.999998 |
There are several excellent free tools available that allow an individual user to analyze their own data. These tools are either accessible on the web, or can be downloaded and used on a desktop machine. Examples include the EPCLUST , GEPAS and FGDP web-based tools and the TMEV desktop tool from TIGR. However, once these tools have been used, and a cluster or other group of genes has been selected, this resulting dataset needs to be made available to other people for browsing and exploration. There are a few visualization tools that allow display of such a static dataset that are available as free software tools, e.g. Michael Eisen's TreeView , JavaTreeView , or the more recent MapleTree . All of these tools are, however, desktop tools that themselves have to be downloaded and work on locally stored datasets. The impetus for the development of GeneXplorer was the desire to provide access to datasets via the Internet, without the requirement to download and install additional software. We developed GeneXplorer for use in web supplements of microarray publications whose raw data are housed within the Stanford Microarray Database (SMD) and for use as a tool to allow SMD users to browse their own data within SMD before publication. Using GeneXplorer, hierarchically clustered gene expression data can be interactively viewed using a web browser on any computer platform. GeneXplorer uses the widely accepted CDT file format produced by several freely available clustering programs (e.g. ), which between them have been downloaded several thousand times. Thus GeneXplorer should be widely usable my SMD and non-SMD users alike.
|
15458579_p1
|
15458579
|
Background
| 4.001084 |
biomedical
|
Other
|
[
0.9981485605239868,
0.00045428008888848126,
0.0013971796724945307
] |
[
0.42802953720092773,
0.566181480884552,
0.00503993546590209,
0.0007490416173823178
] |
en
| 0.999998 |
The application was written using object oriented Perl following the Model-View-Controller (MVC) design paradigm . GeneXplorer consists of two classes, the data model class Microarray::CdtDataset (M), and the presentation logic class Microarray::Explorer (V). The controller, named gx, is a Perl CGI script that dispatches CGI requests to the viewer. The MVC paradigm was used because it dissociates how data are represented internally (the Model) from how they are displayed (the View), from how they are interacted with (the Controller) . The goal of such a separation is that by keeping consistent APIs for the components to interact with each other, each component may be modified extensively internally, with little or no effect on the other parts of the application, thus making code maintenance easier. The Microarray::CdtDataset class provides an application programming interface (API) that allows details of a particular expression cluster to be queried. In turn, instances of the Microarray::Explorer class use this API to retrieve and then display information about the dataset. The controller is a relatively simple CGI Perl script that is responsible for capturing CGI parameters and using them to first create a dataset Microarray::CdtDataset object, which is subsequently used in the instantiation of a Microarray::Explorer object. The controller then invokes the appropriate Microarray::Explorer methods, depending on where, and in which frame the user clicked.
|
15458579_p2
|
15458579
|
Implementation
| 4.02634 |
biomedical
|
Other
|
[
0.9673982262611389,
0.0010901439236477017,
0.03151164948940277
] |
[
0.4637482762336731,
0.5336090326309204,
0.0021387971937656403,
0.0005039493553340435
] |
en
| 0.999995 |
The Microarray::CdtDataset has two essential functions: during dataset creation (see below) it decomposes the data file into its constituent data parts and creates the files needed during data viewing (see below). During data viewing it provides the API for the viewer, and allows searching and retrieval of the data. Under the current model the dataset object itself is immutable. Microarray::CdtDataset was implemented as a client of the Microarray::DataMatrix module, which provides an API for accessing matrices of expression data. In the design of the classes certain compromises had to be made to accommodate the stateless client server environment in which the program operates. Specifically, to allow rapid responses, pre-generated images and correlation data are cached in a compact format on the web-server.
|
15458579_p3
|
15458579
|
Implementation
| 3.147376 |
biomedical
|
Other
|
[
0.9613790512084961,
0.0018011567881330848,
0.036819785833358765
] |
[
0.03689376637339592,
0.961948812007904,
0.0008545343880541623,
0.00030291249277070165
] |
en
| 0.999995 |
There are two stages required to publish a microarray dataset on the web using GeneXplorer. The first stage (executed only once per dataset) involves creation of all the necessary files for GeneXplorer to use. The second stage uses these files to produce the display using the GeneXplorer web front-end.
|
15458579_p4
|
15458579
|
Implementation
| 2.431849 |
biomedical
|
Other
|
[
0.963679313659668,
0.003608487080782652,
0.03271220624446869
] |
[
0.007113820873200893,
0.9919006824493408,
0.0006231570732779801,
0.0003624147502705455
] |
en
| 0.999997 |
Dataset creation requires a file in the Clustered Data Table (CDT) format: a simple tab delimited text file format (see for file format details). This format was introduced with the 'Cluster' and 'TreeView' applications and is widely used for microarray data. A perl script (makeMicroarrayDataset.pl) uses Microarray::CdtDataset to create the various required data files. Correlations between expression-vectors within the dataset are calculated for each pair-wise combination of vectors using the C program 'correlations'. Correlations for each vector above the default cutoff value of 0.5 are saved in a binary format that facilitates rapid searching. Depending on the version of the Perl GD module installed on the system, either png or gif formatted images representing the cluster will be created. These images include both a 2-color image representation of the data matrix and an image representation of the experiment names. The program that creates these files is configurable, such that these images can be created using either a red/green or a yellow/blue color scheme, and in addition, the contrast of the images can be customized and set in steps of log(2) scale. The name and path of a dataset can be defined hierarchically within the file system allowing the creation of many datasets within the same project.
|
15458579_p5
|
15458579
|
Dataset creation
| 4.102334 |
biomedical
|
Other
|
[
0.9933966398239136,
0.0009066003258340061,
0.005696697626262903
] |
[
0.2596774101257324,
0.7369257807731628,
0.002937059151008725,
0.00045982826850377023
] |
en
| 0.999996 |
GeneXplorer is a Perl application that produces a set of html frames that can be used for viewing the expression data . The three frames that it produces are: 1) A radar frame. This frame displays an image map of the data matrix and gives an overall view of the clustered data. The rows correspond to the features or genes (also referred to as reporters), and the columns correspond to the experiments within the dataset. When the image is clicked the next 100 expression patterns starting at the position of the click are displayed in the zoom frame. The position of a bracket on the right side of the radar window indicates the section of the whole radar image that is displayed in the zoom frame. 2) A toolbar frame. Actions in the toolbar may affect either the radar or the zoom frame. There is a tool to set the scaling of the radar image, while the search box allows searching of gene annotations and the expression patterns of the resulting hits are displayed in the zoom frame. In addition the toolbar frame also contains a JavaScript enabled text box that gives feedback depending on the user's mouse position, to provide additional information about the genes and experiments within the cluster. 3) A zoom frame. This frame displays a zoomed view of selected expression patterns, such that the user can see both the individual patterns and the associated annotations. The source of the selected patterns can be either a section of the radar image, the result of a search the user performed in the toolbar, or the result of a nearest neighbor search initiated in the zoom frame itself. The expression profiles themselves in the zoom frame are clickable and the resulting search will display the expression pattern for the most similarly expressed genes to the gene that was clicked on, and provide visual feedback as to the level of similarity in their expression profiles. In addition, when the user moves the mouse over parts of the zoom window, additional information is directed back to the textbox in the toolbar. The experiment name, correlation value and gene annotation is displayed when the mouse is over the experiment image map, the correlation bar, and the expression pattern, respectively.
|
15458579_p6
|
15458579
|
Dataset viewing
| 3.89731 |
biomedical
|
Other
|
[
0.9873867630958557,
0.004225129261612892,
0.008388117887079716
] |
[
0.01742413081228733,
0.9796547293663025,
0.002203082898631692,
0.0007180650718510151
] |
en
| 0.999998 |
The search box in the toolbar enables a string search of either all, or specific gene annotation fields. The string may contain more than one term, where each term in the search string should be at least 2 characters long. Spaces between the terms are interpreted as term separators and the terms are combined using the logical 'AND' operator. Wildcard searches are allowed using the '*' character, such that at least one character should precede the wildcard character. The hits resulting from the search are displayed in the zoom frame, as expression patterns. The number of hits displayed in the zoom window is limited to 200 hits.
|
15458579_p7
|
15458579
|
Full text searching
| 3.316554 |
biomedical
|
Other
|
[
0.9746459126472473,
0.008238025940954685,
0.017116013914346695
] |
[
0.007661059033125639,
0.9904220104217529,
0.0012018573470413685,
0.0007150486926548183
] |
en
| 0.999995 |
GeneXplorer allows configurable linking out of the gene annotations to external databases. The number of these links per a gene is not limited, making it easy to be able to look at the information for a gene in several different databases. A configuration file in the dataset directory is used to control where the various gene identifiers are linked. Templates are available for various organisms, and the existing files can be edited manually if a link to a new database is desired. Because of the current limitations of the input cdt file format, setting up the external database links might require manual editing at the time of dataset creation. This is fully described in the README document that is part of the distribution. The external database annotations are not currently updatable in any automated fashion; this will be addressed as part of our plans to make GeneXplorer able to read MAGE-ML (see future plans) that would allow us to do the updates via web services.
|
15458579_p8
|
15458579
|
Display configuration
| 2.955774 |
biomedical
|
Other
|
[
0.9830960035324097,
0.005015527829527855,
0.011888452805578709
] |
[
0.009323591366410255,
0.9893429279327393,
0.0006180836935527623,
0.000715358299203217
] |
en
| 0.999995 |
The GeneXplorer package is provided as a typical Perl distribution on the Comprehensive Perl Archive Network (CPAN), and adheres to the usual installation mantra of perl modules. After unpacking the software, a user with administrative privileges merely needs to type:
|
15458579_p9
|
15458579
|
Installation and use
| 1.622504 |
biomedical
|
Other
|
[
0.6392335891723633,
0.004174637608230114,
0.3565918207168579
] |
[
0.004018233623355627,
0.9951135516166687,
0.0004915304598398507,
0.0003767996095120907
] |
en
| 0.999997 |
perl Makefile.PL
|
15458579_p10
|
15458579
|
Installation and use
| 1.18705 |
other
|
Other
|
[
0.4783942699432373,
0.010653316043317318,
0.5109524130821228
] |
[
0.005218487232923508,
0.9926208257675171,
0.001193976728245616,
0.0009665758116170764
] |
no
| 0.999995 |
make
|
15458579_p11
|
15458579
|
Installation and use
| 0.967541 |
other
|
Other
|
[
0.20456816256046295,
0.006667450536042452,
0.7887644171714783
] |
[
0.022552452981472015,
0.9720045328140259,
0.0034200495574623346,
0.002022990258410573
] |
sw
| 0.999995 |
make test
|
15458579_p12
|
15458579
|
Installation and use
| 0.889634 |
other
|
Other
|
[
0.14140929281711578,
0.005816556513309479,
0.8527740836143494
] |
[
0.020546210929751396,
0.9727569818496704,
0.004622589331120253,
0.0020741510670632124
] |
et
| 0.999997 |
make install
|
15458579_p13
|
15458579
|
Installation and use
| 0.979921 |
other
|
Other
|
[
0.056574031710624695,
0.005782515276223421,
0.9376435279846191
] |
[
0.003547144355252385,
0.9940720200538635,
0.0013538652565330267,
0.0010268980404362082
] |
no
| 0.857138 |
This will install the libraries and the executable files that are needed for dataset creation by GeneXplorer into the regular system locations, unless otherwise specified during the first step above. The example in Figure 2 shows the file structure if the library and bin directories under the web server's root had been specified for installation of the libraries and executables respectively. To actually use the gx script, it must be copied into a cgi-bin directory, and the various html files must be copied to the appropriate location under the web server's root .
|
15458579_p14
|
15458579
|
Installation and use
| 2.199862 |
biomedical
|
Other
|
[
0.6993281841278076,
0.003907231148332357,
0.296764612197876
] |
[
0.007208773400634527,
0.9922922849655151,
0.00026487026480026543,
0.0002340952050872147
] |
en
| 0.999998 |
In addition to its use within SMD, GeneXplorer has been used by many publications to provide access to microarray datasets through their web supplements, that can be accessed through SMD's publication page , and was used as the basis for visualization of fuzzy k-means cluster data . We demonstrate on an example dataset how GeneXplorer works . Figure 3a shows a display of this dataset in the browser window. The whole dataset is displayed in the radar frame, and the zoom window shows the section of this image that was selected, with the gene annotations at a readable size. Clicking on any of the hyperlinks in the zoom frame brings up a new window displaying the biological information for the selected gene that is found in SOURCE . Searching the dataset for all the genes whose name field contains the keyword 'kinase' results in the zoom window shown in Figure 3c . This type of search allows comparison of the expression patterns of a subset of the genes based on some functional category – e.g. GO process-terms, if the annotation fields contain these terms. Clicking on one of the expression profiles (the one belonging to 'Estrogen Receptor 1', in this case) leads to the display in Figure 3d . In the zoom frame it shows the expression profile of the selected gene as the top row, and all the other expression profiles below with Pearson correlation above 0.5. The length of the small orange bar on the right side of the expression profiles gives a graphical representation of these correlation values, while the actual value is displayed in the info box in the toolbar when the mouse is over the orange bar.
|
15458579_p15
|
15458579
|
Results and discussion
| 3.967131 |
biomedical
|
Study
|
[
0.9983760118484497,
0.0006007733172737062,
0.001023145392537117
] |
[
0.602501392364502,
0.39109495282173157,
0.005056077614426613,
0.0013475449522957206
] |
en
| 0.999998 |
We are planning to further develop GeneXplorer to enable it to handle other data formats. Specifically, we would like it to be able to accept data files in MAGE-ML format , which is becoming a standard file format for communicating gene expression data. In addition, we would like it to be able to display tree views of the clustered data and allow zooming on specific nodes of the cluster.
|
15458579_p16
|
15458579
|
Future developments
| 2.233862 |
biomedical
|
Other
|
[
0.97091144323349,
0.002840518718585372,
0.026247968897223473
] |
[
0.00679894769564271,
0.9923517107963562,
0.00043800685671158135,
0.0004113331960979849
] |
en
| 0.999995 |
We have developed a web-application, GeneXplorer, which allows the visualization of microarray datasets over the Internet using only a web browser. This application has been extremely useful in our experience, where it serves both SMD users during analysis of their data and the public while browsing published datasets.
|
15458579_p17
|
15458579
|
Conclusions
| 1.999835 |
biomedical
|
Other
|
[
0.9654843807220459,
0.002591378055512905,
0.031924232840538025
] |
[
0.0057328203693032265,
0.9931755661964417,
0.0006244944524951279,
0.0004672338836826384
] |
en
| 0.999998 |
GeneXplorer is available at under the MIT Open Source license. It should work on any UNIX-type system capable of running Perl and a Web server, though we ourselves have deployed it on Sun Solaris. Additional information on installation and usage is provided in the installation instructions and documentation that is part of the distribution.
|
15458579_p18
|
15458579
|
Availability and requirements
| 1.202911 |
other
|
Other
|
[
0.08383364975452423,
0.0018721483647823334,
0.9142941832542419
] |
[
0.0018627002136781812,
0.9974762797355652,
0.0003501292085275054,
0.0003107933735009283
] |
en
| 0.999997 |
SMD: Stanford Microarray Database.
|
15458579_p19
|
15458579
|
List of abbreviations used
| 1.154854 |
biomedical
|
Other
|
[
0.8286990523338318,
0.003879654686897993,
0.1674213409423828
] |
[
0.009534656070172787,
0.9885140061378479,
0.001291558495722711,
0.0006597597384825349
] |
en
| 0.999996 |
CAR designed and wrote the initial version of the GeneXplorer. This was extensively re-factored and modularized by JCM (library modules for dataset) and JD (for explorer). DB was involved in the guidance of the early stages of this project. GS wrote the correlations software and the DataMatrix classes, and guided the development of this project. All authors read and approved the final version of the manuscript.
|
15458579_p20
|
15458579
|
Authors' contributions
| 0.901157 |
other
|
Other
|
[
0.13188055157661438,
0.0034994857851415873,
0.8646199703216553
] |
[
0.0026531757321208715,
0.9957127571105957,
0.0010662503773346543,
0.000567868584766984
] |
en
| 0.999998 |
Recent events that provide the rationale for a new Open Access journal, Nutrition & Metabolism ( N&M ) include 1) an awareness of an epidemic of obesity, diabetes, dyslipidemias and related diseases, 2) a sudden increase in the popularity of diets, such as low carbohydrate diets, to achieve weight loss and combat diabetes, and 3) a renewed interest in intermediary metabolism accompanied by the development of new tools and techniques for genomic and metabolic analysis.
|
15507146_p0
|
15507146
|
Editorial
| 2.864178 |
biomedical
|
Other
|
[
0.9924821257591248,
0.0015484493924304843,
0.005969337187707424
] |
[
0.005515165161341429,
0.9465640783309937,
0.04667489975690842,
0.001245876424945891
] |
en
| 0.999997 |
With the considerable activity shown in these areas, rapid and easily accessible dissemination of new information is clearly valuable. Whereas articles in existing journals do discuss intermediary metabolism in a nutritional context, there is a need for a unique and explicit focus for this discipline. In addition, it is precisely because publications in nutritional biochemistry are spread over such a large number of existing journals, few libraries and almost no individual can subscribe to all. It is in areas like this that free, open access becomes important. There is a large published debate on open access (see, e.g. ). Most recently, the UK House of commons issued a report encouraging open access publishing of government-funded research (available with comments through ) and similar motions exist in the US congress . The editors of N&M feel that, at this point, the burden of proof is on proponents of perpetuating the current system. We are, however, not doctrinaire on this point and believe one should pay for a service if it is valuable. Beyond information, printed collections provide convenience and we intend to offer bound copies of articles on individual topics as the journal proceeds.
|
15507146_p1
|
15507146
|
Editorial
| 1.827567 |
biomedical
|
Other
|
[
0.6466860771179199,
0.00444069504737854,
0.3488732874393463
] |
[
0.0013830253155902028,
0.9938788414001465,
0.004430832806974649,
0.00030724648968316615
] |
en
| 0.999996 |
Nutrition and metabolism is a broad field and we welcome submissions from all areas of nutrition and related biochemistry. Like any journal, however, N&M has its own strengths and interests as indicated by the board of editors . Three areas of particular interest are lipoprotein metabolism, amino acids as metabolic signals, and the effect of macronutrient composition of diet on health. This is reflected in our opening research articles by Darimont, et al . on the control of obesity and lipid structure by adrenergic systems, and by Volek, et al . on the effectiveness of low carbohydrate diets, and differential effects on fat and lean mass.
|
15507146_p2
|
15507146
|
Editorial
| 2.538945 |
biomedical
|
Other
|
[
0.9841035604476929,
0.0017758577596396208,
0.01412049401551485
] |
[
0.009365754202008247,
0.8914992809295654,
0.0979803204536438,
0.001154689583927393
] |
en
| 0.999996 |
The sudden popularity of low carbohydrate diets is one of the most remarkable phenomena in nutrition today. A recent editorial by Walter Willett points out how important it is that we understand them . Similarly, the recent conference on Nutritional and Metabolic Aspects of Low Carbohydrate Diets , while not recommending any particular diet, highlighted many of the relevant issues in macronutrient control of metabolism. In our initial publications, contributors to the conference will provide reviews of the various topics covered. In the first posting, Klaas Westerterp summarizes the importance of macronutrient composition in thermogenesis, and Stephen Phinney discusses the impact of ketogenic diets on physical performance. Kimball and Jefferson review the regulation of mRNA translation in general. The article provides a nice overview of various mechanisms involved in the control of protein synthesis when amino acids become limiting. Perhaps the most important from a practical standpoint, Nuttall and Gannon summarize potential benefits of higher protein diets in diabetes.
|
15507146_p3
|
15507146
|
Editorial
| 3.918608 |
biomedical
|
Review
|
[
0.9871203303337097,
0.0034405156038701534,
0.009439072571694851
] |
[
0.00663188099861145,
0.04313121736049652,
0.9491762518882751,
0.0010606455616652966
] |
en
| 0.999997 |
Nutrition & Metabolism welcomes contributions in all areas of research in which nutrition interacts with biochemistry and molecular biology. Emphasis will be on the molecular, biochemical, and physiologic understanding of various metabolic pathways. The journal will publish Original Research, Reviews, Commentaries and Perspectives, Brief Communications, Methods and Book Reviews. Access to all articles in N&M is free. Articles are included in PubMed and archived in PubMed Central. Online submissions can be made at .
|
15507146_p4
|
15507146
|
Editorial
| 1.492324 |
biomedical
|
Other
|
[
0.7541621327400208,
0.010078881867229939,
0.23575899004936218
] |
[
0.0006631670985370874,
0.9965496063232422,
0.00225139781832695,
0.000535811297595501
] |
en
| 0.999997 |
Interview skills, while important in all areas of medicine, are a prime focus of educational endeavour in the teaching of psychiatry. The interview is the cornerstone of psychiatric investigation and the scene for the establishment of rapport and therapeutic engagement. The importance of effective skills training in interviewing for medical students was highlighted in the core curriculum in psychiatry published by The World Psychiatric Association and the World Federation for Medical Education . An additional perspective on this issue has come from consumers who report a distinct difference between effective and ineffective interviewing styles, highlighting the hindering effect of bored, impersonal interviewers who make judgemental assumptions about an individual's behaviour .
|
15377386_p0
|
15377386
|
Background
| 3.767251 |
biomedical
|
Other
|
[
0.9833608865737915,
0.010244050994515419,
0.006395177915692329
] |
[
0.011452454142272472,
0.6888781189918518,
0.29690414667129517,
0.002765315817669034
] |
en
| 0.999998 |
Moving beyond the traditional teaching of interview skills by psychiatrists in the "see one, do one, teach one" mode, we report the development of an innovative approach to the teaching of psychiatric interview skills. This approach began four years ago as a partnership between mental health consumers and academic psychiatry to examine the ongoing feasibility of training mental health consumers as tutors for 4 th year medical students in psychiatry. The idea is based on the belief that consumers have a legitimate experience to share and a rich skill base on which to draw. The purpose of this ongoing project is to contribute to the ultimate development of a workforce of medical practitioners with clinical assessment skills that are better tailored to the needs of mental health consumers. More immediate potential benefits are the promotion of an engaging curriculum in psychiatry for students, offering direct meaningful contact with mental health consumers.
|
15377386_p1
|
15377386
|
Background
| 3.892881 |
biomedical
|
Study
|
[
0.9783397912979126,
0.02019617147743702,
0.0014639744767919183
] |
[
0.6911346912384033,
0.29954540729522705,
0.004466613754630089,
0.004853304009884596
] |
en
| 0.999996 |
Consumers and patients are not new to medical education, offering a unique perspective on their experiences with the health system. There are 3 levels of consumer participation in education. Consumers may be the subject of teaching tutorials (a demonstration), a visitor to a tutorial (sharing their experiences with few guidelines) or a paid trained tutor delivering an agreed curriculum (a 'consumer tutor'). Consumer tutors are distinct from 'professional tutors' (those with a career obligation to teach) a distinction that does not imply a lack of professionalism regarding the consumer tutor. The issue of language is not trivial: the local user support network was committed to the term 'consumer' rather than other common labels like client or patient. The language used was chosen for the perception of action and autonomy and to reflect respect for the role and to make it clear to students and staff that these people were a committed part of the teaching workforce, not visitors only present to tell of their (often negative) experiences.
|
15377386_p2
|
15377386
|
Literature review
| 2.703391 |
biomedical
|
Other
|
[
0.7757461071014404,
0.03379478678107262,
0.19045916199684143
] |
[
0.004070553462952375,
0.9910218119621277,
0.004348781891167164,
0.0005589525680989027
] |
en
| 0.999998 |
This work drew on the Partners in Arthritis project that demonstrated that arthritis patients are at least equal to Consultant Rheumatologists in the teaching of examination techniques for arthritis. Related work included the use of families with experience of paediatric illness in the growth of communication skills for medical students [Reynolds 2003: personal communication] and the use of clinical teaching assistants in pap smear training [Vivienne O'Brien 2003: Personal communication]. Consumer and carer involvement in mental health education has been documented: nurse education by a consumer academic with largely positive outcomes, user and carer involvement in curriculum development and delivery in interprofessional postgraduate mental health education , a randomised trial of brief mental health staff training by consumers with positive post-training attitudes from those taught by consumers and a reminder that there are few published examples of the translation of policy rhetoric regarding consumer and carer involvement in education into teaching reality . In the local area, consumers are involved in Mental Illness Education ACT (MIEACT), a national non-profit outreach education project to high school students and community groups, which aims to reduce stigma and improve mental health literacy of young people . In all these projects consumers were trained, assisted in ongoing curriculum review and contributed their lived experience in the domain of interest. Despite this fertile environment for the establishment of this project and the growing consumer and carer action in psychiatry in general, there was no literature identified using trained consumers in teaching psychiatry to medical students.
|
15377386_p3
|
15377386
|
Literature review
| 3.906262 |
biomedical
|
Study
|
[
0.9976521134376526,
0.0007951369625516236,
0.0015527562936767936
] |
[
0.9826596975326538,
0.0046622008085250854,
0.012467414140701294,
0.00021070614457130432
] |
en
| 0.999996 |
In summary this project set out to train and support mental health consumers as consumer tutors for the delivery of a jointly developed curriculum for 4 th year medical students in effective approaches to interviewing. There was commitment to evaluate the effectiveness of the teaching in terms of (i) changing student attitudes towards consumers, (ii) preparing students for a common examination in psychiatry, (iii) monitoring consumer tutor involvement and feedback.
|
15377386_p4
|
15377386
|
Literature review
| 2.565182 |
biomedical
|
Other
|
[
0.9406312704086304,
0.011253808625042439,
0.048114970326423645
] |
[
0.2399519681930542,
0.7574346661567688,
0.0014621252194046974,
0.001151207135990262
] |
en
| 0.999997 |
The project was set in a medical school (University of Sydney) undergoing transition to graduate entry, with adult self-directed and problem based learning models providing an opportunity to students keen to explore new ways of learning. This environment of educational change added to student and staff enthusiasm to trial new ideas. There was recognition that carers and consumers required the same respect and courtesy as professional tutors, and inequities such as only being paid travel expenses were unsatisfactory . Consumer consultant positions were established to improve the relevance and user friendliness of psychiatry services using trained, paid and supervised staff .
|
15377386_p5
|
15377386
|
The Setting
| 1.782856 |
biomedical
|
Other
|
[
0.4984838664531708,
0.07947932183742523,
0.4220368564128876
] |
[
0.007044755853712559,
0.9904431700706482,
0.0008798105409368873,
0.001632213476113975
] |
en
| 0.999998 |
The Academic Unit of Psychological Medicine approached consumers from the local mental health consumer network seeking expressions of interest to join a steering committee to oversee the project. Consumers were involved at all stages including planning, development, implementation and evaluation. The steering committee met weekly to determine an approach to consumer tutor recruitment and training, and to author the student curriculum for delivery.
|
15377386_p6
|
15377386
|
Phase 1: Curriculum development
| 1.480217 |
other
|
Other
|
[
0.24552270770072937,
0.010130857117474079,
0.7443464994430542
] |
[
0.009513667784631252,
0.9889951944351196,
0.0009489541407674551,
0.0005421724636107683
] |
en
| 0.999998 |
Consumer tutors were recruited, trained in small group methods and assessed. The assessment task was a nine-item quiz. Typical questions included "List three strengths of working in small groups" and "List three strategies to get a discussion going amongst students". Those who wished to teach were then allocated in pairs to a consistent student group of six to eight students for weekly tutorials over seven weeks. Consumer tutors conducted the planned curriculum, provided feedback on each tutorial and contributed to curriculum review.
|
15377386_p7
|
15377386
|
Consumer tutor development
| 1.633081 |
other
|
Other
|
[
0.06429865956306458,
0.002359789563342929,
0.9333415627479553
] |
[
0.06329694390296936,
0.9345991611480713,
0.0012921923771500587,
0.0008116918033920228
] |
en
| 0.999995 |
Evaluation of the content of the curriculum, the quality of the teaching and handouts was measured using a 4-point Likert scale (4 = excellent, 3 = good, 2 = fair, 1 = poor) followed by an open comment item. After each tutorial consumer tutors were debriefed by academic staff and arrangements for the following tutorials confirmed. An expedient payment method was established. Over time, consumer tutors and academic staff periodically reviewed tutor and student feedback and decided on tutorial modification.
|
15377386_p8
|
15377386
|
Consumer tutor development
| 1.675447 |
other
|
Other
|
[
0.08325459063053131,
0.004477221518754959,
0.9122681021690369
] |
[
0.06417028605937958,
0.93163001537323,
0.0029835680034011602,
0.0012160916812717915
] |
en
| 0.999999 |
The steering committee comprised six consumers, three with previous teaching experience at secondary or tertiary level. Professional approaches were adopted for recruitment, training, assessment, graduation and payment. Academic staff drafted a structure for consumer tutor training completed by the committee. The committee determined the priorities for the student curriculum and each oversaw the writing of a tutorial in conjunction with academic staff. Consumer input was central and meaningful rather than at the level of editing academic staff work. The committee were paid regular sitting rates for committee attendance. The steering committee met during the first trial to review progress, an overseeing role replaced later by the consumer tutors themselves.
|
15377386_p9
|
15377386
|
Partnership establishment
| 1.276725 |
other
|
Other
|
[
0.01562146469950676,
0.003038441063836217,
0.9813401103019714
] |
[
0.002463466254994273,
0.9965134263038635,
0.0005946130258962512,
0.0004284889728296548
] |
en
| 0.999998 |
Expressions of interest from potential consumer tutors were sought through the consumer network against selection criteria. These included the essential criteria of being a current consumer of mental health services and having an interest in the development of medical student interviewing skills. Desirable criteria included previous experience in teaching. Applications were reviewed by the steering committee and all applications for training were accepted. Payment for training and tutoring was set at the current university casual tutor rates appropriate to qualifications.
|
15377386_p10
|
15377386
|
Consumer tutor recruitment and training
| 1.767811 |
biomedical
|
Other
|
[
0.4882301390171051,
0.026203056797385216,
0.4855668544769287
] |
[
0.07112953066825867,
0.9264180660247803,
0.0012024585157632828,
0.0012499733129516244
] |
en
| 0.999997 |
Recruitment resulted in a cross section of consumers including several 'marginalised consumers' who are usually under represented in such activities Three training cycles have occurred with 20 consumers (12 women, 8 men) commencing training and 18 consumers graduating from training. Fifteen consumer tutors have taught over the four years, whilst three decided after graduation that they did not wish to teach. Drop out occurred because of illness, disinterest or realising that tutoring was more difficult than first imagined.
|
15377386_p11
|
15377386
|
Consumer tutor recruitment and training
| 1.309658 |
other
|
Other
|
[
0.024907710030674934,
0.0017308617243543267,
0.9733614325523376
] |
[
0.0720488652586937,
0.9256609678268433,
0.0009977677837014198,
0.0012924191541969776
] |
en
| 0.999997 |
The tutor training program comprised six weekly, one and a half hour tutorials delivered by academic staff encouraging discussion, controversy and practice in a supportive environment. See Table 1 for a summary of the consumer tutor training program. A graduation ceremony was conducted and the Dean of the clinical school awarded university badged completion certificates, although the university did not formally accredit the course. Trainee tutor evaluations revealed they valued the training experience, reporting a sense of initial nervousness later replaced by a sense of assurance of their own abilities.
|
15377386_p12
|
15377386
|
Consumer tutor recruitment and training
| 1.930031 |
other
|
Other
|
[
0.40501517057418823,
0.060623329132795334,
0.5343614816665649
] |
[
0.05747520178556442,
0.9383840560913086,
0.0020374793093651533,
0.0021032781805843115
] |
en
| 0.999996 |
Students in one of four teaching centres of the University of Sydney participated in the consumer tutor-led tutorials. Students were oriented by academic staff and completed a pre-participation measure. This measured student attitudes to mental health consumers adapted from work on the 'hated patient' . Five statements were rated on a five point Likert scale (strongly agree to strongly disagree). Typical items included "I value learning from consumers" and "I would like mental health consumers as part of my practice." The final item was an open-ended question about concerns in interviewing.
|
15377386_p13
|
15377386
|
Student participation
| 1.960838 |
other
|
Study
|
[
0.27255088090896606,
0.0061994893476367,
0.7212496399879456
] |
[
0.5569740533828735,
0.4389001727104187,
0.002495212247595191,
0.001630606479011476
] |
en
| 0.999995 |
Students were then introduced to their consumer tutors and participated in an 'ice breaker' session involving an interactive board game designed to sensitise medical students to the experience of being a mental health consumer. This was followed by six tutorials which both consumer tutors and medical students evaluated using the same measure. Students repeated the attitude measure at the end of the program and completed assessment tasks as per the university requirements. Students also participated in a seminar series (including didactic teaching on interview content) with professional tutors similar to that delivered in the other teaching centres. All tutorial evaluation data was analysed using univariate statistics. The pre and post attitude measure was compared using term group means (as completion was anonymous) using an independent samples t-test. The mean scores for teaching and content for both students and tutors were compared using an independent samples t-test.
|
15377386_p14
|
15377386
|
Student participation
| 3.94694 |
biomedical
|
Study
|
[
0.992923378944397,
0.0025413515977561474,
0.004535337910056114
] |
[
0.996823787689209,
0.0024888115003705025,
0.0005367815028876066,
0.0001507069100625813
] |
en
| 0.999999 |
The student curriculum was developed as six one-hour tutorials (see Table 2 for a summary).
|
15377386_p15
|
15377386
|
Delivery of the student curriculum
| 1.499052 |
other
|
Other
|
[
0.20418353378772736,
0.002516432199627161,
0.7932999730110168
] |
[
0.024966344237327576,
0.9722713232040405,
0.001963967690244317,
0.0007983035175129771
] |
en
| 0.999997 |
The tutorials were delivered by pairs of consumer-tutors to small groups of six to eight medical students. The tutorials were graded in terms of level of difficulty beginning with general discussion of sensitive interviewing styles, role playing with tutors, followed by live interviews with volunteer inpatients from the psychiatric unit. Each tutorial included discussion of the pertinent issues, practice, review by the practicing student and feedback from peers and consumer tutors. The consumer tutors independently facilitated and participated in the tutorial without the involvement of academic staff who was available to assist if needed. They were rarely required (usually to resolve room double bookings). The curriculum and written materials underwent several revisions in response to feedback aimed at improving interactivity and clarity. Consumer tutors used the ground rules set out in training for dealing with absences. Reserve tutors were introduced at the start of the term so they were familiar to students if required. Tutor pairs were able to support each other and compensate for ebbs and flows in performance.
|
15377386_p16
|
15377386
|
Delivery of the student curriculum
| 3.540079 |
biomedical
|
Other
|
[
0.7498757243156433,
0.20549269020557404,
0.04463157430291176
] |
[
0.1478131264448166,
0.8388639092445374,
0.007571510039269924,
0.00575146172195673
] |
en
| 0.999996 |
The consumer tutors debriefed following each tutorial with academic staff. These meetings were an important opportunity for tutors to give positive and constructive feedback to each other as well as addressing ways to improve their delivery of the tutorials. They discussed problems and obstacles and brainstormed effective solutions. The larger consumer tutor group contributed to successfully resolving most conflict. Discussions were frank. Formal mediation was used to resolve a conflict between two tutors, in dispute over matters beyond teaching. Mediation was successful in terms of allowing ongoing involvement in teaching for both people. Academic staff informally debriefed the students during other tutorials. While a few students complained about the whole experience of being taught by a consumer, most students were positive. Indeed many reported they used the consumer tutors as a sounding board for other interview-related experiences during the week, seeking advice about alternative styles and approaches.
|
15377386_p17
|
15377386
|
Delivery of the student curriculum
| 1.136906 |
other
|
Other
|
[
0.007383847143501043,
0.0017601947765797377,
0.9908559322357178
] |
[
0.00897511001676321,
0.9879507422447205,
0.0020206798799335957,
0.0010535356123000383
] |
en
| 0.999997 |
Like all tutors, the consumer tutors required support, stimulation and refreshment. This happened in the tutorial debriefs outlined and in occasional workshops to review feedback, revise curriculum and refresh skills. Consumer tutors were encouraged to present reports of their experiences at appropriate meetings and received a national award for consumer research. Consumer tutors' motivation particularly increased when clinical mental health staff asked them about their teaching experiences and recognised that the individual had made many gains since the last episode of acute care.
|
15377386_p18
|
15377386
|
Tutor maintenance
| 1.632872 |
other
|
Other
|
[
0.1983073353767395,
0.03881744295358658,
0.7628751993179321
] |
[
0.008142194710671902,
0.9894894957542419,
0.0012650483986362815,
0.0011032590409740806
] |
en
| 0.999996 |
Consumer and professional tutors were commonly concerned about intervening illness and the impact on teaching. Some consumer tutors became acutely unwell during the term and required care. As a result they developed an agreement to postpone their involvement in the tutoring whilst they received necessary treatment. Consumer tutors and students were understanding of this and students had a rare experience of the longitudinal patterns of an illness and the person.
|
15377386_p19
|
15377386
|
Tutor maintenance
| 1.473758 |
other
|
Other
|
[
0.17263707518577576,
0.01954222470521927,
0.8078206777572632
] |
[
0.011665702797472477,
0.9855726361274719,
0.001385114504955709,
0.0013765274779871106
] |
en
| 0.999997 |
Out of a total cohort of 104 medical students, students completed the pre (n = 72) and post (n = 68) attitudes questionnaire using a 5 point scale (5 = strongly agree, 4 = agree, 3 = uncertain, 2 = disagree, 1 = strongly agree). A comparison of mean scores on 3 items reflecting student attitudes towards consumers was conducted using an independent samples t-test. Results showed that prior to the program the medical students began with positive attitudes towards learning from consumers (n = 57, x = 3.89, s.d. = .865) and working with mental health clients (n = 72, x = 3.68, s.d. = 747). Whilst there was a general trend towards further improvement in their attitudes, their mean scores pre and post the program were not significantly different. However, the medical students did show a significant improvement in their belief that "clients in psychiatric units give reliable histories" (n = 72, x = 3.07, s.d. = .657, p < .005) (see Table 3 ). This general improvement in attitudes to learning from and working with consumers was reflected in the open comments (see sample of comments in Table 4 ).
|
15377386_p20
|
15377386
|
Student attitudes
| 4.073306 |
biomedical
|
Study
|
[
0.9979094862937927,
0.0011555133387446404,
0.0009350134059786797
] |
[
0.9993433356285095,
0.00021580359316430986,
0.0003668377466965467,
0.00007403703784802929
] |
en
| 0.999998 |
In addition, students' greatest concern regarding interviewing mental health consumers changed before and after the teaching. Before, students were preoccupied with violence in the interview. At the conclusion of the program, students remained concerned about violence and unpredictable reactions. However, they reported increased concern with their ability to build rapport, engage and understand the client. The program has since been modified to address their concerns about violence early on in the training.
|
15377386_p21
|
15377386
|
Student attitudes
| 1.68475 |
other
|
Other
|
[
0.16475753486156464,
0.003541588084772229,
0.83170086145401
] |
[
0.0569266676902771,
0.9404441118240356,
0.001802646555006504,
0.0008265345823019743
] |
en
| 0.999998 |
Tutor and medical student evaluations using a 4-point Likert scale (4=excellent, 3=good, 2=fair, 1=poor) were returned on 452 occasions. Analysis of the mean scores of students on the quality of the 'teaching' and 'content' of the program revealed favourable ratings ('teaching' n = 450, x = 2.81, sd.76; 'content': n = 451, x = 2.82, sd= .689). Whereas, tutors tended to rate the program even higher ('teaching': n = 372, x = 3.08, sd = .510; 'content': n = 369, x = 3.14, sd=.496). A comparison of the mean scores of students and tutors using an independent samples t-test showed that this difference was statistically significant (p < 0.001), see Table 5 . Open comments about the program varied as shown in Table 6 .
|
15377386_p22
|
15377386
|
Tutorial evaluations
| 3.971013 |
biomedical
|
Study
|
[
0.9923006296157837,
0.0026172413490712643,
0.005082158371806145
] |
[
0.9991036057472229,
0.0004175623180344701,
0.00039417919469997287,
0.00008455572969978675
] |
en
| 0.999997 |
All medical students who participated in the consumers as tutors program passed the university wide assessment of an observed psychiatric interview rated against defined criteria.
|
15377386_p23
|
15377386
|
Assessment
| 1.977759 |
biomedical
|
Other
|
[
0.9683775305747986,
0.011233675293624401,
0.020388776436448097
] |
[
0.34489038586616516,
0.6505230665206909,
0.001854396192356944,
0.002732181688770652
] |
en
| 0.999995 |
This project established the feasibility of training and supporting mental health consumers as tutors for delivery of a jointly developed curriculum for 4 th year medical students in effective approaches to interviewing. Training and delivery has continued requiring modest maintenance, perhaps in keeping with sustaining professional tutors. Consumer tutors have shown themselves to be reliable, professional in approach and amenable to feedback. Benefits for students (as measured in their open evaluations) included the extended experience of working with a consumer of health services, the development of a clearer perspective regarding consumer views and an opportunity to see people with mental illness in recovery. Students were at least as well prepared as their peers for a structured assessment in interviewing (from the combined effect of traditional and novel teaching). Students largely reported positive experiences, found the curriculum and delivery acceptable and saw tutor experience and knowledge as legitimate and valuable. Ideally it would have been useful to follow up medical students over a longer term to assess their psychiatric interviewing skill, however, this was not practically possible within this study.
|
15377386_p24
|
15377386
|
Discussion
| 4.143946 |
biomedical
|
Study
|
[
0.9961406588554382,
0.0031359887216240168,
0.0007233257056213915
] |
[
0.9978848099708557,
0.001244842540472746,
0.0006855386309325695,
0.00018480756261851639
] |
en
| 0.999998 |
The attempt to measure attitudes deserves discussion. Attitudes are recognised as an important component of curriculum development yet remain the personal business of each of us. It would be reasonable to see education as a means of working past one's own attitudes rather than seeking to refine or replace student attitudes. Guidelines for working with consumers in health care assume that "for consumer participation to be effective, all participants in the process need to respect the different skills and expertise of the other participants" . In this study, student attitudes to consumers had a tendency to improve across all dimensions measured. On average the medical students began the program with largely positive attitudes to working with and learning from consumers which may explain the lack of statistically significant difference in their attitudes pre and post the program. In addition, a finding of lack of significance using a pre and post test design with a small sample of subjects is not usual. The one attitude measured that did improve throughout the program and reached statistical significance was towards mental health clients in psychiatric wards. This finding is understandable in light of the fact that the training took place within a psychiatric unit and the program incorporated practice at live interviews with clients from the unit. In addition, the study found a change in the primary focus of medical student concerns regarding interviewing which moved from issues focused on the consumer (such as violence or unpredictability) to those focused on improving their skills in interviewing and seeing this as a worthwhile activity. In terms of their satisfaction with the training program, based on their open comments, the few students who objected at least had the challenge of working in an educational model they did not admire. This was thought provoking and engaging even if the response produced was negative.
|
15377386_p25
|
15377386
|
Discussion
| 3.973504 |
biomedical
|
Study
|
[
0.9931772947311401,
0.002391528571024537,
0.004431205336004496
] |
[
0.9984608888626099,
0.000823509821202606,
0.0006159160402603447,
0.00009961713658412918
] |
en
| 0.999998 |
Benefits for consumer tutors (as measured by their open evaluations) included enhanced self esteem and financial reward for work done. Consumer tutor curriculum development was novel such as utilising an art therapy vehicle to experience a non-pharmaceutical therapeutic device. Most consumer tutors have continued to teach, with appropriate breaks, and have mentored new tutors. Some have used this experience to step further into paid employment and to rehabilitate previous work skills. Consumer tutors have remained resilient and episodes of relapse appear to be multifactorial in origin (with teaching perhaps one of the factors). This robustness was also found in a study of psychological impact on consumers working in a peer support role in an acute care setting . Consumer presentations have centred on the powerful personal effects of participation in learning new skills and gaining confidence. The largely positive ratings of tutors about the program was not as positive as the medical students, highlighting the need to evaluate both groups to adequately measure the effectiveness of the program.
|
15377386_p26
|
15377386
|
Discussion
| 2.752862 |
biomedical
|
Study
|
[
0.5116333365440369,
0.005488775670528412,
0.48287782073020935
] |
[
0.7421534657478333,
0.2434714138507843,
0.013066827319562435,
0.0013082969235256314
] |
en
| 0.999997 |
Benefits for the health system included the placement of consumers in a 'professional' light. Consumer tutors shared the staff tearoom, were paid as other casual tutors and were seen as well contributors rather than being in the sick role. Professional tutors were aware of the consumer tutor teaching and perhaps viewed it as 'politically correct' rather than educationally effective. Dissemination of findings via service and conference presentations has helped address this common view.
|
15377386_p27
|
15377386
|
Discussion
| 1.430093 |
other
|
Other
|
[
0.06770887225866318,
0.01072444673627615,
0.9215667247772217
] |
[
0.00394868291914463,
0.9940218329429626,
0.0013632937334477901,
0.0006661369698122144
] |
en
| 0.999998 |
Tutoring medical students is a skilful and potentially stressful role, and is not suitable for all mental health consumers. Following the training program some trained tutors realised that teaching was not their interest or strength (a proportion of whom did not teach at all). This was anticipated and should be factored into training plans. Some consumer tutors realised their tolerance level was insufficient to manage student junior skill level and found it hard to resist retelling their 'war stories' of difficult clinical encounters. This was a common theme in debriefing and required active refocusing on the curriculum of effective and ineffective interview techniques. The occasional protesting student required gentle persuasion to see that ongoing participation was a way of exploring contact with consumers. Like most education programs this approach did not run itself. Tutors required sustenance; feedback needed action and materials needed review. New tutors needed to be trained to add to the growing pool of available people. Despite these issues, our experience was that this was manageable and in keeping with maintenance of quality teaching by professional tutors.
|
15377386_p28
|
15377386
|
Discussion
| 3.606617 |
biomedical
|
Other
|
[
0.7494591474533081,
0.22054465115070343,
0.029996223747730255
] |
[
0.2856009900569916,
0.6898322105407715,
0.01428142562508583,
0.010285377502441406
] |
en
| 0.999998 |
We believe this model is another valuable option in a range of consumer involvement programs and could be replicated in health, emergency services and support agency education. Discussions have occurred with carers about possible involvement. At this stage it was decided to invite carers to speak about specific topics in the mainstream program as consumers see their expertise as fundamentally different to that of a carer. Despite the potential for use with other groups, our attempt to use this experience in refreshing interview skills in general practitioners was unsuccessful. Notwithstanding the diligent work by all parties, local general practitioners held fast to the view that consumer tutors would lack the emotional robustness to survive teaching. They were welcome to come and talk of their experience but were not seen as competent to deliver a curriculum. This may well have been shorthand for more complex issues of concerns about confidentiality, power and autonomy. This example reminds us, however, that health education is in change and that new strategies are required to engage today's students in experiences that will produce clinicians skilled to support effective consumer participation in healthcare.
|
15377386_p29
|
15377386
|
Discussion
| 2.691247 |
biomedical
|
Other
|
[
0.5795616507530212,
0.08236941695213318,
0.33806896209716797
] |
[
0.03335309773683548,
0.9595093131065369,
0.005246112123131752,
0.0018913986859843135
] |
en
| 0.999998 |
We have detailed a feasibility study which demonstrates a new level of consumer participation in the design, implementation and evaluation of a medical student training program. The effort has been sustained over four years with appropriate maintenance. Largely positive outcomes were seen for students, consumer tutors and the health care system. These included raising the profile of consumers as 'legitimate teachers' in medical education and contributing to an improvement in the attitude of medical students towards mental health consumers. Together the joint partners in the program were able to manage obstacles, such as, pessimistic attitudes towards the involvement of consumers and difficulties adhering to the curriculum. Adopting a continuous review of the feedback from both medical students and consumer tutors has helped to further refine our ability to deliver the curriculum and better support the participants. Lastly, our experience has been that consumer tutors are an untapped resource offering a richness of experience and a professional approach to teaching that deserves closer examination in other health settings.
|
15377386_p30
|
15377386
|
Conclusions
| 4.100063 |
biomedical
|
Study
|
[
0.9950487017631531,
0.0042085242457687855,
0.0007427959353663027
] |
[
0.9970371723175049,
0.0016189212910830975,
0.0010862109484151006,
0.000257648469414562
] |
en
| 0.999998 |
Pfizer funded the initial pilot in the first year of the study.
|
15377386_p31
|
15377386
|
Competing interests
| 0.960852 |
other
|
Other
|
[
0.07835891097784042,
0.0051659694872796535,
0.9164750576019287
] |
[
0.008187596686184406,
0.9894949793815613,
0.0013220281107351184,
0.0009954373817890882
] |
en
| 0.999998 |
CO conceived of the study, participated in the design of both the consumer tutor curriculum and medical student curriculum and performed the data analysis. CO and RR participated in the training of consumers, monitored the implementation and evaluation phases and coordinated the program. Both authors read and approved the final manuscript.
|
15377386_p32
|
15377386
|
Authors' contributions
| 0.948402 |
other
|
Other
|
[
0.16163426637649536,
0.0035293849650770426,
0.8348363637924194
] |
[
0.014271114952862263,
0.9832664728164673,
0.0017632551025599241,
0.0006991295958869159
] |
en
| 0.999997 |
The pre-publication history for this paper can be accessed here:
|
15377386_p33
|
15377386
|
Pre-publication history
| 1.031347 |
other
|
Other
|
[
0.013091348111629486,
0.0014214670518413186,
0.9854872226715088
] |
[
0.0015875872923061252,
0.997281551361084,
0.0006836647517047822,
0.0004471398133318871
] |
en
| 0.999995 |
Retention of participants has been a consistent problem in clinical studies of barrier contraceptive methods. For example, in six large studies of condoms, diaphragms, and spermicides conducted in the past decade, more than 30% of the participants failed for reasons other than pregnancy to complete the intended six months or six menstrual cycles of follow-up Such high dropout rates seriously compromise the interpretation of trial results.
|
15458571_p0
|
15458571
|
Background
| 3.74912 |
biomedical
|
Study
|
[
0.9985040426254272,
0.001029102597385645,
0.0004668520123232156
] |
[
0.9780594110488892,
0.014471372589468956,
0.00718538835644722,
0.00028380058938637376
] |
en
| 0.999996 |
Issues regarding the design of barrier method studies have become increasingly important to researchers and public health scientists since the onset of the HIV epidemic because of the urgent need for methods to prevent this disease and other sexually transmitted infections. Numerous new barrier contraceptive methods and microbicides are currently in various stages of development and testing. Devising effective approaches to maximize retention in these studies will be critical.
|
15458571_p1
|
15458571
|
Background
| 3.613656 |
biomedical
|
Other
|
[
0.9987196922302246,
0.00038651766953989863,
0.0008938025566749275
] |
[
0.30577951669692993,
0.40234294533729553,
0.2909387946128845,
0.0009387108730152249
] |
en
| 0.999998 |
In this analysis, we used data from a large, recently completed randomized trial of the efficacy and safety of five spermicide products to determine whether we could identify specific subgroups of participants who were at particular risk for failure to complete the trial. Our goal was to provide information that might assist in the development of targeted approaches to improve follow-up in future trials.
|
15458571_p2
|
15458571
|
Background
| 3.871382 |
biomedical
|
Study
|
[
0.9985314607620239,
0.0007764879264868796,
0.000692070578224957
] |
[
0.9989057779312134,
0.0007968809804879129,
0.00021074638061691076,
0.00008650778909213841
] |
en
| 0.999995 |
The primary purpose of this randomized trial was to estimate and compare the probability of pregnancy during six months of typical use of five nonoxynol-9 spermicide products. Safety, acceptability, and product use were additional specified outcomes. The trial was conducted at 14 sites in the United States between June 1998 and August 2002. The study was approved by the institutional review boards at each site and at Family Health International. All participants signed written informed consent forms before enrollment.
|
15458571_p3
|
15458571
|
Methods
| 3.368654 |
clinical
|
Other
|
[
0.31251534819602966,
0.675885021686554,
0.011599637567996979
] |
[
0.08756553381681442,
0.8974677920341492,
0.002020746236667037,
0.012945949099957943
] |
en
| 0.999998 |
A full description of the trial procedures has been published previously . In brief, the study enrolled 1536 healthy, sexually active women aged 18–40 years who had no history suggestive of subfecundity, who were at low risk for sexually transmitted infections, and who stated that they were willing to rely on a spermicide as their only contraceptive method for 7 months and to accept a moderate risk of pregnancy. At the enrollment visit, each volunteer had an interview, pelvic examination, Pap smear, wet prep, and urine pregnancy test. After eligibility was established, she completed a self administered questionnaire that included a question about strength of desire to avoid pregnancy. Each eligible participant was randomly assigned to one of the five study spermicide groups. She was given a supply of her assigned spermicide and a diary on which to record relevant information daily throughout the study. Some participants at two centers were enrolled into a substudy to evaluate colposcopic effects of the spermicides. Participants were encouraged but not required to inform their partners about the study except at one center, where the Institutional Review Board required signed consent of the partner.
|
15458571_p4
|
15458571
|
Methods
| 3.981819 |
biomedical
|
Other
|
[
0.7026621103286743,
0.29333850741386414,
0.003999404143542051
] |
[
0.4671676754951477,
0.5163976550102234,
0.0032705552875995636,
0.013164123520255089
] |
en
| 0.999998 |
Follow-up visits were scheduled at 4, 17, and 30 weeks after admission. Each participant was also asked to return to the study site if she wished to discontinue use of the spermicide. At each visit, the participant was interviewed, and a urine pregnancy test was done. At the 4-week and final visits, she completed a seven-page acceptability questionnaire. A pelvic examination was performed at the final visit and at other visits as indicated. Colposcopy substudy participants had a vaginal colposcopy at each follow-up visit. Each participant was asked to do a pregnancy test at home 2, 10, and 23 weeks after admission and to telephone the site with the result. If a participant missed a scheduled contact, study procedures required that staff make at least four attempts to contact her by at least two different modalities (telephone, mail, etc.) If they could not contact her directly, staff were to try to reach her through an alternate contact person identified by the participant at admission. Compensation for completion of all scheduled visits in the primary study ranged from $120 to $400 at the 14 study sites; at most sites, the amount was divided evenly among the separate visits.
|
15458571_p5
|
15458571
|
Methods
| 3.788532 |
biomedical
|
Study
|
[
0.827124834060669,
0.17010276019573212,
0.002772491192445159
] |
[
0.9659572243690491,
0.029914848506450653,
0.0010654600337147713,
0.003062422387301922
] |
en
| 0.999998 |
In this analysis, we included all randomized participants except for 22 who were discovered to have been pregnant at admission and who therefore contributed no data to the primary analysis. We classified each of the remaining 1514 participants as having completed the study if she considered the spermicide to be her primary contraceptive method for at least 183 days after randomization, or she became pregnant before she stopped relying on it. Otherwise, she was classified as having failed to complete the study. We assigned each participant's last day in the analysis as the earliest of the following dates: the estimated date of fertilization of a pregnancy; the date she was last known to have been relying primarily on the assigned spermicide for contraception; the latest date her pregnancy status could be reliably determined; and 183 days after randomization. These rules were the same as those used in the prior primary pregnancy analyses .
|
15458571_p6
|
15458571
|
Methods
| 4.044872 |
biomedical
|
Study
|
[
0.9821047186851501,
0.01682586595416069,
0.0010694911470636725
] |
[
0.9825009703636169,
0.0162733793258667,
0.00047449488192796707,
0.0007512258016504347
] |
en
| 0.999996 |
We assessed the associations between failure to complete and 17 baseline factors of interest, which were prespecified before the analysis. Among the subset of participants who were in the analysis for at least 6 weeks, we examined the associations between final status category and various factors that characterized their experience during the first 6 weeks in the study. Factors were categorized in part to ensure substantial numbers of participants in each level. Hypotheses about the effects of factors on completion status were tested using chi square tests, Fisher's exact tests, Mantel Haenszel tests. Parameters estimated by multivariable logistic regressions were tested using Wald tests. We included factors in regression models if they were associated with the outcome (alpha<0.10) in bivariable analyses. None of the included factors were highly correlated. In both bivariable and multivariable analyses, a p-value of <0.05 was considered to indicate a significant association.
|
15458571_p7
|
15458571
|
Methods
| 4.09924 |
biomedical
|
Study
|
[
0.9987826943397522,
0.0008159148856066167,
0.00040140689816325903
] |
[
0.9994114637374878,
0.00030679258634336293,
0.0002150675281882286,
0.00006668011337751523
] |
en
| 0.999998 |
Of the 1514 participants in this analysis, 635 (42%) failed to complete the study for reasons other than pregnancy. The proportion who withdrew early at each of the 14 study sites ranged from 17% to 83%. Only 3 centers had completion rates ≥65%. Forty nine participants (8% of those who withdrew) were discontinued by the site investigator because of a concern about their safety (such as increased risk of sexually transmitted infection that would indicate need for condom use, or use of a drug contraindicated in pregnancy that would indicate need for a more effective contraceptive than spermicide alone), staff error, or closure of the trial at the study site (Table 1 ). Of the 586 who withdrew on their own accord, 382 (65%) did not provide a reason, in most cases because they did not return for a discontinuation visit. The other 204 women reported a variety of reasons; 99 cited complaints that might have been related in some way to the spermicide. Of the other 105 participants, only 31 said that they would like to continue using the spermicide after leaving the study.
|
15458571_p8
|
15458571
|
Results
| 4.044364 |
biomedical
|
Study
|
[
0.797568142414093,
0.19963769614696503,
0.002794160507619381
] |
[
0.8486948013305664,
0.14012673497200012,
0.0036585237830877304,
0.0075199720449745655
] |
en
| 0.999998 |
During their time in the analysis, women who failed to complete the study were less compliant with follow-up visits and diary records than women who completed (Table 2 ). Twenty-one percent of the population (135 participants) contributed no data at all to the analysis after admission.
|
15458571_p9
|
15458571
|
Results
| 2.194715 |
biomedical
|
Study
|
[
0.990127444267273,
0.005703742615878582,
0.00416879216209054
] |
[
0.9946099519729614,
0.004611755255609751,
0.0004028586845379323,
0.0003754119388759136
] |
en
| 0.999996 |
Of the 17 baseline factors examined separately, nine were associated with significantly increased (p < 0.05) relative risk of failure to complete the trial (Table 3 ). Factors that did not significantly increase risk included spermicide group, race, educational level, prior spermicide use, strength of desire to avoid pregnancy as reported on the self-administered admission questionnaire, desire for additional children, reason for choosing spermicide as a contraceptive method, and enrollment date relative to notification in 1999 of new data suggesting concern about the possibility that nonoxynol-9 might affect the risk of HIV acquisition. In multivariable analyses including the nine high risk factors and one additional factor (level of schooling, which was marginally associated with withdrawal, p = 0.09), only the associations with young age, unmarried status, frequent intercourse, enrollment at a university center, and enrollment at a center with a lower recruitment rate remained significant.
|
15458571_p10
|
15458571
|
Results
| 4.121749 |
biomedical
|
Study
|
[
0.998009979724884,
0.001702423207461834,
0.00028764386661350727
] |
[
0.9987354874610901,
0.0007014684961177409,
0.00043326441664248705,
0.0001297776761930436
] |
en
| 0.999996 |
Of the 1095 participants who contributed more than 6 weeks to the analysis, those who in their first 6 weeks were not compliant with follow-up visits, coital diary completion, or use of the spermicide during sex were significantly less likely than others to complete the study (Table 4 ). However, among the 925 participants who completed a contact during the initial 6 weeks, neither reported complaints nor any measure of satisfaction with the spermicide during the first 6 weeks was associated with increased risk of early withdrawal. We created a single variable to indicate whether or not each subject was "happy" with the spermicide in the first 6 weeks after admission (i.e., she found it acceptable, had no side effect or adverse event, and had a satisfied partner). Women who were "happy" were not significantly less likely than other women to withdraw early.
|
15458571_p11
|
15458571
|
Results
| 3.989623 |
biomedical
|
Study
|
[
0.9963692426681519,
0.0026073248591274023,
0.0010233965003862977
] |
[
0.9992650151252747,
0.00043348423787392676,
0.0002055080112768337,
0.00009600521298125386
] |
en
| 0.999997 |
In analyzing data from longitudinal studies, researchers commonly assume that the experience of participants who withdraw early, had they stayed in the study, would have been similar to the experience of those who completed. However, this assumption is generally impossible to confirm and is often implausible. If the assumption is false, the study findings may substantially misrepresent the likelihood of the outcome in the study population. If the degree of misrepresentation is not consistent across study groups, comparisons could be seriously biased. Indeed, some expert epidemiologists have suggested that a trial with losses of greater than 20% of the participants "would be unlikely to successfully withstand challenges to its validity" .
|
15458571_p12
|
15458571
|
Discussion and conclusions
| 3.996185 |
biomedical
|
Study
|
[
0.9971266388893127,
0.0003086493816226721,
0.002564638154581189
] |
[
0.8287896513938904,
0.07381606847047806,
0.09704014658927917,
0.00035413948353379965
] |
en
| 0.999999 |
Our study, like other recent barrier contraceptive method studies, did not even approach this standard: 42% of our enrolled participants did not complete the trial. Furthermore, the participants who failed to complete were different in key ways from those who did – they reported significantly more frequent coitus at baseline, and they also were more likely to be younger, unmarried, and poorly compliant with study procedures and method use in the first few weeks after admission. All of these characteristics were associated to some extent with elevated risk of pregnancy in our population , which suggests that our high withdrawal rate indeed may have distorted our findings: the pregnancy probabilities that we reported may be underestimates.
|
15458571_p13
|
15458571
|
Discussion and conclusions
| 3.924878 |
biomedical
|
Study
|
[
0.9986940026283264,
0.0007045951206237078,
0.000601401028688997
] |
[
0.9994056224822998,
0.0003561392077244818,
0.00018600049952510744,
0.000052314167987788096
] |
en
| 0.999997 |
Clearly, increased attention to preventing this problem in future studies is imperative. In performing this analysis, our intention was to explore the potential impact of focusing retention efforts on participants with characteristics that are associated with failure to complete. However, although we did find some factors that were significantly associated with early withdrawal, none was highly predictive; that is, many participants without these factors failed to complete the study, and many with these factors did complete. Therefore, applying special efforts only to the high-risk participants would not likely have been sufficient to raise completion rates to desirable levels. In future trials, aggressive follow-up measures should be instituted universally. Such efforts might include assigning individual "case-workers" to participants, using novel means for communicating with the participants, such as pagers, conducting visits at participants' homes or at other locations convenient for them, providing specific reimbursement for expenses such as travel, parking, and child care, or providing extra incentives for completing follow-up. Researchers should be mindful, however, that one downside to some of these approaches is that they might influence participants' use of the study product or other behaviors related to the study outcome, which is detrimental if the goal of the trial is to estimate effectiveness during "typical use" of the product.
|
15458571_p14
|
15458571
|
Discussion and conclusions
| 4.089318 |
biomedical
|
Study
|
[
0.9983903169631958,
0.000866937218233943,
0.0007428096723742783
] |
[
0.9969940185546875,
0.0021544957999140024,
0.0007711085490882397,
0.00008037885709200054
] |
en
| 0.999998 |
In our study, participants who enrolled at study centers where enrollment was slow were at increased risk of failure to complete the study. The reason for this association is unclear. Factors at these centers that hindered enrollment also may have adversely affected participants' interest in remaining in the study. Alternatively, in responding to pressure to hasten recruitment, these centers may have enrolled women who were not good candidates for study completion. This latter possibility emphasizes the need to maintain a careful balance between recruitment and retention goals: rapid recruitment of participants who then drop out of the study is not beneficial to the study as a whole.
|
15458571_p15
|
15458571
|
Discussion and conclusions
| 3.378416 |
biomedical
|
Study
|
[
0.9969485402107239,
0.0014008816797286272,
0.0016505977837368846
] |
[
0.9978418350219727,
0.0018361267866566777,
0.00023441064695362002,
0.00008760456694290042
] |
en
| 0.999997 |
The amount of reimbursement promised to our participants was strongly associated with final completion status in the bivariable analysis, but this effect was not significant when adjusted for other factors in our multivariable model. Numerous prior studies have shown that modest monetary incentives (e.g., $20 or less) increase response rates to surveys or short follow-up studies Some data also suggest that the value of the incentive matters, although possibly with diminishing returns as the value increases . However, the effect of higher levels of compensation in longer trials such as ours has not been rigorously studied. The possibilities that large financial incentives could be coercive, weaken generalizability, or encourage bogus participation are important concerns .
|
15458571_p16
|
15458571
|
Discussion and conclusions
| 2.652879 |
biomedical
|
Study
|
[
0.9532063007354736,
0.0009690219885669649,
0.04582472890615463
] |
[
0.9959924817085266,
0.0032770473044365644,
0.0006416345713660121,
0.00008886038267519325
] |
en
| 0.999995 |
We were surprised that several of the factors that we expected would be associated with early withdrawal did not show significant associations in this analysis. When we began this analysis, we presumed that one reason for both slow enrollment and poor follow-up rates in barrier method trials is the relatively poor efficacy of these products: women may consider them to be temporary or backup methods and thus may be unwilling to use them as their sole or primary contraceptive for the 6–12 month duration of these studies. However, in our study, participants who strongly wished to avoid pregnancy or who had completed their desired family size were not more likely than others to drop out, nor were participants who expressed concerns about contraceptive efficacy early in the trial. Furthermore, neither early medical problems nor other complaints about the spermicides were predictive of withdrawal. These findings differ from that of a previous randomized trial of spermicides conducted mostly in developing countries. In that trial, participants who initially liked the assigned product very much were more likely than others subsequently to complete the study and to use the product for a longer period of time after admission .
|
15458571_p17
|
15458571
|
Discussion and conclusions
| 4.052747 |
biomedical
|
Study
|
[
0.9973205924034119,
0.0020418469794094563,
0.0006375687662512064
] |
[
0.9990699887275696,
0.0005638189031742513,
0.00027453640359453857,
0.00009164972288999707
] |
en
| 0.999996 |
In one respect, the poor retention rate in our study and in other barrier method trials is a result of the design of these studies, which typically call for censoring data (and in most barrier method trials, terminating active follow-up) when participants stop relying on the assigned contraceptive method. This design prohibits a true intent-to-treat analysis and is consequently a potential source of bias. Clearly, retention would be higher if the trials were designed at the outset to follow all subjects for the full intended duration of follow-up, even if they switched contraceptive methods. However, data from participants who are not using the method under study are not necessarily relevant to the efficacy and safety of the method. For the results of these trials to be meaningful, as many subjects as possible must not only complete follow-up but also continue to use the method during the full follow-up period. In our study, almost all the women who gave a reason for withdrawing early either cited problems with the spermicide or indicated that they wished to switch to another method after leaving the study. Our results are consistent with the findings of the 1995 National Survey of Family Growth, which showed that more than 47% of US spermicide users stopped relying on the method within the first 6 months of use . These findings are discouraging: they suggest that even if the retention in the study could be improved by aggressive follow-up techniques, the likelihood of significant extension of method use is low.
|
15458571_p18
|
15458571
|
Discussion and conclusions
| 4.087857 |
biomedical
|
Study
|
[
0.9985223412513733,
0.000921283382922411,
0.0005563095910474658
] |
[
0.9987422823905945,
0.00035719393054023385,
0.0008339985506609082,
0.00006653495074715465
] |
en
| 0.999997 |
Our results suggest that to reduce bias potentially introduced by a large proportion of participants failing to complete the study, future barrier contraceptive method researchers should consider approaches in addition to those directly aimed at tracking and retaining individual participants. For example, both to reduce the burden on participants and to help the study staff maintain focus on follow-up, limiting data collection to critical variables may be appropriate. Complete collection of key data is clearly preferable to inadequate collection of less important data. Reducing the planned duration of follow-up would also certainly reduce withdrawals; although a larger sample size would be needed to provide the desired levels of precision and power, this disadvantage might be overcome if the shorter study were more attractive to potential participants. Given the large proportion of women who stop using the method earlier than 6 months, it is not clear that 6-month pregnancy probabilities are clinically needed anyway. Adding a run-in period to the trial before randomization might be helpful in excluding participants likely to drop out very early after admission, although such an addition might deter enrollment of other women as well, which is also a problem in these trials. Finally, innovative study designs to measure product efficacy should be evaluated. The design proposed by Steiner et al., which compares the one-month pregnancy probability in a relatively small number of women using a contraceptive method to the probability in women using a placebo, offers an alternative to the traditional 6–12 month trial . It showed some promise in a pilot study and is currently being further tested in a study of a new candidate spermicide.
|
15458571_p19
|
15458571
|
Discussion and conclusions
| 4.050421 |
biomedical
|
Study
|
[
0.9988879561424255,
0.0007271545473486185,
0.00038482050877064466
] |
[
0.9947234392166138,
0.0007997347856871784,
0.004365635570138693,
0.00011125561286462471
] |
en
| 0.999997 |
No authors have any declared interests except the following:
|
15458571_p20
|
15458571
|
Competing interests
| 0.932128 |
other
|
Other
|
[
0.007677216548472643,
0.0010250101331621408,
0.991297721862793
] |
[
0.002905739936977625,
0.9953271150588989,
0.0009383042342960835,
0.0008288425742648542
] |
en
| 0.999998 |
Elizabeth Raymond owns stock in Johnson and Johnson.
|
15458571_p21
|
15458571
|
Competing interests
| 0.990854 |
other
|
Other
|
[
0.010239986702799797,
0.00206538918428123,
0.9876946210861206
] |
[
0.0026416426990181208,
0.9957090616226196,
0.0008867969736456871,
0.0007624772260896862
] |
en
| 0.999998 |
Mitchell Creinin serves as a speaker for Ortho.
|
15458571_p22
|
15458571
|
Competing interests
| 0.919932 |
other
|
Other
|
[
0.010323873721063137,
0.0022248425520956516,
0.9874511957168579
] |
[
0.00223090429790318,
0.9954578876495361,
0.0013484813971444964,
0.000962698832154274
] |
en
| 0.999997 |
Alfred Poindexter has had research grants from Columbia Laboratories and serves as speaker for Ortho.
|
15458571_p23
|
15458571
|
Competing interests
| 0.881382 |
other
|
Other
|
[
0.006927603855729103,
0.0020562862046062946,
0.9910160303115845
] |
[
0.0018090794328600168,
0.9962742328643799,
0.001024663564749062,
0.0008920137770473957
] |
en
| 0.999996 |
EGR helped design the trial, managed the trial, planned this analysis, and drafted the manuscript.
|
15458571_p24
|
15458571
|
Authors' contributions
| 0.96205 |
other
|
Other
|
[
0.18069568276405334,
0.011172140017151833,
0.8081321120262146
] |
[
0.0053495909087359905,
0.9930942058563232,
0.0008424531552009284,
0.0007137652719393373
] |
en
| 0.999996 |
PLC and BPL helped design the trial and/or this analysis, performed the analysis, and contributed to the manuscript.
|
15458571_p25
|
15458571
|
Authors' contributions
| 0.966248 |
other
|
Other
|
[
0.1440896838903427,
0.0035966429859399796,
0.8523136377334595
] |
[
0.004320950713008642,
0.9947380423545837,
0.0005503671709448099,
0.00039066161843948066
] |
en
| 0.999997 |
JL designed the trial and contributed to the manuscript.
|
15458571_p26
|
15458571
|
Authors' contributions
| 0.862782 |
other
|
Other
|
[
0.25078532099723816,
0.008010488003492355,
0.7412042021751404
] |
[
0.010802549310028553,
0.9862914681434631,
0.0019093954470008612,
0.0009965512435883284
] |
en
| 0.999995 |
Other authors participated in the design of the trial, conducted the trial, and contributed to the manuscript.
|
15458571_p27
|
15458571
|
Authors' contributions
| 0.998021 |
other
|
Other
|
[
0.10865108668804169,
0.005690083373337984,
0.885658860206604
] |
[
0.00432604132220149,
0.9944426417350769,
0.0007508816197514534,
0.0004804434720426798
] |
en
| 0.999997 |
The pre-publication history for this paper can be accessed here:
|
15458571_p28
|
15458571
|
Pre-publication history
| 1.031347 |
other
|
Other
|
[
0.013091341592371464,
0.0014214670518413186,
0.9854872226715088
] |
[
0.0015875872923061252,
0.997281551361084,
0.0006836647517047822,
0.0004471398133318871
] |
en
| 0.999998 |
The term "fibromatosis" covers a broad spectrum of benign fibrous tissue proliferations, the biological behavior of which is similar to both benign fibrous lesions and fibrosarcoma. Like fibrosarcoma, fibromatosis is characterized by infiltrative growth and a tendency towards recurrence; however, unlike sarcoma, it never develops metastasis . Therefore, the most important strategy is to prevent direct invasion into adjacent tissues. Extraabdominal fibromatosis principally originates from the connective tissue of muscles and the overlying fascia or aponeurosis. It may occur in a variety of anatomical locations, including the muscles of the shoulder, the chest wall and back, thigh, and head and neck. However, solitary occurrence is rare in retroperitoneal space . Here, we report on a case of extraabdominal fibromatosis in the retroperitoneum. Resection was successfully performed, and the patient has been tumor-free for two years after surgery.
|
15461790_p0
|
15461790
|
Background
| 4.174099 |
biomedical
|
Clinical case
|
[
0.7783027291297913,
0.2198101282119751,
0.00188720365986228
] |
[
0.0608595535159111,
0.0672556683421135,
0.008475159294903278,
0.8634095788002014
] |
en
| 0.999997 |
A 43-year-old woman with a history of schizophrenia since 1982, and a history of hospitalization to help the patient to acquire social communication abilities, at the age of 23 presented with slight pain on her left flank and back. In 1995, she was treated with ureterolysis and ureteroureterostomy because of left-sided ureteral obstruction. Histological evaluation of the biopsy revealed benign fibrous tissue proliferations; however, no further evaluation and surgical excision was planned as her mental state was deteriorating. She was put on regular follow-up with computed tomography (CT) scans. In May 2002, she was referred from the psychiatric hospital to our Department of Urology, as the tumor tended to grow. CT scan with contrast enhancement revealed a tumor located between iliocostalis and psoas muscles in retroperitoneal space. The peripheral part of the tumor was enhanced, while the central part did not. The left paravertebral muscles around the tumor showed atrophy. The medial margin of the tumor was deformed by a left transverse process of the second lumber spine, suggesting invasive behavior . Coronal magnetic resonance imaging (MRI) demonstrated the tumor to be located beneath the left kidney. The central part of the tumor was found to be of iso/low intensity in the T1-weighted phase and of heterogeneously high intensity in the T2-weighted phase. The marginal part showed very low intensity in both phases . In May 2002, needle biopsy was performed and revealed that the tumor consisted of well-proliferated spindle cells rich in collagen fibers, an observation that was inconsistent with the histological pictures made in 1995. In June 2002, resection was performed using a paraspinal approach. Although the tumor strongly adhered to adjacent tissues, including the urinary tract and peritoneum, it was marginally resected, including paravertebral muscles and part of the spine. As the kidney was less affected by the tumor, ablation posed no problem. On gross examination, the cut surface appeared homogeneously gray and glossy . Histologically, a uniform proliferation of spindle cells with a moderate amount of collagen fibers led to a diagnosis of extraabdominal fibromatosis in the retroperitoneal space . No adjuvant treatment was given and during the two years of follow-up, the patient has remained asymptomatic, with no restrictions of daily living. There were no clues as to recurrence of the tumor in computed tomography.
|
15461790_p1
|
15461790
|
Case presentation
| 4.008023 |
clinical
|
Clinical case
|
[
0.12041962891817093,
0.8754441142082214,
0.004136228002607822
] |
[
0.008330835029482841,
0.0068446919322013855,
0.005095816217362881,
0.9797287583351135
] |
en
| 0.999997 |
Extraabdominal fibromatosis may occur in a variety of anatomic locations; the principle sites of the involvement are the shoulder, chest wall and back, thigh and head and neck. Origin of extraabdominal fibromatosis from any mesenchymal tissue is now well recognized . Several authors have reported retroperitoneal fibromatosis in patients with familial adenomatous polyposis (Gardner syndrome) , however, solitary occurrence of fibromatosis is very rarely reported .
|
15461790_p2
|
15461790
|
Discussion
| 3.615597 |
biomedical
|
Other
|
[
0.9992243051528931,
0.0004061000363435596,
0.000369582005077973
] |
[
0.4111984074115753,
0.4803612530231476,
0.10452069342136383,
0.003919567912817001
] |
en
| 0.999996 |
Our patient did not have a family history and upper gastrointestinal endoscopy, colonoscopy, or opthalmoscopy were normal suggesting that our patient may be negative for the syndrome. The exact histological origin of the tumor remains to be verified. The findings of CT suggested an origin from paravertebral muscles. Interestingly, this assumption was corroborated by a computed tomography performed in April 2000, which revealed that the previous tumor was located intramuscularly
|
15461790_p3
|
15461790
|
Discussion
| 2.634812 |
biomedical
|
Clinical case
|
[
0.5379565358161926,
0.4570504128932953,
0.00499303312972188
] |
[
0.009326731786131859,
0.02560286782681942,
0.001543927239254117,
0.9635264873504639
] |
en
| 0.999997 |
Principally, complete resection is the therapy of choice for this type of tumors . Adjuvant therapy using non steroidal anti-inflammatory drugs (NSAIDs), tamoxifen, interferon, anti-neoplastic agents, radiation, and a combinations of these, have been reported for cases that are difficult to resect , the exact benefit offered by them is not known due to thin literature. Radiation therapy is accepted as an effective treatment after incomplete resection . Recently, preoperative radiotherapy was reported to be useful for the local control .
|
15461790_p4
|
15461790
|
Discussion
| 3.82468 |
biomedical
|
Review
|
[
0.9965735673904419,
0.0023350834380835295,
0.0010914681479334831
] |
[
0.024848386645317078,
0.06322363018989563,
0.9106191396713257,
0.001308884471654892
] |
en
| 0.999997 |
In our case the tumor detection was delayed because the psychiatric status of our patient which has been unstable for several years. As wide resection of the tumor reduces the risk of recurrence, an early diagnosis is required for this type of tumor, which is difficult as most of these patients are asymptomatic. While the silent area contains several vital organs, extraabdominal fibromatosis should be considered for the differential diagnosis for such a lesion.
|
15461790_p5
|
15461790
|
Discussion
| 2.898252 |
biomedical
|
Clinical case
|
[
0.7506136894226074,
0.245855912566185,
0.003530323039740324
] |
[
0.015060028992593288,
0.2894372045993805,
0.0020726940128952265,
0.6934301257133484
] |
en
| 0.999997 |
The authors declare that they have no competing interests.
|
15461790_p6
|
15461790
|
Competing interests
| 0.956449 |
other
|
Other
|
[
0.014629657380282879,
0.0016160417580977082,
0.9837543368339539
] |
[
0.0046446844935417175,
0.9930703043937683,
0.0012706100242212415,
0.0010144541738554835
] |
en
| 0.999998 |
AKik and AKid performed the operation, are responsible for the clinical work and helped with the preparation of the manuscript. TK is the orthopedic consultant and helped with the preparation and editing of the manuscript. TH coordinated and drafted the manuscript. All authors read and approved the final manuscript.
|
15461790_p7
|
15461790
|
Authors' contributions
| 0.779191 |
other
|
Other
|
[
0.16669514775276184,
0.008870158344507217,
0.8244346976280212
] |
[
0.002973160007968545,
0.9951804876327515,
0.0008564721792936325,
0.0009898532880470157
] |
en
| 0.999997 |
Eukaryotic genome contains a large excess of non-coding sequences. Conservation of these sequences among species is a strong indication of their functional significance. With the availability of genome sequences it is possible to identify such sequences taking a comparative genomics approach . The clusters of homeotic genes, which are expressed in a coordinated manner , are among the most conserved regions of the vertebrate genome. Clustering of genes that are regulated in a linked manner has been noticed in several other cases . However, the molecular mechanism behind such coordination in regulation is not yet understood. Several mechanisms have been proposed that link the organization of homeotic genes and the spatio-temporally controlled expression . Colinearity in hox complexes was first discovered in Drosophila and later studies on the bithorax complex have demonstrated the role of chromatin organization in its regulation . Recent studies on the HoxD complex suggest a role for higher order chromatin organization in the regulation of this complex involving up to 20 kb upstream region .
|
15462684_p0
|
15462684
|
Background
| 4.508944 |
biomedical
|
Study
|
[
0.999238133430481,
0.0003480449959170073,
0.000413846893934533
] |
[
0.933220386505127,
0.001243998296558857,
0.06522431969642639,
0.00031120755011215806
] |
en
| 0.999996 |
We compared genomic regions flanking hox complexes in order to identify conserved regions with potential regulatory function. Here we report that the upstream regions of HoxD complexes of human, mouse, rat, sacred baboon, horn shark, zebra fish and puffer fish contain long stretches of extremely conserved sequences. In the 25 kb region upstream of the HoxD complex from these organisms we found an extremely conserved region spread in three blocks located within 7 kb from the 3' end of the Evx-2 gene. These conserved regions, designated as C onserved R egion 1 , C onserved R egion 2 and C onserved R egion 3 (CR1, CR2 and CR3) show a degree of conservation not seen before among distant species. Detailed analysis of each region spanning to several hundred base pairs, in particular the CR2 shows several stretches of 100 % conservation, Fig. 2 . We also noticed longer stretches of conservation among mammals, which gradually shortens as we go towards lower vertebrates, defining the core of each conserved region, across the vertebrate classes, see Additional file 1 . This and the fact that in case of shark, as compared to mammals, the intervening sequence lengths between CR2 and CR3, and CR1 and Evx-2 is shorter by ~1300 bp and ~600 bp, respectively suggest that starting from the shorter conserved regions, additional unique sequences have progressively been acquired and conserved during the evolution of primates from lower vertebrates. This may reflect the molecular basis of conservation and elaboration of Hox gene regulation during evolution of these species .
|
15462684_p1
|
15462684
|
Results and discussion
| 4.325015 |
biomedical
|
Study
|
[
0.999371349811554,
0.00037048550439067185,
0.0002582139568403363
] |
[
0.9991763234138489,
0.00022586938575841486,
0.0005085620214231312,
0.00008914130012271926
] |
en
| 0.999998 |
Subsets and Splits
SQL Console for rntc/test-pp-aa
The query retrieves a sample of documents that are clinical cases with an educational score above 3, providing limited analytical value.
Clinical Cases Sample
Returns a sample of 100 clinical case documents, providing a basic overview of the document type's content.