The 11th edition of Harrison's Principles of Internal Medicine welcomes Anthony Fauci to its editorial staff, in addition to more than 85 new contributors. While the organization of the book is similar to previous editions, major emphasis has been placed on disorders that affect multiple organ systems. Important advances in genetics, immunology, and oncology are emphasized. Many chapters of the book have been rewritten and describe major advances in internal medicine. Subjects that received only a paragraph or two of attention in previous editions are now covered in entire chapters. Among the chapters that have been extensively revised are the chapters on infections in the compromised host, on skin rashes in infections, on many of the viral infections, including cytomegalovirus and Epstein-Barr virus, on sexually transmitted diseases, on diabetes mellitus, on disorders of bone and mineral metabolism, and on lymphadenopathy and splenomegaly. The major revisions in these chapters and many

Harrison's Principles of Internal Medicine

Lincoln, Yvonna, and Egon Guba, "Postpositivism and the Naturalist Paradigm," pp. 14-46 in Yvonna Lincoln and Egon Guba, Naturalistic Inquiry . Beverly Hills, CA: Sage, 1985.*

Background Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective. Objectives To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes. Search strategy We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies. Selection criteria Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes. Data collection and analysis Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. Main results We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice. Reviewer's conclusions Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Audit and feedback: effects on professional practice and healthcare outcomes

Regression models are frequently used to develop diagnostic, prognostic, and health resource utilization models in clinical, health services, outcomes, pharmacoeconomic, and epidemiologic research, and in a multitude of non-health-related areas. Regression models are also used to adjust for patient heterogeneity in randomized clinical trials, to obtain tests that are more powerful and valid than unadjusted treatment comparisons.

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Regression Modeling Strategies

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Applied Missing Data Analysis

Worldwide, incidence rates of skin cancer are increasing alarmingly in populations of predominantly Caucasian origin A prospective population-based survey, set up to collect epidemiological information on all excised and histologically confirmed skin cancers, started in Townsville, Australia (population of 127,000) in December 1996 Data on the anatomical distribution of skin cancer has been collected using a detailed body map Estimations of type-specific and site-specific incidence rates were age-standardized according to world standard population Site-specific incidence rates were adjusted for surface proportion of the body site and are given per 100,000 body units Between December 1996 and December 1997, a total of 3,536 patients with 5,945 histologically confirmed skin cancer lesions were recorded Age-standardized incidence rates of basal cell carcinoma were 2,0583 for men and 1,1945 for women, 1,3323 for men and 7548 for women for squamous cell carcinoma, and 491 for men and 417 for women for cutaneous melanoma (CM) Site-specific incidence rates of non-melanocytic skin cancer were extreme on sun-exposed areas of the face, whereas site-specific incidence rates of CM were highest for neck, posterior trunk and face Less exposed body sites, such as unexposed upper limbs or thighs, showed reduced incidence rates for all types of skin cancer Tropical North Queensland has the world's highest incidence rates of skin cancer of all types Site-specific incidence rates demonstrate that highly sun-exposed body sites are at high risk of developing skin cancer and provide, therefore, strong indirect evidence for the causal relationship between sun exposure and skin cancer

https://onlinelibrary.wiley.com/doi/pdf/10.1002/%28SICI%291097-0215%2819981123%2978%3A5%3C587%3A%3AAID-IJC10%3E3.0.CO%3B2-E

Incidence rates of skin cancer in Townsville, Australia

Background: basal cell carcinoma (BCC) is the most common cancer worldwide in white-skinned populations. Recent studies suggest that BCC is not a single entity and that different histological subtypes show different clinical behaviour and might have different aetiology.

Objectives: to provide information on the incidence of BCC by histopathological subtype and body site.

Methods: a case series of BCC from a prospective population-based register study collecting information on all excised and histologically confirmed skin cancers in Townsville, north Australia between 1997 and 1999.

Results: age-standardized incidence rates for nodular BCC were 727·1 per 100 000 inhabitants per year for males and 411·8 for females, while rates for superficial BCC were 336·5 for males and 251·4 for females. Incidence rates for 'high risk' BCC were 261·3 for males, 146·5 for females with infiltrative, and 156·7 for males and 100·2 for females with micronodular types. Superficial BCC occurred at a younger age, particularly in female patients. For all histological subtypes and both genders relative tumour density was highest for the face, followed by the neck. An exception was superficial BCC in males, where the posterior trunk was second, followed by the neck.

Conclusions: the study found a higher rate of superficial BCC than previous studies from less sun-exposed countries, and a more equal distribution of superficial BCC on face, trunk and limbs. These results seem to blur the difference between intermittent and continuous sun exposure as the causative environmental agents. The clinical implications of 'high risk' BCC rates are discussed.

Basal cell carcinoma: histological classification and body-site distribution.

Background
Anastomotic leakage is associated with high mortality, high reoperation rate, and increased hospital length of stay. Although many studies have examined the risk factors for anastomotic leak, large prospective series that report on long-term survival rates are lacking.

Risk Factors and Outcomes for Anastomotic Leakage in Colorectal Surgery: A Single-Institution Analysis of 1576 Patients

BACKGROUND There is no consensus regarding the appropriate management of asymptomatic and minimally symptomatic patients with stage IV colorectal cancer and irresectable metastases. METHODS A literature search was conducted on Medline and Embase. Outcome measures included: survival; postoperative morbidity and mortality; complications from the primary tumor and the need for surgery to manage complications; the likelihood of curative surgery after initial response to primary therapy; and length of hospital stay. Quantitative meta-analysis was performed where appropriate. RESULTS Eight retrospective studies, including 1,062 patients, met the criteria for inclusion in this study. Meta-analysis has shown an improvement in the survival of patients managed with palliative resection of their primary tumor, with an estimated standardized median difference of 6.0 months (standardized difference, 0.55; 95% confidence interval (CI), 0.29, 0.82; p < 0.001). Patients managed with chemotherapy alone were 7.3 times more likely to have a complication from the primary tumor (95% CI, 1.7, 34.4; p = 0.008). There was no difference in the response rates to chemotherapy, making metastatic disease amendable to curative resection (0.85; 95% CI 0.40, 1.8; p = 0.662). CONCLUSIONS To date, only retrospective data are available, showing that palliative resection of the primary tumor in asymptomatic or minimally symptomatic patients with stage IV colorectal cancer is associated with longer survival. Resection of the primary tumor reduces the likelihood of complications from the primary tumor and avoids the need for emergency procedures.

Meta-Analysis of Survival of Patients with Stage IV Colorectal Cancer Managed with Surgical Resection Versus Chemotherapy Alone

BACKGROUND

The objective of this study was to describe recent developments in cutaneous melanoma from the German speaking countries in Europe (Germany, Austria, and Switzerland) and from Queensland, Australia.



METHODS

All incident invasive cutaneous melanoma cases recorded between 1986 and 1996 by the Queensland Melanoma Register and by the Central Malignant Melanoma Registry of the German Dermatological Society were included in the analysis. Weighted linear trend analyses were performed to assess significant changes over the years using yearly sample sizes as weights.



RESULTS

In Central Europe, the median tumor thickness decreased from 1.2 mm in 1986 to 0.8 mm in 1996 (P < 0.001), whereas it varied insignificantly between 0.5 mm and 0.6 mm in Queensland. The percentage of patients with Clark Level II invasion increased significantly in Queensland (P < 0.001; 1996, 61.1%) and in Central Europe (P = 0.041; 1996, 24.5%). The percentage of superficial spreading melanomas rose in Central Europe (P = 0.043; 1996, 64.4%), whereas it decreased slightly in Queensland (P = 0.032; 1996, 75%). In Queensland and in Central Europe, younger people and women presented more frequently with thinner melanomas (≤ 0.75 mm).



CONCLUSIONS

In both Central Europe and Queensland, trends toward thinner and less invasive melanomas were observed between 1986 and 1996, although the median tumor thickness decreased significantly only for Central European data. Men and elderly individuals should be the focus of health-promotion activities, because they tended to present on average with thicker and prognostically poorer melanomas. Cancer 2000;89:1269–78. © 2000 American Cancer Society.

Petra G. Buettner

Papers

Incidence rates of skin cancer in Townsville, Australia

Basal cell carcinoma: histological classification and body-site distribution.

Risk Factors and Outcomes for Anastomotic Leakage in Colorectal Surgery: A Single-Institution Analysis of 1576 Patients

Meta-Analysis of Survival of Patients with Stage IV Colorectal Cancer Managed with Surgical Resection Versus Chemotherapy Alone

Time trends of cutaneous melanoma in Queensland, Australia and Central Europe