justified by appeal to a constructivist perspective and do not rely on a foundationalist view or assume any particular epis¬ temology. Indeed, each of the models can be defended from a number of epistemological perspectives. We tried to indi¬ cate that the differences in the models rests
different of and roles. of of autonomy, values, obligations, conceptions Clearly, the difference between Tibbies' foundationalist view and our contructivist view of ethics cannot be fully explored in a letter. Nevertheless, it is important to note that in affirming the deliberative model as the ideal, we do not— and need not—make any deeper philosophical claims about the truth of a particular metaphysics or epistemology. And yet the models can be evaluated by which one provides a more coherent vision.
1. Dworkin R. Taking Rights Seriously. Cambridge, Mass: Harvard University Press; 1977:chap 2-4, 6. 2. Rawls J. A Theory of Justice. Cambridge, Mass: Harvard University Press; 1971: sections 4, 9, 87. 3. Rawls J. Kantian constructivisim in moral theory. J Philos. 1980;70:513-572. 4. Emanuel EJ. The Ends of Human Life. Cambridge, Mass: Harvard University Press; 1991:chap 2, 5.
Screening for Lung Cancer Has No Proven Utility To the Editor.\p=m-\DrsLin and Ihde1 began their discussion of lung cancer therapeutics with a selected case of a 45-year-old asymptomatic male smoker with a normal physical exami-
nation who had a nodule found on a "routine" chest roentgenogram. Although he was staged as T2,N0, he developed metastatic disease soon after lobectomy. If he had been my patient and I had followed the preventive care guidelines of the American College of Physicians, the Canadian Task Force on the Periodic Health Examination, the US Preventive Services Task Force, and the American Cancer Society,2 a chest roentgenogram would not have been ordered routinely, even though he was at risk based on his smoking history. His cancer would have been discovered when he developed hemoptysis and his outcome would have been no different from what it was in this case. I wonder if Lin and Ihde chose this case for a reason, and if so, if it was to illustrate the fact that routine chest roentgenograms do not affect survival in lung cancer and that the guidelines are correct, or that the guidelines are incorrect and more frequent use of screening roentgenograms may have detected this cancer earlier before it metastasized (or per¬ haps that adenocarcinoma behaves like small cell cancer and we should assume the presence of occult micrometastasis in all cases).
Albert Y. Lin, MD Daniel C. Ihde, MD National Cancer Institute Bethesda, Md 1. Mulley AG. The periodic health evaluation. In: Kelley WN, ed. Textbook of Internal Medicine. 2nd ed. Philadelphia, Pa: JB Lippincott; 1992:34-38. 2. Melamed M, Flehinger B, Miller D, et al. Preliminary report of the lung cancer detection program in New York. Cancer. 1977;39:369-382. 3. Levin M, Tockman M, Frost J, Ball W. Lung cancer mortality in males screened by chest x-ray and cytologic sputum examination: a preliminary report. Recent Results Cancer Res. 1982;82:138-146. 4. Fontana R, Sanderson D, Woolner L, Taylor W, Miller W, Muhm J. Lung cancer screening: the Mayo program. J Occup Med. 1986;28:746-750.
Red Cell Distribution Width in Alcoholics: Not due to Liver Disease To the Editor.\p=m-\Intheir reply to our letter, Drs Bessman and McClure1 suggest that the high red cell distribution width (RDW) in alcoholics might be due to liver disease, since liver disease has been found to be a common cause of isolated increased RDW.2 Consequently, they state that the challenge would now be to distinguish alcohol abuse per se from the liver disease that commonly results from alcohol abuse. Our previous results3 provide a basis for considering this problem. Among the alcoholic men studied, 41% had a high RDW (>14.1%). None of the alcoholics (n=106), however, showed signs or symptoms of alcoholic liver disease. To investigate further the possibility that alcoholic liver disease explained the elevated RDW values among alcoholics, we have now reexamined results in these subjects of several tests that might indicate liver disease. No statistically significant differences in any of the tested parameters were found between those alcoholics with normal and those with high RDW (mean\m=+-\SD):platelets (215±61xl09/L vs 215±83xl09/L; P=NS), serum aspartate aminotransferase (59+71.5 U/L vs 61 ±43.2 U/L; P=NS), serum alanine ami¬ notransferase (59±91 U/L vs 63±69 U/L; P=NS), serum al¬ kaline phosphatase (177±39 U/L vs 170±42 U/L; P=NS), serum 7-glutamyltransferase (114± 155 U/L vs 169± 184 U/L;
High
P=NS).
These results provide no support for the possibility that the seen in our alcoholic subjects was mediated by alcohol-induced liver disease. Instead, they suggest that high RDW is caused by alcohol abuse in some other manner. The main theory for the high erythrocyte mean cell volume in alcohol abusers is that it is caused by the direct toxic effect of alcohol on red cells.4 We suggest that this may be true also with RDW.
high RDW
Kaija Sepp\l=a"\,MD University of Tampere (Finland) Pekka Sillanaukee, MSc Helsinki, Finland
MD Ill
Hirsch,
Carpentersville,
AY, Ihde DC. Recent developments in the treatment of lung cancer. JAMA. 1992;267:1661-1664. 2. Hayward RSA, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991. Ann Intern Med. 1991;114:758-783. 1. Lin
In Reply.\p=m-\The"routine" chest roentgenogram in our patient performed by referring physicians. The case was chosen for presentation to illustrate that distant metastases are a major threat even to patients with localized lung cancer who undergo complete surgical resection. The characteristics of a disease that is suitable for periodic health evaluation among asymptomatic subjects are well described.1 The fact that there is no highly effective treatment modality available for treating occult distant metastases hamwas
cancer.
on
Ezekiel J. Emanuel, MD Dana-Farber Cancer Institute Linda L. Emanuel, MD Massachusetts General Hospital Boston
Ronald L.
pers the effectiveness of periodic screening for lung cancer. Major studies have addressed this specific issue.2-4 We agree that at present there is no proven utility in screening for lung
1. Bessman JD, McClure S. Red cell distribution width in alcohol abuse and iron de-
anemia. JAMA. 1992;267:1071. 2. Bessman JD, Gilmer PR Jr, Gardner FH. Classification of anemias
ficiency
by MCV and RDW. Am J Clin Pathol. 1983;80:322-326. abuse and iron deP. Red cell distribution width in alcohol Sillanaukee Sepp\l=a"\K, ficiency anemia. JAMA. 1992;267:1070. 4. Wu A, Chanarin I, Levi AJ. Macrocytosis of chronic alcoholism. Lancet. 1974;1: 829-830. 3.
The Death of a Baby: Neither Forgiven Nor Forgotten To the Editor.\p=m-\Hereis a different perspective on the article by Hickson et al.1 I am a plaintiffs negligence attorney, experienced in medical malpractice defense, and am married
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/16/2015
a physician. My wife was pregnant with our first child. We used an obstetrician-gynecologist group that employed a classmate of hers. During the pregnancy, that associate left the group without our knowledge. We decided to remain with the group since they were familiar with her prenatal care. In my wife's 37th week, the doctor thought the fetus was in a breech position. If its position did not change, he said, a
to
section would be indicated. No cesarean was scheduled. At my wife's next appointment, she was examined by a physician who was not familiar with her case. The fetus was still in a breech position, and again no cesarean date was scheduled, nor were special instructions or tests given. She was to return in 5 days. We vowed on the next visit to ask about scheduling a cesarean. Thirty-six hours later, my wife's membranes ruptured and the umbilical cord prolapsed through her cervix. Despite the heroic efforts of many and a "crash" cesarean section, our baby was delivered. She had devastating neurological defi¬ cits, to which she succumbed 5 days later. The surgeon said the fetus was a double-footling breech presentation. He was surprised that an ultrasound had not been previously ordered. He also revealed that my wife had a heart-shaped uterus, predisposing to a breech presen¬ tation. No one from the obstetrician-gynecologist group ever called to inquire why the scheduled appointment was not kept. Afterward, we tried to call the group. Didn't they want to know the outcome of the pregnancy? Was there something to learn from this? No one returned our calls. Finally, when my wife did get a call, condolences were offered without admis¬ sion of any errors in patient management. We never heard from the physician who performed the last examination. Does she even remember my wife's name? Many people, including some physicians, suggested that we bring a malpractice claim. The surgeon had strongly hinted that errors were committed, but we wanted a baby, not a monetary windfall. We are still extremely angry with our original physicians: they totally lacked the skills to communicate, yet, in truth, nothing they could have said would have satisfied us. Why did we not bring a claim? First, our baby died. The laws of our state allow only minimal damages for the death of a newborn. Our emotional and psychological harm was totally noncompensable without an independent physical in¬ jury to the mother. No decent attorney would accept a neo¬ natal death case with such limited potential recovery. Second, a claim would subject us to abuse from defense attorneys, who might even accuse us of wrongdoing. We did not want to relive this nightmare until a claim was closed. Today, we have neither forgiven nor forgotten. cesarean
This case illustrates several of our findings. Mr Feilich said:
"Afterward, we tried to call the group," and "No one returned our calls." Few patients in our study believed that their physicians returned such calls in a timely manner. While we can only speculate about the reasons for this seeming reluctance, at least some hesitancy may relate to physicians' lack of training in how to deal with grieving and angry families. Some physicians may also fear that their offers of regret could be misconstrued as admissions of guilt. Perhaps an appro¬ priate strategy in such cases would be to schedule an office visit with the family. Adequate time could be allotted to express condolences, answer questions, and face the family's complaints. In addition, scheduling a meeting would permit
those involved to review medical records including those from physicians who provided emergency care and to consult with risk managers if indicated. The case also illustrates a practice style that may contrib¬ ute to misunderstandings and patient dissatisfaction, espe¬ cially if there is an adverse outcome. Families recognize that their primary physician cannot be available for each prenatal visit. Families do expect, however, that someone is still in charge, knowledgeable about the case and responsible for communication of the care plan among all members of the group. When a physician declares that "a cesarean section would be indicated," then as far as the family is concerned, the standard has been set. Each physician subsequently exam¬ ining the patient must be guided by the standard or explain why the plan is no longer appropriate. Given the family, the physicians' statements, the cord prolapse, and the ultimate outcome, it is not surprising that the family recognized that a problem had occurred and were encouraged to file by the "hints" of medical acquaintances. Our study and this letter suggest that some families have noneconomic goals that prompt them to file claims. Bringing a lawsuit is an effective way to get the attention of one who allegedly has wronged another. There may, however, be more efficient ways to achieve the same goal. It seems worthwhile for physicians and states to explore the development of al¬ ternative forums for communication between families and physicians. No one should have to file suit to find out what happened or to be able to express anger. Finally, Feilich's comments illustrate how tort reforms that limit recovery in cases of fetal death undermine families' already limited abil¬ ities to seek redress of their grievances, especially when those grievances are not primarily economic in nature. Gerald B. Hickson, MD Ellen Wright Clayton, MD, JD Vanderbilt University School of Medicine Nashville, Tenn
Burt Feilich New York, NY 1. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families
to file medical malpractice claims following perinatal injuries. JAMA.
1363.
1992;267:1359\x=req-\
In Reply.\p=m-\Thisstory unfortunately is typical of many cases examined in seeking to identify factors prompting families to file malpractice claims. In almost all cases, and independent of determinations of liability, families indicated that there were problems with patient-physician communication and that these problems were often "the last straw" in their decisions to file claims. Many told us they pursued litigation even though they realized that the process might rekindle old feelings of grief and subject them to the trauma of the courtwe
Errors in Table. \p=m-\In the article entitled "Mortality Among Workers at Oak Ridge National Laboratory: Evidence of Radiation Effects in Follow-up Through 1984," published in the March 20, 1991, issue of The Journal (1991;265:1397-1402), a number of errors occurred in the three bottom rows in the "Leukemia" category in Table 4, on page 1399. The values under the "Leukemia" heading in the first column should be 0, 5, and 10 (not 0,10, and 20); the values under "Increase, %" in the second column should be 2.60,2.93, and 3.75 (not 6.38, 6.88, and 9.15); the values under "SE" in the third column should be 3.95, 4.01, and 4.05 (not 10.71,10.93, and 11.07); the values under "\g=x\2(1 df)" in the fourth column should be 0.4, 0.5, and 0.7 (not 0.0, 0.0, and 0.6); and the values under "P value" in the fifth column should be .53, .48, and .40 (not 1.0,1.0, and .44). The leukemia results reported in Table 5 were correct.
room.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/16/2015
different of and roles. of of autonomy, values, obligations, conceptions Clearly, the difference between Tibbies' foundationalist view and our contructivist view of ethics cannot be fully explored in a letter. Nevertheless, it is important to note that in affirming the deliberative model as the ideal, we do not— and need not—make any deeper philosophical claims about the truth of a particular metaphysics or epistemology. And yet the models can be evaluated by which one provides a more coherent vision.
1. Dworkin R. Taking Rights Seriously. Cambridge, Mass: Harvard University Press; 1977:chap 2-4, 6. 2. Rawls J. A Theory of Justice. Cambridge, Mass: Harvard University Press; 1971: sections 4, 9, 87. 3. Rawls J. Kantian constructivisim in moral theory. J Philos. 1980;70:513-572. 4. Emanuel EJ. The Ends of Human Life. Cambridge, Mass: Harvard University Press; 1991:chap 2, 5.
Screening for Lung Cancer Has No Proven Utility To the Editor.\p=m-\DrsLin and Ihde1 began their discussion of lung cancer therapeutics with a selected case of a 45-year-old asymptomatic male smoker with a normal physical exami-
nation who had a nodule found on a "routine" chest roentgenogram. Although he was staged as T2,N0, he developed metastatic disease soon after lobectomy. If he had been my patient and I had followed the preventive care guidelines of the American College of Physicians, the Canadian Task Force on the Periodic Health Examination, the US Preventive Services Task Force, and the American Cancer Society,2 a chest roentgenogram would not have been ordered routinely, even though he was at risk based on his smoking history. His cancer would have been discovered when he developed hemoptysis and his outcome would have been no different from what it was in this case. I wonder if Lin and Ihde chose this case for a reason, and if so, if it was to illustrate the fact that routine chest roentgenograms do not affect survival in lung cancer and that the guidelines are correct, or that the guidelines are incorrect and more frequent use of screening roentgenograms may have detected this cancer earlier before it metastasized (or per¬ haps that adenocarcinoma behaves like small cell cancer and we should assume the presence of occult micrometastasis in all cases).
Albert Y. Lin, MD Daniel C. Ihde, MD National Cancer Institute Bethesda, Md 1. Mulley AG. The periodic health evaluation. In: Kelley WN, ed. Textbook of Internal Medicine. 2nd ed. Philadelphia, Pa: JB Lippincott; 1992:34-38. 2. Melamed M, Flehinger B, Miller D, et al. Preliminary report of the lung cancer detection program in New York. Cancer. 1977;39:369-382. 3. Levin M, Tockman M, Frost J, Ball W. Lung cancer mortality in males screened by chest x-ray and cytologic sputum examination: a preliminary report. Recent Results Cancer Res. 1982;82:138-146. 4. Fontana R, Sanderson D, Woolner L, Taylor W, Miller W, Muhm J. Lung cancer screening: the Mayo program. J Occup Med. 1986;28:746-750.
Red Cell Distribution Width in Alcoholics: Not due to Liver Disease To the Editor.\p=m-\Intheir reply to our letter, Drs Bessman and McClure1 suggest that the high red cell distribution width (RDW) in alcoholics might be due to liver disease, since liver disease has been found to be a common cause of isolated increased RDW.2 Consequently, they state that the challenge would now be to distinguish alcohol abuse per se from the liver disease that commonly results from alcohol abuse. Our previous results3 provide a basis for considering this problem. Among the alcoholic men studied, 41% had a high RDW (>14.1%). None of the alcoholics (n=106), however, showed signs or symptoms of alcoholic liver disease. To investigate further the possibility that alcoholic liver disease explained the elevated RDW values among alcoholics, we have now reexamined results in these subjects of several tests that might indicate liver disease. No statistically significant differences in any of the tested parameters were found between those alcoholics with normal and those with high RDW (mean\m=+-\SD):platelets (215±61xl09/L vs 215±83xl09/L; P=NS), serum aspartate aminotransferase (59+71.5 U/L vs 61 ±43.2 U/L; P=NS), serum alanine ami¬ notransferase (59±91 U/L vs 63±69 U/L; P=NS), serum al¬ kaline phosphatase (177±39 U/L vs 170±42 U/L; P=NS), serum 7-glutamyltransferase (114± 155 U/L vs 169± 184 U/L;
High
P=NS).
These results provide no support for the possibility that the seen in our alcoholic subjects was mediated by alcohol-induced liver disease. Instead, they suggest that high RDW is caused by alcohol abuse in some other manner. The main theory for the high erythrocyte mean cell volume in alcohol abusers is that it is caused by the direct toxic effect of alcohol on red cells.4 We suggest that this may be true also with RDW.
high RDW
Kaija Sepp\l=a"\,MD University of Tampere (Finland) Pekka Sillanaukee, MSc Helsinki, Finland
MD Ill
Hirsch,
Carpentersville,
AY, Ihde DC. Recent developments in the treatment of lung cancer. JAMA. 1992;267:1661-1664. 2. Hayward RSA, Steinberg EP, Ford DE, Roizen MF, Roach KW. Preventive care guidelines: 1991. Ann Intern Med. 1991;114:758-783. 1. Lin
In Reply.\p=m-\The"routine" chest roentgenogram in our patient performed by referring physicians. The case was chosen for presentation to illustrate that distant metastases are a major threat even to patients with localized lung cancer who undergo complete surgical resection. The characteristics of a disease that is suitable for periodic health evaluation among asymptomatic subjects are well described.1 The fact that there is no highly effective treatment modality available for treating occult distant metastases hamwas
cancer.
on
Ezekiel J. Emanuel, MD Dana-Farber Cancer Institute Linda L. Emanuel, MD Massachusetts General Hospital Boston
Ronald L.
pers the effectiveness of periodic screening for lung cancer. Major studies have addressed this specific issue.2-4 We agree that at present there is no proven utility in screening for lung
1. Bessman JD, McClure S. Red cell distribution width in alcohol abuse and iron de-
anemia. JAMA. 1992;267:1071. 2. Bessman JD, Gilmer PR Jr, Gardner FH. Classification of anemias
ficiency
by MCV and RDW. Am J Clin Pathol. 1983;80:322-326. abuse and iron deP. Red cell distribution width in alcohol Sillanaukee Sepp\l=a"\K, ficiency anemia. JAMA. 1992;267:1070. 4. Wu A, Chanarin I, Levi AJ. Macrocytosis of chronic alcoholism. Lancet. 1974;1: 829-830. 3.
The Death of a Baby: Neither Forgiven Nor Forgotten To the Editor.\p=m-\Hereis a different perspective on the article by Hickson et al.1 I am a plaintiffs negligence attorney, experienced in medical malpractice defense, and am married
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/16/2015
a physician. My wife was pregnant with our first child. We used an obstetrician-gynecologist group that employed a classmate of hers. During the pregnancy, that associate left the group without our knowledge. We decided to remain with the group since they were familiar with her prenatal care. In my wife's 37th week, the doctor thought the fetus was in a breech position. If its position did not change, he said, a
to
section would be indicated. No cesarean was scheduled. At my wife's next appointment, she was examined by a physician who was not familiar with her case. The fetus was still in a breech position, and again no cesarean date was scheduled, nor were special instructions or tests given. She was to return in 5 days. We vowed on the next visit to ask about scheduling a cesarean. Thirty-six hours later, my wife's membranes ruptured and the umbilical cord prolapsed through her cervix. Despite the heroic efforts of many and a "crash" cesarean section, our baby was delivered. She had devastating neurological defi¬ cits, to which she succumbed 5 days later. The surgeon said the fetus was a double-footling breech presentation. He was surprised that an ultrasound had not been previously ordered. He also revealed that my wife had a heart-shaped uterus, predisposing to a breech presen¬ tation. No one from the obstetrician-gynecologist group ever called to inquire why the scheduled appointment was not kept. Afterward, we tried to call the group. Didn't they want to know the outcome of the pregnancy? Was there something to learn from this? No one returned our calls. Finally, when my wife did get a call, condolences were offered without admis¬ sion of any errors in patient management. We never heard from the physician who performed the last examination. Does she even remember my wife's name? Many people, including some physicians, suggested that we bring a malpractice claim. The surgeon had strongly hinted that errors were committed, but we wanted a baby, not a monetary windfall. We are still extremely angry with our original physicians: they totally lacked the skills to communicate, yet, in truth, nothing they could have said would have satisfied us. Why did we not bring a claim? First, our baby died. The laws of our state allow only minimal damages for the death of a newborn. Our emotional and psychological harm was totally noncompensable without an independent physical in¬ jury to the mother. No decent attorney would accept a neo¬ natal death case with such limited potential recovery. Second, a claim would subject us to abuse from defense attorneys, who might even accuse us of wrongdoing. We did not want to relive this nightmare until a claim was closed. Today, we have neither forgiven nor forgotten. cesarean
This case illustrates several of our findings. Mr Feilich said:
"Afterward, we tried to call the group," and "No one returned our calls." Few patients in our study believed that their physicians returned such calls in a timely manner. While we can only speculate about the reasons for this seeming reluctance, at least some hesitancy may relate to physicians' lack of training in how to deal with grieving and angry families. Some physicians may also fear that their offers of regret could be misconstrued as admissions of guilt. Perhaps an appro¬ priate strategy in such cases would be to schedule an office visit with the family. Adequate time could be allotted to express condolences, answer questions, and face the family's complaints. In addition, scheduling a meeting would permit
those involved to review medical records including those from physicians who provided emergency care and to consult with risk managers if indicated. The case also illustrates a practice style that may contrib¬ ute to misunderstandings and patient dissatisfaction, espe¬ cially if there is an adverse outcome. Families recognize that their primary physician cannot be available for each prenatal visit. Families do expect, however, that someone is still in charge, knowledgeable about the case and responsible for communication of the care plan among all members of the group. When a physician declares that "a cesarean section would be indicated," then as far as the family is concerned, the standard has been set. Each physician subsequently exam¬ ining the patient must be guided by the standard or explain why the plan is no longer appropriate. Given the family, the physicians' statements, the cord prolapse, and the ultimate outcome, it is not surprising that the family recognized that a problem had occurred and were encouraged to file by the "hints" of medical acquaintances. Our study and this letter suggest that some families have noneconomic goals that prompt them to file claims. Bringing a lawsuit is an effective way to get the attention of one who allegedly has wronged another. There may, however, be more efficient ways to achieve the same goal. It seems worthwhile for physicians and states to explore the development of al¬ ternative forums for communication between families and physicians. No one should have to file suit to find out what happened or to be able to express anger. Finally, Feilich's comments illustrate how tort reforms that limit recovery in cases of fetal death undermine families' already limited abil¬ ities to seek redress of their grievances, especially when those grievances are not primarily economic in nature. Gerald B. Hickson, MD Ellen Wright Clayton, MD, JD Vanderbilt University School of Medicine Nashville, Tenn
Burt Feilich New York, NY 1. Hickson GB, Clayton EW, Githens PB, Sloan FA. Factors that prompted families
to file medical malpractice claims following perinatal injuries. JAMA.
1363.
1992;267:1359\x=req-\
In Reply.\p=m-\Thisstory unfortunately is typical of many cases examined in seeking to identify factors prompting families to file malpractice claims. In almost all cases, and independent of determinations of liability, families indicated that there were problems with patient-physician communication and that these problems were often "the last straw" in their decisions to file claims. Many told us they pursued litigation even though they realized that the process might rekindle old feelings of grief and subject them to the trauma of the courtwe
Errors in Table. \p=m-\In the article entitled "Mortality Among Workers at Oak Ridge National Laboratory: Evidence of Radiation Effects in Follow-up Through 1984," published in the March 20, 1991, issue of The Journal (1991;265:1397-1402), a number of errors occurred in the three bottom rows in the "Leukemia" category in Table 4, on page 1399. The values under the "Leukemia" heading in the first column should be 0, 5, and 10 (not 0,10, and 20); the values under "Increase, %" in the second column should be 2.60,2.93, and 3.75 (not 6.38, 6.88, and 9.15); the values under "SE" in the third column should be 3.95, 4.01, and 4.05 (not 10.71,10.93, and 11.07); the values under "\g=x\2(1 df)" in the fourth column should be 0.4, 0.5, and 0.7 (not 0.0, 0.0, and 0.6); and the values under "P value" in the fifth column should be .53, .48, and .40 (not 1.0,1.0, and .44). The leukemia results reported in Table 5 were correct.
room.
Downloaded From: http://jama.jamanetwork.com/ by a Simon Fraser University User on 06/16/2015
