The principal goals of the pending health care reform initiatives in the United States are improving access to health care and controlling its costs. There are multiple proposals designed to reach these goals. Regardless of the final result, health care reform is likely to have significant implications for postgraduate surgical education. The teaching environment is already rapidly changing. Present environmental influences include the explosion of surgical knowledge, demographic changes, expansion of regulatory requirements from within the health care delivery system and within surgery as a discipline, societal and cultural changes, and economic pressures. Current and pending concerns prompt several questions: What should we teach? Where do we teach? How long should it take? Who are our learners? How do we evaluate our educational programs? Who should pay? A number of predictable changes affecting surgical education are proposed. New, more complex technologies will result in increased surgical specialization. Demands on surgical education will require that it be shorter, more relevant, more efficient, more effective, and more accountable. Surgical manpower requirements must be more clearly defined. Better and more relevant measures of clinical outcomes will be developed. Use of improved informational technology to manage clinical activity will expand. Solutions to the problem of foreign medical graduates will be clarified. The issue of who pays for surgical education will require resolution with some new and creative results. A proposal for shorter and more effective surgical residency is advocated.

Education, Medical, Continuing↗

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Heart transplantation for Barth syndrome.

Barth syndrome is an X-linked recessive disorder comprising dilated cardiomyopathy, muscular hypotonia, and cyclical neutropenia. Affected children usually die during infancy as a consequence of septicemia, cardiac failure, or both. We report a patient with Barth syndrome who underwent successful heart transplantation.

Cardiomyopathies↗

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Fecal leukocytes in stool specimens submitted for Clostridium difficile toxin assay.

To determine their diagnostic utility, fecal leukocytes were sought by methylene blue stain in 502 consecutive stool specimens submitted for Clostridium difficile toxin assay. In addition, the stability of fecal leukocytes was assessed by daily examination of 23 stool specimens stored at 4 degrees C and room temperature. The sensitivity, specificity, and positive and negative predictive values of fecal leukocytes in predicting C. difficile toxin assay results were 28%, 92%, 27%, and 93%, respectively. At 4 degrees C, fecal leukocytes retained morphology for a minimum of 3 days. Leukocytes survived as long in stool specimens containing either C. difficile toxin or an enteric pathogen as they did in stool specimens with neither finding. We conclude that testing stool specimens for fecal leukocytes is not useful for predicting the presence of C. difficile toxin, because 72% of stool specimens positive for C. difficile toxin are negative for fecal leukocytes despite their stability.

Adolescent↗

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Developing clinical expertise in the care of addicted patients in acute care settings.

Patients with problems related to addiction are frequently encountered in acute care hospitals. Behavioral difficulties and other obstacles to treatment often threaten the smooth application of compassionate plans of care for these patients. The authors describe the use of an addiction nurse expert and a group of clinical resource nurses to advance the level of practice at one institution with regard to addicted patients. The work of Benner on the process of skill acquisition in nursing is used as a framework for the discussion.

Adult↗

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Drug use behaviors among Asian drug users in San Francisco.

Due to a pervasive bias toward Asian Americans, such as tendency to view Asian Americans as model minorities, drug use behaviors among them are often ignored by health professionals, researchers, and community members, including Asian community members. This study identified patterns of drug use behaviors in relation to cultural factors among Asian drug users in San Francisco, CA. A sample of 92 Asian drug users (35 Chinese, 31 Filipino, 26 Vietnamese) who were not currently enrolled in drug treatment programs were recruited through targeted sampling methods and interviewed using a questionnaire with open-ended questions. The study evaluated responses of the participants and used content analyses. This study clearly revealed that the patterns of drug use among Asian drug users are unique to their ethnicity, gender, immigrant status, and age groups. Also, Asian drug users share cultural constructs related to drug use such as fear of addiction and injecting drugs, and stigma attached to drug users in the community. Therefore, drug abuse prevention programs should address both common factors among Asian drug users, as well as unique factors in specific target groups (e.g., ethnic groups, Asian immigrants, Asian women, refugees, and adolescents).

Adult↗

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What is the relevance of the various immunomodulatory effects of interferons?

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Animals↗

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Childhood psoriasis: a clinical review of 1262 cases.

Our aim was to describe the types of psoriasis seen in a large series of patients presenting to a tertiary referral pediatric dermatology department using a classification system combining conventional terminology and additional categories based on the site and characteristics of the rash. A total of 1262 patients seen consecutively in the dermatology department of the Royal Alexandra Hospital for Children, Sydney, Australia, between 1981 and 1995 are described and classified according to the pattern of psoriasis at the time of presentation. Additional information recorded included family history, facial involvement, and history of a psoriatic type of diaper rash in infancy. The ages of the children ranged from 1 month to 15 years. There was an equal gender distribution and a high rate of positive family history at 71%. Twenty-six percent of children had a history of a psoriatic diaper rash and facial involvement occurred in 38% of children. Plaque psoriasis was the most common type overall, affecting 430 patients (34%). Three hundred forty-five children were less than 2 years of age, and this is the largest series of children with psoriasis in this age group presented to date. An entity defined by us as psoriatic diaper rash with dissemination was the most common type of psoriasis in the less than 2-year age group, affecting 155 (45%) patients. This large series offers information on the manifestations of psoriasis in childhood, but is particularly useful in examining the previously less well-described infant age group. The classification used is proposed as a practical way to describe psoriasis in children, particularly with respect to future descriptive studies.

Adolescent↗

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Endocarditis due to Corynebacterium pseudodiphtheriticum: five case reports, review, and antibiotic susceptibilities of nine strains.

Five cases of endocarditis due to Corynebacterium pseudodiphtheriticum are described. Two patients died, two patients with prosthetic valve endocarditis were successfully treated with antibiotics and valve replacement, and one patient with native valve endocarditis was successfully treated with penicillin alone. We also review 12 previously reported cases of C. pseudodiphtheriticum endocarditis. In vitro susceptibilities to 15 antibiotics were determined for nine isolates. The minimum inhibitory concentrations (MICs) of penicillin, amoxicillin, cefamandole, cephalexin, and rifampicin were all less than or equal to 0.12 mg/L. The MICs of vancomycin and ciprofloxacin for all strains were less than or equal to 0.5 mg/L. Tobramycin was the most active aminoglycoside, with MICs for all strains that were less than or equal to 0.12 mg/L. On the basis of in vitro data and the results of previous reports, penicillin alone or in combination with an aminoglycoside should achieve bacteriologic cure. Vancomycin should be used in patients who are allergic to penicillin.

Adolescent↗

PubMedDate not supplied

Transforming perspectives using a political assessment inventory.

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Attitude of Health Personnel↗

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Modulation of Bcl-2 family proteins in primary endothelial cells during apoptosis.

We studied the expression of Bcl-2 family proteins during cytokine- and verotoxin (VT)-induced apoptosis in primary human umbilical vein endothelial cells (HUVECs). Our experiments demonstrated that high initial expression of Bcl-2 protein was significantly downregulated in HUVECs treated with IFN-gamma whereas TNF-alpha gave a less pronounced decrease in Bcl-2 level. Treatment with the combination of cytokines was more efficient in downregulating Bcl-2 protein. HUVECs pretreated with cytokines and incubated with VT gave a further significant decrease in Bcl-2 level. Simultaneous measurement of Bcl-xl level did not reveal any significant changes. Bax protein was upregulated in HUVECs stimulated with TNF-alpha alone or in combination with IFN-gamma. However, addition of VT did not give any further increase in Bax level suggesting that Bax upregulation is more important for cytokine- rather than VT-mediated apoptosis. Total endothelial cell growth factor deprivation gave a significant increase in apoptosis accompanied by a decrease of Bcl-2 in apoptotic cells while Bcl-xl and Bax levels were unaffected. Our data indicate that anti-apoptotic protein Bcl-2 and pro-apoptotic protein Bax are reciprocally regulated during apoptosis, whilst Bcl-xl is essentially unaffected. This implies that Bcl-2/Bax ratio rather than Bcl-xl controls apoptosis in primary endothelial cells.

Apoptosis↗

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Quantitation of HCV RNA in liver of patients with chronic hepatitis C.

BACKGROUND/AIMS: Liver HCV RNA has been quantitated in few studies and the feasibility and the role of this parameter in the evaluation of patients with chronic HCV hepatitis still warrant study. Our aim was to determine the concentrations of HCV RNA in the liver of chronic HCV patients and to correlate the results with serum viral load. We also studied the relation of levels of HCV RNA in the liver with serum aminotransferases levels and with the presence of cirrhosis. METHODS: Twenty patients (14 males, aged 28 to 61 years) were studied. Twelve were infected by HCV type 1, six by type 3 and one by type 5. Percutaneous liver biopsy samples were obtained from 14 patients, and the remainder from liver explant in patients undergoing OLT. Twelve had chronic hepatitis and eight cirrhosis. HCV RNA levels were determined by bDNA. RESULTS: HCV RNA levels below the detection limit were found in one liver and in five serum samples. HCV RNA (mean +/- SD) was 2.1 x 10(8) +/- 2.2 x 10(8) Eq/gm in the liver and 94 x 10(5) +/- 93 x 10(5) Eq/mL in serum, with a significant correlation between these values (r = 0.89; P < 0.0001). Serum HCV RNA levels were significantly lower (P = 0.001) in cirrhotic than in chronic hepatitis patients, while the groups did not differ in liver HCV RNA levels. No correlation was observed between liver or serum HCV RNA and serum ALT or AST. CONCLUSIONS: Quantitation of HCV RNA is possible even in small liver samples. Although average levels are more than one log higher than those observed in serum, hepatic concentrations correlate with those observed in serum. The application of this technology to monitoring antiviral therapy and understanding the pathogenesis of the disease remains to be determined.

Adult↗

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A digital videofluoroscopic technique for spine kinematics.

The kinematic behaviour of the vertebral segments under the influence of spinal injury and other mechanical problems is difficult to quantify in patients. This paper describes the use of a calibration model and human subjects to investigate the accuracy of a method for determining lumbar intervertebral rotations using images digitized from an image intensifier. The main influences were found to be observer error in marking co-ordinates, scaling of the image presented by the computer's monitor, distortion caused by out-of-plane images and loss of image quality as a result of scattered radiation from the soft tissues. The technique may be valuable in the light of its efficiency and low X-ray exposure to patients.

Biomechanical Phenomena↗