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PubMed2002

ACOG Committee Opinion: number 280, December 2002. The role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer.

The purpose of this Committee Opinion is to define the role of the generalist obstetrician-gynecologist in the early detection of ovarian cancer. Currently, it appears that the best way to detect early ovarian cancer is for both the patient and her clinician to have a high index of suspicion of the diagnosis in the symptomatic woman. In evaluating symptoms, physicians should perform a physical examination, including a pelvic examination. In premenopausal women with symptoms, a CA 125 measurement has not been shown to be useful in most circumstances. In postmenopausal women with a pelvic mass, a CA 125 measurement may be helpful in predicting a higher likelihood of a malignant tumor than a benign tumor, which may be useful in making consultation or referral decisions or both. A woman with a suspicious or persistent complex adnexal mass requires surgical evaluation by a physician trained to appropriately stage and debulk ovarian cancer. Data suggest that currently available screening tests do not appear to be beneficial for screening low-risk, asymptomatic women. An annual gynecologic examination with an annual pelvic examination is recommended for preventive health care.

CA-125 Antigen↗
PubMed2001

[Gain, loss and agreement between respiratory specialists and generalists in the diagnosis of asthma].

OBJECTIVE: To determine and analyze the degree of agreement and disagreement in the diagnosis of bronchial asthma (BA) by respiratory disease specialists and generalists in regional hospital and primary care settings. MATERIAL AND METHODS: Ninety-six outpatients (16 to 70 years of age) were studied; all had been assigned a diagnosis of BA by the referring physician or by the respiratory disease specialist. We recorded 1) clinical symptoms, determining the initial probability of a diagnosis (IPD)of BA to be high, medium or low; 2) results of spirometry and bronchodilator testing (BDT), peak flow variability and methacholine challenge testing; 3) prick test results, eosinophil levels and total serum IgE levels. Three diagnoses were recorded: the initial diagnosis (ID) by the referring physician to whom follow-up data were unavailable; diagnosis by the respiratory disease specialist based only on clinical symptoms (RSS); and the final diagnosis(FD). To arrive at a FD of BA, it was necessary to have a high or medium IPD and a positive BDT. A Kappa test was used to analyze the degree of agreement among the three diagnoses. Group features associated with greater or lesser agreement were analyzed by chi-square tests and analysis of variance. RESULTS: Agreement was acceptable between RSS and FD (K = 0.63) but very low between ID and RSS and between ID and FD. In the latter two cases, agreement was greatest for patients diagnosed in hospital and for those with high IgE levels (p < 0.05), with high IPD, longer course of disease and a history of asthma (p < 0.01) (odds ratio =59.8). Diagnostic disagreement occurred mainly for patients for whom a BA diagnosis was gained later, the of under-diagnosis being 39%. The patients involved visited the physician only because they had observed an isolated symptom related to asthma (odds ratio = 119) and to arrive at a diagnosis bronchomotor tests other than BDT were required (p < 0.01). CONCLUSIONS: a) The degree of agreement for a diagnosis of BA is low. b)The functional profile of patients for whom diagnostic agreement exists differs from that of patients for whom diagnosis is gained through testing. c) In the context of this study, a high rate of under-diagnosis is evident.

Adolescent↗
PubMed1992

Specialists and generalists in obstetrics and gynecology: conflicts of interest in referral and an ethical alternative.

Referral patterns of physicians have a direct impact upon the care of patients, particularly in obstetrics and gynecology. The choice of referral is influenced by the history of specialization, physician altruism, and intricate patterns of financial conflicts of interest. The conflicts of interest are further obscured by the lack of clear definition of roles and responsibilities for generalist, specialist, and subspecialist. Alternate patterns for referral based on financial incentives or directed referral care plans are reviewed to examine the potential conflicts of interest. An ethics-based format for referral is outlined to address these conflicts of interest.

Attitude of Health Personnel↗
PubMed1999

Consultation for asthma: results of a generalist survey.

BACKGROUND: There are few studies that examine referral patterns for asthma and few studies that examine the referring physicians' reasons for consultation. OBJECTIVE: The purpose of this study was to survey generalist physicians on their referral patterns for adult patients with asthma. METHODS: We mailed a questionnaire to all the staff (faculty) in the Department of Family Medicine and the Division of Community Internal Medicine at the Mayo Clinic in Rochester, Minnesota. There were 37 completed questionnaires (18 family medicine and 19 internal medicine) out of a total of 58 for a response rate of 64%. The survey asked what were reasons for consultation, whether allergists or pulmonologists were preferred, and the characteristics of a good consultation. RESULTS: We asked respondents to indicate "how often you consult a specialist for an adult asthma patient" for a variety of clinical indications. The percentage responding "always" (for the top five indications) were if the patient requests one (46%), for allergen immunotherapy (38%), for single life-threatening attack (27%), for allergy testing (14%), and for steroid-dependent asthma or poorly controlled asthma (11%). Twenty-seven percent of respondents generally consulted allergists only, 22% generally consulted pulmonologists only, 3% indicated both, while 46% had no preference. Respondents did express a preference for a pulmonologist when the reported reason for the consultation was diagnosis of asthma uncertain, chronic cough, asthma in smoker, exercise training, or for an allergist when the reported reason for consultation was allergy evaluation or immunotherapy. The respondents indicated that the top six characteristics of a good consultation were the following: clear recommendations, clinically appropriate recommendations, high patient satisfaction, including recommendations for future management scenarios, including educational content in the consultation, and calling the referring physician before requesting a secondary consultation. CONCLUSIONS: These results suggest that while consultation occurs often for severe or uncontrolled asthma, some asthma patients who may benefit from consultation may not be seeing the specialist. There were no systematic preferences for consultations with allergists versus pulmonologists for asthma although for some clinical indications pulmonologists or allergists were favored. Referring physicians value clear, clinically appropriate recommendations.

Adult↗
PubMed2003

Digestive efficiency of a generalist avian feeder, the Cape White-eye (Zosterops pallidus).

Digestive processes determine whether the particular diet of a bird is utilized efficiently and whether energetic demands are met. Assimilation efficiency is often used as an index of whether a diet is digested optimally. Studies on the digestive processing of generalist feeders are scarce. Cape White-eyes (Zosterops pallidus) have a diverse diet of fruit, nectar and insects. The nutrient contents of these three diets vary considerably and require quite different digestive processing. This study compared the digestive efficiencies of Cape White-eyes on these three diets by measuring transit times and assimilation efficiency. Cape White-eyes lost body mass significantly when fed fruit, while they maintained and gained body mass on nectar and mealworm diets, respectively. Assimilation efficiency varied significantly between the three diet types (nectar>mealworms>apples). When given a choice of diets, Cape White-eyes selected the diet, which was most efficiently digested and yielded the greatest energetic reward. Diet preference trials further showed that Cape White-eyes regulated daily energy intake. Assimilation efficiency depends on the accessibility of nutritional contents of a diet. Cape White-eyes did not maximize assimilation efficiency. Instead, they adjusted transit time to maximize the rate of energy gain per gram of food in order to maintain energy balance.

Animals↗
PubMed2001

Seasonal occurrence of specialist and generalist insect predators of spider mites and their response to volatiles from spider-mite-infested plants in Japanese pear orchards.

In two adjacent Japanese pear orchards (orchards I and 2), we studied the seasonal occurrence of the Kanzawa spider mite. Tetranychus kanzawai, and its predators. Also the response of these predators to the volatiles from kidney bean plants infested with T kanzawai was investigated using trap boxes in orchard 1. The mite density in orchard 1 was unimodal. with one peak at the end of August. In this orchard, population development of the specialist insect predators, Scolothrips takahashii, Oligota kashmiria benefica and Stethorus japonicus was almost synchronized with that of the spider mites. These predators disappeared when the density of their prey became very low in mid-September. Both S. takahashii and O. kashmirica benefica abruptly increased in number in orchard 2 when the spider mite population in orchard 1 decreased. These results suggested that some of the predators migrated from orchard 1 to orchard 2. In this period, predator-traps with T kanzawai-infested bean plants attracted significantly more S. takahashii than traps with uninfested plants. Very few individuals of S. japonicus and O. kashimirica benefica were found in the traps, despite their abundance in orchard 1. The generalist insect predator, Orius sp., was attracted to the traps throughout the experimental period irrespective of the density of spider mites, although this predator was never observed inside the orchards.

Animals↗
PubMed2003

Larval exposure to oviposition deterrents alters subsequent oviposition behavior in generalist, Trichoplusia ni and specialist, Plutella xylostella moths.

The present study was undertaken to determine the effects of larval feeding experience on subsequent oviposition behavior of the resulting moths. Larvae of the cabbage looper (Trichoplusia ni, Noctuidae) and the diamondback moth (Plutella xylostella, Plutellidae) were exposed to the phenylpropanoid allelochemical trans-anethole (at 100 ppm fw in artificial diet) or the limonoid allelochemical toosendanin (10 ppm sprayed on cabbage leaves). Both compounds had been shown to deter oviposition in naive moths in previous choice tests. Moths developing from "experienced" larvae (both sexes) showed a decrease in oviposition deterrence response when given a choice between control and treated leaves, unlike naïve moths. This phenomenon, analogous to habituation to feeding deterrents in lepidopteran larva, occurred irrespective of duration of feeding on the deterrent compound. We also observed that F1 larvae resulting from experienced moths (previously exposed to toosendanin as larvae) grew as well on toosendanin-treated foliage as on control foliage. In contrast, growth of F1 larvae from naïve moths was significantly impaired by toosendanin. These results demonstrate that host-selection behavior in cabbage looper (a generalist) and diamondback moth (a specialist) may be shaped by feeding experience according to Hopkins' Host Selection Principle in addition to chemical legacy.

Allylbenzene Derivatives↗
PubMed2003

Synergistic effects of three Piper amides on generalist and specialist herbivores.

The tropical rainforest shrub Piper cenocladum, which is normally defended against herbivores by a mutualistic ant, contains three amides that have various defensive functions. While the ants are effective primarily against specialist herbivores, we hypothesized that these secondary compounds would be effective against a wider range of insects, thus providing a broad array of defenses against herbivores. We also tested whether a mixture of amides would be more effective against herbivores than individual amides. Diets spiked with amides were offered to five herbivores: a naïve generalist caterpillar (Spodoptera frugiperda), two caterpillar species that are monophagous on P. cenocladum (Eois spp.), leaf-cutting ants (Atta cephalotes), and an omnivorous ant (Paraponera clavata). Amides had negative effects on all insects, whether they were naïve, experienced, generalized, or specialized feeders. For Spodoptera, amide mixtures caused decreased pupal weights and survivorship and increased development times. Eois pupal weights, larval mass gain, and development times were affected by additions of individual amides, but increased parasitism and lower survivorship were caused only by the amide mixture. Amide mixtures also deterred feeding by the two ant species, and crude plant extracts were strongly deterrent to P. clavata. The mixture of all three amides had the most dramatic deterrent and toxic effects across experiments, with the effects usually surpassing expected additive responses, indicating that these compounds can act synergistically against a wide array of herbivores.

Amides↗
PubMed2004

Interactive effects of genotype, environment, and ontogeny on resistance of cucumber (Cucumis sativus) to the generalist herbivore, Spodoptera exigua.

Host-plant genotype, environment, and ontogeny all play a role in determining plant resistance to herbivory, yet little is known about the nature of the interactions among these factors. We investigated resistance of cucumber plants Cucumis sativus to the generalist herbivore Spodoptera exigua in a manipulative experiment involving three factors. In particular, we tested the effects of bitter (cucurbitacins present) vs. sweet (cucurbitacins absent) plants (genotype), with or without previous herbivory (environment), and cotyledons vs. true leaves (ontogeny). Contrary to our expectations, S. exigua growth was 54% higher on bitter plants than on sweet plants; growth was 63% higher, however, on undamaged plants compared to damaged plants, and 59% higher on true leaves compared to cotyledons. Moreover, all two-way interaction terms between genotype, environment, and ontogeny were significant. For example, S. exigua performance was higher on bitter than on sweet plants; however, this effect was strongly influenced by whether the tissue consumed was a cotyledon or true leaf and also whether it had been previously damaged. An examination of leaf nutritional chemistry revealed that some of our results could be explained by genotypic, environmental, and ontogenic differences in foliar nitrogen content. In contrast, the cucurbitacin content of plants did not appear to affect caterpillar growth. Our results provide evidence for the importance of interactions between genotype, environment, and ontogeny in determining herbivory and illustrate the value of manipulative experiments in revealing the complexities of these interactions.

Adaptation, Physiological↗
PubMed2004

Attack rate and success of the parasitoid Diaeretiella rapae on specialist and generalist feeding aphids.

Lipaphis erysimi (Kaltenbach) is a specialist crucifer feeding aphid and Myzus persicae (Sulzer) is a generalist feeding aphid. The foraging behavior of Diaeretiella rapae (McIntosh), a parasitoid with the ability to parasitize both of these species, was assessed using a series of attack rate and success bioassays, with turnip, Brassica rapa var rapifera, as the host plant. The attack rate of D. rapae was significantly greater on L. erysimi than on M. persicae when aphids were feeding on turnip leaf discs in Petri dishes, irrespective of the aphid species upon which the parasitoids were originally reared. Attack rate bioassays with leaf discs absent, using both satiated and starved aphids, revealed that background chemistry and internal aphid chemistry may have small effects on attack rate. Excision of D. rapae pupae from mummy cases and subsequent use of the fully developed adults in attack rate bioassays showed that cues received by D. rapae at the time of adult emergence provide cues that prime D. rapae to attack L. erysimi at a greater rate than M. persicae. However, the relative success of D. rapae on these two aphid species, in terms of the percentage of attacks resulting in a successful adult parasitoid, was not significantly different.

Animals↗
PubMed2005

Generalist genes and learning disabilities.

The authors reviewed recent quantitative genetic research on learning disabilities that led to the conclusion that genetic diagnoses differ from traditional diagnoses in that the effects of relevant genes are largely general rather than specific. This research suggests that most genes associated with common learning disabilities--language impairment, reading disability, and mathematics disability--are generalists in 3 ways. First, genes that affect common learning disabilities are largely the same genes responsible for normal variation in learning abilities. Second, genes that affect any aspect of a learning disability affect other aspects of the disability. Third, genes that affect one learning disability are also likely to affect other learning disabilities. These quantitative genetic findings have far-reaching implications for molecular genetics and neuroscience as well as psychology.

Humans↗
PubMed1999

Differences in curriculum emphasis in US undergraduate and generalist residency education programmes.

OBJECTIVES: Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. DESIGN: Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. SETTING: US allopathic medical schools. SUBJECTS: Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). RESULTS: Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. CONCLUSIONS: The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.

Curriculum↗
PubMed1997

Differences in generalist and specialist physicians' knowledge and use of angiotensin-converting enzyme inhibitors for congestive heart failure.

OBJECTIVE: To quantify the extent and determinants of underutilization of angiotensin-converting enzyme (ACE) inhibitors for patients with congestive heart failure, especially with respect to physician specialty and clinical indication. DESIGN: Survey of a national systematic sample of physicians. PARTICIPANTS: Five hundred family practitioners, 500 general internists, and 500 cardiologists. MEASUREMENTS AND MAIN RESULTS: Physicians' choice of medications were determined for four hypothetical patients with left ventricular systolic dysfunction: (1) new-onset, symptomatic; (2) asymptomatic; (3) chronic heart failure, on digitalis and diuretic; and (4) asymptomatic, post-myocardial infarction. For each patient, randomized controlled trials have demonstrated that ACE inhibitors decrease mortality or the progression of symptoms. Among the 727 eligible physicians returning surveys (adjusted response rate 58%), approximately 90% used ACE inhibitors for patients with chronic heart failure who were already taking digitalis and a diuretic. However, family practitioners and general internists chose ACE inhibitors less frequently (p < or = .01) than cardiologists for the other indications. Respective rates of ACE inhibitor use for each simulated patient were new-onset, symptomatic (family practitioners 72%, general internists 76%, cardiologists 86%); asymptomatic (family practitioners 68%, general internists 78%, cardiologists 93%): and asymptomatic, postmyocardial infarction (family practitioners 58%, general internists 70%, cardiologists 94%). Compared with generalists, cardiologists were more likely [p < or = .05] to increase ACE inhibitors to a target dosage (45% vs 26%) and to tolerate systolic blood pressures of 90 mm Hg or less [43% vs 15%). CONCLUSIONS: Compared with cardiologists, family practitioners and general internists probably underutilize ACE inhibitors, particularly among patients with decreased ejection fraction who are either asymptomatic or post-myocardial infarction. Educational efforts should focus on these indications and emphasise the dosages demonstrated to lower mortality and morbidity in the trials.

Adult↗
PubMed2004

Disentangling food quality from resistance against parasitoids: diet choice by a generalist caterpillar.

The relative importance of food quality and enemy-reduced space is a central but unresolved issue in the evolutionary ecology of host use by phytophagous insects. Indeed, a practical obstacle to experimentally disentangling the functional roles of these factors is the host specificity of insect herbivores, particularly toxic plant specialists. In this study, we employ a toxic plant generalist to uniquely disentangle these alternative explanations. We experimentally demonstrate that the value of enemy-reduced space supersedes that of food quality in determining the diet and host preference of the polyphagous woolly bear caterpillar Grammia geneura (Lepidoptera: Arctiidae). Caterpillars sacrificed superior growth efficiency in choosing a mixed diet that included toxic host plants and provided resistance against parasitoids. The resistance of individual caterpillars was associated with the relative amount of defensive plants eaten as well as with the sequestration of pyrrolizidine alkaloids from one such plant (Senecio longilobus).

Ambrosia↗
PubMed2003

Cyanogenic potential in cassava and its influence on a generalist insect herbivore Cyrtomenus bergi (Hemiptera: Cydnidae).

The hypothesis that cyanogenic potential in cassava is a defense mechanism against arthropod pests is one of the crucial questions relevant to current efforts to reduce or eliminate cyanogenic potential (CNP) in cassava. The generalist arthropod Cyrtomenus bergi, which attacks cassava roots, was used in a bioassay relating oviposition and survival to CNP, concentration of nonglycosidic cyanogens, and linamarase (beta-glycosidase) activity in twelve selfed cassava siblings and their parental clone, which has segregated for different levels of cyanogenesis. Electron microscopic evaluation revealed an intracellular pathway of the stylet of C. bergi in the cassava root tissue to rupture cell walls. This feeding behavior causes cyanogenesis and increased linamarin content in the hemolymph of C. bergi while feeding on a cyanogenic diet. This diet resulted in a significant reduction in oviposition, especially at levels of CNP above 150 ppm (expressed as hydrogen cyanide) on fresh weight basis (or 400 ppm on dry weight basis) in cassava roots. An exponential decline in oviposition was observed with increasing levels of CNP, beginning 12 d after exposure to the cyanogenic diet. Cyanogenic potential and dry matter content showed a positive effect on survival. No relationship was found between concentrations of nonglycosidic cyanogens or linamarase activity in the cassava root and either oviposition or survival. According to our results, there is a significant difference between potentially noncyanogen and high cyanogen clones, but there may not be a significant difference between potentially noncyanogen and low cyanogen clones. Consequently, more frequent outbreaks or higher levels of damage might not be anticipated in potentially noncyanogen cassava clones than that anticipated in low cyanogenic clones. The negative effect of cyanogenesis on oviposition concurrent with a positive effect on survival of this pest is most likely the result of a physiological trade-off between survival and oviposition. The question of whether ovipositional rates could be recovered after a long-term exposure to cyanide remains unanswered.

Animals↗
PubMed1995

A generalist's place is (also) in the home.

Regardless of how many generalist physicians we eventually have, patients will not get the treatment they need if doctors continue to work without house calls. For decades, patients have been coaxed out of their sickbeds to report to emergency rooms during "off hours," and once in the emergency room they are part of high-tech, test-driven health care. Only a return of the house call by the personal physician can reliably forestall this protocol-driven excess. There are obstacles aplenty to reviving the house call: few teachers survive who can teach this art; doctors now consider the house call burdensome work; present payment does not cover the costs; and doctors won't be safe on the streets at night. Some bureaucratic changes will be needed, of course, but most changes have to do with skills and attitudes. Care in the home is appropriate for many acute illnesses and chronic conditions. Patients need it, and doctors should provide it.

Emergencies↗
PubMed1995

Academic health centers and HMOs: a systems perspective on collaboration in training generalists physicians and advancing mutual interests.

Academic health centers (AHCs) and health maintenance organizations (HMOs) often hold each other at arm's length because of fundamental organizational differences. AHCs view HMOs as too intrusive in the clinical management of patients and too concerned with the financial bottom line. HMOs view AHCs as organizationally fragmented and expensive in providing health care services. AHCs must expand their primary care networks and reassess their mission and public accountability in training a more balanced physician workforce. HMOs are growing rapidly and need well-trained generalist physicians to support that growth. This paper uses an organizational systems model in examining AHCs and HMOs to identify common needs, mutual interests, areas for potential collaboration, and bridging strategies. These include health care systems development, professional education, information management systems, and health services research. As the financing and delivery of health care continue to change and to become more integrated, both organizations have much to gain from collaboration.

Academic Medical Centers↗
PubMed1999

Institutional change: embracing the initiative to train more generalists.

Dartmouth Medical School was one of 16 U.S. medical schools that received a Generalist Physician Initiative (GPI) grant from The Robert Wood Johnson Foundation in 1994. This article describes institutional change at the school, noting that while the context in which the GPI was launched was receptive, the grant enabled Dartmouth to accelerate institutional changes already under way. Perhaps even more important is that Dartmouth used an approach to change that worked, and although the specific actions may not generalize to other schools, the authors hope the principles will. Key among these principles were capitalizing on a sense of urgency for change, creating and empowering a guiding coalition, developing and communicating the vision, generating short-term wins, consolidating gains, and anchoring new approaches to the existing institutional culture. Changes at Dartmouth are described in the areas of admission and recruitment, undergraduate and graduate medical education, and supporting community practice. The authors also describe shortcomings in developing the program, such as maintaining the guiding coalition in the face of the changing health care system and clinical pressures, developing a vision and strategy in areas managed by the state, and engagement of a broad-based group.

Curriculum↗