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PubMed1987

Reversed vein bypass to infrapopliteal arteries. Modern results are superior to or equivalent to in-situ bypass for patency and for vein utilization.

In recent years many reports have attributed improved patency and improved vein utilization with lower extremity arterial bypass to infrapopliteal arteries to the use of the in-situ vein graft technique (ISVB). This report describes 110 reversed vein bypasses (RVB) to infrapopliteal arteries performed from 1980-1986. Thirty-three per cent of these patients did not have an intact ipsilateral greater saphenous vein. One hundred per cent of patients had autogenous RVB performed using a variety of techniques, including vein splicing, use of arm veins, lesser saphenous veins, branch veins, and use of graft origins distal to the common femoral artery. The life table patency figures for these grafts are 90%, 85%, and 85% at 1 year, 3 years, and 5 years, respectively. The life table limb salvage at 5 years is 93%. These figures for patency, vein utilization, and limb salvage for modern RVB to infrapopliteal arteries are clearly equal to or superior to any reported figures for ISVB. Results for RVB are greatly improved when compared with historic controls, as are results for ISVB. There is no evidence to date demonstrating superiority of one technique versus another.

Adult↗

PubMed2000

Modern airway management for the trauma patient.

Over the last decade there has been significant advancement in airway management and a recent closed claims analysis indicates a decrease in claims since the 1980s. Studies and new airway devices have focused on managing the difficult airway and the failed intubation, problems which are common to the trauma patient. Although new airway devices have improved our ability to ventilate these patients, they are not 100% reliable nor do they provide a definitive airway. Formal training in airway management and the use of these airway devices has much room for improvement. With increased emphasis on training and the development of improved intubating aids, modern management of the difficult airway may approach 100% success.

Journal Article↗

PubMed1992

Modern trends in bone marrow transplantation for acute myeloid and acute lymphoblastic leukemia.

A greater understanding of the underlying mechanisms of hematopoiesis and leukemogenesis in the clinical management of acute myeloid and lymphoblastic leukemia has led to an improvement in survival from what were invariably fatal diseases. Bone marrow transplantation is increasingly becoming an accepted form of therapy for acute myeloid leukemia and acute lymphoblastic leukemia in certain situations. This review seeks to address some of the recent advances and controversies including whether bone marrow transplantation is more efficacious than modern intensive chemotherapy, the role of autologous bone marrow transplantation and matched-unrelated donor transplants, the graft-versus-leukemia effect, and the role of purging in autologous bone marrow transplantation. Furthermore, advances in supportive therapy including the introduction of hematopoietic growth factors is critically evaluated. Finally, the appropriate timing and role of bone marrow transplantation is discussed in the context of previous ongoing and future clinical trials.

Acute Disease↗

PubMed1998

Using modern information technology to profile faculty activities.

Most academic medical centers (AMCs) have developed mechanisms for tracking the financing of their faculty members' research and clinical activities. However, information systems for managing and reporting financial data often do not provide fully accurate or complete pictures of the accomplishments of an institution or its faculty. Modern information technology can help AMCs integrate more extensive information about their faculties from many different sources; in particular, Web publishing technologies permit large numbers of users to have easy secure access to databases across different platforms. The authors briefly describe five faculty information systems now in use. They then describe in detail the development and implementation of one of these systems, The Johns Hopkins University School of Medicine Faculty Information System (FIS), which uses Web publishing technologies, collecting and making available information about the clinical, teaching, and research activities of faculty members.

Academic Medical Centers↗

PubMed2001

Origins of modern premedical education.

The author reviews the contributions of those individuals and major academic and professional organizations responsible for the development of the modern concepts of the premedical education of a physician. The late 19th century gave rise to scientifically-based medical education in U.S. medical education. It followed that this new emphasis, in medical schools, on laboratory investigation of disease processes demanded a sound introduction to the natural sciences by those who would be candidates for this type of challenging education. Starting with a vocal few, the message gradually was received throughout the country that a properly schooled physician must have the equivalent of a broad baccalaureate education in the natural sciences as well as in the traditional humanities. This essential was recognized by a small nucleus of individuals responsible for the creation of The Johns Hopkins University in 1876 and its school of medicine in 1893; the group was led by the university's first president, Daniel Coit GILMAN: Almost simultaneously other established academic institutions incorporated similar changes and a new era began.

Curriculum↗

PubMed2006

The Medicare Prescription Drug Improvement and Modernization Act: prescription drugs and academic medicine.

The Medicare Prescription Drug, Improvement, and Modernization Act (MMA) provides universally available prescription drug benefits to elderly and disabled Medicare beneficiaries for the first time. This paper first discusses three controversial features of this legislation: (1) the form of the prescription drug benefit package; (2) the use of competing private plans; and (3) the uncertainty about the future cost of the new prescription drug benefit. The paper then evaluates the implications for academic medicine of the prescription drug benefit and other MMA legislative provisions aimed at improving the quality of medical practice and shifting away from acute care. Ultimately, the health of seniors and the efficient use of public funds in the new prescription drug benefit depend centrally on the prescribing practices of physicians. Academic medicine should turn its attention to training the next generation of physicians to be more effective agents and advocates for their patients in their use of pharmaceuticals.

Academic Medical Centers↗

PubMed1987

Principles of modern urodynamic studies.

Modern urodynamic equipment should have at least three channels to record the cystometrogram, the electromyogram of the periurethral striated sphincter, and intrarectal pressure. The addition of simultaneous transrectal ultrasonography is helpful. The bladder should not be irritated when introducing the urodynamics catheter. Variables affecting the performance of the catheter used for measuring the urethral pressure profile include the size of the lumen, the size of the side hole, the speed with which the catheter is withdrawn, and the rate of infusion. The entire curve of the cystometrogram should be examined, not simply initial rise. Initial overshoots can occur if older apparatus is used or if the urodynamics catheter is partially blocked; such overshoots should be disregarded.

Diagnosis, Differential↗

PubMed1997

Should a modern antihypertensive drug possess cardioprotective properties?

PROTECTIVE EFFECTS OF ANTIHYPERTENSIVE DRUGS: Treatment of hypertension has been shown to reduce cardiovascular morbidity and mortality. This is especially true for the beneficial effect against stroke. The protective effects against coronary heart disease have also been significant but numerically less impressive than the effect against stroke. It is conceivable that a modern drug should possess cardioprotective properties in order to achieve a better protection against coronary heart disease. EFFECTS OF MIBEFRADIL: The novel calcium antagonist mibefradil, which blocks both transient (T) and long-lasting (L) calcium channels, has a hemodynamic profile which may have cardioprotective properties. Mibefradil reduces arterial pressure by a vasodilating effect with little or no effect on cardiac output. Recently reported effects of antihypertensive treatment with a calcium antagonist on stroke morbidity in the European trial on systolic hypertension (Syst-Eur) have confirmed previous findings with a calcium antagonist in the Shanghai Trial Of Nifedipine in the Elderly (STONE). Thus the pharmacodynamic profile of mibefradil might offer additional cardioprotective benefit. This possibility deserves assessment in a proper prospective intervention study.

Antihypertensive Agents↗

PubMed1987

Stigma perceived by patients attending modern treatment settings. Some unanticipated effects of community psychiatry reforms.

In recent years reforms were instituted in the Federal Republic of Germany that were designed to facilitate the integration of psychiatric services and psychiatric patients into community life. One goal of this reform was to reduce patients' feelings of stigmatization. Because such feelings were thought to arise through patients' tenure at large, isolated state hospitals, we hypothesized that patients sent to such hospitals would feel more stigmatized than would patients assigned to a modern, integrated university hospital. Further, we hypothesized that patients in the two settings would adopt different strategies to cope with the stigma they perceived and that staff members in the two settings would share patients' views concerning these matters. Although we found that the staff in both hospitals shared our prediction that state hospital patients would perceive more stigmatization, our findings showed just the opposite. State hospital patients were significantly less likely than university hospital patients to believe that most people would devalue and discriminate against mental patients. Nor did we find strong evidence of different styles of coping with stigma among patients in the two settings. Taken together, our results suggest that in the realm of stigmatization well-intentioned efforts of reforms may have had undesirable unanticipated consequences. Given this, we suggest approaches for intervening more directly with patients in the form of "Daily Living Groups," which are designed to explicitly discuss actual and feared stigmatization.

Adaptation, Psychological↗

PubMed1999

Biomechanical analysis of supracondylar femoral fractures fixed with modern retrograde intramedullary nails.

OBJECTIVES: Several new retrograde supracondylar intramedullary nails have been developed to specifically address fractures of the distal femur. The nails appear clinically effective, but there are few biomechanical data documenting the stability of the fixation or the mechanical stiffness of the different designs. The goal of this study was to assess the torsional and bending stiffness of four designs of intramedullary nails developed for this application. METHODS: Four nail designs were tested in torsion and bending to determine system stiffness: Ace supracondylar, Richards "five hole" and "multi-hole" supracondylar, and Biomet retrograde. The nails were inserted into cadaveric femurs in which a one-centimeter distraction osteotomy had been created seven centimeters proximal to the condyles. The constructs were then tested on an Instron biaxial testing system. RESULTS: There were no statistically significant differences in bending stiffness among the groups of nails (range 0.79 to 1.18 newtons/meter; p > 0.1). However, the Ace nails (1.10 newtonmeters/degree) did exhibit a statistically lower torsional stiffness compared with the other nails (2.20 to 2.21 newton-meters/ degree; p < 0. 1). No differences were noted as a function of the number of locking holes. CONCLUSIONS: The bending stiffness of four currently available designs of retrograde intramedullary nails does not appear to be dependent on design variations. The torsional stiffness did vary among the four designs, but this was not determined by the number of fixation holes provided. It appears that a well-placed retrograde supracondylar nail of modern design should have sufficient stiffness to support the femur and provide stability during fracture healing.

Biomechanical Phenomena↗

PubMed1983

Modern management of gestational trophoblastic disease.

Gestational trophoblastic disease is a disorder of pregnancy which may present in a very benign or malignant fashion. Hydatidiform mole complicates approximately 1 in 2000 pregnancies in the United States. The diagnosis may be made prior to evacuation if the signs and symptoms are kept in mind. When the patient presents with spontaneous expulsion of typical molar tissue, a complete evaluation is carried out, including physical examination, uterine curettage for histologic study, and initiation of weekly beta subunit of HCG determinations. At 8 weeks' post-evacuation, about 50% of patients continue to have detectable serum HCG levels. Of these patients, about half may develop chorioadenoma destruens (invasive mole) or choriocarcinoma and require chemotherapy (6, 16). Patient stratification in a clinical classification system based on anatomical extent of disease and certain risk factors is essential for proper management. Review of results obtained at gestational trophoblastic disease treatment centers has shown that with exception of the high-risk patient, virtually 100 per cent cure is possible with early diagnosis and appropriate treatment. Treatment of the high-risk patient with initial triple-drug chemotherapy and simultaneous irradiation of liver or brain metastases may be expected to yield a 90 per cent complete remission. If complete remission in the high-risk patient is maintained for 3 months after cessation of treatment, there appears to be a 98 per cent chance of remaining free of disease (47). The information accumulated in the 25 years since methotrexate was introduced into the treatment of gestational trophoblastic disease has made these excellent results possible. Aggressive multiagent chemotherapy, proper patient classification, radiation, surgery, and utilization of the beta subunit of HCG to monitor therapy are all pivotal in achieving these successes of modern management.

Adult↗

PubMed2003

The biochemical detection of biliary etiology of acute pancreatitis on admission: a revisit in the modern era of biliary imaging.

INTRODUCTION: Compared with traditional radiologic methods for the detection of cholelithiasis, early transient hypertransaminasemia had provided a useful prediction of biliary etiology in patients with acute pancreatitis. AIM: To investigate whether this application remains valid in the modern era of imaging for microlithiasis. METHODOLOGY: The biochemical detection (LFT) of cholelithiasis was based on an increase in serum alanine transaminase of >or=80 IU/L (normal range, 0-45 IU/L) within 24 hours of admission. We have taken the collective findings of abdominal ultrasound (USS), endoscopic ultrasound (EUS), and postmortem examination to represent the denominator for the diagnosis of cholelithiasis against which comparison with LFT was made. RESULTS: Of 68 patients with acute pancreatitis who were treated between October 2000 and December 2001, cholelithiasis was the etiological factor in 44 patients (65%). EUS detected microlithiasis in 5 of 10 patients examined. The etiology remained idiopathic in 3 patients (4.4%). The sensitivity, specificity, and positive and negative predictive values for USS were 86%, 100%, 100%, and 80% respectively; for LFT, they were 91%, 100%, 100%, and 86%; and for USS and LFT combined, they were 98%, 100%, 100%, and 96%, respectively. CONCLUSIONS: In patients with acute pancreatitis, the biochemical analysis within 24 hours of admission provided a simple, rapid, and more accurate prediction of cholelithiasis than USS. The combination of LFT and USS detected or excluded a biliary etiology in almost all patients.

Acute Disease↗

PubMed1992

Physicians' negative perception of sclerotherapy for venous disorders: review of a 7-year experience with modern sclerotherapy.

Sclerotherapy is the injection of a sclerosing substance directly into a varicosity or telangiectasia to cause damage, fibrosis, and eventual obliteration of the vessel. Although sclerotherapy has been shown to be effective with a low incidence of side effects, many physicians in the United States are unaware of the technique or view it in a negative way. To better define the extent of physician unfamiliarity or prejudice toward sclerotherapy, we surveyed a local medical community of gynecologists by anonymous written questionnaire. The results indicated that 82% of the responding physicians believed that their knowledge of sclerotherapy was insufficient to advise their patients, leaving patients to learn about sclerotherapy from mass media sources. Sclerotherapy was perceived as only slightly effective therapy for varicose veins and was thought to have a relatively high incidence of side effects. With recent improvements in the technique, our collaborative experience with 3000 patients receiving 50,000 injections over the past 5 years has shown that sclerotherapy is a safe procedure achieving outstanding cosmetic results with concomitant symptomatic relief of painful varicosities and telangiectases. Sclerotherapy, as practiced today, offers an effective, simple, and less costly alternative to surgical stripping for most varicose and telangiectatic veins. The survey data demonstrate the need to educate the American medical community about the technique and merits of modern sclerotherapy so that patients may be properly guided by their physicians to the best sources of care for their aching and unsightly leg veins.

Adolescent↗

PubMed1997

Modern analysis of pathologic uterine rings.

A computerized medical record search of 61,406 live births from January 1, 1990, through December 31, 1994, identified 14 cases of pathologic uterine rings. This yielded an incidence of pathologic uterine rings of 0.02% of all live births. In a retrospective, matched study design, three control subjects having vaginal delivery and three having cesarean delivery were matched with each case of pathologic uterine ring for age, race, parity, estimated gestational age, single or multiple gestation, primary or repeat cesarean section, and indication for the cesarean delivery. Comparison with controls who had cesarean section showed no significant differences in duration of labor, rupture of membranes, use of oxytocin, or fetal head position. Pathologic uterine rings continue to occur in modern obstetrics, but their reported incidence has decreased. These data suggest that the characteristics of parturition have no clear association with the formation of a pathologic uterine ring.

Case-Control Studies↗

PubMed1991

A trial of modern rehabilitation for chronic low-back pain and disability. Vocational outcome and effect of pain modulation.

Of 66 nonoperated low-back pain patients who entered a 4-week program of modern active rehabilitation after 13 months' sick leave, only 15 (23%) had returned to work at 18 months' follow-up. Effective pain modulation with pool traction did not influence the vocational status or pain level at the time of follow-up. The prevalence of blue-collar workers among the clients were doubled compared with the general population, and a high proportion were unskilled (71%). It is concluded that the resources of health services should be used in the subacute stage to produce an earlier and more precise organic and psychosocial diagnosis and to state the preference of an active attitude supported by general physical training.

Adult↗

PubMed1999

The modern hippocratic tradition. Some messages for contemporary medicine.

Hippocrates (5th century B.C.), the most prominent physician of antiquity, was born in the small Greek island of Kos, which is near the coast of Asia Minor. Before his era, medicine was practiced as an empirical art and had a religious nature. Hippocratic medicine represents the landmark for the evolution of Western medicine. This "father" of rational medicine assimilated the accumulated knowledge of the past and formed a diagnostic system based on clinical observation and logical reasoning. The great physician attributed diseases to natural causes, believed in the healing power of nature, and gave special emphasis to the prevention and prognosis of illnesses. He treated patients as psychosomatic entities (a holistic medical approach) in relation to their natural environment. In his treatises, Hippocrates defined the ethical principles guiding medical practice. His entire work was inspired by humanistic ideals and an undeviating dedication to the patient. Modern medicine can derive valuable lessons from the Hippocratic tradition. For the coming 21st century, medicine more than ever senses the need to combine the concepts of humanistic values and the Hippocratic messages with the technologic "imperative" (power). This bond is necessary to the improvement of medicine in the future because, currently, the enormous biomedical technology so far has contributed little to the traditionally human fields of psychosomatic and functional disturbances, posing new dilemmas and threatening scientific problems.

Ethics, Medical↗

PubMed1990

Historical and modern role of cystoscopy and bladder mucosal biopsy in detecting bladder cancer in a high-risk population.

The use of cystoscopy and bladder biopsy to screen cohorts of persons with no history of bladder carcinoma would be unsatisfactory because of the low prevalence of the disease, even in the highest risk occupations. Cystoscopy/biopsy should follow noninvasive modern-day techniques that can be used for screening at reasonable cost and no risk to the workers involved. Dipstick testing for hematuria, urinary cytology, flow cytometry, quantitative fluorescence image analysis, and other emerging technologies are far more useful as screening methods. Examples of bladder tumors and benign lesions are included to demonstrate the heterogeneity of bladder carcinoma and the difficulties the urologist faces in deciding which lesions may be malignant. Positive preliminary tests increase the sensitivity and specificity of the diagnostic examination.

Biopsy↗

PubMed2003

Neural systems controlling food intake and energy balance in the modern world.

PURPOSE OF REVIEW: Obesity continues to increase around the globe, and creates a major health problem because of its comorbidities such as diabetes and cardiovascular disease. Considering that the major cause of most human obesities is the modern lifestyle in a rapidly changing environment, this suggests that the battle is between brain areas controlling internal metabolic homeostasis and those dealing with cognitive and emotional processing of external information. Thus, this review is intended to bridge this apparent neural dichotomy and highlight possible ways of interactions between these homeostatic and nonhomeostatic systems. RECENT FINDINGS: Rapid progress has been made in identifying the molecular mechanisms underlying the neural circuits regulating food intake and energy balance. Specific populations of peptidergic neurons in the medial hypothalamus can be considered metabolic integrators sensing both short and long-term availability of fuels. These cell groups in turn connect with various other brain regions to orchestrate adaptive responses through changes in food intake, as well as endocrine and autonomic responses. Alternatively, the impact of the environmental changes on ingestive behavior have been documented, and many of the underlying cortico-limbic pathways are starting to be identified. It has been proposed that a switch from instinctual control of energy balance to a more cognitive control will be necessary to stop the obesity epidemic. SUMMARY: The realization that there is nothing wrong with the homeostatic regulatory system in common obesity suggests that a systematic investigation of pathways that link the 'cognitive' with the 'metabolic' brain might be a more promising area of research. Such an investigation would reveal new molecular and cellular mechanisms providing new drug targets, leading to behavioral therapies that are directed more towards the causes of common obesity.

Developed Countries↗