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PubMed2003

Interns learning to care for dying patients.

OBJECTIVE: To examine interns' perceptions of the emotional support they were able to provide to dying patients and their families, as well as their evaluation of attending physicians as role models caring for dying patients and their families. METHODS: A semistructured, face-to-face interview of a convenience sample of 38 internal medicine interns in two New York City teaching hospitals who were the primary house officers of patients dying between January 2000 and April 2000. RESULTS: Fifty-eight percent of interns rated their comfort level in talking to their patient and family about end-of-life issues as good to excellent. Sixty percent of interns estimated that their impact on their patient's emotional experiences as they approached death as none to minimal. Seventy-four percent of interns rated their patient's physical comfort level good to excellent. Interns rated attending physicians as effective role models in 66% of cases; 34% percent were rated as poor to mediocre. Observation of attending physicians with patients and families was rated as the most effective method to learn how to care for dying patients. CONCLUSIONS: While most interns felt comfortable speaking to their patients and their families about end-of-life issues, they also believed that they provided only minimal emotional support. Interns believe that direct observation of attending physicians is the most effective way to improve their skills caring for dying patients and their families; however, they report wide variability in attending physician performance as role models.

Adult↗
PubMed1999

Functional outcome of internal fixation for pelvic ring fractures.

OBJECTIVE: Evaluation of the functional outcome after unstable pelvic ring fractures stabilized with internal fixation. METHODS: Between January 1, 1990, and September 1, 1997, 37 patients were treated with internal fixation for unstable pelvic fracture. Demographic data, type of accident, Hospital Trauma Index-Injury Severity Score, and fracture type according to Tile classification were scored. One patient died the day after the accident from neurologic injury. A Short Form-36 health questionnaire and a form regarding functional result after pelvic trauma, adapted from Majeed et al., were returned by 31 of 36 patients (86%). Twenty-eight patients (78%) were seen for physical and radiologic examination. RESULTS: Twenty-six men and 11 women, with an average age of 34.7 years (range, 15-66 years) were included. The mean Injury Severity Score reached 30.4 (range, 16-66). According to the Tile classification, there were 16 type B fractures and 21 type C fractures. Seven patients were treated with open reduction and internal fixation of the pubic arch, 10 patients were treated with a combination of anterior open reduction and internal fixation with additional external fixation to increase the stability of the posterior ring. Nineteen patients underwent internal fixation of both anterior and posterior arch. In the remaining case, percutaneous posterior screw fixation was combined with anterior external fixation, because of estimated infectious risk. The average follow-up time was 35.6 months. Patients scored 78.6 of 100 on the Majeed score. Remarkable was the reported change in sexual intercourse in 12 patients (40%). Only 12 patients (40%) did not have complaints when sitting. On the SF-36 scales physical and social functioning, role limitations due to physical problems and vitality were limited compared with the averages for the Dutch population. Patients treated with combined anterior and posterior internal fixation scored significantly better on both the Majeed score and on the categories physical functioning, pain, general health and social functioning compared with patients with similar fractures treated with a combination of anterior internal fixation with external fixation. At the physical examination, 11 of 28 patients (39%) did not have any abnormality. Nineteen patients (68%) were back at their original job, which was physically demanding in 9 cases. There was a suspicion of nonunion of the posterior arch in two patients, which could be confirmed with a computed tomographic scan. CONCLUSION: In general, limitations in functioning are reported, even after long-term follow-up. In partially unstable fractures, solitary anterior fixation gives good results. In completely unstable fractures, patients treated with combined internal fixation anterior as well as posterior scored a better outcome compared with combined internal and external fixation. Therefore, this technique is recommended as treatment of first choice in completely unstable fractures.

Activities of Daily Living↗
PubMed2006

A cost/utility analysis of open reduction and internal fixation versus cast immobilization for acute nondisplaced mid-waist scaphoid fractures.

BACKGROUND: Open reduction and internal fixation and cast immobilization are both acceptable treatment options for nondisplaced waist fractures of the scaphoid. The authors conducted a cost/utility analysis to weigh open reduction and internal fixation against cast immobilization in the treatment of acute nondisplaced mid-waist scaphoid fractures. METHODS: The authors used a decision-analytic model to calculate the outcomes and costs of open reduction and internal fixation and cast immobilization, assuming the societal perspective. Utilities were assessed from 50 randomly selected medical students using the time trade-off method. Outcome probabilities taken from the literature were factored into the calculation of quality-adjusted life-years associated with each treatment. The authors estimated medical costs using Medicare reimbursement rates, and costs of lost productivity were estimated by average wages obtained from the U.S. Bureau of Labor Statistics. RESULTS: Open reduction and internal fixation offers greater quality-adjusted life-years compared with casting, with an increase ranging from 0.21 quality-adjusted life-years for the 25- to 34-year age group to 0.04 quality-adjusted life-years for the > or =65-year age group. Open reduction and internal fixation is less costly than casting ($7940 versus $13,851 per patient) because of a longer period of lost productivity with casting. Open reduction and internal fixation is therefore the dominant strategy. When considering only direct costs, the incremental cost/utility ratio for open reduction and internal fixation ranges from $5438 per quality-adjusted life-year for the 25- to 34-year age group to $11,420 for the 55- to 64-year age group, and $29,850 for the > or =65-year age group. CONCLUSIONS: Compared with casting, open reduction and internal fixation is cost saving from the societal perspective ($5911 less per patient). When considering only direct costs, open reduction and internal fixation is cost-effective relative to other widely accepted interventions.

Adult↗
PubMed1999

The evolution of the internal dialogue during the psychoanalytic psychotherapy process.

This article illustrates curative changes occurring in psychoanalytic psychotherapy by developing the internal dialogue in the mind. By the internal dialogue, I mean the internalization of the therapy process during the recurrent therapy sessions so that the external dialogue between therapist and patient becomes the corresponding internal structure of the patient. In this way, there is a development of the patient's capacity to identify himself and the therapist as separate, sentient, thinking, and reflecting individuals, who have a free internal world of their own. The evolution of the internal dialogue takes place by gradually progressing symbolization achieved through a four-step symbolization-reflectiveness approach. This process is one of the specific curative factors in the psychotherapeutic treatment of borderline patients. The psychodynamics are illustrated by material from one session each of the early and the final stages of therapy, showing a shift from monologue to internal dialogue. The evolved internal dialogue is a central part of the patient's budding thinking capacity, which creates a ground for her subjectivity and autonomy. This study underlines and specifies three factors as cornerstones of the evolution of identity in psychotherapy: symbolization, reflectiveness, and the internal dialogue.

Adult↗
PubMed2006

Open reduction and internal fixation compared with circular fixator application for bicondylar tibial plateau fractures. Results of a multicenter, prospective, randomized clinical trial.

BACKGROUND: Standard open reduction and internal fixation techniques have been successful in restoring osseous alignment for bicondylar tibial plateau fractures; however, surgical morbidity, especially soft-tissue infection and wound necrosis, has been reported frequently. For this reason, several investigators have proposed minimally invasive methods of fracture reduction followed by circular external fixation as an alternative approach. To our knowledge, there has been no direct comparison of the two operative approaches. METHODS: We performed a multicenter, prospective, randomized clinical trial in which standard open reduction and internal fixation with medial and lateral plates was compared with percutaneous and/or limited open fixation and application of a circular fixator for displaced bicondylar tibial plateau fractures (Schatzker types V and VI and Orthopaedic Trauma Association types C1, C2, and C3). Eighty-three fractures in eighty-two patients were randomized to operative treatment (forty-three fractures were randomized to circular external fixation and forty to open reduction and internal fixation). Follow-up consisted of obtaining a history, physical examination, and radiographs; completion of the Hospital for Special Surgery (HSS) knee score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and the Short Form-36 (SF-36) General Health Survey; and recording of complication and reoperation rates. RESULTS: There were no significant differences between the groups in terms of demographic variables, mechanism of injury, or fracture severity and/or displacement. However, patients in the circular fixator group had less intraoperative blood loss than those in the open reduction and internal fixation group (213 mL and 544 mL, respectively; p=0.006) and spent less time in the hospital (9.9 days and 23.4 days, respectively; p=0.024). The quality of osseous reduction was similar in the groups. There was a trend for patients in the circular fixator group to have superior early outcome in terms of HSS scores at six months (p=0.064) and the ability to return to preinjury activities at six months (p=0.031) and twelve months (p=0.024). These outcomes were not significantly different at two years. There was no difference in total arc of knee motion, and the WOMAC scores at two years after the injury were not significantly different between the groups with regard to the pain (p=0.923), stiffness (p=0.604), or function (p=0.827) categories. The SF-36 scores at two years after the injury were significantly decreased compared with the controls for both groups (p=0.001 for the circular fixator group and p=0.014 for the open reduction and internal fixation group), although there was less impairment in the circular fixator group in the bodily pain category (a score of 46) compared with the open reduction and internal fixation group (a score of 35) (p=0.041). Seven (18%) of the forty patients in the open reduction and internal fixation group had a deep infection. The number of unplanned repeat surgical interventions, and their severity, was greater in the open reduction and internal fixation group (thirty-seven procedures) compared with the circular fixator group (sixteen procedures) (p=0.001). CONCLUSIONS: Both techniques provide a satisfactory quality of fracture reduction. Because percutaneous reduction and application of a circular fixator results in a shorter hospital stay, a marginally faster return of function, and similar clinical outcomes and because the number and severity of complications is much higher with open reduction and internal fixation, we believe that circular external fixation is an attractive option for these difficult-to-treat fractures. Regardless of treatment method, patients with this injury have substantial residual limb-specific and general health deficits at two years of follow-up.

Adult↗
PubMed2007

Referring physicians' attitudes toward international interpretation of teleradiology images.

OBJECTIVE: We evaluated referring physician attitudes toward the international interpretation of radiologic images. MATERIALS AND METHODS: A five-question, scenario-based survey describing features of a hypothetic local radiology firm compared with those of its hypothetic overseas counterpart, international radiology, was sent by mail to 350 physicians from a broad range of medical and surgical specialties. One hundred nineteen physicians responded, for a response rate of 34%. Referring physicians were asked to indicate their preference for local versus international interpretation in each scenario using a 5-point Likert scale, with a score of -2 indicating a strong preference for international services, 0 indicating no preference, and 2 indicating a strong preference for local services. RESULTS: When all variables are held to be equal, referring physicians strongly prefer local services (mean score, 1.77; SD, 0.77). When international teleradiology provides either a 2-day faster turnaround time for reports or a 30 dollars lower out-of-pocket cost to the patient, referring physicians still prefer local services, although less than they did with all variables held equal (mean score, 0.42-0.44; SD, 1.30-1.40). When international teleradiology provides both a 2-day faster turnaround time and a 30 dollars lower out-of-pocket cost to the patient, referring physicians preferred international teleradiology, albeit only slightly (mean, -0.25; SD, 1.50). Finally, when the credentials of the international radiologists are perceived to be less than those of the local radiologists, even in the face of faster turnaround time and 30 dollars lower cost to the patient, referring physicians overall strongly prefer local services (mean, 1.51; SD, 0.86). CONCLUSION: Referring physicians prefer local interpretation of radiologic images to international interpretation when all things are equal. However, the timeliness of image interpretation and the cost to the patient are important factors in this decision.

Attitude of Health Personnel↗
PubMed2006

Changes in career decisions of internal medicine residents during training.

BACKGROUND: Little is known about the timing and stability of internal medicine resident career decisions during the course of residency training. OBJECTIVE: To assess changes in reported career plans among internal medicine trainees during their training. DESIGN: Observational cohort using data collected as part of the annual Internal Medicine In-Training Examination (IM-ITE) survey. SETTING: 411 internal medicine residency programs in North America participating in the annual IM-ITE. PARTICIPANTS: 2638 internal medicine residents who took the IM-ITE and responded to career plan questions on the test survey in all 3 years of training (2002-2004). MEASUREMENTS: Self-reported career plans for individual residents during their postgraduate year 1 (PGY-1), postgraduate year 2 (PGY-2), and postgraduate year 3 (PGY-3) of training. RESULTS: 2281 of 2638 residents (86.5%) identified a specific career plan in internal medicine during PGY-3. Of these 2281 residents, 1417 (62.1%) changed career plans at least once during the study period. Career plans reported by PGY-1 and PGY-2 residents matched subsequent PGY-3 plans for 55.1% and 68.4%, respectively. Six hundred eighty-six (26.0%) PGY-1, 278 (10.5%) PGY-2, and 205 (7.8%) PGY-3 residents remained undecided about their career plans at the time of the IM-ITE. Only 25.0% of graduating residents reported plans for a general internal medicine career. LIMITATIONS: The study cohort represents a convenience sample and is restricted to the subset of residents sitting for the IM-ITE and responding to career plan questions in all 3 years of postgraduate training. Career plans were assessed by self-report, and it is possible that residents who responded in all years of training differed from those who did not. CONCLUSIONS: In a subset of internal medicine residents in the class of 2004, career decisions changed late into residency training and enthusiasm for careers in general internal medicine remained low.

Career Choice↗
PubMed2001

[A survey on attitudes and practice concerning International Health].

OBJECTIVE: A survey was conducted to help understanding of the attitudes and practice of Japanese medical students concerning "International Health". MATERIALS AND METHODS: One thousand seven hundred and ninety six students from eleven medical schools responded in the questionnaire study. One thousand and ninety seven were males and 699 were females with average ages of 22 and 21 years, respectively. RESULTS: 32.3% of the students answered that they have/had an interest in "International Health". About half of the students answered that they wanted to have a lecture on "International Health" and they also had a willingness to engage in activities for "International Health" someday. Further, 4% of the students had experience of participation in activities related to "International Health". Female students showed that they have a stronger willingness to take part in the "International Health activities" than males. CONCLUSION: Human resources that can work in the field of international cooperation are required because ODA from Japan has ranked first in the world for nine years in succession. However, the willingness to participate in "International Health activities" among students decreased conversely with their years of learning in medical school. This result might be a basic material when we look at the education toward "International Health" in the medical school.

Adult↗
PubMed1970

Replacement of the international standard for tetanus antitoxin and the use of the standard in the flocculation test.

Since 1935 the International Unit for Tetanus Antitoxin has been defined as the activity contained in a certain weight of the first International Standard for Tetanus Antitoxin. As stocks of this standard had become depleted, 11 laboratories in 8 countries were requested to participate in a collaborative assay of a preparation proposed as a replacement.The assay results were analysed and presented to the WHO Expert Committee on Biological Standardization in 1969 which established the preparation studied as the second International Standard for Tetanus Antitoxin and defined the International Unit for Tetanus Antitoxin as the activity contained in 0.03384 mg of the second International Standard for Tetanus Antitoxin. This definition would ensure the continuity of the size of this international unit.The analysis of the collaborative studies also showed that the second International Standard for Tetanus Antitoxin has suitable properties for use in the flocculation test for the determination of the antigen content of tetanus toxoids in Lf values. The designation Lf-equivalent is described and the problems relating to the use of this term for the expression of results of in vitro assays are analysed in relation to the use of international units for expressing results of in vivo assays. As the second International Standard for Tetanus Antitoxin has an in vivo/in vitro ratio of 1.4, the Lf-equivalent of this antitoxin is 1.4 times less than its unitage.

Animals↗
PubMed1994

Third-year medical student attitudes toward internal medicine.

BACKGROUND: Student attitudes offer insight into career decisions and may suggest causes of the diminished interest in internal medicine. Students entering a salaried managed health care environment may have different attitudes about careers and potential income. Additionally, we evaluate the effect of an ambulatory experience on student attitudes and career selection. METHODS: We surveyed 163 medical students from the Uniformed Services University of the Health Sciences, Bethesda, Md, at the successful completion of the third year to determine their attitudes regarding the work, lifestyle, prestige, patient type, and challenge of internal medicine, as well as primary care interest, and the importance of income in career selection. A subgroup of 107 volunteers was randomized to either the traditional internal medicine clerkship (n = 69), or to 6 weeks of ambulatory medicine and 6 weeks of ward medicine (n = 38). RESULTS: The selection rate was low for internal medicine (10%) and was high for family practice and transitional internships (37%). Although most students highly valued their internal medicine training, relatively few selected internal medicine as a career. Students saw chronic illness and type of work, but not lifestyle, as disincentives toward choosing an internal medicine career. Half of the students believed that income potential would be a major factor in attracting students into internal medicine, and that reimbursement should be shifted from procedural fields to primary care. The ambulatory clerkship did not affect student attitudes nor type of internship selected. CONCLUSIONS: Medicine clerkships, whether traditional or ambulatory, are highly valued educational experiences yet may be insufficient by themselves to attract students to an internal medicine career. Income potential remains an important concern in the setting of salaried managed care, even for students who lack financial debt.

Adult↗
PubMed1994

Surgical treatment of isolated left anterior descending coronary stenosis. Comparison of left internal mammary artery and venous autograft at 18 to 20 years of follow-up.

To assess the long-term results of the surgical treatment of isolated left anterior descending coronary artery stenosis and compare surgical strategies for graft selection, we reviewed 100 consecutive patients receiving left internal mammary artery-to-left anterior descending artery grafts and 100 consecutive patients who received a saphenous vein autograft to the left anterior descending artery. All patients underwent operation from 1971 through 1973. The internal mammary artery and saphenous vein graft groups were equivalent with regard to preoperative clinical and angiographic variables, except that patients receiving left internal mammary artery grafts had a higher prevalence of noncritical disease (less than 50% stenosis) in the circumflex and right coronary arteries than did the saphenous vein graft group. Mean follow-up for the internal mammary artery and saphenous vein graft groups was 18.7 years and 20.7 years, respectively. The 18-year outcome was superior for the internal mammary artery group. Cox regression analysis confirmed that patients with left internal mammary artery grafts had superior survival, intervention-free survival, and event-free survival (all p < 0.01). The presence of noncritical disease in other vessels adversely affected intervention-free survival and event-free survival for both groups (all p < 0.03) and decreased survival for the saphenous vein graft group (p = 0.01) but not for the internal mammary artery group (p = 0.24). We conclude that in long-term follow-up of surgically treated isolated left anterior descending artery stenosis (1) the left internal mammary artery consistently yields better overall and intervention-free survival than does the saphenous vein graft, (2) outcome is influenced by the presence of noncritical disease in other vessels at the initial operation, and (3) deployment of the left internal mammary artery in the treatment of isolated left anterior descending artery stenosis yielded 18 years of intervention-free survival of 60.5% and provides a standard for comparison with other forms of therapeutic intervention.

Coronary Angiography↗
PubMed1996

[Organizational structure of internal medicine in Chile].

Internal Medicine, as a comprehensive discipline, has become increasingly dismembered during the last decades due to several reasons, some of which are the growing complexities of its practice, its obstinate confinement to hospital-based practice, its generation of and subsequent disfunction from general internal medicine and the medical subspecialities. In Chile internal medicine is currently organized in three levels of patient care, each of anarchical and distortioned proportions. These levels do not constitute a fluent network of progressive patient care but rather an heterogeneous combination of ironclad compartments in search of their own autonomy. A few of the many problems and challenges that internal medicine faces in Chile are: (a) in primary care medicine, problem-solving abilities must be improved and programmed care must be privileged over free choice. Specialist in general medicine must be assigned to primary care and multiprofessional teams must be strengthened; (b) Secondary care is underdeveloped due to the waning prestige of internal medicine and waxing attractiveness of its subspecialities. Programmed formation of specialist in internal medicine has been so far rigorous and demanding, but excessive in number in relation to available post. This leads trained internist to practice as subspecialist, without having the adequate conditions for such a practice. To avoid this situation, the scope of internal medicine emergency wards, integral medicine clinics, and medical student teaching should be handed over to it; (c) Tertiary care is a task of subspecialist. It is not known how many subspecialist are required, or how many physicians are currently practicing as a subspecialist. Most of the currently practicing subspecialist are self-qualified or have received quick training through short rotations by not always well-qualified centers. Many are only former internal medicine residents. In this setting, it is not possible to devise a prospective plan of subespecialty training. To make internal medicine in Chile efficient and timely, its is necessary to restore and restructure a rational patient care network that will do away with the current red tape and waiting list as well as to allow the insertion of well-trained specialist in the corresponding levels of patient care.

Chile↗
PubMed1997

Intern learning and education in a short stay unit. A qualitative study.

OBJECTIVE: To study interns' perceptions of their learning during their rotation through a short stay unit (SSU). DESIGN: Case-based, qualitative research study. SETTING: A tertiary care pediatric hospital (The Children's Hospital, Boston, Mass). PARTICIPANTS: Ten interns who had worked in the SSU in the 3 months prior to June 1, 1995, and on a general medical team in the previous 12 months. INTERVENTION: None. MAIN OUTCOME MEASURES: In July 1995, the interns participated in focused, open-ended interviews lasting about 40 to 60 minutes to document their perceptions of their learning during their SSU rotation. The interviews were recorded on audiotape and transcribed prior to analysis. Data were analyzed to discern and categorize themes from the interns' responses. RESULTS: All interns responded favorably to their educational and learning experiences during their rotation through the SSU. Two major themes emerged: (1) the interns' learning, which was affected by the role of the attending physician, the organization and structure of the SSU, and the teaching strategies in the SSU; and (2) the interns' collaborative work with the nursing staff in the SSU, which affected patient care but did not facilitate the interns' learning. CONCLUSION: Clustering in the SSU of patients whose symptoms suggested straightforward diagnoses enhanced interns' educational experiences.

Adult↗
PubMed2006

Interns' compliance with accreditation council for graduate medical education work-hour limits.

CONTEXT: Sleep deprivation is associated with increased risk of serious medical errors and motor vehicle crashes among interns. The Accreditation Council for Graduate Medical Education (ACGME) introduced duty-hour standards in 2003 to reduce work hours. OBJECTIVE: To estimate compliance with the ACGME duty-hour standards among interns. DESIGN, SETTING, AND PARTICIPANTS: National prospective cohort study with monthly Web-based survey assessment of intern work and sleep hours using a validated instrument, conducted preimplementation (July 2002 through May 2003) and postimplementation (July 2003 through May 2004) of ACGME standards. Participants were 4015 of the approximately 37 253 interns in US residency programs in all specialties during this time; they completed 29 477 reports of their work and sleep hours. MAIN OUTCOME MEASURE: Overall and monthly rates of compliance with the ACGME standards. RESULTS: Postimplementation, 1068 (83.6%; 95% confidence interval [CI], 81.4%-85.5%) of 1278 of interns reported work hours in violation of the standards during 1 or more months. Working shifts greater than 30 consecutive hours was reported by 67.4% (95% CI, 64.8%-70.0%). Averaged over 4 weeks, 43.0% (95% CI, 40.3%-45.7%) reported working more than 80 hours weekly, and 43.7% (95% CI, 41.0%-46.5%) reported not having 1 day in 7 off work duties. Violations were reported during 3765 (44.0%; 95% CI, 43.0%-45.1%) of the 8553 intern-months assessed postimplementation (including vacation and ambulatory rotations), and during 2660 (61.5%; 95% CI, 60.0%-62.9%) of 4327 intern-months during which interns worked exclusively in inpatient settings. Postimplementation, 29.0% (95% CI, 28.7%-29.7%) of reported work weeks were more than 80 hours per week, 12.1% (95% CI, 11.8%-12.6%) were 90 or more hours per week, and 3.9% (95% CI, 3.7%-4.2%) were 100 or more hours per week. Comparing preimplementation to postimplementation responses, reported mean work duration decreased 5.8% from 70.7 (95% CI, 70.5-70.9) hours to 66.6 (95% CI, 66.3-66.9) hours per week (P<.001), and reported mean sleep duration increased 6.1% (22 minutes) from 5.91 (95% CI, 5.88-5.94) hours to 6.27 (95% CI, 6.23-6.31) hours per night (P<.001). However, reported mean sleep during extended shifts decreased 4.5%, from 2.69 (95% CI, 2.66-2.73) hours to 2.57 (95% CI, 2.52-2.62) hours (P<.001). CONCLUSION: In the first year following implementation of the ACGME duty-hour standards, interns commonly reported noncompliance with these requirements.

Adult↗
PubMed1990

Structural features of the cytoplasmic region of CD4 required for internalization.

CD4, the T cell surface antigen, is phosphorylated and internalized when T cells are activated or treated with a phorbol ester, PMA. The actual phosphorylation sites have been identified and the role of phosphorylation of each on CD4 internalization investigated. Seven different mutants, in each of which one, two or all three of the serine residues of the cytoplasmic region was modified to alanine(s) (CD4.SA mutants) and one mutant in which the whole amino acid sequence from Gln421 to the C-terminal Ile433 was changed (CD4.EP mutant) were constructed and used to determine the effect of phosphorylation on CD4 internalization. Ser408 was the most efficiently phosphorylated by PMA treatment, Ser415 next and Ser431 to a minor extent. The effect of mutation on internalization was well matched with the effect on extent of phosphorylation, i.e. Ser408 was the residue most important for internalization. However, complete inhibition of CD4 internalization was achieved only by mutating all three serine residues. Interestingly, the mutant CD4.EP in which Ser408 was present and phosphorylated was not measurably internalized, suggesting that phosphorylation of Ser408 induces CD4 internalization only when other structural features of the cytoplasmic domain remain intact. In addition, the data suggest the existence of an additional minor pathway for CD4 internalization which is phosphorylation independent.

Amino Acid Sequence↗
PubMed1999

Differential modes of regulation of cxc chemokine-induced internalization and recycling of human CXCR1 and CXCR2.

Studies of human neutrophil IL-8 receptors, CXCR1 and CXCR2, have shown that the two receptors are differentially regulated by ELR(+)-CXC chemokines, that they differ functionally and may have diverse roles in mediating the inflammatory process. To elucidate the role of CXCR1 and CXCR2 in inflammation and to delineate the basis for the divergent regulation of these receptors by IL-8 and NAP-2, we characterized the IL-8- and NAP-2-induced mechanisms regulating the expression of each receptor, focusing on receptor internalization and recycling. Using HEK 293 cell transfectants, IL-8 was shown to induce significantly higher levels of CXCR2 internalization than NAP-2. Moreover, although CXCR2 bound IL-8 and NAP-2 with similarly high affinity, IL-8 functionally competed with and displaced NAP-2, and prompted high levels of internalization, similar to those induced by IL-8 alone. In a system providing an identical cellular milieu for reliable comparisons between CXCR1 and CXCR2, we have shown that the mechanisms controlling the internalization of CXCR1 diverge from those regulating CXCR2 internalization. Whereas IL-8-induced internalization of CXCR1 was profoundly dependent on a region of the carboxyl terminus expressing six phosphorylation sites, internalization of CXCR2 was primarily regulated by a membrane proximal domain of the carboxyl terminus that does not express phosphorylation sites. Analysis of receptor re-expression on the plasma membrane indicated that at early time points following removal of free ligand and incubation of the cells at 37 degrees C, receptor recycling accounted for recovery of CXCR1 and CXCR2 expression, whereas at later time points other processes may be involved in receptor re-expression. Phosphorylation-independent mechanisms were shown to direct both receptors to the recycling pathway. The differential control of CXCR1 vs CXCR2 internalization by IL-8 and NAP-2, as well as by phosphorylation-mediated mechanisms, suggests that a chemokine- and receptor-specific mode of regulation of internalization may contribute to the divergent activities of these receptors.

Amino Acid Sequence↗
PubMed1983

Radical mastectomy with intrapleural en bloc resection of internal mammary lymph node by sternal splitting.

An operative method of extended radical mastectomy involving intrapleural en bloc resection of the internal mammary lymph nodes by sternal split was proposed. The operation enables complete resection of axillary and internal mammary lymph nodes. Seventy patients with primary breast cancer underwent the extended operation and two patients with recurrence in the internal mammary lymphnode chain following standard radical mastectomy underwent resection of internal mammary lymphnodes by sternal split, with no fatalities and no increase in postoperative disabilities. Metastases to the internal mammary lymphnode chain were histopathologically found in 14 of 70 patients with primary breast cancer and in two with recurrence in the internal mammary lymphnode chain, following standard radical mastectomy; The location of the metastatic internal mammary lymphnodes was from just below the subclavicular vein to the third intercostal space along the internal mammary vessels. Cancer cells were seen not only in the lymphnodes, but also in lymphatics of areolar tissue near the node or in lymphatics between the parietal pleura and endothoracic fascia in patients with primary breast cancer. And cancer invasion to parietal pleura was seen in patients with recurrence in the internal mammary lymphnode chain following standard radical mastectomy. All these findings indicate the rationality of our extended procedures.

Adult↗
PubMedDate not supplied

The inter-rater reliability and internal consistency of a clinical evaluation exercise.

OBJECTIVE: To assess the internal consistency and inter-rater reliability of a clinical evaluation exercise (CEX) format that was designed to be easily utilized, but sufficiently detailed, to achieve uniform recording of the observed examination. DESIGN: A comparison of 128 CEXs conducted for 32 internal medicine interns by full-time faculty. This paper reports alpha coefficients as measures of internal consistency and several measures of inter-rater reliability. SETTING: A university internal medicine program. Observations were conducted at the end of the internship year. PARTICIPANTS: Participants were 32 interns and observers were 12 full-time faculty in the department of medicine. The entire intern group was chosen in order to optimize the spectrum of abilities represented. Patients used for the study were recruited by the chief resident from the inpatient medical service based on their ability and willingness to participate. INTERVENTION: Each intern was observed twice and there were two examiners during each CEX. The examiners were given a standardized preparation and used a format developed over five years of previous pilot studies. MEASUREMENTS AND MAIN RESULTS: The format appeared to have excellent internal consistency; alpha coefficients ranged from 0.79 to 0.99. However, multiple methods of determining inter-rater reliability yielded similar results; intraclass correlations ranged from 0.23 to 0.50 and generalizability coefficients from a low of 0.00 for the overall rating of the CEX to a high of 0.61 for the physical examination section. Transforming scores to eliminate rater effects and dichotomizing results into pass-fail did not appear to enhance the reliability results. CONCLUSIONS: Although the CEX is a valuable didactic tool, its psychometric properties preclude reliable assessment of clinical skills as a one-time observation.

Clinical Competence↗