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PubMed1995

International Society on Thrombosis and Haemostasis (ISTH), and International Union of Pure and Applied Chemistry (IUPAC), Clinical Properties and units in the clinical laboratory sciences. V. Properties and units in thrombosis and haemostasis (recommendation 1995). International Society on Thrombosis and Haemostasis (ISTH) and International Union of Pure and Applied Chemistry (IUPAC),and International Federation of Clinical Chemistry (IFCC).

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Chemistry, Clinical↗
PubMed1991

Medical student interest in internal medicine. Initial report of the Society of General Internal Medicine Interest Group Survey on Factors Influencing Career Choice in Internal Medicine.

OBJECTIVE: To determine the factors that attract students toward and push students away from a career in internal medicine. DESIGN: National survey of senior U.S. medical students using a stratified random cluster sampling of medical schools. PARTICIPANTS: The survey included 1650 U.S. senior students from 16 medical schools, of whom 1244 (76%) responded. MEASUREMENTS AND MAIN RESULTS: A survey instrument was developed and pilot tested at 17 medical schools. Twenty-four percent of the respondents to the final survey chose a career in general internal medicine (9%) or subspecialty internal medicine (15%). A career in internal medicine had been "seriously considered" by 608 respondents (50%) who finally chose a career other than internal medicine (the "switchers"). Compared with other specialties, internal medicine was perceived as being more stressful to residents, more demanding of time and workload as a career and a residency, and as an easier residency to enter. Internal medicine was also seen as providing less satisfaction for residents, having lower income potential, and allowing less leisure time. For the 608 switchers, the most important influences leading to their decision to switch were the type of patient seen in internal medicine (for example, chronically ill, alcohol and drug abusing patients) as well as dissatisfaction and stress among internal medicine residents. Factor analysis showed that three factors, "intellectual challenge of internal medicine," "primary care interests," and "the medicine clerkship" attracted students toward internal medicine, whereas three others, "taking care of chronically ill patients," "level of satisfaction among internists and medical residents," and "workload and stress" pushed students away from internal medicine. Factors pushing students away from internal medicine were significantly more negative with regard to a career in general as opposed to subspecialty internal medicine (P less than 0.001). CONCLUSION: Medical students have serious reservations about internal medicine as a career choice. Perceptions about the medical residency, the patients they expect to see, and the dissatisfaction among residents and internists are foremost in their thinking. Changes to improve the attractiveness of internal medicine should address these adverse perceptions while building on the positive influences identified by the respondents.

Career Choice↗
PubMed1995

The impact of an ambulatory rotation on medical student interest in internal medicine. The Society of General Internal Medicine Task Force on Career Choice in Internal Medicine.

OBJECTIVE: To determine whether students who take ambulatory rotations in internal medicine are more likely to choose internal medicine careers. DESIGN: National survey. SETTING AND PARTICIPANTS: The intended sample was 1,650 senior U.S. medical students from 16 medical schools, of whom 1,244 (76%) responded. Representative schools nationwide were selected using a stratified, random-sampling method. MEASUREMENTS: The questionnaire asked about characteristics of the ambulatory rotation, perceptions of internal medicine, and factors influencing students toward or away from an internal medicine career. RESULTS: Ambulatory rotations were taken by 543 students (43%). Of these rotations, 73% were required, 74% were during the fourth year, 77% were in general internal medicine, 73% provided continuity of care, and 19% were during the medicine clerkship. Overall, 24% of the students chose careers in general (9%) or subspecialty internal medicine (15%). Thirty percent of the students who did ambulatory rotations planned internal medicine careers, compared with 19% of the students who had no rotation [odds ratio (OR) = 1.8, 95% confidence interval (CI) 1.3 to 2.4, p = 0.0001]. This association was of similar magnitudes for students completing required rotations (OR = 1.6, 95% CI 1.2 to 2.2, p = 0.002) and for students completing rotations before or in proximity to when they chose careers (OR = 1.7, 95% CI 1.1 to 2.4, p = 0.01). Ninety percent of the 543 students who had ambulatory rotations were satisfied with the experience. Thirty-eight percent of the highly satisfied students chose internal medicine careers, compared with 21% of the students who had low or moderate satisfaction (p = 0.0001). CONCLUSIONS: An ambulatory rotation is strongly associated with positive perceptions of, attraction to, and choice of a career in internal medicine. Research is needed to determine specific components of an effective rotation. Further development of ambulatory rotations could help attract more students to internal medicine.

Adult↗
PubMed1993

The attractiveness of internal medicine: a qualitative analysis of the experiences of female and male medical students. Society of General Internal Medicine Task Force on Career Choice in Internal Medicine.

OBJECTIVE: To understand better the decline in medical student interest in internal medicine. DESIGN: Qualitative analysis of 500 essays from respondents who participated in a national survey of graduating medical students from the class of 1990 in 16 medical schools. Medical students were asked the open-ended question, "What suggestions do you have for improving the attractiveness of internal medicine?" A model of career choice was developed for the analysis that included the following factors: ambulatory care exposure and primary care (including relationships with patients); attending physician-student interactions and learning climate; stress and workload; income and prestige; and intellectual stimulation. PARTICIPANTS: The original survey included 1650 fourth-year medical students; 500 essay respondents were stratified by sex and then randomly chosen for the analysis. RESULTS: Students most frequently suggested that ambulatory care experiences be increased and that better relationships with patients be established during medical training (65% of women and 50% of men, P < 0.01). The second most frequent suggestion was to improve internal medicine attending physicians' interactions with students (51% and 48% of women and men, respectively). Students who had seriously considered a career in medicine but switched to other primary care careers (general pediatrics, family medicine) had few concerns about income and prestige, whereas those who chose internal medicine had reservations about expected workload and income. Women were more likely than men to reject internal medicine for other primary care fields (26% of women compared with 16% of men, P = 0.05). CONCLUSIONS: Students, particularly female students, expressed a strong interest in establishing better relationships with patients. Lack of respect by medical attendings and negative teaching methods were important sources of dissatisfaction among both men and women. Attention to these relationship issues, in addition to housestaff stress and expected future income, may improve the attractiveness of internal medicine.

Adult↗
PubMed1989

The future of general internal medicine. Council on Long Range Planning and Development in Cooperation with the American College of Physicians, the American Society of Internal Medicine, and the Society of General Internal Medicine.

The American Medical Association Council on Long Range Planning and Development has been publishing a series of reports that assess trends in the environment of medicine and their impact on physicians and health care provision. The Council believes that each specialty in medicine has unique characteristics and will respond differently to changes in the health care arena. This report, developed in cooperation with the American College of Physicians, the American Society of Internal Medicine, and the Society of General Internal Medicine, provides an overview and environmental analysis of the specialty of general internal medicine. The Council first reviews socioeconomic data pertinent to general internal medicine. This is followed by a review of key issues pertinent to internists that relate to such topics as graduate medical education, reimbursement, scope of practice, manpower, and competition. In the conclusions, the Council suggests activities for the medical profession to pursue in response to the identified environmental trends.

Adult↗
PubMed1994

[International guidelines on the diagnostic applications of magnetic resonance. International Non-Ionizing Radiation Committee of the International Radiation Protection Association].

Magnetic resonance imaging has become an established diagnostic modality. The clinical usefulness of in vivo magnetic resonance spectroscopy was demonstrated in several instances and is being explored further. These techniques involve exposure of the patient to static and time-varying magnetic fields and radiofrequency electromagnetic fields. In particular exposure situations, these fields may pose a health hazard. The purpose of this paper is to provide information on the guidelines issued by the International Non-Ionizing Radiation Committee of the International Radiation Protection Association on levels of exposure and health effects from magnetic and radiofrequency electromagnetic fields associated with magnetic resonance diagnostic devices, and on precautions to be taken to minimize health hazards to patients undergoing magnetic resonance examinations.

Biophysical Phenomena↗
PubMed1996

Future roles and training of internal medicine subspecialists. American Board of Internal Medicine Task Force on Subspecialty Internal Medicine.

While fellowship training programs are being reduced in size to better conform to societal needs, the training of subspecialist basic scientists and clinical investigators must be protected to ensure continued discovery and the scholarly application of knowledge to patient care. Fewer subspecialist clinicians must be appropriately trained to serve as consultants, as principal care providers, and as scholarly leaders and educators in their subspecialties. This article describes the recommendations of the American Board of Internal Medicine for subspecialty training. To encourage physicians to choose careers as investigators, overlapping but different training paths are delineated for subspecialist clinicians and investigators. More didactic coursework is recommended for both paths. To maximize the contribution of fewer subspecialists, it is essential to provide rigorous training that is appropriately relevant and realistically matched with career opportunities.

Certification↗
PubMedDate not supplied

Epilepsy and driving: an international perspective. Joint Commission on Drivers' Licensing of the International Bureau for Epilepsy and the International League Against Epilepsy.

Individuals with a history of seizures may be granted driving privileges if the risks of future seizure while driving are relatively low. Different nations have defined these risks in a wide variety of ways. Some countries, e.g., Japan, Greece, Brazil, India, and Russia, preclude driving after a single seizure. Other countries, such as Canada and the United States, allow driving < or = 3 months after certain types of seizures. A Joint Commission of the International Bureau for Epilepsy/International League Against Epilepsy has summarized regulations in several countries. From a consideration of medical literature and existing practices, a series of proposed guidelines for driving and epilepsy is recommended. In general, these guidelines suggest use of a seizure-free interval, generally 1-2 years but less in particular instances, to determine fitness to drive. Required physician reporting is discouraged, but physicians should report patients whom they believe pose a danger to themselves and to public safety. Individualized consideration should be given to special circumstances that may modify a general driving prohibition. Education and information programs are necessary for medical and regulatory authorities to develop a rational approach to driving and epilepsy worldwide.

Accidents, Traffic↗
PubMed1993

Demography, auxology and response to recombinant human growth hormone treatment in girls with Turner's syndrome in the Kabi Pharmacia International Growth Study. International Board of the Kabi Pharmacia International Growth Study.

Demographic and auxological data were analysed from 818 girls with Turner's syndrome treated with recombinant human growth hormone (GH) and entered into the Kabi Pharmacia International Growth Study. Size at birth was low and correlated with the heights of both parents. The median age at start of GH treatment was 11.4 years and the parents had a median height SDS of -2.9. Height SDS at the start of treatment correlated with parental heights. Height velocities conformed to Turner-specific standards. The weight-for-height index increased sharply above 9 years of age. The frequency of spontaneous appearance of Tanner breast stage 2 was high (34.1% of girls > 10 years of age). Bone age (Greulich and Pyle) data were described by the equation: bone age = 1.61(chronological age) - 0.04(chronological age)2 - 3.61. This equation was used to correct adult height predictions. The median initial dose of GH was 0.8 IU/kg/week and was maintained during the first 3 years of treatment. The median frequency of injections was six/week. Height velocity increased from 4.1 to 6.8 cm/year in the first year, and height velocity SDS for chronological age remained positive for 4 years. The height prediction corrected for bone age increased over the first 2 years only. Differences in demography and auxology were described according to karyotype and country of origin. A greater height velocity SDS was observed at higher GH doses and when oxandrolone was used concomitantly.

Age Determination by Skeleton↗
PubMed1993

Characteristics of children with idiopathic short stature in the Kabi Pharmacia International Growth Study, and their response to growth hormone treatment. International Board of the Kabi Pharmacia International Growth Study.

The auxological characteristics and the response to growth hormone (GH) treatment of children with idiopathic short stature were studied, using the database of the Kabi Pharmacia International Growth Study. Pretreatment data from a total of 271 children were analysed. The children were selected for a birth weight above -2 SDS. The correlation coefficient of birth weight SDS and birth length SDS was 0.51, compared with 0.72 for the reference population. Median length at birth was -0.6 SDS, which fell to -2.5 SDS by 3 years of age. Thereafter, there was no further loss in height SDS. The response to GH treatment was studied in 222 of these prepubertal children who were given six or seven injections/week over a 3-year period. During this time, the median height SDS increased from -2.5 to -1.5, with those children receiving more than 0.65 IU/kg/week having a greater gain in height SDS than those on 0.5 IU/kg/week or less. The degree of bone age delay did not appear to influence the response to GH therapy.

Adolescent↗
PubMed1993

Auxology and response to growth hormone treatment of patients with intrauterine growth retardation or Silver-Russell syndrome: analysis of data from the Kabi Pharmacia International Growth Study. International Board of the Kabi Pharmacia International Growth Study.

Using the database from the Kabi Pharmacia International Growth Study, 105 patients with intrauterine growth retardation (IUGR) (82 males, 23 females) and 45 with Silver-Russell syndrome (SRS) (32 males, 13 females) with persistent postnatal growth failure were studied. Patients with IUGR had a birth length and birth weight more than 2 SD below the mean for gestational age. Their height deficit at the start of GH treatment was -3.0 SDS at a median chronological age of 8.7 years and a median bone age of 7.0 years. Mean paternal and maternal heights were 166 and 153 cm, respectively. The median dose of GH was 0.5 IU/kg/week, given at a median frequency of five injections/week. The median height SDS for chronological age after 1, 2 and 3 years of GH treatment were -2.5, -2.1 and -1.9, respectively. In the 45 patients with SRS, median chronological age and median bone age at the start of treatment were 6.7 and 3.2 years, respectively, and mean paternal and maternal heights were 167.5 and 160 cm, respectively. The median dose of GH was 0.7 IU/kg/week, given at a median frequency of six injections/week. The median height SDS for chronological age at the start of treatment and after 1, 2 and 3 years were -3.5, -2.9, -2.8 and -2.2, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Birth Weight↗
PubMed1993

Internal vibrations of a molecule consisting of rigid segments. I. Non-interacting internal vibrations.

For molecular crystals, a procedure is proposed for interpreting experimentally determined atomic mean square anisotropic displacement parameters (ADPs) in terms of the overall molecular vibration together with internal vibrations with the assumption that the molecule consists of a set of linked rigid segments. The internal librations (molecular torsional or bending modes) are described using the variable internal coordinates of the segmented body. In paper I of this two-part report, it is assumed as a zero-order approximation that the internal vibrations about the linkage axes between pairs of segments are uncorrelated with each other and with the overall molecular rigid-body vibrations. As a first-order approximation, the possibility that each internal vibration can be correlated with the external vibrations is also considered. An important feature of this approach is that the internal librations are required to give zero contribution to the overall momentum of the molecule at all times, so the internal coordinates must be orthogonal to the external ones. Also, each of the internal librations involves the motion of all atoms in the molecule. The resulting internal vibrational parameters are invariant to the choice of reference segment. With this procedure, the experimental ADPs obtained from crystal structure determinations involving six small molecules (sym-trinitrobenzene, adenosine, tetra-cyanoquinodimethane, benzamide, alpha-cyanoacetic acid hydrazide and N-acetyl-L-tryptophan methylamide) have been analyzed. As a consequence, vibrational corrections to the bond lengths and angles of the molecule are calculated as well as the frequencies and force constants (with e.s.d.'s) for each internal torsional or bending vibration. Compared with other models used for describing internal vibrations, there are differences in how the total ADP is partitioned between the internal and overall molecular vibrations.

Adenosine↗
PubMed1993

Establishment of the second international standards for porcine and human calcitonins: report of the international collaborative study.

The biological potency of calcitonins in clinical use in long-term treatment of Paget's disease of bone and, increasingly, in osteoporosis is usually expressed international units defined by the relevant World Health Organization international reference preparation. The international reference preparations for porcine and human calcitonins were ampouled in 1970 and stocks are now exhausted. Replacement standards were ampouled in 1989 and have been evaluated and calibrated by an international collaborative study comprising 16 laboratories in 12 countries. Evaluations included high-performance liquid chromatography and in vitro bioassay; calibration of each new ampouled preparation in terms of its international reference preparation was by in vivo rat hypocalcaemia bioassay. On the basis of the results of the study and with the agreement of the participants, replacement standards were established by the Expert Committee on Biological Standardization of the World Health Organization in 1991: the international standard for porcine calcitonin (ampoule code 89/540), with an assigned potency of 0.8 international units per ampoule, and the international standard for human calcitonin, with an assigned potency of 17.5 international units per ampoule. Both international standards appeared to be sufficiently stable to serve as the international standards for in vivo biological assays. Comparison of the two species of calcitonin in the same hypocalcaemia assay showed that they were approximately equipotent when the doses were given intravenously but that the human peptide was four- to sixfold more potent than porcine calcitonin when doses were given subcutaneously, emphasizing the need to compare "like with like".

Animals↗
PubMed1993

Intern candidates who withdraw from contracts: incidence and internal medicine program directors' attitudes.

OBJECTIVE: To study the prevalence of intern candidates accepted through the National Resident Matching Program (NRMP) or after the match who subsequently withdraw and the attitudes of program directors regarding this issue. DESIGN: Mailed survey. SETTING: Four hundred fifty-four internal medicine program directors. MEASUREMENTS: Questionnaires assessing program directors' attitudes toward interns who contract for positions after having verbal or written agreements elsewhere (and the program directors who accept them), the importance of this problem, and the incidence of this problem. MAIN RESULTS: Fifty-five programs (of the 221 responding) experienced intern withdrawals. Programs with larger numbers of open positions after the match had more intern withdrawals (p = 0.03). Eleven of the program directors knew of the prior commitment of the intern, and in all cases the other program director was called for permission to accept the intern. Program directors had negative feelings about both the interns who withdrew and the program directors who accepted them. Community, municipal, and Veterans Affairs hospital program directors were significantly less negative than those in university and university-affiliated hospitals toward interns who withdrew from written commitments (p = 0.001) and the program directors who accepted them (p < 0.05). CONCLUSION: Problems with intern candidate withdrawals from offered/matched programs affect a significant proportion of programs, especially those with larger numbers of unmatched positions. Program directors are generally disapproving.

Analysis of Variance↗
PubMed1991

Mutagenesis of the human transferrin receptor: two cytoplasmic phenylalanines are required for efficient internalization and a second-site mutation is capable of reverting an internalization-defective phenotype.

Site-specific mutagenesis has been used to define the sequences required for efficient internalization of the human transferrin receptor. It has previously been shown that the sole cytoplasmic tyrosine, at position 20, is required for efficient internalization. When two other cytoplasmic aromatic residues, the phenylalanines at positions 13 and 23, are substituted with alanines internalization is also reduced. The phenylalanine 23 mutation decreases the internalization rate constant approximately threefold, and mutation of phenylalanine 13 decreases it by approximately twofold. The mutation at position 23 has as serious an effect on internalization as substitution with a nonaromatic amino acid for the single tyrosine. These results demonstrate the importance of several aromatic amino acids in maintaining efficient internalization of the transferrin receptor. Substitution of a tyrosine at a second site, for a serine at position 34, within the cytoplasmic domain of a transferrin receptor with a nonaromatic amino acid at position 20, results in a complete reversion of the internalization-defective phenotype. This reversion is completely dependent upon a tyrosine, as phenylalanine substituted at position 34 does not revert the internalization-defective phenotype. This result demonstrates that a tyrosine placed outside of its native context can still function in the internalization of the transferrin receptor, suggesting a flexibility in surrounding sequences required for efficient internalization.

Amino Acid Sequence↗
PubMed1978

Effects of internal free calcium upon the sodium and calcium channels in the tunicate egg analysed by the internal perfusion technique.

1. The unfertilized egg of the tunicate, Halocynthia roretzi, was intracellularly perfused with various solutions. 2. The perfusion apparatus consisted of lower and upper compartments which were connected by a small glass funnel. A denuded egg cell without chorion was dropped into the funnel and brought into close contact with the glass wall of the funnel. The membrane of the egg faced to the lower compartment was ruptured by a slight difference of hydrostatic pressure and the inside of the egg was perfused with the internal solution flowing through the lower compartment. The current across the upper membrane was analysed by voltage-clamp technique. 3. The egg cell in contact with 400 mM-Na external solution and perfused intracellularly with 400 mM-Na for 30 min showed a relatively low Na reversal potential, +6 mV, in comparison with +60 mV in the intact egg in standard artificial sea water. The exchange efficiency was monitored by observing the shift of Na reversal potential during perfusion with high Na internal perfusate. 4. The internal perfusate containing F- ions stabilized the egg membrane and kept the excitability for 1--2 hr during the intracellular perfusion. With the internal F- perfusate the intracellular cationic content was changed to 400 mM-Na, K, Rb or Cs (external solution of 400 mM-Na) and permeability ratios of the egg Na channel were estimated as PNa:PK:PRb:PCs=1.0:0.14:0.05:0.04. The internal F- perfusate abolished Ca current which was consistently observed in the intact egg, while the internal Cl- perfusate kept both Na and Ca current as in the intact egg. However with the internal Cl- perfusate the egg cell could not be kept in good condition more than 20-30 min. 6. The effects of intracellular free Ca ions upon the egg Na and Ca channels were analysed by using Ca ion-buffered internal Cl- and high Na perfusate. The results showed that internal Ca ions above 10(-6) reduced the Ca current and enhanced the Na current at the same time. In the range between 10(-5) and 10(-4) M the Ca current became half of the control obtained with zero free Ca perfusate while the Na conductance at the zero current level doubled. The internal Ca ions above one mM seemed to abolish the Ca current and to reduce the Na current as well. The reciprocal effect of intracellular Ca ions upon the egg Na and Ca channels was demonstrated in the concentration range from 10(-6) to 10(-3) M.

Animals↗
PubMedDate not supplied

[The internal thoracic blood vessels (internal thoracic arteries and veins) and their practical significance].

Internal thoracic blood vessels (A. et Vv. thoracicae internae) are parietal vessels of the thoracic anterior wall. Because of their position, they are often exposed to injuries during the fracture of the ribs and the sternal bone. These facts require a general knowledge about the anatomical variations of these vessels, specifically the knowledge concerning their mutual relationship, their anastomoses and their distance from the lateral margins of the sternal bone. Due to the poor and different data in the available literature, we directed our investigations towards the study and confirmation of the described anatomical variations of the internal thoracic blood vessels. In this study we investigated the distance between the internal thoracic artery and the lateral margins of the sternal bone, the level of its bifurcation, the number of the internal thoracic veins and anastomoses between them. The investigation was carried out on 300 formalin specimens consisting of the anterior wall of the thorax (persons of different ages and sexes) by using the method of dissection and the method of contrast injection. In adults (200 specimens), the distance between the arterial trunk and the lateral margin of the sternal bone was not equal in the first fifth or sixth intercostal spaces, but in children up to five years of age (100 specimens), the distance was almost the same. In adults, the internal thoracic artery was nearest to the sternal bone in the first intercostal space, but going downward the artery was gradually more and more distant from the sternum and in the sixth intercostal space the distance measured approximately from 11 mm to 13 mm. In children, the distance of the artery from the lateral margin of the sternal bone, just in the above mentioned intercostal spaces, was from 5 mm to 10 mm. There was no difference according to sex in any of the two groups. Most frequently, the internal thoracic artery gave off its terminal branches at the level of the sixth costal cartilage (adults--35% and children--45%), and most rarely, the bifurcation of the artery was at the level of the seventh costal cartilage (adults--10% and children--8%). The internal thoracic vein that accompanies the same named artery, could be either single or double, on one or both sides. In cases of double veins-the artery was situated between the two of them, but in cases of single vein-the vein was located medially to the artery. In 82% of cases in the adult group, and in 69% of cases in the children-group, there were two veins accompanying the artery. The right and the left internal thoracic veins were connected in the region of the sternal bone by the retrosternal venous net (specifically in the region of the manubrium) and by one venous vessel lying in front of the xiphoid process. According to the position and the course of that venous vessel it could be called "arcus venosus prexiphoideus". The internal thoracic blood vessels were enclosed by the unique fascial sheath. They were superiorly separated from the costal pleura by the endothoracic fascia and inferiorly by the transversal thoracic muscle (m. transversus thoracis). The safest approach to the internal thoracic artery was at the level of the second and the third intercostal space. During the approach through some of the lower intercostal spaces it was necessary to be very careful because they could be narrowed at their anterior ends.

Adult↗