[Patients as customers? The term "customer" in the perception of medical students at the end of their university training]. / Der Patient als Kunde? Zur Perzeption eines marktwirtschaftlich geprägten Begriffs bei Medizinstudierenden am Ende ihres Studiums.

In the preceding decades a new perspective on the role of patients in the health-care system has gained ground, considering patients not merely as "suffering persons" but additionally as "customers". Physicians, however, tend to disagree with this approach because of the economic connotation of the term customer. Until now, there is only poor evidence of whether students of medicine - who are going to work as physicians in the future - agree or disagree with that approach and whether they are ready to accept patients as customers. In the following study students of medicine were interviewed on their perspectives towards that approach, in particular on their attitudes towards the idea of "the patient as customer", the appropriateness of the term consumer in different clinical settings and sectors of health care, the implementation of consumer orientation in clinical routine, and their favoured model of physician-patient relationship.As the study could not build upon data of prior similar studies, a quantitative and qualitative cross-sectional study with a descriptive-explorative design was conducted. Using a semi-standardised questionnaire, 313 medical students (response rate: 95%) were interviewed in Spring 2010. At the time of the survey, the students were enrolled at the faculty of medicine at Freiburg University, Germany, and were in their last semester which immediately preceded their exam.The future physicians do not consider patients primarily as customers. More than 80% of the respondents "absolutely" or "largely" supported the idea that patients are considerably more than customers. The analysis of the qualitative data of the study shows different results. Here, more statements were made that patients could equally be seen as customers (449 students supported this idea, 298 did not). Statements contradicting the customer approach referred mostly to the asymmetry of the physician-patient relationship and the special role of the patient. The highest level of acceptance of the customer approach was found in classical service settings such as pharmacies, the lowest level in emergency medical aid. According to medical students, a consumer orientation has been realised in different health service areas in correspondingly different degrees: On top of the list are plastic surgery clinics, followed by private health insurances and homeopathic clinics. A minority of medical students predict the implementation of consumer orientation in the emergency medical aid. Future physicians consider their relationship to patients largely as a relationship between a healing person and a person seeking help rather than a relationship between a service provider and a customer.Considering recent developments in the organisation of medical services and health services in general, it becomes increasingly important to know what kind of 'service behaviour' patients expect from their doctors and other health providers. Obviously, it is not self-evident for medical students to perceive their future patients as customers and to act as customer-oriented 'service providers'. In view of this, the faculties of medicine at universities - which provide professional training to students of medicine - should be aware of the challenge to 'socialise' their students so that they can keep up with patients' expectations.

[Eyelid reconstruction after removal of tumours, using chondroperichondrial grafts from auricular concha]. / Odtwarzanie powiek po wycieciu nowotworów zlosliwych, z wykorzystaniem wolnych przeszczepów ochrzestnowo-chrzestnych z malzowiny usznej.

INTRODUCTION: The main goal in reconstruction of the full thickness defects of the eyelids after tumour resection is the reconstitution of the tarsal plate as supportive layer of the lid. AIM OF STUDY: We report a simple, one stage reconstruction procedure of repairing the eyelid internal lamella. METHOD: The chondroperichondrial graft from auricular concha was used to reconstruct the tarsoconjunctival layer in nine patients with surgical defects following excision of skin cancer. Local cutaneous flaps were used to reconstruct the external lamella. RESULTS: All grafts appeared completely without reabsorption, healing of the wounds was rapid. Epithelialization on the perichondrium from the surrounding conjunctiva occurred between 2 and 3 weeks. The functional and aesthetic results were judged as very good in seven patients after reconstruction of the lower eyelid. One patient after reconstruction of the upper eyelid has good result too. The last patient needed secondary very extensive operation because of the tumour recurrence. CONCLUSIONS: Conchal chondroperichondrial free graft provides simple, one-stage reconstruction of the lower and upper eyelid. Perichondrium substitutes the conjunctiva in early postoperative period and it makes epithelialization possible.

Extensive periocular defect reconstruction with local flaps and conchal cartilage graft.

BACKGROUND: Advanced, histologically aggressive basal cell carcinomas (BCCs) of eyelids are difficult to eradicate. OBJECTIVE: To describe a case of BCC of both eyelids and lateral canthus and the reconstruction procedures used. METHODS: A two-stage reconstruction procedure was used. First, only mobilization of the forniceal conjunctiva and the musculocutaneous flap technique were used. The because of shortage and insufficiency of the upper eyelid the flap/graft technique was performed. A conchal complex cartilage-perichondrial graft was selected. RESULTS: The described procedure resulted in a very good functional and aesthetic outcome.

[Bilateral aggressive basal cell carcinoma of the eyelids and face--case report]. / Obustronny agresywny rak podstawnokomórkowy skóry powiek i twarzy--opis przypadku.

In this paper we present a case of sclerosing basal cell carcinomas affecting both sides of periocular regions in a 68-years old woman. Neoplastic tissues were surgically removed and the extend of resection was controlled microscopically during the operation. After fixing the remaining palpebral structures to ocular muscles and bones the split-thickness skin grafts were placed at the defects. We planned to perform the second step reconstructive procedures of the eyelids, but we resigned because of unexpectedly good functional nad esthetic results. We present this case because the cancers were long-term, multiple and of a great advancement, the treatment was difficult and the results were very good.

Upper lip reconstruction with local island flap after neoplasm excision.

BACKGROUND: The upper lip is an important esthetic unit of the face and its reconstruction is a big challenge to the dermatosurgeon. OBJECTIVE: The aim of the paper is to present results of upper lip reconstruction for moderately sized defects with single island subcutaneously pedicled flaps, or in combination with additional local flaps. METHODS: Thirteen patients were operated upon mostly for malignant skin neoplasms. Defects of skin only were covered with island flaps planned individually to fit esthetic units of the face. Defects in skin and vermillion were covered with island flaps, and additionally and independently with flaps that reconstructed the vermilion. RESULTS: The healing process was in all the cases but one (partial flap necrosis) free of complications. Follow-up results were also very good functionally and esthetically.

Development of a knowledge test in the science of prevention of lung diseases.

We developed a 50-item multiple choice test to assess knowledge of preventive pulmonary medicine. We derived the content of test items from a comprehensive preventive pulmonary curriculum, which we developed. The test was administered to 167 medical students, residents, and practicing physicians to establish its psychometric properties and to determine if the test scores discriminated between different levels of training. Using this sample, the reliability of the test was 0.86, and the test significantly differentiated between levels of training in pulmonary medicine. We are using this multiple choice test to assess changes in knowledge of second-year medical students and of fourth-year medical students completing a pulmonary medicine elective rotation.

Chronic and recurrent pneumonia.

Recurrent pneumonia is defined as two or (usually) more separate episodes of lower respiratory tract infection that generally are accompanied by fever, leucocytosis, and purulent sputum production. These episodes are separated by an asymptomatic interval of at least 1 month or clearing of the chest visible by radiograph. Clinical improvement and radiological clearing should result after appropriate antimicrobial therapy. Chronic pneumonia is an illness that lasts at least 6 weeks and is caused by a microorganism. The chest radiograph usually shows diffuse or focal shadows. The incidence of either chronic or recurrent chest infections is unknown. Neither condition is common, but when present, they frequently present a difficult diagnostic challenge. Chronic pneumonias are usually caused by slow-growing organisms, such as fungi or mycobacteria. Occasionally, chronic pneumonias cannot be diagnosed, even when lung biopsy specimens are cultured or studied histopathologically. When a patient presents with recurrent pulmonary parenchymal infections, the clinician needs to identify the likely etiologies. Possible etiologies are structural abnormalities, underlying medical conditions, and immunological abnormalities, including infection by the human immunodeficiency virus (HIV).

Immunohistochemical detection of steroid receptors in a case of pulmonary lymphangioleiomyomatosis.

Abnormal proliferation of smooth muscle cells in pulmonary lymphangioleiomyomatosis (LAM) is thought to be influenced by estrogen and progesterone. However, the results of previous studies using cytosolic methods to measure estrogen and progesterone receptor content in lung tissue from these patients have been inconsistent. We used immunohistochemical methods to study the tissue distribution of estrogen and progesterone receptors in LAM as well as in smooth muscle of several other organs, including histologically normal lung, colon, bladder, prostate, uterus, and uterine leiomyomas. Progesterone receptor was expressed strongly and estrogen receptor more weakly by the abnormal myoid cells of LAM. Hormone receptors were absent from all other constituents of lung tissue in our patient. These findings were similar to those in histologically normal myometrium and uterine leiomyomas. Although we found focal labeling of prostatic stromal cells with anti-progesterone receptor, no other smooth muscle tissue expressed either estrogen or progesterone receptor. We conclude that LAM is an abnormal proliferation of smooth muscle cells that express both estrogen and progesterone receptors.

Short-term regulation of fatty acid synthesis in isolated alveolar type II cells from adult rat lung. Effects of free fatty acids and hormones.

We measured the total rate of fatty acid synthesis in alveolar type II cells freshly isolated from the lungs of adult rats. The rate of incorporation of 3H from 3H2O into cellular fatty acids was linear during 3-hr incubations and was very brisk [18 ng-atoms 3H/10(6) cells/hr +/- 2 (mean +/- SD, n = 23)]. When the nutrient medium (Minimum Essential Medium) was supplemented with various hormones or free fatty acids, the long-chain fatty acids (C14-C20) caused a decrease in the rate of 3H incorporation to a variable degree depending on the species of fatty acid. Stearate (10(-4) M) and palmitate (10(-4) M) caused the greatest inhibition of de novo cellular fatty acid synthesis, followed by myristate, arachidonate, and oleate. Insulin (10(-7) M), glucagon (10(-8) M), terbutaline (10(-5) M), 8-bromo-cyclic AMP (10(-3) M), the essential fatty acid linoleate (10(-4) M), and the medium-chain-free fatty acids laurate and octanoate (10(-4) M) did not alter the rate of fatty acid synthesis in type II cells. We demonstrated that the alveolar type II cell is a major lipogenic cell type in the rat. We also demonstrated that the availability of preformed fatty acids in the extracellular milieu is one factor regulating the rate of fatty acid synthesis in these cells.

Metabolic properties and ultrastructure of alveolar type II cells isolated with elastase.

We used porcine pancreatic elastase to isolate type II cells from the lungs of rats; the yield and purity of the type II cells was better than that obtained by methods using trypsin. In 102 experiments we obtained 82 +/- 23 . 10(6) cells/rat, 68 +/- 11% (mean +/- S.D.) of which type II cells. This preparation of cells, when centrifuged over a discontinuous density gradient, yielded 25 +/- 10 . 10(6) cells/rat, 80 +/- 13% of which were type II cells (n = 102). The cells, after density gradient centrifugation, could be futher purified by centrifugal elutriation (94 +/- 3% type II cells, n = 22) or adherence in primary culture (94 +/- 2% type II cells, n = 34). Type II cells isolated with elastase are similar morphologically and biochemically to type II cells isolated from rats with trypsin. The preparations of cells appeared healthy by several different criteria: ultrastructure, exclusion of vital dye, lack of stimulation of oxygen consumption by exogenous sodium succinate, and linear rates of oxidation of [1-14C]palmitic acid and of incorporation of [1-14C]acetate into fatty acids. Type II cells consumed 75 +/- 20 nmol O2/10(6) cell per h, oxidized [1-14C]palmitic acid at a rate of 0.4 nmol/10(6) cells per h, and incorporated [1-14C]acetate into fatty acids at a rate of 7.5 nmol/10(6) cells per h.

[Granulomatous orchitis (author's transl)]. / Ein Beitrag zur Orchitis granulomatosa.

A rare disease of orchitis granulomatosa is presented. The patient was 38 years of age, which is below the average age. The classification into an acute or chronic and the clinical features for an acute course. The differential diagnosis of tumour of the testis or tuberculosis must be considered. Orchiectomy is the therapy of choice. The etiology is not clear. Urinary tract infections, caused by bacteria or fungis, and immunological causes are discussed.

The pathogenesis of pulmonary and miliary tuberculosis.

Tuberculosis is spread from human to human by airborne transmission; it is not a highly infectious disease. Primary infection remits in 90% of cases and is progressive in the remainder; it is accompanied by lymphohematogenous seeding of many organs, and reactivation may occur as early as three months or many years after initial infection. Primary infection generally confers immunity from subsequent reinfection. The risk of reactivation of tuberculosis is greatest in the year after infection, declining sharply thereafter for most patients. Acute miliary tuberculosis has a distinctive pathogenesis that is different from localized postprimary disease. Miliary tuberculosis may appear in a patient with a normal chest roentgenogram; even in patients with abnormal chest roentgenograms, sputum cultures for acid-fast organisms may be negative. Transbronchial biopsy is the preferred method of diagnosis and prompt initiation of treatment is essential.

Public health and preventive aspects of pulmonary tuberculosis. Infectiousness, epidemiology, risk factors, classification, and preventive therapy.

Tuberculosis is usually of a low order of infectivity. Once treatment has begun, patients are no longer infectious to close contacts, and there is no benefit to isolating them. Among the risk factors associated with tuberculosis that reactivates after many years of dormant infection, the coexistence of silicosis, diabetes mellitus, and the postgastrectomy state with tuberculosis are reasonably well demonstrated. Preventive treatment begins with prompt institution of chemotherapy in the index case. Isoniazid is extremely effective in preventing tuberculosis infection from becoming tuberculosis disease. The benefits of BCG vaccine are controversial, and it is little used in the United States. Hepatotoxicity is a potential serious side effect of isoniazid chemoprophylaxis. Clinical monitoring for prodromal symptoms makes the drug safe and effective for patients under 35 years of age.

An investigation of the mechanism of ethanol-induced bronchoconstriction.

A 28-year-old Asian-American woman complained of symptoms of acute bronchoconstriction after drinking alcohol beverages. We documented the presence of ethanol-induced bronchoconstriction in this patient by administering oral ethanol challenges under controlled conditions. Bronchoconstriction was not prevented by pretreatment with atropine sulfate or cromolyn, suggesting that neither cholinergic postganglionic pathways nor mediator release from mast cells was the cause of the acute airway narrowing. The rapid decrease in specific airway conductance after ethanol ingestion and the association with symptoms of vasomotor sensitivity suggest that ethanol may have acted in this patient by releasing one or more secondary mediators with vasoactive and bronchoactive properties.