Thyroid hormone and thyromimetics inhibit myelin and axonal degeneration and oligodendrocyte loss in EAE.

We have previously demonstrated that thyromimetics stimulate oligodendrocyte precursor cell differentiation and promote remyelination in murine demyelination models. We investigated whether a thyroid receptor-beta selective thyromimetic, sobetirome (Sob), and its CNS-targeted prodrug, Sob-AM2, could prevent myelin and axonal degeneration in experimental autoimmune encephalomyelitis (EAE). Compared to controls, EAE mice receiving triiodothyronine (T3, 0.4 mg/kg), Sob (5 mg/kg) or Sob-AM2 (5 mg/kg) had reduced clinical disease and, within the spinal cord, less tissue damage, more normally myelinated axons, fewer degenerating axons and more oligodendrocytes. T3 and Sob also protected cultured oligodendrocytes against cell death. Thyromimetics thus might protect against oligodendrocyte death, demyelination and axonal degeneration as well as stimulate remyelination in multiple sclerosis.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Amyloid in the aged heart: frequency and clinical significance.

Cardiac amyloid accumulation is a common autopsy finding in elderly persons, the frequency increasing with each advancing age decade. In most cases the deposits are microscopic, confined to the atrial subendocardium, and of dubious significance. In a few cases, however, there is much more extensive cardiac involvement, with infiltration of the ventricular musculature and intracardiac conduction system. In the authors' recent autopsy study of 100 patients over 60 years of age, 10 had diffuse cardiac amyloidosis with biventricular involvement. Microscopically, the amyloid deposits often resembled foci of interstitial fibrosis. Significant cardiac enlargement (weight greater than 380 gm) was present in only 2 of these patients, and in only one of them were the clinical signs and symptoms clearly attributable attributable to the amyloid infiltration. It was difficult to assess the possible contribution of ventricular amyloid to congestive failure since most of the patients also had coronary arteriosclerosis. In the aged, clinically significant cardiac amyloidosis associated with cardiac enlargement appears to be part of a disease spectrum more commonly characterized by focal, clinically insignificant cardiac amyloid deposits. Yet several features suggest that senile cardiac amyloidosis may differ from the clinically significant cardiac amyloidosis occassionally seen in younger patients.

Use of a structured functional assessment format in a geriatric consultative service.

Interdisciplinary team assessment may not be feasible in the consultative setting because of scarce institutional resources. We explored the extent to which a physician-administered multifaceted assessment could meet the needs of a geriatric consultative service and also provide for the comprehensive functional assessment of elderly patients. Fifty-one consecutive patients, mean age 78, were evaluated. Domains measured included physical and mental health, socioeconomic resources, and activities of daily living. Despite a majority of consult requests for transfer of seemingly stable patients, unrecognized remediable problems were identified in most cases. Compliance with the consultant's recommendations was consistently poor, averaging less than 33% for all of the domains assessed. Nine of the study patients subsequently were transferred to the care of an interdisciplinary team on the geriatric assessment unit. Numbers and types of problems identified by the geriatric consultation using a structured assessment format allows for the comprehensive and efficient disclosure of pertinent management issues. Improved compliance with consultant recommendations may be effected by better education of care providers to the special needs of the geriatric population.

Nutritional assessment of community-living well elderly.

Nutritional assessment parameters were studied in a sample of 132 community-living well elderly. Results are presented for biochemical parameters of serum albumin, hemoglobin, and total lymphocyte count and anthropometric parameters of height, weight, mid-arm circumference, and triceps skinfold. The data show that, although there are some differences between age groups (young-old and old-old), all values remain well within normal limits established for younger individuals.

Curricular variations in combined baccalaureate-M.D. programs.

The authors review curricular characteristics of combined baccalaureate-M.D. programs at 28 U.S. medical schools from 1961, when the first programs started, until 1991-92. Initially, in the 1960s, these programs were created (1) to offer talented high school graduates an accelerated track leading to the baccalaureate and M.D. degrees, (2) to reduce educational expenses, (3) to improve education in the humanities, and (4) to attract outstanding students into careers in medicine. In the 1970s these objectives were modified to address national health care needs, particularly the need to graduate more physicians more quickly, especially primary care physicians for underserved areas. In the 1980s the objectives were broadened to achieve more diverse goals, including emphases on the humanities, community medicine, and biotechnology, in addition to the continued stress on the education of primary care physicians.

An assessment of the student partnership program at the University of Missouri-Kansas City School of Medicine.

The partnership program at the University of Missouri-Kansas City (UMKC) School of Medicine pairs less experienced students with more experienced students to work together during the last four years of a six-year curriculum. The present study has explored how the partnership program is supposed to work, whether in reality it does work, what function it actually serves, and under what circumstances it operates best. In 1986 and 1987, the authors analyzed information from formal school documents, created and used questionnaires for the students and faculty, conducted semistructured interviews with selected students, and used the results of an annual survey, begun in 1978, of supervisors of first-year students who graduated from UMKC. The students and docents were found to favor the partnership system and reported that most partnerships worked well. The system's chief outcome is seen to be teaching teamwork: learning from and working together with student partners. The characteristics of the students, docents, and setting that contributed to successful partnerships are identified. The authors conclude that the partnership system at UMKC does achieve its objectives, which are described.

Preparing high school students for a career in the health sciences.

The Summer Scholars Programs at the University of Missouri-Kansas City School of Medicine are designed to identify talented minority or economically disadvantaged high school students and to encourage these students toward careers in the health sciences. In the summer of 1984, 31 students participated in a one-month educational program during which they observed and participated in selected patient care procedures. They developed interpersonal and interviewing skills needed for successful application to health education programs. Students were provided information about numerous health careers to help them clarify their perceptions of health roles.To assess the programs' impact, the 18 scholar participants, who were high school seniors, responded to a questionnaire that sought information about their academic program during the senior year and their plans for higher education. Responses indicated that all had pursued rigorous academic programs, had achieved at a superior level in these courses, and were enrolling in college in the fall of 1985. Fourteen of the 18 students were planning careers in medicine. Responses indicated that the students felt that the programs had been effective in helping them learn about, prepare for, and make appropriate choices regarding careers in the health sciences.

Predictors of black medical student success.

This study identifies those variables, cognitive and noncognitive, that relate significantly to the successful completion of the combined BA/MD degree program. The study sample included 69 black students who entered at year one, directly from high school, between 1972 and 1981. The Student's t-test identified statistically significant differences in the means of selection variables of successful and nonsuccessful black students. Single order correlations between predictor variables and the criterion of graduation were determined. This was followed by a stepwise regression procedure. The same predictor variables were correlated with grade point average (GPA) at the end of year one, and a further analysis added year one GPA to the predictors of graduation in a stepwise regression procedure. The same statistical analyses were carried out on a stratified sample of 69 nonminority students. Predictors of graduation for black students were parents' level of education, admission test score, self-evaluation, and council index (average vote of all committee members on an applicant). Year one GPA was a strong predictor of success for both cohorts of students. This study supports the inclusion of noncognitive information when considering black applicants for medical school. In particular, parents' levels of education and applicants' self-appraisals, along with admission test scores, showed a significant relationship to graduation 6 years later with the MD degree.

Predictors of performance of minority students in the first two years of a BA/MD program.

This study examines cognitive and noncognitive selection variables as predictors of multiple criteria of performance for minority and nonminority students entering the University of Missouri-Kansas City School of Medicine between 1972 and 1977. Data analysis aims at identifying characteristics associated with success in the crucial first two years of the combined BA/MD program. Pearson product moment correlations and multiple regression equations have been determined for all selection variables and three criteria measures. A number of nontraditional variables are significantly predictive of minority student performance. The cognitive variables of aptitude test and high school science/mathematics preparation are significant predictors of all three performance measures in both racial groups. The data support the position that separate equations are not necessary to predict performance of minority and nonminority students, but that admission committees, when selecting minority students, should recognize both personal attributes and academic preparation as indicators of potential success or failure.

Rheumatic diseases in the elderly. Finding a way through the maze.

The manifestations of rheumatic disease in the elderly present a confusing array of diagnoses to the primary care physician. Helpful guidelines in pursuing a definitive diagnosis are outlined, with special mention of three rheumatic conditions (pseudogout, polymyalgia rheumatica, and temporal arteritis) which are uniquely characteristic of elderly patients.

Geriatric issues in the diagnosis and management of patients with rheumatic disorders.

The musculoskeletal diseases account for the most frequent complaints among older persons. Rarely is it possible to provide the patient with complete symptomatic relief. Instead, the patient needs to be taught good health habits, good concepts of preventive care, the value of rehabilitation, the gains to be achieved through non-pharmacologic therapy, and a recognition that symptoms reflect emotional problems as well as diseased musculoskeletal tissue. Most important, the patient needs to be taught that he or she can live a full exciting life despite the limitations imposed by the musculoskeletal disease. Encouragement of this attitude and institution of any and all measures that will enhance the patient's ability to retain independence are the major components of ongoing care for this growing segment of our population.

Nosocomial infections in hand surgery.

The active and experienced hand surgeon should have enough knowledge to recognize both common and uncommon hand infections. Control of hospital-acquired infections, including surgical site infections, requires a knowledge of potential personal risk factors and ongoing surveillance systems to aid in prevention and early detection. Current national trends may soon require that surgical-site infections be diagnosed by specific criteria that will allow comparisons of data from various locations. Although most hand surgery procedures are now performed on an ambulatory basis, it is important for the hand surgeon to be aware of current methodologies for the prevention, control, surveillance, and treatment of hospital-acquired infections. These intriguing aspects of hospital-acquired infections are reviewed in this article.

Carpal tunnel syndrome in the work place.

The management of patients with the CTS that appears to be related to occupational tasks is a complex issue. At this time, there is no definite evidence to show that any job is the sole cause of an individual worker's symptom complex. Management of patients in this situation requires surgical restraint coupled with an understanding of the worker's overall lifestyle. The most effective outcomes for all concerned appear to occur when there is cooperation among the patient, the physician, and the employer or his or her representatives. The recent prospective study by MacDougal that attempted to correlate job classifications with surgical outcome may be a very positive step in this direction.