Morning report. A successful format.

Morning report can function as an instructive teaching conference capable of providing a broad coverage of topics in internal medicine. A format at our institution that utilizes brief case presentations by on-call interns, followed by an in-depth discussion of key points among representative subspecialty staff, provided coverage of 85.6% of material present in three major medical references. An internal monitoring system used to guide case selection assures a broader coverage of topics. In addition, preconference preparation to delineate major teaching points, timely follow-up of previously discussed cases, and the generation of a pertinent bibliography are significant features of a format for morning report that provides a conference for exposing house staff to a wide variety of internal medicine problems.

Factors affecting compliance for general medicine consultations to non-internists.

For a general medicine consultation service to be effective, compliance with recommendations is essential, as is an understanding of the factors that improve compliance. Residents in a general medicine consultation service attempted prospectively to improve their skills as consultants and to enhance compliance by implementing the following steps, reported to influence compliance: identify critical recommendations; make early, direct oral contact with the referring surgeon; limit the number of recommendations; and render definite recommendations. At the end of the study period, recommendations were tabulated and categorized as to whether each was diagnostic or therapeutic and critical or noncritical, and the time of contact with the referring surgeons was noted when applicable. Multivariate analysis of the factors, in relation to the type of recommendation, demonstrated that compliance can be improved, especially if a consultant clearly identifies the critical recommendations and makes contact with the referring physician within 24 hours.

Response to upright exercise after cardiac transplantation.

There is little information on the hemodynamic response to upright exercise in patients who have undergone cardiac transplantation. We compared the hemodynamic and metabolic response to upright bicycle exercise in 11 patients with heart transplants and 12 controls. Patients performed two tests--a steady-state test with a right heart catheter and a maximal incremental test. During steady-state exercise at 20% of their predicted maximum workload, patients with heart transplants had a higher (mean +/- SD, p < 0.05) heart rate (108 +/- 11 vs. 96 +/- 15 beats/min), mean systemic blood pressure (116 +/- 17 vs. 101 +/- 11 mmHg), mean pulmonary artery pressure (29 +/- 9 vs. 22 +/- 3 mmHg), mean pulmonary wedge pressure (14 +/- 6 vs. 9 +/- 2), pulmonary (302 +/- 101 vs. 220 +/- 50 d-sec-cm-5-m2) and systemic (2049 +/- 531 vs. 1459 +/- 520) resistance indices, and lactate concentration (3.4 +/- 1.7 vs. 1.7 +/- 0.4 mmol/l), and a lower stroke index (39 +/- 8 vs. 50 +/- 8 ml/m2) compared with controls. Cardiac index, right atrial pressure, and mixed venous oxygen saturation were similar. During the maximal exercise test, patients with heart transplants achieved a significantly lower percentage of predicted maximum heart rate (77 +/- 13 vs. 91 +/- 8%), workload (70 +/- 25 vs. 102 +/- 23%), oxygen consumption (63 +/- 11 vs. 108 +/- 19%), and ventilation (67 +/- 18 vs. 89 +/- 15%) compared with controls. Heart transplant patients also had a lower blood pressure and anaerobic threshold. We conclude that heart transplant patients have an altered hemodynamic and metabolic response to upright bicycle exercise.

Clinical evaluation of a rapid immunoinhibition assay for creatine kinase-MB in suspected myocardial infarction.

We examined the clinical performance of a new immunoinhibition assay (INH) for the measurement of creatine kinase isoenzyme MB (CK-MB). In 196 consecutive patients admitted for exclusion of acute myocardial infarction, serial blood samples were evaluated by INH, immunoradiometric assay (IRMA), and electrophoresis (ELP). Using receiver operating characteristic curve analysis, the diagnostic performance of the INH assay was comparable to IRMA and ELP. As compared with these alternative methodologies, this newly available INH assay for CK-MB provides similar diagnostic accuracy and increased convenience at a greatly reduced cost.

Management of orthotopic heart transplant recipients at Brooke Army Medical Center.

Advances in heart transplantation and post-operative rejection therapy have given new hope to patients with end-stage congestive heart failure and cardiomyopathies. The growing numbers of pre- and post-transplant patients and the complexity of their care underscore the need for a multispecialty approach to patient management. This study examines the success of a multi-service program at Brooke Army Medical Center which offers pre- and post-transplant care to active duty, dependent, and retired military personnel.

Spontaneous thrombosis of iatrogenic femoral artery pseudoaneurysms: documentation with color Doppler and two-dimensional ultrasonography.

Two-dimensional ultrasonography and color Doppler were used over an 18-month period for the diagnosis and management of femoral artery pseudoaneurysms in six patients with pulsatile groin masses found after catheterization. A diagnosis of pseudoaneurysm was made when color Doppler demonstrated pulsatile systolic flow into echolucent masses. One patient underwent surgical repair of a symptomatic pseudoaneurysm after the initial Doppler study. Serial color Doppler studies were performed in five subjects, all of whom showed resolution of flow after a mean of 18 days (range 7 to 42). Despite an absence of flow, one patient underwent surgical drainage of persistent hematoma. After a mean interval of 233 days (range 84 to 552) all patients have remained free of other complications or symptoms related to the pseudoaneurysm. This experience suggests that urgent surgical repair is not required in all cases of small iatrogenic pseudoaneurysms, and that asymptomatic patients can be safely followed with serial color Doppler examinations.

Comparison of adenosine, dipyridamole, and dobutamine in stress echocardiography.

OBJECTIVE: To compare adenosine, dipyridamole, and dobutamine in stress echocardiography with regard to sensitivity, specificity, accuracy, and side effects. DESIGN: Crossover, blinded comparison, with coronary angiography serving as the criterion standard. SETTING: U.S. Army tertiary care hospital. PARTICIPANTS: Forty participants, 25 with coronary disease and 15 without coronary disease. Patients were eligible if they had coronary angiography within 6 weeks of stress testing or if they had a risk for coronary disease of less than 5%. MEASUREMENTS: Left ventricular wall motion was recorded after dobutamine (0.38 mg/kg body weight), adenosine (0.84 mg/kg body weight), and dipyridamole (0.84 mg/kg body weight) stress testing. Stress echocardiographic evaluation was considered to be abnormal if the patient developed new or progressive wall motion abnormalities. The rate of side effects for the types of echocardiography and the patient preference were recorded. MAIN RESULTS: The sensitivity of dobutamine stress echocardiography (76%; 95% CI, 59% to 93%) was significantly higher than that of adenosine echocardiography (40%; CI, 21% to 59%; P less than 0.001) and that of dipyridamole echocardiography (56%; CI, 37% to 75%; P = 0.019). The specificity of adenosine testing (93%; CI, 80% to 100%) was significantly higher than that of dobutamine echocardiography (60%; CI, 35% to 85%; P = 0.008) and that of dipyridamole echocardiography (67%; CI, 43% to 91%; P = 0.028). Symptoms were more frequent with adenosine echocardiography (100%) than with dipyridamole (88%; P less than 0.001) or dobutamine (80%; P less than 0.001) echocardiography. Treatment for persistent symptoms was required in more patients after dipyridamole echocardiography (40%) than after dobutamine (12%; P less than 0.001) or adenosine (0%; P less than 0.001) echocardiography. More patients preferred dobutamine (48%) or dipyridamole (40%) echocardiography to adenosine echocardiography (12%; P less than 0.001). CONCLUSIONS: Dobutamine stress echocardiography is more sensitive and is better tolerated than adenosine or dipyridamole stress echocardiography. Adenosine echocardiography is more specific than dobutamine or dipyridamole echocardiography and is less likely to cause persistent symptoms.