Evaluating the impact of CPAP weaning procedures on total days on nasal CPAP: A retrospective chart review.

BACKGROUND: There is no consensus on how to wean infants from Nasal Continuous Positive Airway Pressure (NCPAP). We hypothesized that ceasing NCPAP abruptly would decrease the duration required, compared with a gradual wean. METHODS: This retrospective chart review included preterm infants requiring NCPAP for over 48 hours. Cohort1 weaned NCPAP by cycling on and off, while cohort 2 ceased NCPAP abruptly. The primary outcome was total days on NCPAP. Secondary outcomes included rate of bronchopulmonary dysplasia, weight gain, duration of hospital stay, and compliance with the use of stability criteria. RESULTS: 81 infants met inclusion criteria in cohort one, and 89 in cohort two. Median days on NCPAP were 17.0 and 11.0 days, respectively, not significant. There was no significant difference in secondary outcomes. CONCLUSIONS: There was no significant association between the two NCPAP weaning protocols and the outcomes studied.

A survey of sued and nonsued physicians and suing patients.

To systematically assess the impact of malpractice litigation on the doctor-patient relationship and to collect data that might suggest effective tort reform, we surveyed 642 sued physicians, nonsued physicians, and suing patients in Wisconsin. Parallel forms of survey instruments obtained information regarding changes in physicians' practices, changes in attitudes toward patients or physicians, and changes in physical and emotional well-being as a result of malpractice litigation or the threat of the same. In addition, opinions regarding causes and deterrents of malpractice litigation were obtained. Results suggested that claims or threats of malpractice suits had a negative impact on physicians' practices and emotional well-being; that this negative impact was more pronounced when the sued physician had been more personally involved with his patient prior to the malpractice claim; and that suing patients' and sued physicians' understanding of their relationship before the malpractice claim significantly differed. All respondents viewed improved physician-patient communication as the most effective method of preventing malpractice claims. Informal, alternative dispute resolution mechanisms in hospitals and clinics and improved peer review may decrease litigation and its deleterious effects.

What students value: learning outcomes in a required third-year ambulatory primary care clerkship.

PURPOSE: To determine learning outcomes from the students' perspective on the clinical portion of a third-year primary care ambulatory clerkship. METHOD: Over 18 months (December 1994 to June 1996), students at the Medical College of Wisconsin identified what they had learned during the clerkship in each of seven learning settings. Responses were transcribed and a coding dictionary developed. Response frequencies were compared by logistic regression analysis over time and between rural and urban sites. Course goals set by faculty were compared to learning outcomes reported by students. RESULTS: The authors coded 3,030 student outcomes into 48 categories. The top ten learning outcomes by frequency are reported. Logistic regression analysis revealed no significant difference by time of year or by rural versus urban clerkship experiences. Twenty-six of 29 original course goals were congruent with the student-generated outcomes. CONCLUSION: Basic professional knowledge, skills, and attitudes were the learning outcomes most valued throughout the year. Being alone with patients and working with their preceptors were the students' most valued learning settings.

Students' time allocation in a required third-year ambulatory care clerkship.

PURPOSE: To assess time use by students during clinic sessions of an ambulatory care clerkship. METHOD: All 207 third-year students at the Medical College of Wisconsin during 1991-92 were asked to report their time use in eight categories during two clinic sessions of the three-week clinical component of the required clerkship in ambulatory care medicine. Other variables assessed were site of clinical rotation, first versus third week of rotation, and time of year of rotation. The statistical methods used were t-tests and one-way analysis of variance. RESULTS: Of the 207 students, 192 (93%) completed time-allocation reports for the first and third weeks of their rotations. The average time spent per clinic session was four hours. Compared with the students at faculty practice sites, the students at private practice sites spent significantly more time observing and working with preceptors as they saw patients and significantly less time doing solo clinical work (reviewing and writing in charts). During the course of each rotation, the students increased the time they saw patients by themselves and decreased the time they observed preceptors. As the year progressed, later cohorts of students spent less time observing preceptors and more time working by themselves. CONCLUSION: Both within and across rotations, the students eventually spent less time observing and more time working independently. However, the results suggest that preceptors in private practice may not allow students as much autonomy as do faculty preceptors. Further research is needed to determine (1) whether the differences between types of preceptors result in meaningful differences in the quality of education and (2) which activities or mixes of activities contribute most to students' education.

Effect of student and preceptor gender on clinical grades in an ambulatory care clerkship.

BACKGROUND: Although several studies have addressed the effect of student gender on clinical performance evaluation, none has looked at the effect of preceptor gender or the interaction of preceptor gender and student gender. We investigated the possibility of gender effects in an ambulatory care clerkship where the preceptor-student ratio is usually one to one. METHOD: Clinical grades given by preceptors to third-year students after a required one-month ambulatory care medicine clerkship were analyzed by student gender, preceptor gender, and preceptor-student gender pairs. The study was conducted from August 1990 to October 1992 at the Medical College of Wisconsin. A total of 121 preceptors (97 men and 24 women) and 375 students (233 men and 142 women) participated. Analyses of variance were used to detect significant differences. RESULTS: On a scale of 0 to 4, the female students received a higher mean clinical grade than the male students (3.1 versus 3.0, p < .04). Preceptor gender had no effect on clinical grades until student gender was considered. The highest mean grade of 3.3 was given by male preceptors to female students, and the lowest mean grade of 2.9 was given by female preceptors to male students (p < .01). CONCLUSION: The female students received higher clinical grades in the ambulatory care clerkship, especially when the preceptor was male. Perhaps gender interaction should be considered when assigning students to preceptors and evaluating grading practices.

Graded exercise stress test training in family practice and internal medicine residencies.

A mail survey of upper Midwest family practice and internal medicine residency program directors was performed to determine the prevalence and characteristics of exercise stress test training. Two mailings provided a 68% response rate for the 184 programs surveyed. Internal medicine programs were significantly more likely to offer exercise stress test training than family practice programs (57% vs 34%). Overall, an estimated 31% of family practice and internal medicine residency graduates are performing exercise stress tests in their practice. Programs provided an average of 7.3 hours of didactic instruction and 32.7 stress tests per resident. A minority (43%) had an established minimum number of exercise stress tests recommended for competency. Programs with and without exercise stress test training did not differ significantly with respect to age, size of program, or size of community. There were some interstate differences in the extent of exercise stress test training provided by family practice residency programs. Internal medicine programs were more likely to require a minimum number of treadmill tests. Otherwise there were few differences between family practice and internal medicine program instruction in exercise stress test training. Family practice program directors were more likely to believe that their residents should be taught this procedure and to include family physicians in their panel of instructors. Specific guidelines should be created to assure adequate stress test training for interested residents.

New use for alpha blockers: benign prostatic hyperplasia.

Treatment with alpha 1-adrenergic blockers can be a reasonable alternative to surgery for patients with symptomatic benign prostatic hypertrophy. Alpha blockers may also be useful as an adjunct to finasteride in the treatment of this disorder. Pretreatment evaluation is essential to ensure that the patient does not have an infection, prostate cancer or another serious cause of the prostatic symptoms. The patient should be monitored for side effects, and the dosage should be increased slowly. Side effects can be minimized by administering the medication at night and reversed by discontinuing the drug. In more than 50 percent of patients, treatment with alpha blockers results in objective and subjective symptomatic relief.

Clonal heterogeneity of synovial fluid T lymphocytes from patients with rheumatoid arthritis.

Although substantial evidence suggests that synovial T lymphocytes are critical in the pathogenesis of rheumatoid arthritis (RA), little is known regarding their antigenic specificities, antigen receptor gene rearrangements, and mechanisms of activation. To assess the extent of expansion of specific clones among RA synovial fluid T cells, Southern blot analyses of T-cell receptor (TCR) gene rearrangements were performed on 40 RA synovial fluid T-cell clones, as well as on both fresh and polyclonally activated T cells from RA synovial fluid, RA peripheral blood, and normal peripheral blood. Two of the clones had identical TCR rearrangement patterns, but the remainder were unique. The nonclonal RA T-cell samples showed the same pattern of TCR beta-chain rearrangement that was observed among normal peripheral blood T cells, indicating no dominant clonal T-cell population in these samples. It was noted that with sufficient exposure of autoradiograms of the Southern blots, discrete TCR gene rearrangements, representing in some cases common D beta J beta (D, diversity; J, joining) rearrangements, were evident in T cells from peripheral blood of normal individuals and patients with RA, as well as T cells from RA synovial fluid. Taken together, the findings indicate that only a minor degree of oligoclonality can be demonstrated among T lymphocytes from RA synovial fluid.

Structure and chromosomal location of the human gene encoding cartilage matrix protein.

Cartilage matrix protein (CMP) is a major component of the extracellular matrix of nonarticular cartilage. The structure and chromosomal location of the human gene encoding CMP was determined by molecular cloning analysis. We used a partial chicken CMP cDNA probe to isolate three overlapping human genomic clones. From one of these clones, a probe containing 2 human CMP exons was isolated and used to map the gene to chromosome 1p35 and to screen a human retina cDNA library. Two overlapping cDNA clones were isolated. The predicted protein sequence of 496 amino acids includes a 22-residue signal peptide and a 474-residue mature protein of Mr 51,344. The human CMP gene and polypeptide are strikingly similar to the chicken CMP gene and polypeptide. Human CMP is 79% identical to chicken CMP and contains two homologous domains separated by an epidermal growth factor-like domain. One potential N-glycosylation site is conserved between the two species. The human CMP gene spans 12 kilobase pairs with 8 exons and 7 introns which are similar in size to those of the chicken CMP gene. Both RNA splice junctions of intron G in the human and chicken CMP genes are nonconforming to the consensus splice sequences. This suggests that the CMP gene utilizes a new RNA splicing mechanism.

Complete amino acid sequence of human cartilage link protein (CRTL1) deduced from cDNA clones and chromosomal assignment of the gene.

Little is known about the primary amino acid structure of human cartilage link protein (CRTL1). We screened a human genomic library with a cDNA encoding the 3' untranslated region and the adjoining B1 domain of chicken link protein. One clone was isolated and characterized. A 3.5-kb EcoRI-KpnI fragment from this genomic clone that contains the human B1 exon was used to map the gene to chromosome 5q13----q14.1. The same fragment was used to screen a cDNA library prepared from mRNA of Caco-2, a human colon tumor cell line. Two overlapping clones were isolated and shown to encode all of CRTL1. The deduced amino acid sequence is 354 residues long. The amino acid sequence shows a striking degree of identity to the porcine (96%), rat (96%), and chicken (85%) link protein sequences. Furthermore, there is greater than 86% homology between the 3' untranslated region of the genes encoding human and porcine link proteins. These results indicate that there has been strong evolutionary pressure against changes in the coding and 3' untranslated regions of the gene encoding cartilage link protein.

A somatic cell hybrid map of human chromosome 13.

We have constructed a chromosome 13 somatic cell hybrid map using seven cell lines: PGMEA6, a hybrid containing the entire chromosome 13, and six hybrids containing various deletions of chromosome 13 (BARF7, PPF22, KBF11, KSF39, CF25, and CF27). We have mapped 80 markers that define 10 regions of chromosome 13 with respect to 10 breakpoints in the mapping panel; these regions range in size from 4 to 24 Mb, with an average size of 8 Mb. The 80 markers sublocalized on our mapping panel include 10 Alu-PCR clones, 6 of which were converted to sequence-tagged sites; 40 (CA)n repeat-containing clones, 27 of which are microsatellite PCR markers; 8 (AAAG)n repeat-containing PCR markers, 1 two-allele PCR marker, 4 genes or expressed sequences, and 17 anonymous DNA probes. This low-resolution physical map can be used as a backbone map for more refined physical mapping using radiation hybrids or yeast artificial chromosomes.