Ten- to 14-year clinical followup of the cementless Natural Knee system.

Of 300 consecutive knees (238 patients) that had undergone arthroplasty with the cementless Natural Knee prosthesis from 1985 to 1989, 176 knees (141 patients) were available for followup at an average of 12 +/- 1 years after the operation. Knee function was improved significantly. Modified Hospital for Special Surgery knee scores improved from 59.1 +/- 13.2 points preoperatively to 97.8 +/- 4.7 points at last followup. At last followup, knee range of motion averaged 0 degrees +/- 2 degrees to 120 degrees +/- 10 degrees. Implant survival was 93.4% (including infection and simple polyethylene exchanges) and 95.1% (excluding infection and simple polyethylene exchanges) at 10 years when applying the Kaplan-Meier survival analysis, using loose components, revision, or both as failure criteria. Besides the three revisions for infection, only two femoral and one tibial component required revision. The patellar component survivorship at 10 years was 95.1%. All patellar revisions were attributed to edge wear. Subsequent operative and design changes, including patellar component medialization and countersinking, have decreased the incidence of patellar revision. The long-term results of this cementless knee system compare favorably with those of cemented systems. The Natural Knee design has provided excellent and predictable long-term clinical results in the current series of active patients.

Encounters with pharmaceutical sales representatives among practicing internists.

BACKGROUND: Although pharmaceutical sales representatives provide physicians with information on new products, these encounters have rarely been studied in practice settings. We examined these interactions among practicing internists and assessed whether prior residency policies limiting pharmaceutical sales representative access affected the subsequent behavior of practitioners. METHODS: We conducted a mail survey of the internal medicine staffs of a medical school hospital and two affiliated community hospitals. A second request was sent to nonresponders. After the second mailing, a random sample of nonresponders was compared with a similar sample of respondents. Multivariate odds ratios (OR) and 95% confidence intervals (CI) were estimated with logistic regression. RESULTS: Of the 346 (40%) internists who responded, 22% were women and 60% were trained in university hospitals. There were no differences in gender, subspecialization, or type of training when survey responders and nonresponders were compared. Two hundred eighty-seven (83%) physicians had met with pharmaceutical sales representatives within the previous year, of whom 248 (86%) had received drug samples. Having had a policy that limited access to pharmaceutical sales representatives during residency did not affect the subsequent likelihood of seeing these representatives (P = 0.20) or accepting samples in practice (P = 0.99). Those describing themselves as busy practitioners were significantly less likely to abstain from meeting pharmaceutical sales representatives (OR = 0.2, 95% CI: 0.1 to 0.6, P <0.001). Those with very frequent contacts (>10 times/month) were virtually all busy practitioners. CONCLUSIONS: Encounters between physicians and pharmaceutical sales representatives are common in internal medicine practice, especially in busy offices. Policies designed to limit pharmaceutical sales representative access during residency do not appear to affect the subsequent likelihood of meeting with pharmaceutical sales representatives or accepting samples.

Sexual practices of older adults in a high HIV prevalence environment.

Based on recent epidemiologic evidence, AIDS in older persons (ages 55-79) in Maryland appears to be increasingly contracted heterosexually, particularly in women. Little is known about sexual practices or beliefs about HIV in older persons living in high HIV prevalence urban populations. The purpose of this study was to assess sexual practices, particularly high risk behavior, modifications of behavior including condom use, and perceptions of risk. A behavioral survey, containing 41 potential responses, was developed through modification of The National AIDS Behavioral Survey, focusing on heterosexual activity. The survey was administered to a convenience sample of 55 to 79 year olds attending the Union Memorial Hospital medical clinic. Sexual activity is common within the older population, especially among men. Multiple partners is not unusual in older men. Condoms are commonly used. Older individuals typically are aware of HIV heterosexual transmission risk and a proportion have modified sexual behavior because of perceived risks.

Characteristics of acquired immunodeficiency syndrome in older adults.

OBJECTIVE: To examine demographic and clinical features of older AIDS patients in comparison with younger individuals. DESIGN: Data base review. SETTING: Maryland AIDS Registry from 1981 through the end of 1994. PARTICIPANTS: All registered Maryland AIDS cases greater than or equal to 60 years of age at diagnosis and all Maryland AIDS cases aged 20 to 39. MAIN OUTCOME MEASURES: Demographic features, mode of transmission and change in mode over time, clinical presentations, CD4+ counts, and survival time. RESULTS: A total of 321 (2.7%) AIDS cases diagnosed in Maryland were people 60 years of age or older compared with 7511 cases (63.9%) in people aged 20 to 39 years. The proportion of whites was higher in the older group, but the gender distribution was similar to younger counterparts. Transfusion was the primary cause of exposure of 32% of the older people with AIDS; however, during the last few years, sexual transmission and drug abuse have been implicated more frequently. Twelve percent of older patients had no reported risk factors compared with 4% of younger AIDS patients. The most common presenting AIDS indicator disease in older cases was Pneumocystis carinii pneumonia. Wasting syndrome, candidiasis, and HIV encephalopathy also occurred frequently. Median life span was 9 months compared with 22 months in the young. CONCLUSION: Our study demonstrates that transfusion is no longer the leading cause of AIDS in older people in Maryland. The relatively increased prominence of transmission by other modes in this age group raises the importance of preventive and educational measures. Older patients generally have a shorter survival than younger individuals.

Discovering asymptomatic biochemical abnormalities on a Baltimore internal medicine service.

To assess the frequency of abnormalities that could be discovered through biochemical profile screening on patients admitted to a city hospital internal medicine ward service, we conducted a prospective cross-sectional chart and laboratory review. All unassigned patients admitted to the general medicine service during 1- to 2-month period in late 1993 and the spring of 1994 were eligible. The main outcome measures were frequency of abnormal test results and identification of significance. Admitted patients (N = 222) were evaluated with a 24-panel biochemical profile. Of 5,328 tests, 29% were outside the standard reference range. Of 3,851 tests classified as screening, 1,049 (27%) were outside the reference range. Of overall screening tests, 741 (19%) were judged potentially important by the predetermined criteria. The prevalence did not differ significantly when analyzed by age, race, gender, or history of substance abuse. Our experience indicates that asymptomatic biochemical abnormalities are common in patients admitted to a city hospital medical service and that admission biochemical screening is an effective method of identifying potential comorbidity. Further studies are needed to assess the impact of this approach.

Relative importance to elderly patients of effectiveness, adverse effects, convenience and cost of antihypertensive medications. A pilot study.

This pilot study was designed to investigate the attitudes of elderly patients regarding the choice of drugs for the treatment of hypertension. A questionnaire was administered to a sample of elderly patients receiving antihypertensive therapy regarding effectiveness, adverse effects, cost and convenience. Forced choices were used in order to reflect practice realities. 44 patients, mean age 75.2 years, rated effectiveness and adverse effects more important than cost and convenience. Choices regarding adverse effect risk were slightly influenced by costs of the drugs and insurance status of the patients. Choices regarding convenience were heavily influenced by financial considerations. Our study indicates that elderly patients are most concerned about effectiveness and safety, and express a willingness to pay more for these qualities in their antihypertensive drugs.

Serum albumin and prealbumin as predictors of clinical outcomes of hospitalized elderly nursing home residents.

OBJECTIVE: To investigate the prevalence of hypoalbuminemia and hypoprealbuminemia in hospitalized, elderly, skilled nursing facility residents and to correlate these findings with clinical outcomes. DESIGN: Prospective cohort study. SETTING: A 300-bed community hospital. PARTICIPANTS: Eighty-one hospitalized, skilled nursing facility patients, average age 83.1 years. INTERVENTIONS: None. OUTCOME MEASURES: Serum albumin and prealbumin (transthyretin) were measured at admission, mid-week, 1 week, and 1 month. Patients were followed for 90 days for the outcomes of length of hospitalization and mortality. RESULTS: The prevalence of hypoalbuminemia was 99% and of hypoprealbuminemia, 79%. Both means dropped significantly from admission to midweek nadirs of 25 g/L for albumin and 14 mg/L for prealbumin. Severe hypoalbuminemia at mid-week predicted mortality (RR = 4.1 95%, CI 2.0-8.5) and extended length of hospitalization (RR = 5.2 95%, CI 2.8-9.8). Severe hypoprealbuminemia predicted extended hospitalization (RR = 3.2, CI 1.5-6.7) but not mortality. CONCLUSIONS: Hypoalbuminemia and hypoprealbuminemia are very common in this clinical setting and vary in parallel fashion over time. Severe hypoalbuminemia was a stronger predictor than hypoprealbuminemia of 90-day mortality and extended length of stay. Serum albumin on admission was not as strong a predictor of outcomes as serum albumin at mid-week.

Replacing an old drug with a new one.

One of the constants facing the individual who practices clinical medicine is the evaluation of the continuing flow of new pharmaceutical products. It is a formidable challenge to use the most up-to-date therapeutic agents judiciously and with proper monitoring. This commentary will discuss issues for the practitioner to consider when faced with the prospect of replacing an old drug with a new one. It will attempt to develop a framework to facilitate rational decision-making in this context.

Assessment of respiratory exposures during gilsonite mining and milling operations.

An industrial hygiene study of the entire United States gilsonite industry was done by the National Institute for Occupational Safety and Health (NIOSH) to evaluate the potential for occupational health problems resulting from exposures to gilsonite and its constituents. Gilsonite is a solidified hydrocarbon substance mined only in northeastern Utah to Colorado. Industrial hygiene samples were collected at four gilsonite mining companies including nine mines and three mills. Gilsonite workers had no measurable exposures to polynuclear aromatic hydrocarbon (PNA) compounds, asbestos fibers, or hydrogen sulfide gas. Several organic gases/vapors and metals were detected in the airborne samples; but, none exceeded the current exposure standards/health criteria of the Mine Safety and Health Administration (MSHA), the American Conference of Governmental Industrial Hygienists (ACGIH), or NIOSH. Gilsonite workers in some job categories were exposed to high levels of dust, exceeding ACGIH nuisance dust recommendations. These dusts, comprised largely of aliphatic hydrocarbons, had a large aerodynamic size distribution with average mass median aerodynamic diameters (MMAD) above 30 microns.

Declining appeal of foreign medical education for U.S. students.

Concerns over the poor educational standards of some foreign medical schools and the cost of postgraduate education at a time of a projected physician surplus in the United States have led to efforts to pass federal legislation that would limit or remove access of U.S. graduates of foreign medical schools to residency programs in the United States. However, the need for such legislation has been diminished since the appeal of foreign medical education for U.S. students is on the decline. In this paper, the author reviews the economic and educational environment that in the mid-1970s led to the growth in the numbers of U.S. students who sought foreign medical education and contrasts it with the environment in the mid-1980s. Recent data are cited that support a reversal of that earlier trend.