Dermatomyositis and nasopharyngeal carcinoma.

A nasopharyngeal carcinoma was diagnosed in a 37-year-old man with a two year history of dermatomyositis. The physical and laboratory examinations excluded further medical problems. To our knowledge, this is the first case of dermatomyositis associated with nasopharyngeal carcinoma in a white Israeli Jewish patient.

A successful academic-community partnership to improve the public's health.

As academic health center seek to address the changes in the health care system and in medical education, several approaches have been tried, some successfully, others not. The authors describe a successful approach that involves a close partnership between the health professions schools at two academic institutions, and agencies from the surrounding community. Specifically, the Center for Healthy Communities, begun in 1991 and formally institutionalized in 1994 in Dayton, Ohio, is a partnership among the schools of medicine, nursing, and professional psychology at Wright State University (WSU); the department of social work at WSU; the Allied Health Division of Sinclair Community College; more than 200 individuals (from grassroots neighborhood people to civic leaders); and 50 health and human services organizations in the Dayton area. The Center is recognized as a force for change in health professions education and health care delivery both in the community and in the academic settings. The authors explain how the Center was formed, list its goals (such as establishing strong partnerships among community educators and providers and educating students in the delivery of primary health care in the community), explain three principles that have been followed and that were crucial to the success of the Center (for example, individuals in the community must become empowered to capitalize on their strengths), and discuss the major difficulties that the community and the academic institutions encountered and strategies for meeting them (such as the importance of building trust and the importance of learning the needs identified by the community partners, not just those identified by the academic partners). The authors maintain that a successful community-academic partnership must be built on the foundation of community health development, a concept analogous to economic development, and that such a partnership can be a powerful tool for making a difference in the community's health.

Comparing clerkship sites in a community-based medical school by evaluating students' undergraduate and postgraduate performances.

BACKGROUND: Studies have generally found clinical training sites within the same clerkship to be comparable regarding students' performances--by using undergraduate measures in individual clerkships at medical schools with university hospitals. The present study examined performance comparability among sites within two clerkships in a community-based medical school and used both undergraduate and postgraduate measures. METHOD: The participants were the 349 graduates from the classes of 1988-1991 at Wright State University School of Medicine who took an internal medicine clerkship (332 of the graduates, in five principal combinations of sites) and a general surgery clerkship (349 at six sites). The undergraduate measures were final percent scores for the clerkships and subtest and total scores on the National Board of Medical Examiners (NBME) Part II examination. The postgraduate measures were supervisors' ratings from the first year of residency (210 graduates) and total score on the NBME Part III (212). Univariate analysis of variance and Tukey's multiple-range test were used for the comparisons. RESULTS: The only statistically significant difference among sites was for the medicine clerkship and involved only one undergraduate measure, the clerkship score (and the differences were slight, less than four percentage points). CONCLUSION: Virtually no differences in the students' performances on the undergraduate and postgraduate measures were found among sites for the two clerkships.

Implementing the Association of Teachers of Preventive Medicine's recommendations into the undergraduate medical school curriculum.

In 1989, an expert panel appointed by the Association of Teachers of Preventive Medicine proposed minimum curricular content requirements for health promotion-disease prevention, including recommendations for timing, duration, and course sequencing during medical school. Making clinical preventive medicine an integral part of a primary care rotation is a central feature of the proposal. The panel presents recommendations for using the Guide to Clinical Preventive Services, which assesses the effectiveness of 169 types of prevention interventions, in both undergraduate and postgraduate medical education. Recommendations for incorporating the guide into the undergraduate medical school curriculum are outlined. The recommendations include options for using the guide as part of a curriculum in quantitative skills, in clinical preventive medicine, in a primary care rotation, as a health services and community dimension curriculum, and as part of continuing self-education. Recognizing that teaching methods and curriculum structures are varied in preventive medicine, the panel designed the recommendations to be adaptable to all medical schools' programs. The recommendations are aimed at achieving the goal of making preventive medicine an integral part of the education, training, and practice of physicians.

The Association of Teachers of Preventive Medicine's recommendations for postgraduate education in prevention.

The Guide to Clinical Preventive Services, prepared in 1989 by the U.S. Preventive Services Task Force, assesses the effectiveness of 169 types of preventive interventions. In 1990, the Association of Teachers of Preventive Medicine formed a panel to review the guide and recommend ways it could be used to enhance both undergraduate and postgraduate medical education. This paper outlines the panel's recommendations of the types of knowledge and attitudes on which postgraduate medical education in prevention should be built. Detailed recommendations are presented, based on the summary findings of the guide, for residency education in prevention. Implementation of these recommendations will integrate preventive services into the continuum of medical care. These recommendations are presented to achieve the goal of educating physicians to approach the total patient, putting the patient's health rather than the disease process in the forefront of primary medical care.

Metastatic renal cell carcinoma (RCC): spontaneous regression, long-term survival and late recurrence.

We report 4 cases of metastatic renal cell carcinoma (RCC) with long-term survival either following radical nephrectomy alone or in combination with radio- or hormonal therapy. Two patients with lymph node metastases showed a long-term survival of 12 or more years following radical tumour nephrectomy (with lymphadenectomy) and radiotherapy. One of them exhibited a histologically proven tumour recurrence nearly 12 years after primary surgical treatment and died shortly later; the other one is still without any evidence of metastatic disease. Two other patients exhibited spontaneous regression of pulmonary metastases: one regression occurred after radical tumour nephrectomy alone, the other one after successful primary hormonal treatment and subsequent radical tumour nephrectomy. The following important aspects are emphasized: 1. Renal cell carcinoma is a very unpredictable tumour. Once the diagnosis of renal cell carcinoma is proved, a patient can never be considered cured. 2. Although adjuvant palliative nephrectomy has produced contradictory results in several reports, radical tumour nephrectomy either alone or in combination with other adjuvant therapies such as radiotherapy, hormonal or immunological treatment, can be worthwhile. Cases with long-term survival and spontaneous regression of distant metastases are proof of this. Besides, if carefully selected, the mortality rate of different adjuvant therapies is not significantly higher in patients with metastatic disease than in patients without metastases. The world literature on this subject is reviewed.

A combined primary care residency in internal medicine and pediatrics.

The authors describe the development and evaluation of a primary care residency program encompassing both internal medicine and pediatrics. The combined residency is a four-year program of alternating six-month rotations in the two disciplines. One-fourth of the program is ambulatory medicine and includes training in a clinic for children and adults. Patient demographics are maintained for each resident, and an ambulatory-medicine-focused curriculum consisting of weekly conferences and self-directed independent study is used. The program is routinely evaluated and is highly rated by patients and residents. Factors critical to its success include emphasizing goals and experiences in outpatient versus inpatient care, developing an ambulatory practice to help support resident salaries, adequately preparing residents to take the board examinations in both disciplines, and providing a comprehensive primary care curriculum.

Medical student, resident, and faculty use of a computerized literature searching system.

The experiences of medical students, residents, and faculty with a computerized literature searching system were evaluated. Third-year medical students, internal medicine and family practice residents, and full-time and voluntary faculty at one medical school had the opportunity to use a full-text and bibliographic medical literature retrieval system free of charge for an eleven-month period. Subjects conducted nearly nine thousand literature searches over a period of 942 system hours. Questionnaire data showed that participants could learn to use and would use an electronic information system, felt capable of using the system, utilized the system for a variety of purposes and in a number of different ways, and viewed the system as a valuable tool in searching the medical literature. The results are discussed in the context of the educational needs of the four user-groups and medical education planning by institutions.

Tracking patient demographics and disease categories in a primary care residency.

The residency training of primary care physicians must include experiences with multiple types of ambulatory patients and disease processes. Most residency programs, however, do not accurately monitor or quantify these experiences. We developed a simple computerized system, using a relational data base, to record and track patient demographics and disease categories. This system maintains a profile for each resident physician which is used to guide the assignment of future patients. The system can be simply modified to meet the specific patient and/or disease characteristics needed.

Use of a predictor for total body potassium content: application to nutrition and hypertension.

Total body potassium (TBK), measured at different institutions, has no reference standard for comparison. A useful reference formula, however, based on body size and age, has been derived at the Brookhaven National Laboratory. This formula was used to help calibrate a simple whole body counter for measuring total potassium and applied to nutrition and hypertension studies. A sodium iodide detector was used for counting gamma rays emitted by potassium-40 to estimate TBK. The mean ratio (+/- S.D.) of adjusted TBK measurements to predicted values was 1.002 +/- 0.047. The ratio of lean body mass estimated by the TBK measurement to that derived from skin fold thickness was 1.069 +/- 0.056. In hypertensives on low dose thiazide, the ratio of TBK measurements to predicted values was 0.994 +/- 0.052. Thus, our TBK measurements were adjusted in close agreement with a predictor formula, provided higher estimates of lean body mass than did skin fold thickness, and showed no change in thiazide treated hypertensives.

Effects of thiazide on erythrocyte sodium and potassium concentrations and Na+K+ATPase in hypertensive patients.

The mechanism of thiazide induced sodium and potassium transport across the cell membranes of humans has not been extensively studied. To assess the effects of thiazide diuretics on erythrocyte sodium transport and potassium distribution we measured intracellular sodium and potassium, sodium-potassium ATPase activity (with and without ouabain) and total body potassium in normokalemic and mildly hypokalemic hypertensive patients. We also measured serum and urine sodium, potassium, calcium and magnesium, plasma renin activity and serum aldosterone levels. The study patients, on long-term thiazide, had measurements obtained during, one month after cessation and one month after resumption of thiazide. In this study of normokalemic and mildly hypokalemic hypertensives there were no significant measurement changes, in contrast to previous studies of severely hypokalemic hypertensives. These results suggested that thiazide did not routinely affect erythrocyte active membrane transport and potassium distribution in the absence of severe hypokalemia.