Will neurology residents with large student loan debts become academicians?

Medical education in the United States is expensive, with 4-year tuition at some institutions totaling more than 150,000 US dollars. Most US graduates have student debt burdens. Using an internet survey, we tested the hypothesis that high student debt adversely affects neurology residents' desire to pursue careers in academic neurology. The results indicate median year 2000 US graduate neurology resident student debt is in the 50,000 to 75,000 US dollars range and that this debt burden may deter US graduates from pursuing careers in academic neurology.

Allergic bronchopulmonary aspergillosis as presenting sign of cystic fibrosis in an elderly man.

BACKGROUND: Although cystic fibrosis is the most common genetic disorder of children, its heterogeneous spectrum of severity lends itself to underdiagnosis in the older adult patient population where the index of suspicion is not high. METHODS: We report a 60-year-old Hispanic man with asthma who presented with progressive dyspnea and wheezing unresponsive to inhaled corticosteroid treatment. Additionally, he had clinical findings and a past history suggestive of cystic fibrosis. Skin testing, radiography and laboratory studies were completed to evaluate for allergic bronchopulmonary aspergillosis (ABPA) and cystic fibrosis. RESULTS: Test results revealed peripheral eosinophilia and hyper IgE. Skin testing to Aspergillus fumigatus (Af) was positive. IgG, IgM, and Af specific antibodies were present. High resolution CT scan showed central bronchiectasis. Sweat tests were positive on two separate occasions and gene analysis showed our patient to have a positive gene mutation at D127ON/D127ON. CONCLUSION: Cystic fibrosis should be suspected in the older adult patient with a compatible clinical presentation.

Bone mineral density in women with asthma on long-term inhaled corticosteroid therapy.

BACKGROUND: Inhaled corticosteroids (ICS) have become first line agents in the management of moderate-to-severe asthma. Long-term use of ICS is associated with decreased bone mineral density (BMD). OBJECTIVE: To investigate the prevalence of BMD loss and its severity in women with asthma on long-term ICS. METHODS: Fifty-six women with asthma on long-term ICS, attending an inner-city allergy clinic were selected to undergo bone densitometry in order to evaluate the association between BMD and the long-term use of ICS at different dose ranges. RESULTS: Women (60.7%) had decreased BMD either at the lumbar spine or hip region. Among postmenopausal women, 17.1% of those <65 years and 42.9% of those > or =65 years had osteoporosis compared with 5.7% (95% CI-3.9% to 8.5%) of those <65 and 29.3% (95% CI-25.7%-33.5%) of those > or =65 years reported in the NHANES III survey. The prevalence of low BMD increased as ICS dose increased from 5% in the low dose group to 50% in the high dose group (P < .002). There were significant linear trends of decline by dose in mean BMD for the hip (P < .001) and the lumbar spine (P < .002). Women who received medium or high doses of ICS had significantly greater bone loss than those receiving low doses. CONCLUSION: The findings of increasing BMD loss with increasing ICS dose reinforce the necessity to monitor BMD periodically in women on ICS, particularly in the high risk postmenopausal group and those on medium to high doses. There should be a concurrent continual attempt to lower the dose by supplemental nonsteroidal controller medications and providing nutritional and pharmacologic treatment of identified BMD loss in these patients.

Superior clinical outcomes of inner city asthma patients treated in an allergy clinic.

BACKGROUND: Asthma morbidity and mortality continue to increase especially in the inner cities despite medical advances in disease management. OBJECTIVE: To investigate the clinical outcomes of inner city asthma patients treated in an allergy clinic. METHODS: Phase 1 involved random review of medical records of 100 asthma patients treated in an allergy clinic for 2 consecutive years, assessing the frequency of hospitalizations, emergency room visits (ERV) and asthma severity during three periods; 1 year prior to initial visit (year 0) and during the first (year 1) and second (year 2) years of intervention. Phase 2 involved administration of quality of life (QOL) survey to 23 patients volunteered from allergy clinic (group I), and 21 patients volunteered from emergency room (group II), treated by primary care or emergency room physicians during the previous year. RESULTS: The frequency of hospitalizations and ERV significantly declined over time (P < .001) with greatest declines during year 1. Disease severity of all patients significantly declined over time (P < .001); good compliers had significant improvement over poor compliers (P < .023). Quality of life scores were significantly lower for both groups than for the general population; and although the scores were higher in the allergy clinic group than in the non-allergy clinic group, significant differences were achieved only in mental health and social functioning domains. CONCLUSIONS: Patients treated in an allergy clinic demonstrate superior clinical outcomes.

Delineation of pulmonary artery sarcoma with multiplane and panoramic transesophageal echocardiography.

A 38-year-old woman came for treatment with massive hemoptysis. A hilar density was observed on a chest radiograph. Transthoracic echocardiography demonstrated an intravascular pulmonary arterial mass that was studied in further detail with multiplane and panoramic transesophageal echocardiography. Surgical resection proved the mass to be a sarcoma arising from the main pulmonary artery. This case report demonstrates the utility of multiplane and panoramic transesophageal echocardiography in the study of intravascular tumors of the thorax.

Single, biplane, multiplane, and three-dimensional transesophageal echocardiography. Echocardiographic-anatomic correlations.

Advances in TEE instrumentation have led to the emergence of this modality as a powerful diagnostic tool. Numerous investigations in humans have clearly defined the plethora of clinical applications of TEE in a variety of patient care scenarios. Research in progress in the area of transducer technology and computerized image processing is likely to bring 3-D TEE to the clinical front.

Multiplane transesophageal echocardiography. Imaging planes, echocardiographic anatomy, and clinical experience with a prototype phased array OmniPlane probe.

Multiplane transesophageal echocardiography is a new exciting development in echocardiography. We examined the methodology and echo-anatomic correlations of multiplane transesophageal echocardiography and its clinical applications in 100 patients. We used a 5-MHz phased array multiplane (OmniPlane) transesophageal probe. In this instrument, the transducer array can be steered through 180 degrees from any transducer location. This provides a vast assembly of imaging planes, allowing for detailed visualization of all dimensions of cardiac anatomy. This report presents our observations on the echocardiographic anatomy seen in various image planes and the unique clinical potential of multiplane transesophageal echocardiography in the diagnostic assessment of cardiovascular disorders. This technique appears to provide incremental diagnostic information that enhances the interpretative ability. Less esophageal probe manipulation is required with consequent decrease in patient discomfort. We conclude that multiplane transesophageal echocardiography enhances the versatility of transesophageal examination and offers many new avenues for developments such as three-dimensional echocardiography.

Training perception of acute airflow obstruction.

Ten asthmatics selected for their tendency to experience frequent acute exacerbations were instructed in peak flow measurement. Each subject then recorded estimated peak flow (EPF) and measured peak flow (PF) at home twice daily. Data for up to 56 consecutive observations (4 weeks) per subject were analyzed. The correlation coefficient between EPF and PF following PF drops of 15% was .993 overall and was not significantly different following PF drops even greater than 25%. The absolute and proportional differences between PF and EPF were also not significantly affected by the magnitude of PF drop but decreased over time indicating improved accuracy of estimates with practice. Asthmatics can be trained to estimate accurately acute drops in airflow. Such ability has not been demonstrated in prior studies which utilized verbal symptom reports as indicators of subjective perception of airflow. Accurate perception would be a useful aid in achieving early recognition of acute exacerbations and in improving medication compliance. It is an adjunct to regular peak flow measurement, not a substitute for it.

Training perception of air flow obstruction in asthmatics.

Eighteen asthmatics, aged 7 to 43, rated their breathing on a scale of 0 to 5 (worst to best). They were then informed of their predicted normal peak expiratory flow rate (PEFR) and instructed in proper PEFR measurement. Each subject then estimated and measured PEFR under physician supervision and subsequently rated breathing, estimated and measured PEFR at home twice daily recording the observations. At the initial home observation, the correlation coefficient (r1) between estimated and measured PEFR was .98. After ten observations r1 was greater than or equal to .97 in all 18 subjects (group mean .99). The r1 remained unchanged in those subjects who completed 28 and 42 observations. The r1 was .98 when only the observations where measured PEFR was less than 20% predicted were considered, demonstrating the validity of the relationship during abnormal expiratory flow. Multiple regression analysis showed no significant trend in the difference between estimated and measured PEFR over time after the initial observation. Of 12 subjects, 4 were significant underestimators of PEFR and 3 were overestimators, but the magnitude of either tendency was relatively small. The correlation coefficient (r2) between a subjective verbal breathing score and measured PEFR ranged from -.23 to .92 on an individual basis over the three time periods, with statistically significant group mean values of .37, .39, and .45 at 10, 28, and 42 observations, respectively. The r2 for observations where measured PEFR was abnormal was only .14 and not significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Reliability and predictive value of salivary theophylline levels.

The reliability and accuracy of salivary theophylline levels as a predictor of serum theophylline levels was investigated in 28 hospitalized chronic asthmatics, free of other chronic diseases, on continuous aminophylline infusion for greater than 24 hours. Twenty paired blood and saliva theophylline levels from 12 patients (group 1) were used to develop a formula for predicting serum theophylline levels from salivary levels. Twenty-one paired blood and saliva theophylline levels from 16 patients (group 2) were used to test the formula obtained. The formula predicted the serum theophylline concentration within 1.51 microgram/mL in 76% of the samples and within 1.88 microgram/mL in 100% of the samples. There was an excellent correlation between the predicted and actual serum theophylline concentrations, r = .93; thus under controlled conditions of steady-state pharmacokinetics in patients free of other diseases, salivary theophylline levels can be used to accurately predict serum levels.

Perforated gastric ulcer in an asthmatic treated with theophylline and steroids. Case report and literature review.

We presented a patient with status asthmaticus treated with a combination of theophylline and prednisone who developed a perforated gastric ulcer. The relative etiologic significance of the stress of status asthmaticus, administration of theophylline, or corticosteroids is open to question. The literature, except for anecdotal reports, does not support a significant increase of ulcers in asthmatic patients on either theophylline or steroids. A study following large patient groups on theophylline and a combination of theophylline and steroids might clarify the risk of ulcer formation in patients being treated with these medications for asthma.

Study of social, educational, environmental and cultural aspects of childhood asthma in clinic and private patients in the city of New York.

A group of asthmatics treated in a clinic setting were compared to a group treated by private allergists. Statistical differences were found regarding family income, racial distribution, family structure, educational level, reading habits, management of acute asthma attacks, housing, living space, school absences and hospital admissions.