Nodal and systemic recurrence following observation of a positive sentinel lymph node in melanoma.

BACKGROUND: Two RCTs found no survival benefit for completion lymphadenectomy after positive sentinel lymph node biopsy compared with observation with ultrasound in patients with melanoma. Recurrence patterns and regional control are not well described for patients undergoing observation alone. METHODS: All patients with a positive sentinel node biopsy who did not have immediate completion lymphadenectomy were identified from a single-institution database (1995-2018). First recurrences were classified as node only, local and in-transit (LCIT) only, LCIT and nodal, or systemic. Regional control and factors associated with recurrence survival were analysed. RESULTS: Median follow-up was 33 months. Of 370 patients, 158 (42·7 per cent) had a recurrence. The sites of first recurrence were node only (13·2 per cent), LCIT only (11·9 per cent), LCIT and nodal (3·5 per cent), and systemic (13·8 per cent). The 3-year postrecurrence melanoma-specific survival rate was 73 (95 per cent c.i. 54 to 86) per cent for patients with node-only first recurrence, and 51 (31 to 68) per cent for those with initial systemic recurrence. In multivariable analysis, ulceration in the primary lesion (hazard ratio (HR) 2·53, 95 per cent c.i. 1·27 to 5·04), disease-free interval 12 months or less (HR 2·38, 1·28 to 4·35), and systemic (HR 2·57, 1·16 to 5·65) or LCIT and nodal (HR 2·94, 1·11 to 7·79) first recurrence were associated significantly with decreased postrecurrence survival. Maintenance of regional control required therapeutic lymphadenectomy in 13·0 per cent of patients during follow-up. CONCLUSION: Observation after a positive sentinel lymph node biopsy is associated with good regional control, permits assessment of the time to and pattern of recurrence, and spares lymphadenectomy-related morbidity in patients with melanoma.

Testicular Microlithiasis: Is Sonographic Surveillance Necessary? Single Centre 14 Year Experience in 442 Patients with Testicular Microlithiasis.

PURPOSE: Increased prevalence of germ cell tumour (GCT) is seen with testicular microlithiasis (TM) suggesting TM is a premalignant condition with US surveillance advocated. We present a cohort of patients with TM followed up in a single centre and deliberate on the value of US surveillance. MATERIALS AND METHODS: A retrospective analysis of subjects with underlying US diagnosis of TM between 1998 and 2012. One-yearly US follow-up was offered to all patients with TM and a database maintained. Any co-existing tumour at presentation with TM was recorded. TM was divided into limited (< 5 microliths/field), classical (≥ 5 microliths/field) and florid ('snowstorm' appearance). Patient demographics, follow-up details and the development of any scrotal abnormalities were recorded. The radiological and histological findings were documented when a testicular lesion occurred during the follow-up period. RESULTS: 20 224 patients were examined: 867/20 224 (4.3 %) had TM. 21/867 (2.4 %) patients had histology proven malignant tumours at presentation. All TM patients consented to follow-up with 442/867 (51.0 %) achieving this and entering into a follow-up program (mean duration 28 months, range 8 - 165 months). Two patients developed primary GCT during the follow up period. One patient (limited TM) had undergone a previous orchiectomy for contralateral GCT and developed a palpable mass at follow up month 21. The other (limited TM) had an atrophic testis; a tumour was found on US at follow up month 62. CONCLUSION: Two patients of 442 (0.5 %) followed up for all forms of TM in a single centre developed a GCT over a mean duration of 28 months, both had independent risk factors for the development of GCT. These findings suggest that US surveillance is not required when TM is the only abnormality in the absence of any clinical risk factors for the development of GCT.

Percutaneous image-guided thermal ablation of lung cancer: What is the evidence?

Thermal ablation techniques have now been used for more than twenty years in the treatment of primary lung tumours, predominantly non-small cell lung cancer (NSCLC). Although primarily used for the treatment of early-stage disease in non-surgical patients, thermal ablation is now also being used in selected patients with oligometastatic and oligoprogressive disease. This review discusses the techniques available for thermal ablation, the evidence for use of thermal ablation in primary lung tumours in early- and advanced-stage disease and compares thermal ablation to alternative treatment strategies.

A rare late complication of traumatic diaphragmatic hernia repair.

We report a case of sudden cardiovascular collapse several weeks following surgical repair of a traumatic diaphragmatic hernia. The patient presented with features of circulatory shock without a clear diagnosis, therefore an urgent computed tomography scan of the chest and abdomen was undertaken, which revealed a pericardial effusion with evidence of cardiac tamponade. Ultrasound-guided needle pericardiocentesis with aspiration of blood from the pericardial sac in the Emergency Department provided an immediate response and her cardiac output improved. On review of the imaging, it is likely a surgically-placed permanent metallic fixation device, sitting near the pericardium, caused bleeding into the pericardial sac due to local trauma as a delayed postoperative complication.

Neural coding of temporal information in auditory thalamus and cortex.

How the brain processes temporal information embedded in sounds is a core question in auditory research. This article synthesizes recent studies from our laboratory regarding neural representations of time-varying signals in auditory cortex and thalamus in awake marmoset monkeys. Findings from these studies show that 1) the primary auditory cortex (A1) uses a temporal representation to encode slowly varying acoustic signals and a firing rate-based representation to encode rapidly changing acoustic signals, 2) the dual temporal-rate representations in A1 represent a progressive transformation from the auditory thalamus, 3) firing rate-based representations in the form of monotonic rate-code are also found to encode slow temporal repetitions in the range of acoustic flutter in A1 and more prevalently in the cortical fields rostral to A1 in the core region of marmoset auditory cortex, suggesting further temporal-to-rate transformations in higher cortical areas. These findings indicate that the auditory cortex forms internal representations of temporal characteristics of sounds that are no longer faithful replicas of their acoustic structures. We suggest that such transformations are necessary for the auditory cortex to perform a wide range of functions including sound segmentation, object processing and multi-sensory integration.

Neural coding of temporal information in auditory thalamus and cortex.

How the brain processes temporal information embedded in sounds is a core question in auditory research. This article synthesizes recent studies from our laboratory regarding neural representations of time-varying signals in auditory cortex and thalamus in awake marmoset monkeys. Findings from these studies show that 1) the primary auditory cortex (A1) uses a temporal representation to encode slowly varying acoustic signals and a firing rate-based representation to encode rapidly changing acoustic signals, 2) the dual temporal-rate representation in A1 represent a progressive transformation from the auditory thalamus, 3) firing rate-based representations in the form of a monotonic rate-code are also found to encode slow temporal repetitions in the range of acoustic flutter in A1 and more prevalently in the cortical fields rostral to A1 in the core region of the marmoset auditory cortex, suggesting further temporal-to-rate transformations in higher cortical areas. These findings indicate that the auditory cortex forms internal representations of temporal characteristic structures. We suggest that such transformations are necessary for the auditory cortex to perform a wide range of functions including sound segmentation, object processing and multi-sensory integration.

Correlation of carotid stenosis diameter and cross-sectional areas with CT angiography.

PURPOSE: Carotid stenosis quantification traditionally uses measurements of narrowest stenosis diameter. The stenotic carotid lumen, however, is often irregularly shaped. New PACS workstation tools allow for more precise calculation of carotid geometry. We compare the narrowest stenosis diameter with 2D area stenosis measurements, with the hypothesis that the narrowest diameter is a good predictor of the more precise area measurement. METHODS: Two neuroradiologists evaluated 178 stenosed carotids in a blinded protocol. Carotid artery bulb stenosis was identified on axial CT angiography and measured in millimeters at its narrowest diameter. An AGFA Impax 4.5 Volume Tool (VT) using Hounsfield units was used to estimate the cross-sectional area of the contrast luminogram. Pearson correlation coefficients were calculated between the millimeter stenosis and the VT area, as well as between the VT area and the calculated area (radius based on narrowest diameter). Regression analysis was performed with the VT area and narrowest diameter datasets. RESULTS: Excellent interobserver correlation (correlation coefficients, 0.71-0.85; 2-tailed significance = .01) permitted averaging of measurement data. There is excellent correlation between the VT area and the narrowest diameter (correlation coefficient, 0.88; n = 176). The VT area was generally greater than the calculated area by an average of 2.77 mm2. There was excellent correlation between the VT area and the calculated area (correlation coefficient, 0.87; n = 176). Regression analysis shows the ability of the diameter measurements to predict corresponding area stenosis. CONCLUSION: Although some carotid stenoses are irregularly shaped and noncircular, measurement of the narrowest stenosis is a reasonably reliable predictor of the cross-sectional area.

Quantification of carotid stenosis on CT angiography.

PURPOSE: Carotid artery stenosis quantification uses percent diameter ratios from conventional angiography. Multidetector high-speed CT angiography (CTA) allows direct millimeter measurement of carotid stenosis. We hypothesize a linear relationship between millimeter stenosis measurements and derived percent, alleviating cumbersome ratio calculations. METHODS: Two neuroradiologists separately reviewed CTAs of 268 carotid arteries, blinded to other information. The narrowest portion of each carotid stenosis was measured in millimeters from axial source images. Distal internal carotid arteries (ICAs) were measured beyond the bulb, where walls are parallel. North American Symptomatic Carotid Endarterectomy Trial (NASCET)-style ratios were calculated for each ICA, except for suspected near-occlusions. Interobserver agreement was calculated for all measurements. Correlation coefficients were calculated comparing millimeter and derived percent stenosis, followed by regression analysis. Sensitivity and specificity values tested validity. RESULTS: Interobserver agreement correlations were excellent, from 0.78 to 0.89 (2-tailed P

Diagnosing carotid stenosis near-occlusion by using CT angiography.

BACKGROUND/PURPOSE: Identification of carotid near-occlusion is essential before calculation of percent stenosis because stroke risk is lower than other severe stenosis and the treatment benefit is less. Calculations with reduced distal diameters are fallacious. CT angiography (CTA) is convenient and accurately quantifies internal carotid artery (ICA) stenosis. METHODS: In a blinded protocol, 268 carotid artery CTAs for known or suspected carotid disease were independently evaluated by 2 neuroradiologists. All carotid arteries were measured in millimeters at the narrowest diameter of the stenotic bulb, distal ICA well beyond the tapering bulb, and distal external carotid artery (ECA). Near-occlusions were independently identified, with disagreements settled by consensus meeting. Receiver operating characteristic (ROC) curve analysis defined the threshold values that best predicted near-occlusion according to (1) ICA stenosis, (2) distal ICA, (3) distal ICA: contralateral distal ICA, and (4) distal ICA: ECA. Paired permutations of variables were evaluated. RESULTS: Forty-two near-occlusion distal ICAs were identified. The ROC-derived threshold values determined near-occlusion carotid stenosis with a sensitivity range, 90.2-97.3; specificity, 84.1-89.9; positive predictive value (PPV), 61.3-66.7; and negative predictive value (NPV), 96.7-99.4. Ranges for paired permutations were also determined: sensitivity, 82.9-91.9; specificity, 95.4-96.8; PPV, 78.6-85.7; and NPV, 96.3-98.4. CONCLUSIONS: Threshold values provide guidelines for CTA interpretation when assessing carotid artery disease and the presence of near-occlusion. Ultimate identification of near-occlusion requires the interpreter's judgment, with attention to the following criteria: (1) notable stenosis of the ICA bulb and (2) distal ICA caliber reduction compared with (A) expected size, (B) contralateral ICA, and (C) ipsilateral ECA. Near-occlusion distal ICAs can be reliably identified on CTA.

Chasing "chasing the dragon" with MRI: leukoencephalopathy in drug abuse.

UNLABELLED: Spongiform leukoencephalopathy is a rare complication from inhalation of heated heroin vapour, a practice called "chasing the dragon". The MRI findings are considered pathognomonic, making MRI important for diagnosis. This is especially true in busy urban emergency departments where a variety of patients may present obtunded, unable or unwilling to provide a useful history. Even though the MR pattern of "chasing" toxicity is considered pathognomonic, there are mimickers. We compare the MRI findings of two classic cases of chasing leukoencephalopathy with one case of mimickery from cocaine exposure only. All three cases had diffuse symmetrical white matter changes. MR spectroscopy (MRS) in chasing patients showed increased lactic acid and myo-inositol, decreased N-acetyl aspartate and creatine, normal to slightly decreased choline, and normal lipid peak. MRS in the cocaine exposure patient showed marked increase in lactic acid and lipids. MR perfusion in one chasing patient was normal. IN CONCLUSION: (1) All three cases have MR findings suggestive of spongiform leukoencephalopathy. MRS may help differentiate toxicity due to inhaled heroin from other non-heroin related toxicities. (2) Discordance between perfusion and spectroscopy in one chasing patient adds evidence that the disease is due to impaired energy metabolism at the cellular level. (3) MR findings of spongiform leukoencephalopathy secondary to chasing heroin can progress despite apparent abstinence of the drug and during clinical improvement, suggesting the MR changes may represent an evolving injury.

Evaluation of a treatment limitation policy with a specific treatment-limiting order page.

BACKGROUND: Concerns about misinterpretation, misunderstanding, poor communication, and lack of documentation prompted a revision of our hospital's treatment limitation policy. The revised policy was designed to explicate do-not-resuscitate (DNR) orders, structure the use of DNR and other treatment-limiting orders in a logical and standard way, and improve communication. Use of a Specific Treatment-Limiting Order Page (STOP) was required. METHODS: To evaluate the policy's effects, we conducted (1) a prospective cohort study (involving 2733 patients) of treatment limitation practices before and after the new policy and (2) cross-sectional surveys of 58 nurses and 62 physicians. Outcome measures included documented treatment-limiting orders, documented discussions of these decisions, and deaths. Staff opinions about effects on communication and patient care were elicited. RESULTS: Rates of death (5.4% before and 5.6% after the policy; P = .80) and rates of DNR orders (9.3% vs 9.2%, P = .9) did not change. The use of the STOP enhanced the clarity of DNR orders and, among DNR patients, greatly increased the frequency of orders limiting 12 other specific treatments for conditions short of arrest. For example, before the policy, orders prohibited mechanical ventilation in 2% of DNR patients, compared with 66% after the policy (P < .001). Staff reported that the policy improved communication among health professionals, patients, and families. CONCLUSIONS: The treatment limitation policy with the STOP improved documentation and communication of treatment-limiting decisions. On the basis of our results, we offer a STOP for use and evaluation by others.

Impaired prepulse inhibition of acoustic startle in schizophrenia.

BACKGROUND: Schizophrenics show deficits in sensorimotor gating, as measured by prepulse inhibition of acoustic startle (PPI). The goal of this investigation is to further characterize PPI and habituation deficits in schizophrenia, and to examine whether differing subgroups of schizophrenics would show comparable PPI deficits. METHODS: PPI was measured in 24 male schizophrenic subjects (9 acutely decompensated inpatients and 15 stable outpatients) and in 20 age-matched normal control subjects. Schizophrenic subjects were rated for positive and negative symptoms at the time of testing. RESULTS: Schizophrenic subjects showed deficits in prepulse inhibition and habituation as compared to normal subjects. Similar latency facilitation was produced by the prepulse in both groups. Acutely decompensated inpatients and stable outpatients did not differ in percent PPI. PPI did not correlate with severity of positive or negative symptoms. CONCLUSIONS: These results suggest that schizophrenic subjects have impaired central inhibitory mechanisms as measured by PPI, and support the hypothesis that periods of relative clinical remission are not accompanied by normalization of sensorimotor gating.

Reproducibility of cerebral glucose metabolic measurements in resting human subjects.

Positron emission tomography with 11C-2-deoxyglucose was used to determine the test-retest variability of regional cerebral glucose metabolism in 22 young normal right-handed men scanned twice in a 24-h period under baseline (resting) conditions. To assess the effects of scan order and time of day on variability, 12 subjects were scanned in the morning and afternoon of the same day (a.m.-p.m.) and 10 in the reverse order (p.m.-a.m.) with a night in between. The effect of anxiety on metabolism was also assessed. Seventy-three percent of the total subject group showed changes in whole brain metabolism from the first to the second measurement of 10% or less, with comparable changes in various cortical and subcortical regions. When a scaling factor was used to equate the whole brain metabolism in the two scans for each individual, the resulting average regional changes for each group were no more than 1%. This suggests that the proportion of the whole brain metabolism utilized regionally is stable in a group of subjects over time. Both groups of subjects had lower morning than afternoon metabolism, but the differences were slight in the p.m.-a.m. group. One measure of anxiety (pulse at run 1) was correlated with run 1 metabolism and with the percentage of change from run 1 to run 2. No significant run 2 correlations were observed. This is the first study to measure test-retest variability in cerebral glucose metabolism in a large sample of young normal subjects. It demonstrates that the deoxyglucose method yields low intrasubject variability and high stability over a 24-h period.

Effect of a haloperidol challenge on regional brain metabolism in neuroleptic-responsive and nonresponsive schizophrenic patients.

OBJECTIVE: The CNS metabolic response to a neuroleptic challenge in treatment-responsive and nonresponsive schizophrenic patients was measured in order to examine the relation between treatment outcome and the capacity to alter neurochemical function in response to acute receptor blockade. METHOD: Positron emission tomography (PET) and [18F]fluorodeoxyglucose (FDG) were used to measure regional cerebral metabolism in seven schizophrenic patients judged to have been responsive to drug treatment previously and seven nonresponsive schizophrenic patients after a drug-free period of at least 3 weeks (baseline) and again 12 hours after administration of 5.0 mg of haloperidol. RESULTS: The haloperidol challenge caused widespread decreases in absolute metabolism in the nonresponsive patients but not the responsive patients. These group differences reflect the findings on the second (challenge) scans, since metabolic values at baseline were not statistically different in the two groups. The pattern of decreased metabolic activity in the nonresponders after the haloperidol challenge is similar to that previously observed in normal subjects. CONCLUSIONS: The metabolic response to drug challenge separates treatment responders from nonresponders and normal subjects. The results suggest that subtyping of schizophrenia (and other psychiatric disorders) can be achieved by measuring the physiologic response to a pharmacologic challenge in vivo with chemical brain-imaging techniques.

Effects of haloperidol challenge on regional cerebral glucose utilization in normal human subjects.

OBJECTIVE: Positron emission tomography and the fluorodeoxyglucose (FDG) method were used to determine the brain's metabolic response to neuroleptic challenge in a normal, disease-free state. METHOD: FDG measurements were obtained before and 12 hours after administration of 5 mg of haloperidol to 12 young normal men. These values were compared with test-retest FDG measures obtained from nine normal male control subjects who received no drug intervention. RESULTS: After haloperidol administration, the haloperidol subjects showed significantly lower glucose utilization in the neocortex, limbic cortex, thalamus, and caudate nucleus but not in the putamen or cerebellum. After adjustment for global effects, significant reductions were still evident in the frontal, occipital, and anterior cingulate cortex, whereas the putamen and cerebellum showed significant increases. CONCLUSIONS: This study, measuring the brain's metabolic response to acute receptor blockade, is a first step in the development of an assay of CNS pharmacological activity. By determining the response to neuroleptic challenge in a normal state, the study establishes a comparison group for determining response to challenge in various psychiatric conditions.

Selective sensitization to the psychosis-inducing effects of cocaine: a possible marker for addiction relapse vulnerability?

Patients in inpatient rehabilitation for uncomplicated cocaine dependence were asked whether, compared with the time of their first regular use, they could now identify changes in the effects of similar doses of cocaine. We asked about a spectrum of cocaine effects "then" and "now" and whether the same amount of drug caused effects to occur to about the same degree, less intensely (tolerance), or more intensely (sensitization). Nearly half our sample developed predominantly paranoid psychoses in the context of cocaine use. Sensitization was consistently linked only to psychosis-related cocaine effects. It has been proposed that mesolimbic dopaminergic sensitization might contribute to addiction severity. A preliminary followup of patients who were sensitized or nonsensitized to psychosis development suggests that rehospitalization for treatment of addiction may be more frequent in the sensitized group.

Effects of paired-pulse and repetitive stimulation on neurons in the rat medial geniculate body.

Many behaviorally relevant sounds, including language, are composed of brief, rapid, repetitive acoustic features. Recent studies suggest that abnormalities in producing and understanding spoken language are correlated with abnormal neural responsiveness to such auditory stimuli at higher auditory levels [Tallal et al., Science 271 (1996) 81-84; Wright et al., Nature 387 (1997) 176-178; Nagarajan et al., Proc. Natl. Acad. Sci. USA 96 (1999) 6483-6488] and with abnormal anatomical features in the auditory thalamus [Galaburda et al., Proc. Natl. Acad. Sci. USA 91 (1994) 8010-8013]. To begin to understand potential mechanisms for normal and abnormal transfer of sensory information to the cortex, we recorded the intracellular responses of medial geniculate body thalamocortical neurons in a rat brain slice preparation. Inferior colliculus or corticothalamic axons were excited by pairs or trains of electrical stimuli. Neurons receiving only excitatory collicular input had tufted dendritic morphology and displayed strong paired-pulse depression of their large, short-latency excitatory postsynaptic potentials. In contrast, geniculate neurons receiving excitatory and inhibitory collicular inputs could have stellate or tufted morphology and displayed much weaker depression or even paired-pulse facilitation of their smaller, longer-latency excitatory postsynaptic potentials. Depression was not blocked by ionotropic glutamate, GABA(A) or GABA(B) receptor antagonists. Facilitation was unaffected by GABA(A) receptor antagonists but was diminished by N-methyl-D-aspartate (NMDA) receptor blockade. Similar stimulation of the corticothalamic input always elicited paired-pulse facilitation. The NMDA-independent facilitation of the second cortical excitatory postsynaptic potential lasted longer and was more pronounced than that seen for the excitatory collicular inputs. Paired-pulse stimulation of isolated collicular inhibitory postsynaptic potentials generated little change in the second GABA(A) potential amplitude measured from the resting potential, but the GABA(B) amplitude was sensitive to the interstimulus interval. Train stimuli applied to collicular or cortical inputs generated intra-train responses that were often predicted by their paired-pulse behavior. Long-lasting responses following train stimulation of the collicular inputs were uncommon. In contrast, corticothalamic inputs often generated long-lasting depolarizing responses that were dependent on activation of a metabotropic glutamate receptor. Our results demonstrate that during repetitive afferent firing there are input-specific mechanisms controlling synaptic strength and membrane potential over short and long time scales. Furthermore, they suggest that there may be two classes of excitatory collicular input to medial geniculate neurons and a single class of small-terminal corticothalamic inputs, each of which has distinct features.

Comparison of the fine structure of cortical and collicular terminals in the rat medial geniculate body.

Neurons throughout the rat medial geniculate body, including the dorsal and ventral divisions, display a variety of responses to auditory stimuli. To investigate possible structural determinants of this variability, measurements of axon terminal profile area and postsynaptic dendrite diameter were made on inferior colliculus and corticothalamic terminal profiles in the medial geniculate body identified by anterograde tracer labeling following injections into the inferior colliculus or cortex. Over 90% of the synapses observed were axodendritic, with few axosomatic synapses. Small (<0.5 microm(2)) and large (>1.0 microm(2)) collicular profiles were found throughout the medial geniculate, but were smaller on average in the dorsal division (0.49+/-0.49 microm(2)) than in the ventral division (0.70+/-0.64 microm(2)). Almost all corticothalamic profiles were small and ended on small-caliber dendrites (0.57+/-0.25 microm diameter) throughout the medial geniculate. A few very large (>2.0 microm(2)) corticothalamic profiles were found in the dorsal division and in the marginal zone of the medial geniculate. GABA immunostaining demonstrated the presence of GABAergic profiles arising from cells in the inferior colliculus. These profiles were compared with GABAergic profiles not labeled with anterograde tracer, which were presumed to be unlabeled inferior colliculus profiles or thalamic reticular nucleus profiles. The distributions of dendritic diameters postsynaptic to collicular, cortical and unlabeled GABAergic profiles were compared with dendritic diameters of intracellularly labeled medial geniculate neurons from rat brain slices. Our results demonstrate a corticothalamic projection to medial geniculate body that is similar to other sensory corticothalamic projections. However, the heterogeneous distributions of excitatory inferior collicular terminal sizes and postsynaptic dendritic diameters, along with the presence of a GABAergic inferior collicular projection to dendrites in the medial geniculate body, suggest a colliculogeniculate projection that is more complex than the ascending projections to other sensory thalamic nuclei. These findings may be useful in understanding some of the differences in the response characteristics of medial geniculate neurons in vivo.

Effective approaches to patient education for the busy pediatrician.

Pediatricians spend 35% to 41% of their direct patient care time on patient education and counselling. However, studies indicate that teaching alone generally is ineffective. It is logical that the patient or parent must have an understanding of the basics of the regimen in order to follow the pediatrician's advice. However, teaching, even when supplemented by pamphlets or audiovisual programs, generally is not sufficient to bring about behavior change. A "stepped approach" to patient education is recommended. This approach consists of three steps: (1) using interpersonal skills to establish rapport and provide reassurance; (2) teaching about the illness, regimen, and other health matters; and (3) identifying and overcoming obstacles to behavior change. Step 3 is not necessary if steps 1 and 2 have been successful in achieving patient adherence to physician recommendations. By questioning the patient or parent at the follow-up visit, the pediatrician can identify the obstacles that are interfering with acceptance of his or her advice--this process is the "behavioral diagnosis." Once the cause of the problem has been determined, selection of the appropriate solution is usually straight-forward. This three-step approach to patient education can be more effective and less time-consuming than traditional approaches.

How can patient education help attain the objectives for the nation?

The publication of Healthy People and Promoting Health/Preventing Disease represents a milestone in the development of a national health promotion policy. The growth of patient education programs, one component of clinical preventive medicine, suggests an avenue for achievement of these health promotion objectives. I report the findings of surveys of patient education activities and programs, which found that a substantial number of patient education efforts address the Objectives for the Nation. I then discuss the results of an analysis of the Objectives for the Nation that found that 15.7% of the 370 measures pertain, either implicitly or explicitly, to patient education. I conclude by making suggestions for strengthening the links between patient education and health promotion policy.