Hyperprolinemia and prolinuria in a new inbred strain of mice, PRO-Re.

A hyperprolinemia was discovered, in a new inbred strain of mice, which was equivalent to about a sevenfold elevation above the concentration of proline in the blood of either of the original parental lines, or of 12 other inbred strains with diverse genetic constitution. In addition, mice of this PRO/Re strain exhibited a marked prolinuria, whereas the other 14 inbred strains had no proline detectable in their urine.

Patterns of comorbidity in elderly patients with multiple sclerosis.

This study explored the prevalence of comorbid conditions in hospitalized patients with multiple sclerosis (MS) who were 65 years of age or older. Using 1989 data from the Quality of Care Medicare Provider Analysis and Review (MEDPAR) file, hospitalized MS patients were compared with respect to discharge diagnoses to an age- and sex-matched group of hospitalized patients without MS. As expected, the following discharge diagnoses were more common (P < 0.05) for MS patients: urinary tract infection, pneumonia, septicemia and cellulitus. In contrast, MS patients were less likely (P < 0.05) to have discharge diagnoses of acute myocardial infarction, heart failure, hypertension, angina pectoris, cerebrovascular disease, diabetes mellitus and chronic obstructive pulmonary disease. Possible explanations include under-reporting of certain comorbid conditions on discharge records of MS patients, a protective effect of MS or its treatment, reduced prevalence of risk factors, disproportionate mortality in younger MS patients with comorbidity and the benefits of medical surveillance.

Gender concordance between family practice residents and their patients in an ambulatory-care setting.

To determine whether women residents are more likely than men residents to treat female patients, the author analyzed data concerning resident-patient encounters in an ambulatory care setting from 107 family practice residents completing a university training program from 1979 through 1988. While the mean numbers of encounters for the men and women residents were similar, 70.5% of the women residents' encounters were with female patients, compared with 63.1% of men residents' encounters with female patients (p less than .0001). The women residents saw 3.6 times more female than male patients aged 13 to 20 years and 3.9 times more women than men patients aged 21 to 40. The women residents had more encounters for contraception, vaginitis, prenatal care, and health maintenance for women patients and fewer encounters for prostatic/testicular problems and health maintenance for men patients.

Does problem-based learning work? A meta-analysis of evaluative research.

The purpose of this review is to synthesize all available evaluative research from 1970 through 1992 that compares problem-based learning (PBL) with more traditional methods of medical education. Five separate meta-analyses were performed on 35 studies representing 19 institutions. For 22 of the studies (representing 14 institutions), both effect-size and supplementary vote-count analyses could be performed; otherwise, only supplementary analyses were performed. PBL was found to be significantly superior with respect to students' program evaluations (i.e., students' attitudes and opinions about their programs)--dw (standardized differences between means, weighted by sample size) = +.55, CI.95 = +.40 to +.70 - and measures of students' clinical performance (dw = +.28, CI.95 = +.16 to +.40). PBL and traditional methods did not differ on miscellaneous tests of factual knowledge (dw = -.09, CI.95 = +.06 to -.24) and tests of clinical knowledge (dw = +.08, CI.95 = -.05 to +.21). Traditional students performed significantly better than their PBL counterparts on the National Board of Medical Examiners Part I examination--NBME I (dw = -.18, CI.95 = -.10 to -.26). However, the NBME I data displayed significant overall heterogeneity (Qt = 192.23, p < .001) and significant differences among programs (Qb = 59.09, p < .001), which casts doubt on the generality of the findings across programs. The comparative value of PBL is also supported by data on outcomes that have been studied less frequently, i.e., faculty attitudes, student mood, class attendance, academic process variables, and measures of humanism. In conclusion, the results generally support the superiority of the PBL approach over more traditional methods. Acad. Med. 68 (1993):550-563.

Student performances on Step 1 and Step 2 of the United States Medical Licensing Examination following implementation of a problem-based learning curriculum.

PURPOSE: To examine students' performances on Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE) following the implementation of a problem-based learning curriculum. METHOD: Performances on Step 1 of the USMLE for four classes at the University of Missouri-Columbia School of Medicine that completed a new problem-based learning curriculum (1997, 1998, 1999, and 2000) were compared with those of the last two classes to learn in the traditional curriculum (1995 and 1996). Performances on Step 2 of the USMLE for the classes of 1997, 1998, and 1999 were also compared with those of the classes of 1995 and 1996. The authors analyzed matriculation data (GPAs and MCAT scores) for all six classes. They compared all data with those of U.S. and Canadian first-time USMLE takers. RESULTS: The mean scores were higher on USMLE Step 1 for classes in the problem-based learning curriculum than for classes in the traditional curriculum. The mean scores for Step 2 were above the national mean for classes in the revised curriculum and below the national mean for classes in the traditional curriculum. The admission profiles of these classes were essentially the same before and after the change in curriculum. CONCLUSIONS: Major PBL revisions of the curriculum did not compromise the performances of medical students on the licensing examinations; in fact, they may have contributed to higher scores.

Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative.

The Generalist Physician Initiative (GPI) was created by The Robert Wood Johnson Foundation to help medical schools increase the number of predoctoral and residency graduates entering generalist careers. The underlying assumption of the GPI is that more medical graduates will become generalists if schools select candidates whose personal characteristics are compatible with generalist careers and if schools provide for them an educational environment that values generalist careers in the same manner it has valued specialist careers. In essence, the GPI is helping schools modify the culture in which medical education occurs so that they may increase their production of generalists. Fourteen grants for six years of support were made to 16 U.S. medical schools in 1994. These schools are developing institution-wide efforts that span the continuum from the recruitment and selection of students through their medical school and residency education to their entry into practice, and include support of the practice. Most schools have developed external partners (e.g., state legislatures, managed care organizations, area health education centers) to assist in achieving their goals. The project is now (1997) at its halfway mark. This article describes the conceptual bases for the program (e.g., changes in admission criteria to favor applicants oriented to generalism), identifies common approaches to intervention chosen by the participating schools (e.g., establishing longitudinal, generalist-oriented clinical experiences throughout the four years of medical school), and explores issues being faced by the schools as they implement change (e.g., difficulties in decentralizing clinical education to include community physicians as teachers and role models).

The effects of stress and social support on health: a research challenge for family medicine.

Family physicians frequently encounter patients who have recently experienced stressful life changes and who have weak social supports. Since an accumulation of evidence indicates that these psychosocial profiles are associated with health impairment, further investigation of these factors is of importance to family medicine. This paper reviews conceptual and methodologic issues involved in the assessment of the health effects of stress and social support and identifies particular questions and directions appropriate for family medicine research. The ultimate goal of research inquiry in this area is to develop effective clinical and public health strategies that prevent or minimize adverse health consequences.

Epidemiologic inquiry: observational studies.

A major objective of epidemiologic investigation is to determine whether or not an association between an exposure and a condition exists in a human population. The presence of such an association cna be explored using three distinct strategies, the cohort, the case-control, and the cross-sectional approaches. This paper describes each of these research designs and discusses their advantages and disadvantages.

The life space drawing as a measure of social relationships.

The life space drawing was prospectively assessed as a predictor of 12-month morbidity in 27 white female participants of a clinical trial. Women who subsequently experienced a high rate of self-reported morbidity (greater than or equal to 3 restricted-activity days per month) had a higher proportion of interpersonal relationships characterized by poor communication than did women with less than or equal to 2 restricted activity days per month. The quality of the relationship with a spouse/significant other appeared to be a particularly strong predictor of morbidity in this small self-selected group of women.

Publication patterns of presentations at the Society of Teachers of Family Medicine and North American Primary Care Research Group annual meetings.

BACKGROUND AND OBJECTIVES: The annual meetings of the Society of Teachers of Family Medicine (STFM) and the North American Primary Care Research Group (NAPCRG) are important peer-reviewed venues for family medicine academicians to present their research. However, a relatively small number of individuals actually hear each presentation. In order to permanently share their research with a large number of peers, these presenters need to take the next step and publish completed manuscripts. This study examined the frequency with which presentations at these meetings are eventually published. METHODS: All abstracts from the 1987 and 1988 meetings of NAPCRG and the PEER and research sections of STFM were followed by performing a Medline computer search for the presenting author. Publications that matched the presentations were identified, and information was recorded about the elapsed time between presentation and publication, and the journal where publication occurred. RESULTS: Just under half (48%) of all the presentations were published within 4 or 5 years. There was no difference between 1987 and 1988 presentations, nor between NAPCRG and the combined STFM presentations. However, 69% of STFM research presentations were published compared to 31% of the peer presentations (X2 = 20.6, df = 2, P < .001). The STFM research publications also tended to be in print sooner than other presentations. Fifty-six percent of the publications occurred in family practice journals, with Family Medicine and the Journal of Family Practice being the most common journals. CONCLUSIONS: Approximately half of the presentations at STFM and NAPCRG annual meeting are published within 4 to 5 years. This is consistent with publication rates found for other specialty meetings. The reasons for not publishing are numerous and need to be better elucidated to help family medicine academicians complete the research loop and disseminate their findings to the scientific community.

A randomized controlled evaluation of a psychosocial intervention in adults with chronic lung disease.

The effect of a stress management program on morbidity and psychosocial and physical function in patients with chronic lung disease was assessed. Adults attending either a VA pulmonary clinic or university hospital pulmonary rehabilitation clinic who met criteria for obstructive or restrictive pulmonary disease were randomly assigned to receive the intervention or to a control group. The intervention was provided by a nurse and included one to three teaching sessions, reading material, audiotapes, and telephone follow-up. The program focused on stress management techniques such as cognitive restructuring, progressive relaxation, breathing exercises, and visual imagery. The 45 experimental subjects were similar to the 49 controls with respect to baseline characteristics. Experimental and control subjects had similar rates of mortality, hospital days, bed-disability days, restricted-activity days, and physician visits during the 12-month follow-up. There were no differences between the two groups in physical or psychosocial function at six months or in levels of stressful life changes, social supports, and self-esteem at six and 12 months. Intervention recipients had better function at 12 months, suggesting a possible benefit of the intervention.

Inflammation on the cervical Papanicolaou smear: the predictive value for infection in asymptomatic women.

BACKGROUND: The clinical significance of inflammation on the cervical Papanicolaou (Pap) smear of asymptomatic women is unknown. This study assessed the possible association between inflammation on Pap smears with the presence of cervical/vaginal pathogens. METHODS: A questionnaire was given to 290 asymptomatic women seen for routine gynecologic examination, including Pap smear, in a primary care setting. The women were tested for the presence of Candida species, Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonnorrhoeae, and Chlamydia trachomatis. RESULTS: Recovery of Chlamydia and Trichomonas was more frequent in women with inflammation on Pap smear than in women without inflammation, but the positive predictive value of inflammation was only 7% for Chlamydia and 14% for Trichomonas. Seventy-one percent of the women with inflammation had no evidence of any of the organisms. After a 6-month follow-up period, women with inflammation on Pap smear were no more likely than their matched counterparts without inflammation to return for a clinic visit with symptoms of vaginitis. CONCLUSIONS: In this study, inflammation on Pap smear had a relatively low predictive value for the presence of vaginal pathogens in asymptomatic women.

Rational theophylline use in older asthmatics.

In the sick adult, the variability of clearance from patient to patient may be greater than 50%. A given dose of theophylline that is predicted to result in a serum concentration of 15 micrograms/ml may result in an actual range of serum concentrations from 6.6 to 33 micrograms/ml. Respiratory infections, both acute and chronic, seem to have an adverse effect on theophylline clearance. Studies in adults with acute viral upper respiratory infections, pneumonia, and chronic obstructive pulmonary disease show a significant decrease in clearance.

Acute pancreatitis.

Acute pancreatitis is most often secondary to prolonged excessive alcohol intake or biliary tract disease. The diagnosis is based on a combination of physical, laboratory, and radiologic findings. Differentiation from intra-abdominal processes that require surgical intervention is important. Treatment involves restoration of intravascular volume, correction of hypoxemia and metabolic derangements, and resting the gastrointestinal tract. Prognostic indicators are useful in identifying severe cases that may benefit from more aggressive monitoring, peritoneal lavage, antibiotic therapy, and surgical intervention. The recovery period may be complicated by sequellae of pancreatic necrosis and by sepsis.

Salicylate poisoning from enteric-coated aspirin. Delayed absorption may complicate management.

Acute salicylate poisoning with enteric-coated aspirin may result from accidental ingestion, a suicide attempt, or a complication of long-term therapy. Because absorption of enteric-coated aspirin is delayed, use of the Done nomogram to determine toxicity may lead to underestimating the severity of the poisoning. Treatment options include induction of emesis or diuresis, gastric lavage, administration of activated charcoal, and surgery.

A point-source epidemic of leptospirosis. Description of cases, cause, and prevention.

Leptospirosis is a zoonotic disease that consists of fever, headache, myalgias, and multiple organ involvement, has varying clinical severity and morbidity, and can occur in epidemic form. Diagnosis is based on culture or serologic demonstration of recent infection. There is evidence that doxycycline therapy started early in the course of the disease favorably affects duration and severity. Antibiotic therapy is often initiated because of a strong suspicion of the disease, before bacteriologic or serologic confirmation of the diagnosis is completed. Public health measures play an important role in minimizing the incidence of leptospirosis.

Extrinsic rearfoot posts.

The addition of an extrinsic rearfoot post to an orthotic device allows the podiatric practitioner to modify the function of the device. Specifically, rearfoot posts are used to allow for a more inverted heel position at contact, to provide greater resistance to abnormal frontal plane motion of the calcaneus and to provide for motion for shock absorption. The authors present nine prescription variables that each provide for a specific functional change to be incorporated into the orthotic device.

Walking and hiking injuries. A one year follow-up study.

Injury patterns associated with walking and hiking activities were examined for all patients presenting to the clinic over a 1-year period. Among the patient group, the authors found that most injuries were unilateral, resulting from overuse, and occurred in the lower extremity, particularly in the foot, ankle, and knee. There are limited studies investigating walking and hiking injury rates in the general population. The results can be applied only to a small specific sample of the population.

Limb length discrepancies.

Examining for a possible limb length discrepancy is an important part of the podiatric biomechanical examination. The authors present a review of the literature pertaining to the definition of and examination for a limb length discrepancy. They present a typical rationale for lift therapy in the treatment of this pathology.

The myth of running limb varus.

Even though the authors believe that there are many flaws in treadmill-based video analysis, they do believe that this study shows that running limb varus is not as important a concept as previously discussed by many authors. The FootTrak system is the first system available to give biomechanical researchers the ability to document the tibia-to-vertical angle with computerized digitation. The clinician with a knowledge of biomechanics understands that functional orthotic devices are more effective on primary calcaneal motions and positions than motions and positions produced by extrinsic tibial, knee, or hip factors. Thus, functional foot orthoses tend to work better in controlling varus during running that is produced by the calcaneus, rather than the tibia.