Respiratory manifestations of malaria

Respiratory distress develops in up to 25% of adults and 40% of children with severe falciparum malaria. Its diverse causes include respiratory compensation of metabolic acidosis, noncardiogenic pulmonary edema, concomitant pneumonia, and severe anemia. Patients with severe falciparum, vivax, and knowlesi malaria may develop acute lung injury (ALI) and ARDS, often several days after antimalarial drug treatment. ARDS rates, best characterized for severe Plasmodium falciparum, are 5% to 25% in adults and up to 29% in pregnant women; ARDS is rare in young children. ARDS pathophysiology centers on inflammatory-mediated increased capillary permeability or endothelial damage leading to diffuse alveolar damage that can continue after parasite clearance. The role of parasite sequestration in the pulmonary microvasculature is unclear, because sequestration occurs intensely in P falciparum, less so in P knowlesi, and has not been shown convincingly in P vivax. Because early markers of ALI/ARDS are lacking, fluid resuscitation in severe malaria should follow the old adage to "keep them dry." Bacteremia and hospital-acquired pneumonia can complicate severe malaria and may contribute to ALI/ARDS. Mechanical ventilation can save life in ALI/ARDS. Basic critical care facilities are increasingly available in tropical countries. The use of lung-protective ventilation has helped to reduce mortality from malaria-induced ALI/ARDS, but permissive hypercapnia in unconscious patients is not recommended because increased intracranial pressure and cerebral swelling may occur in cerebral malaria. The best antimalarial treatment of severe malaria is IV artesunate .From the Mahidol Oxford Tropical Medicine Research Unit (Drs Taylor, Turner, White, and Dondorp), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; the Centre for Tropical Medicine (Drs Taylor, Turner, White, and Dondorp), Nuffield Department of Medicine, Oxford University, The Churchill Hospital, Headington, England; the Service de la Médicine Internationale et Humanitaire (Dr Taylor), H?pitaux Universitaires de Genève, Geneva, Switzerland; and Cairns Base Hospital (Dr Hanson), Cairns, QLD, Australia.Correspondence to: Walter R. J. Taylor, MD, Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, 420/6 Rajvithi Rd, Bangkok, 10400, Thailand; e-mail: bob@tropmedres.acFinancial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Drs Hanson, White, and Dondorp are supported by The Wellcome Trust as part of the Wellcome Trust Mahidol University Oxford Tropical Medicine Research Programme.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.     

ABSTRACT

THE NEW ZEALAND SOCIETY OF GASTROENTEROLOGY and THE GASTROENTEROLOGICAL SOCIETY OF AUSTRALIA The following are abstracts of papers presented at the Combined Quadrennial Scientific Meeting of The New Zealand Society of Gastroenterology and The Gastroenterological Society of Australia, held in Queenstown, New Zealand, 25–27 September, 1991. THE MANAGEMENT OF UPPER GI HAEMORRHAGE IN A SPECIALISED UNIT 1976–91. D P Edge* Palmerston North Hospital, New Zealand. GOLYTELY AND GOLYTELY-RSS FOR COLONSCOPY: PATIENT ACCEPTANCE AND EFFECTIVENESS. G Ali* M Schlup, J Shaw Department of Medicine and School of Pharmacy, University of Otago, Dunedin. PLACEBO RESPONSE IN NON ULCER DYSPEPSIA. G Ali*. M Schlup. GO Barbezat, R Lubcke Department of Medicine, University of Otago, Dunedin COLONSCOPY: AN AUDIT OF TECHNICAL COMPETENCE. G Ali*, SM Williams, M. Schlup Departments of Medicine and Preventive and Social Medicine, University of Otago, Dunedin. STRUCTURAL DETERMINANTS OF HEPATIC EXTRACTION OF SMALL PEF'TIDES FROM PORTAL BLOOD. R P Anderson* T J Butt and V S Chadwick Dept Experimental Medicine, University of Otago Medical School, Dunedin, NZ. DOSE DEPENDENT EFFECTS OF KETANSERIN ON SPLANCHNIC AND SYSTEMIC HAEMODYNAMICS IN CIRRHOSIS J Colman*, P Jones, G Jennings, H Debinski, C. Finch F Dudley Gastroenterology Department, Alfred Hospital, Melbourne IS STRONGYLOIDES COLITIS AN ENTITY? A. Brotodihardjo*, K. Goulston, R. Newland and T. Gottlieb Departments of Gastroenterology, Anatomical Pathology and Microbiology, Concord Hospital, Sydney, Australia. CROHN'S DISEASE IN CHILDRFN: THE MELBOURNE EXPERIENCE. *P.M. Davidson and B.I. McLain Depts of Surgery and Gastroenterology, The Royal Children's Hospital, Melbourne, Australia. DECREASED UPTAKE OF RETINOL LABELLED CHYLOMICRA BY LIVERS OF RATS TREATED WITH N-NITROSO-DIMETHYLAMINE. BR Dobbs^l, GWT Rogers and R Fraser Depts of Surgery and Pathology, Christchurch School of Medicine, Christchurch, New Zealand. INTRAGASTRIC AND INTRADUODENAL SEPARATION OF 99mTc COLLOIDAL MARKERS FROM MEAL FAT, BUT NOT CARBOHYDRATE IN ORAL TEST MEALS. *E H Drabble L Ilincic M F Grahn P Dean N Garvie D L Wingate N S Willim The Surgical Unit, The Royal London Hospital, Whitechapel, London El 1BB, England. ENDOSCOPIC BlLlARY STENTING. A Doty, C Stiff, PV Desmond, RG Shaw and LC Mollison* Department of Gastroenterology, St Vincent's Hospital, Victoria Pde., Fitzroy, Victoria, 3065 THE NATURE OF HUMAN POSTPRANDIAL MOTILITY IN RESPONSE TO ORAL AND INTRADUODENAL MEAL INGESTION. *E H babble L Ilincic M F Grahn D L Wingate N S Willimns The Surgical Unit, The Royal London Hospital, Whitechapel, London El 1BB. OMEPRAZOLE IN SEVERE ULCERATIVE OESOPHAGITIS IN TREATMENT FAILURES OF CONSECUTIVE COURSES OF HIGH EOSE RANITIDINE AND FAMOTIDINE. D P Edge* Paherston North Hospital, Palmerston North, New Zealand. INTRALUMINAL IRIDIUH-192 AND EXTERNAL IRRADIATION IN BILIARY TRACT MALIGNANCY. S. FAIRLEY*, B. LAURENCE, F. CAMERON GE UNIT/DEPT RADIOTHERAPY, SIR CHARLES GAIRDNER HOSPITAL., PERTH, WESTERN AUSTRALIA ALTERATIONS IN REGIONAL GUT TRANSIT IN IRRITABLE BOWEL SYNDROME. PR Evans*, AM Scott, JE Kellow, B. Shuter, ME' Jones, R. Hoschl Depts Medicine & Nuclear Medicine, Royal North Shore Hospital, Sydney, Australia. EXPERIMENTAL AUTOIMMUNE HEPATITIS: ATTEMPTED INDUCTION BY ADMINISTRATION OF DRUGS ASSOCIATED WITH CHRONIC ACTIVE HEPATTITS (CAH). S.A. Fox*, N.R. Swanson, W.D. Reed Dept. Medicine, The University of Western Australia, W.A., 6009. EFFECT OF STRAIN DIFFERENCES ON GASTRIC MUCOSAL PROLIFERATION MAY AFFECT AN IN VIVO STOMACH GENOTOXICITY ASSAY. A.G. Fraser, E.S.Debnum, A.P. Dhillon, R.E. Pounder Academic Department of Medicine, Royal Free School of Medicine, London NW3, United Kingdom. LIVER TRANSPLANTATION FROM WESTERN AUSTRALIA 1985–1991. H Glaser* and WD Reed Gastroenterology/Liver Unit, Sir Charles Gairdner Hospital, Nedlands, Western Australia. RANITIDINE, CIMETIDINE AND FAMOTIDINE HAVE NO EFFECT ON POST-PRANDIAL ALCOHOL ABSORPTION IN HEALTHY VOLUNTEERS. A.G.Fraser, E.J.Prewett, M.Hudson, A.M.Sawyerr, S.Rosalki, R.E.Pounder Academic Department of Medicine, Royal Free Hospital School of Medicine, London, UK. OESOPHAGEAL ACHALASIA. M Hadler*, P E Morum, R J Stewart, R S Stubbs University Department of Surgery, Wellington School of Medicine, Wellington, New Zealand. GASTRIC MUCOSAL BARRIER: INTERGRANULAR MATRIX OF MUCUS IDENTIFIED AS GASTRIC SUHFACTANT. Brian A. Hills Department of Physiology, University of New England, Armidale, N.S.W., Australia. Does Body Posture Or Gravity Influence Oropharyngeal And Upper Oesophageal Sphincter Function During Swallowing? F. Johnsson, D.W. Shaw*, M. Gabb, I.J. Cook Depts. Gastroenterology, Surgery & Radiology, Royal Adelaide Hospital, Adelaide, South Australia. PROSPECTIVE STUDY OF OUTCOME OF LAPAROSCOPIC CHOLECYSTECTOMY IN 100 UNSELECTED CASES. HUGH TB*, CHEN FC. LI B ST VINCENT'S HOSPITAL, SYDNEY AUSTRALIA. HEPATOPROTECI'ION OF MISOPROSTOL ON ISCHAEMIA-REPERFUSION lNDUCED LIVER INJURY IN THE RAT. SP Lim*, FJ Andrews, C Christophi and PE O'Brien Dept. of Surgery, Monash Medical School, Alfred Hospital, Melbourne, Australia. IMPROVED DIAGNOSIS OF HEPATITIS C IS BY SIMULTANEOUS MEASUREMENT OF ANTIBODIES TO CORE AND NONSTRUCTURAL REGIONS. R Lin(1), H Yatsuhashi(2), M Yano(2) and GC Farrell(1) ¹Dept of Medicine, Westmead Hospital, Sydney and ²WHO Reference Centre for Viral Hepatitis, Nagasaki Chuo National Hospital, Japan. UREASE INHIBITORS AS A POSSIBLE MODE OF TREATMENT FOR HELICOBACTCR PYLORI INFECTION. K Phillips, D Munster, J Keenan, K Allardyce, P Bagshaw. Dept of Surgery, Christchurch School of Medicine. UPDATE IN DIAGNOSTIC ULTRASOUND IN GASTROENTEROLOGY. R.Lubcke Dept. of Medicine (Gastro), University of Otago Medical School, Dunedin, New Zealand. PRIMARY SCLEROSING CHOLANGITIS (PSC) AND BILIARY TRACT CALCULI. CS Pokorny*, GW McCaughan and WS Selby AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia. MÉNÉTRIER'S DISEASE - DRAMATIC RESPONSE TO ANTI-FIBRINOLYTICS BUT NOT OCTREOTIDE. NJ Porter, JM Duggan*. Gastroenterology Dept., John Hunter Hospital, Newcastle. N.S.W. Australia. METYRAPONE STABILISES CYTOCHROME P450 ISOFORMS IN PRIMARY CULTURES OF RAT HEPATOCYTES. T Rooney, J George, M Taoner, M Murray & GC Farrell Dept Medicine, Westmead Hosp, NSW 2145 COMPARISON OF ONE DAY DOSING WITH THREE BISMUTH COMPOUNDS FOR SUPPRESSION OF HELICOBACTER PYLORI IN VIVO ASSESSED BY THE ¹³C UREA BREATH TEST. EJ Prewett, AG Fraser, YW Luk, WM Lam, RE Pounder University Department of Medicine, Royal Free Hospital School of Medicine, LONDON, U.K. HELICOBACTER PYLORI IN NUD: LOW PREVALENCE IN SOUTHERN NEW ZEALAND. M. Schlup*, R. Massey⁺, N. Hung⁺, A. Patterson⁺ Dept of Medicine*, Pathology⁺, Microbiology⁺, University of Otago, Dunedin, New Zealand. THE PREVALENCE OF GALLBLADDER DISEASE IN DIABETES MELLITUS: A CASE CONTROL STUDY. I Wilson*, G Egar, N Stewart, R Allen, R Chisholm, C Frampton, R Scott, N Pattinson, B Chapman Departments of Gastroenterology, Radiology and Diabetic Services, Christchurch Hospital, Christchurch, New Zealand. GLOMERULAR HYPERFILTRATION IN WELL COMPENSATED ALCOHOLIC CIRRHOSIS. F. Wong*, D. Massie, P. Hsu, F. Dudley Gastroenterology Department, Alfred Hospital, Victoria, Australia. A COMPARISON BETWEEN BEZAFIBRATE AND SIMVASTATIN ON BILE COMPOSITION AND GALLBLADDER EMPTYING IN FEMALE NON INSULIN DEPENDENT DIABETICS. I Wilson* M Hurrell, N Pattinson, B Chapman Departments of Radiology and Gastrenterology, Christchurch Hospital, Christchurch, New Zealand. THE DOSE DEPENDENT EFFECT OF AN ORAL PROSTAGLANDIN E₁ ANALOGUE ON RENAL FUNCTION IN ALCOHOLIC CIRRHOSIS. F. Wong*, D, Massie, P Hsu, F. Dudley, Gastroenterology Department, Alfred Hospital, Victoria, Australia. pH PROFILE AND TRANSIT TIME IN THE GASTRO-INTESTINAL TRACT. JJ Wyeth*, and EW Pomare Department of Medicine, Wellington School of Medicine, Wellington, New Zealand. FECAL α₁-ANTITRYPSIN AS A TEST FOR LARGE BOWEL CANCER. Young GP*, Deacon M, Gibson PR, St John DJB University Dept. of Medicine and Dept. of Gastroenterology, The Royal Melbourne Hospital, Melbourne, Vic 3050, Australia. THE LIVER IN HEPATITIS C INFECTION - A HISTOPATHOLOGICAL STUDY. ML Yeong*, J Wyeth, N Stace, J Miller and M Toblas Wellington School of Medicine, Wellington; Communicable Disease Centre, Porirua.     

A survival guide for generalist physicians in academic fellowships

Summary  Generalist physicians pursuing fellowship training should develop an early strategic plan to guide them through their fellowship years. Though each fellow’s plan must be individualized, fellows should get started on independent projects early, decide how much time to allocate to various activities, strike an individualized balance between course work and independent projects, and learn how to choose and maintain relationships with mentors. Early decision making with regard to these aspects of fellowship will allow trainees to maximize their learning, development, and progress toward career goals. Presented in part as a precourse at the National Meeting of the Society of General Internal Medicine, San Francisco, Calif, April 1999. Dr. Whooley is supported by a Research Career Development Award from the Department of Veterans Affairs, Health Services Research and Development Service. Dr. Saha was a fellow in the Robert Wood Johnson Clinical Scholars Program, University of Washington, and Health Services Research and Development, VA Puget Sound Health Care System. Drs. Christakis and Saint were fellows in the Robert Wood Johnson Clinical Scholars Program, University of Washington, Dr. Whooley was a fellow in the Clinical Epidemiology Fellowship, San Francisco VA Medical Center and University of California, San Francisco, Dr. Simon was a fellow in the Harvard General Internal Medicine Fellowship and Faculty Development Program, and the Thomas O. Pyle Fellowship in Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care.     

Predicting cardiac complications in patients undergoing non-cardiac surgery

The authors prospectively studied 455 consecutive patients referred to the general medical consultation service for cardiac risk assessment prior to non-cardiac surgery, in order to validate a previously derived multifactorial index in their clinical setting. They also tested a version of the index that they had modified to reflect factors they believed to be important. For patients undergoing major surgery, the original index performed less well in the validation data set than in the original derivation set (p<0.05), but still added predictive information to a statistically significant degree (p<0.05). The modified index also added predictive information for patients undergoing both major and minor surgery, demonstrating an area under the Receiver Operating Characteristic curve of 0.75 (95% confidence interval of 0.70 to 0.80). A simple nomogram is presented which will enable conversion of pretest probabilities into posttest probabilities using the likelihood ratios associated with each risk score. It is recommended that clinicians estimate local overall complication rates (pretest probabilities) for the clinically relevant populations in their settings before they apply the predictive properties (likelihood ratios) demonstrated in this study in order to calculate cardiac risks for individual patients (posttest probabilities). Received from the Departments of Health Administration and Medicine, University of Toronto, and the Division of General Internal Medicine and Clinical Epidemiology, Toronto General Hospital, Toronto, Ontario, Canada. Supported by an Ontario Ministry of Health Research Grant (DM616 and 00621) and the Toronto General Hospital Foundation. Also supported in part by the National Health and Research Development Program (Canada) through a National Health Research Scholar Award to Dr. Detsky.     

慢性活动性EBV感染的诊疗进展

慢性活动性EBV感染是一种少见病,主要表现为慢性或复发性传染性单核细胞增生症样症状,包括发热、淋巴结肿大、肝肿大、脾肿大、肝功能异常、血小板减少、蚊虫叮咬过敏、皮疹等;伴有外周血EBV载量升高和(或)EBV抗体谱异常,以及在病变组织中有EBV阳性的淋巴细胞浸润。该病往往持续进展,可因免疫功能受损,出现机会感染、噬血细胞性淋巴组织细胞增生症、多脏器功能衰竭或EBV相关淋巴瘤。临床预后较差,发病机制目前尚不清楚。传统的抗病毒治疗无效,免疫抑制剂、免疫调节治疗、免疫细胞治疗等措施效果也不肯定。惟一被证明有效的方法是异基因造血干细胞移植。     

Clinical assessment of biomedical technology

The rapid expansion of new, unproven, and often expensive biomedical technology requires controlled clinical assessment before widespread diffusion into clinical practice. The accuracy, reliability, and validity all need to be assessed in an unbiased manner to determine whether implementation is of benefit to the clinician and patient. This article briefly describes the methodology available to determine whether new technologies such as diagnostic imaging techniques may be of benefit in clinical practice.Dr. Solomon was supported in part by: The Wigston Foundation, Toronto, Canada; Ethicon Canada Ltd.; Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Canada; and Jenour Foundation, Australia.     

‘The Mentor's Quality Determines the Probability of Success of the Young Researcher’: An Interview with Prof. Makoto Otsuki

In this interview, Professor Makoto Otsuki points out the importance of mentorship during young researchers' development. Dr. Otsuki, a Professor and Chair of the Third Department of Internal Medicine at the University of Occupational and Environmental Health, has contributed significantly to the field of pancreatic physiology. In addition, his epidemiological research has been fundamental for understanding the pathogenesis of pancreatitis and establishment of the guidelines for its diagnosis and improvement of case fatality.     

Roundtable Discussion: Problems in the Management of Hypertension

Following a symposium on hypertension sponsored by the National Heart, Lung, and Blood Institute in Chicago, IL on October 3, 2001, a panel was convened to discuss various aspects of hypertension treatment. Moderating the panel was Dr. Marvin Moser, Clinical Professor of Medicine at The Yale University School of Medicine. Panel members included Dr. George Bakris, Professor of Preventive Medicine and Director, Hypertension/Clinical Research Center at the Rush-Presbyterian-St. Luke's Medical Center in Chicago, Illinois and Dr. Henry Black, Professor of Medicine, Associate Vice President for Research, and Chairman of the Department of Preventive Medicine at Rush-Presbyterian.     

New Coding in the International Classification of Diseases, Ninth Revision, for Children's Interstitial Lung Disease

The term "children's interstitial lung disease" (chILD) refers to a heterogeneous group of rare and diffuse lung diseases associated with significant morbidity and mortality. These disorders include neuroendocrine cell hyperplasia of infancy, pulmonary interstitial glycogenosis, surfactant dysfunction mutations, and alveolar capillary dysplasia with misalignment of pulmonary veins. Diagnosis can be challenging, which may lead to a delay in recognition and treatment of these disorders. Recently, International Classifications of Diseases, Ninth Revision codes have been added for several of the chILD disorders. The purpose of this article is to give an overview of the chILD disorders and appropriate diagnostic coding.From the Georgia Pediatric Pulmonology Associates (Drs Popler and Lesnick), Atlanta, GA; the Department of Pathology (Dr Dishop), University of Colorado Denver School of Medicine, Children's Hospital Colorado; and the Department of Pediatrics (Dr Deterding) University of Colorado Denver, Aurora, CO.Correspondence to: Jonathan Popler, MD, FCCP, Georgia Pediatric Pulmonology Associates, 1100 Lake Hearn Dr, Ste 450, Atlanta, GA 30342; e-mail: JPopler@gppa.netFinancial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Deterding is the Director of the Children's Interstitial and Diffuse Lung Disease (chILD) Research Network and is on the chILD Foundation Board. Drs Popler, Lesnick, and Dishop have reported that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.Other contributions: We thank Frank McCormack, MD, and Lawrence Nogee, MD; Diane Krier-Morrow, MBA, MPH, of the American College of Chest Physicians; the American Thoracic Society; the American Association of Pediatrics, Pulmonary Section; the chILD Research Network; and the members of the ICD-9-CM Coordination and Maintenance Committee for their efforts in creating these classifications.Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.     

Roundtable discussion: problems in the management of hypertension

Following a symposium on hypertension sponsored by the National Heart, Lung, and Blood Institute in Chicago, IL on October 3, 2001, a panel was convened to discuss various aspects of hypertension treatment. Moderating the panel was Dr. Marvin Moser, Clinical Professor of Medicine at The Yale University School of Medicine. Panel members included Dr. George Bakris, Professor of Preventive Medicine and Director, Hypertension/Clinical Research Center at the Rush‐Presbyterian‐St. Luke's Medical Center in Chicago, Illinois and Dr. Henry Black, Professor of Medicine, Associate Vice President for Research, and Chairman of the Department of Preventive Medicine at Rush‐Presbyterian.     

BOOK REVIEWS FOR GASTROENTEROLOGISTS

Book Reviewed in this article:
DISORDERS OF LANGUAGE: Ciba Foundation Symposium. A.V.S. deReuck, M.Sc., D.I.C., A.R.C.S., and Maeve O'Conner, B.A.
THE HISTORY OF DIABETES MELLITUS: N. S. Papaspyros, M.D., Director of the Diabetic Center of Athens. Preface by R. D. Lawrence, M.A., M.D., F.R.C.P. (London).
DISORDERS DUE TO INTESTINAL DEFECTIVE CARBOHYDRATE DIGESTION AND ABSORPTION: Edited by P. Durand. Contributors: A. Dahlquist, P. Durand, J. H. Van de Kamen, G. M. Lamedica, S. Nordio, H. A. Weigers.
PHYSICAL DIAGNOSIS OF ACUTE ABDOMINAL DISEASE AND INJURIES: Endre Kelemen, Jr., M.D., Chief Surgeon of the Balassa Janos General Hospital, Szekszan, Hungary. Translanted by Dr. J. Sivo.
ANIMAL EXPERIMENTS ON THE ETIOLOGY OF MYELOPATHY: Tibor Lehoczki, M.D., Prof. Dr. Jozsef Sos, and Margit Halasy, M.D. Translated by Dr. Elek Farkas.
THE SMALL INTESTINE, ITS FUNCTION AND DISEASES: Thomas W. Sheehy, M.D., F.A.C.P., Assistant Chief, Department of Gastroenterology, Walter Reed Army Institute of Research, Washington, D. C, Assistant Professor, Department of Medicine, University of Puerto Rico School of Medicine, San Juan and Martin H. Floch, M.D., Assistant Attending Physician, Montefiore Hospital, New York, Formerly Chief of Gastroenterology Section, U. S. Army Tropical Research Medical Laboratory, and Instructor, Department of Medicine, University of Puerto Rico School of Medicine, San Juan.
FERMENTDIAGNOSTIK INTERNER ERKRANKUNGEN: Priv. Doz. Dr. D. Amelung, I. Medizinische Klinik der Medizinischen Akadcmie Dusseldorf.     

Medical students’ motivation for internal medicine

Objective: To verify that motivational concepts tested in other educational settings are relevant to understanding medical students’ choice of a career in internal medicine. More specifically, to compare the effects of “facilitating students’ interest” versus “controlling students’ learning” as educational models during the internal medicine clerkship. Design: An observational retrospective study of 89 fourth-year medical students. Structural equation modeling compared the two models statistically. Main outcome measure: Student choice of internal medicine residency. Results: Instructors who supported students’ autonomy engendered in students greater feelings of competence and interest in internal medicine than did controlling instructors. Perceived competence further enhanced students’ interest in internal medicine. In turn, interest predicted students’ choosing an internal medicine residency. Overall, the facilitating students’ interest model better explained students’ choice of internal medicine than did the controlling students’ learning model.Conclusions: The results verify that the nature of the learning climate during the internal medicine clerkship is an important predictor of students’ subsequent pursuit of internal medicine training. Instructors who teach in an autonomy-supportive manner enhance students’ perceived competence and interest in internal medicine, which increases the likelihood they will select an internal medicine residency. Received from the Program for Biopsychosocial Studies and the Human Motivation Research Program, University of Rochester, Rochester, New York. Drs. Williams and Wiener are currently at the Department of Internal Medicine, The Genesee Hospital, University of Rochester; Dr. Markakis is currently at the Department of Internal Medicine, Highland Hospital, Rochester; Drs. Williams and Deci are currently with the Human Motivation Program, Department of Psychology, University of Rochester; and Dr. Reeve is currently at the Department of Educational Psychology, University of Wisconsin, Milwaukee, Wisconsin.     

Determinants of fasting and postprandial serum bile acid levels in healthy man

The relationship between serum levels of conjugates of cholic acid measured by radioimmunoassay, bile acid absorption, and hepatic clearance was studied in order to define the determinants of fasting and postprandial serum bile acids in healthy man. Acute or chronic interruption of the enterohepatic circulation caused a significant decrease in basal serum levels of cholyl conjugates, while liquid or solid meals caused a marked and reproducible increase in serum cholyl conjugates. A temporal correlation was demonstrated postprandially or after intravenous cholecystokinin between intestinal transit of bile acids and simultaneous changes in levels of serum cholyl conjugates. Finally, the plasma disappearance of intravenously injected cholylglycine was shown to be unaffected by serum levels of endogenous cholyl conjugates. These data are consistent with the interpretation that, in the presence of normal hepatic function, the major determinant of serum bile acids is their rate of intestinal absorption.This work was supported by Mayo Foundation and USPHS Grant AM 16770.A part of this work was presented at the 1975 meeting of the American Association for the Study of Liver Disease and published in abstract form (1). Dr. Hoffman's present address is: Division of Gastroenterology, Department of Medicine, University of Texas, Houston, Texas. Dr. Korman's present address is: Department of Medicine, Monash University, Prince Henry's Hospital, Melbourne, Australia. Dr. Cowen's present address is: Department of Medicine, Royal Brisbane Hospital, Queensland, Australia.     

利奈唑胺联合方案治疗耐多药结核病效果及不良反应研究

目的探讨含利奈唑胺联合方案治疗对耐多药结核病患者痰菌阴转率、病灶吸收情况、空洞变化情况及不良反应的影响。方法收集2012年1月—2017年12月于我院治疗的60例耐多药结核病患者临床资料,根据治疗方案将患者分为对照组与研究组。对照组治疗方案为左氧氟沙星、阿米卡星、吡嗪酰胺、丙硫异烟胺及对氨基水杨酸。研究组治疗方案为在对照组治疗方案基础上给予利奈唑胺治疗。比较2组患者痰菌阴转率、病灶吸收情况、空洞变化情况及不良反应。结果治疗6个月,研究组痰菌阴转率与病灶吸收有效率均大于对照组(P均<0.05),空洞变化有效率及不良反应发生率与对照组无显著差异(P均> 0.05)。结论含利奈唑胺联合方案治疗可提高耐多药结核病患者痰菌阴转率和病灶吸收有效率,但易发生血小板减少,贫血等不良反应,须定期进行血常规检查。空洞变化有效率及不良反应与对照组相同。     

The hazards of using active clinic patients as a source of subjects for clinical studies

The authors describe and empirically demonstrate a form of bias that results from deriving subjects for clinical studies from available patients currently being followed in specific disease clinics instead of inception cohorts (patients enrolled at a uniform and early point in their disease). They label this effect “clinic patient bias.” It is a variation of prevalence-incidence (Neyman) bias in that it also results from the time gap between the onset of a specific characteristic (a risk factor, exposure or disease) and enrollment in the study, causing selective exclusion of fatal or short episodes, or mild or silent cases. Clinic patient bias may distort an estimate of relative risk in either direction. The empirical example is derived from a study of risk factors for developing complications such as peritonitis among end-stage renal disease patients treated with continuous ambulatory peritoneal dialysis (CAPD). The use of available clinic patients rather than an inception cohort (patients newly beginning CAPD) resulted in the demonstration of false apparent risk relationships for two variables: the calendar date when patients began CAPD (with those enrolled at an earlier time appearing to be at lower risk), and serum albumin level at the start of CAPD (with those having lower albumin levels appearing to be at higher risk). This example demonstrates one of the potential hazards of using active or available clinic patients as a source of subjects for clinical studies. Received from the Departments of Health Administration, Medicine and Preventive Medicine, and Biostatistics, University of Toronto: and the Divisions of General Internal Medicine and Clinical Epidemiology. Nephrology, and Gastroenterology, Toronto General Hospital, Toronto, Ontario, Canada. Supported by the National Health Research and Development Programme (Canada) through a project grant (6606-2362-42) and a National Health Research Scholar Award to Dr. Detsky.     

Acute fatty liver of pregnancy with hepatic coma and mallory-weiss syndrome: Report of a case

Summary A case of acute fatty liver of pregnancy with unusual complications is presented. These include upper gastrointestinal bleeding due to a Mallory-Weiss lesion, coagulation disturbances, and hepatic encephalopathy with hyperammonemia. The patient survived after massive corticosteroid therapy.We are indebted to Dr. Robert Goldstein, Chief of the Section of Hematology, Department of Medicine, for the extensive hematologic studies in this case, and to Dr. Hans Popper, Director, Department of Pathology, Mount Sinai Hospital, for his aid in the interpretation of the liver biopsy.     

Transforming Clinical Practice to Eliminate Racial–Ethnic Disparities in Healthcare

Racial–ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial–ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial–ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial–ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. Funding: Drs. Washington (#RCD-00-017), Saha (#RCD-00-028), and Moody (#RCD-03-183) are supported by grants from the Department of Veterans Affairs, Health Services Research and Development Service. Dr. Saha is supported by a Generalist Physician Faculty Scholar award from the Robert Wood Johnson Foundation. Drs. Horowitz (#P60 MD00270) and Brown (#P20MD00148) are supported by grants from the National Center on Minority Health and Health Disparities. Dr. Brown also received support from the University of California, Los Angeles, Resource Center in Minority Aging Research (#AG02004) and the Beeson Career Development Award (#AG26748). Dr. Cooper is supported by a grant from the National Heart, Lung, and Blood Institute (K24HL083113).     

Granular cell myoblastoma of the common bile duct

Summary Two cases of granular cell myoblastoma of the common bile duct are reported. One tumor caused extrahepatic cholestasis and another was an incidental finding at autopsy. These are the second and third cases reported involving the common bile duct.Supported in part by US Public Health Service Research Grant FR-5590, from the Division of Research Facilities and Resources, NIH.The authors are indebted to Drs. J. Paul Decker, Frank P. Brooks, and Ralph M. Myerson for their critical review of this paper, and to Dr. P. V. Skerrett for review of the pathologic material.