Evaluation of ambulatory care training by graduates of internal medicine residencies

In 1984, 154 physicians who had completed residencies in internal medicine at 15 major teaching hospitals in 1982 evaluated their residency training in ambulatory care. A majority of the physicians would have liked more experience in practical areas related to career planning and office management, more input from subspecialties such as orthopedics and dermatology, greater knowledge about the management of psychosocial problems, and more information about exercise and nutrition. Although many physicians also wanted more time devoted to several other topics, less than 20 percent recommended spending less time on 26 of the 27 topics being evaluated. Since these recommendations are similar to those reported in evaluation studies published over the past 25 years, it appears that training programs in internal medicine have not been successful in restructuring their curricula to meet many of the needs of practicing physicians.     

Further morphological and biochemical observations on early low dose streptozocin diabetes in mice.

Conflicting published data regarding the role of macrophages and other cell types during the early stages of diabetes mellitus led us to further study this problem. To this end we diabetized mice, using low doses of streptozocin (STZ), 40 mg/kg body wt/day/5 days, and processed their pancreatic tissue for immunocytochemistry and ultrastructural observations; immunohistochemistry was performed on days 5 and 18 after the first STZ injection, and islets were observed ultrastructurally on days 5, 9, 10, and 18. Animals were tested for fasting serum glucose, and isolated islets were assayed for insulin secretion capacity. Immunohistology demonstrated that expression of major histocompatability complex class 2 antigens is strongly induced by multiple, low dose STZ treatments prior to impaired insulin release, and that different types of cells within the islet are capable of expressing Ia molecules. Ultrastructurally we found (a) a small number of macrophages (most probably resident monocytes/macrophages) containing B-cell debris, that were located close to either damaged or intact B cells; (b) a large number of recruited macrophages in a vascular or perivascular position; and (c) macrophages recognizable in the exocrine portion, close to the islets, occasionally containing exocrine cell debris. This led us to believe that recruited macrophages play an important role in the early islet-infiltrating stage.     

Paratesticular papillary mesothelioma

A case of uncommon paratesticular mesothelioma in a young patient is presented. Its questionable malignancy, as well as the method of treatment are discussed.     

Relationship between health beliefs and psychological variables in diabetic patients

The present paper is focused on the relationship between psychological variables and health beliefs in 93 diabetic men. A Diabetes Health Belief Scale was used to assess general health motivation, treatment beneficial, severity, susceptibility, psychological barriers, cues to action, and structural elements. The psychological variables included two measures of locus of control, depression, somatization, interpersonal sensitivity, obsessive—compulsiveness, anxiety, self-esteem, and attitudes toward diabetes, doctor, and medical care. Ten of the 11 psychological variables were correlated with various aspects of health beliefs. This indicates the extent to which the health beliefs are enmeshed with the psychological dynamics of the person. It would seem important to take such a psychological profile into consideration when attempting to understand and even alter the health beliefs.     

Prevention of shoulder subluxation after stroke with electrical stimulation

BACKGROUND AND PURPOSE: Subluxation is a significant problem in poststroke hemiplegia, resulting in pain and loss of function. Current treatments are not proved and not considered effective. It has been demonstrated that cyclical electrical stimulation of the shoulder muscles can reduce existing subluxation. The purpose of this study was to determine whether electrical stimulation could prevent subluxation in both the short and long terms. METHODS: A prospective, randomized controlled study was used to determine the efficacy of electrical stimulation in preventing shoulder subluxation in patients after cerebrovascular accidents. Forty patients were selected and randomly assigned to a control or treatment group. They had their first assessment within 48 hours of their stroke, and those in the treatment group were immediately put on a regimen of electrical stimulation for 4 weeks. All patients were assessed at 4 weeks after stroke and then again at 12 weeks after stroke. Assessments were made of shoulder subluxation, pain, and motor control. RESULTS: The treatment group had significantly less subluxation and pain after the treatment period, but at the end of the follow-up period there were no significant differences between the 2 groups. CONCLUSIONS: Electrical stimulation can prevent shoulder subluxation, but this effect was not maintained after the withdrawal of treatment.     

Variation in hospital charges for total joint arthroplasty: an investigation of physician efficiency

Total joint arthroplasty is a common procedure for which consistent, clinically satisfactory outcomes are expected. Data from 796 total joint procedures performed by 20 surgeons at one center were evaluated to identify sources of variability in costs (as measured by hospital charges) where clinical outcome is expected to remain constant. Stepwise multivariate regression characterized the contribution of six variables to hospital charges listed in order of explanatory power: postoperative length of stay, surgical time, patient preoperative morbidity, units of blood transfused, perioperative complications, and procedure type (hip or knee) accounted for 46% of variability in hospital charges (multiple R2). In a subsequent analysis, after statistical adjustment for preoperative comorbid diagnoses, the sampling distribution of mean values for surgical time, total units of blood transfused, and total hospital charges were summarized and compared among surgeons. Despite adjustment for comorbid diagnoses, substantial variation and significant differences remained between surgeons in markers of resource utilization and "surgical efficiency." These findings suggest there is substantial variability in hospital charges not attributable to patient characteristics or category of procedure--a distinct and economically significant portion of this variability is practitioner specific.     

Risk-Adjusted Cancer Screening and Prevention (RiskAP): Complementing Screening for Early Disease Detection by a Learning Screening Based on Risk Factors

BackgroundRisk-adjusted cancer screening and prevention is a promising and continuously emerging option for improving cancer prevention. It is driven by increasing knowledge of risk factors and the ability to determine them for individual risk prediction. However, there is a knowledge gap between evidence of increased risk and evidence of the effectiveness and efficiency of clinical preventive interventions based on increased risk. This gap is, in particular, aggravated by the extensive availability of genetic risk factor diagnostics, since the question of appropriate preventive measures immediately arises when an increased risk is identified. However, collecting proof of effective preventive measures, ideally by prospective randomized preventive studies, typically requires very long periods of time, while the knowledge about an increased risk immediately creates a high demand for action.SummaryTherefore, we propose a risk-adjusted prevention concept that is based on the best current evidence making needed and appropriate preventive measures available, and which is constantly evaluated through outcome evaluation, and continuously improved based on these results. We further discuss the structural and procedural requirements as well as legal and socioeconomical aspects relevant for the implementation of this concept.