The practices of general and subspecialty internists in counseling about smoking and exercise.

We compared the practices of subspecialists and general internists in counseling about smoking and exercise, using data from a study of recent graduates of United States training programs in internal medicine. Information on the characteristics of physicians and their clinical practices was obtained from self-report questionnaires. The internists most likely to counsel smokers regardless of the presence or absence of diseases associated with smoking are cardiologists, pulmonary specialists, nephrologists, and generalists trained in a primary care residency funded by the Robert Wood Johnson Foundation or Health Resources Administration. Most internists practice tertiary prevention by counseling a high percentage of smokers with heart or lung disease. Rheumatologists counsel a higher percentage of all patients with poor exercise habits but a lower percentage of such patients with heart disease than do other internists. The differences in counseling related to training are not explained by different levels of involvement as a primary care physician. Rather, these differences appear to reflect training and subspecialty-specific priorities for counseling.     

Measurement of normal portal venous blood flow by Doppler ultrasound.

The volume flow rate of blood in the portal vein was measured using a duplex ultrasound system. The many errors inherent in the duplex method were assessed with particular reference to the portal vein and appropriate correction factors were obtained by in vitro calibration. The effect of posture on flow was investigated by examining 45 healthy volunteers in three different positions; standing, supine and tilted head down at 20 degrees from the horizontal. The mean volume blood flow in the supine position was 864 (188)ml/min (mean 1SD). When standing, the mean volume blood flow was significantly reduced by 26% to 662 (169)ml/min. There was, however, no significant difference between flow when supine and when tilted head down at 20 degrees from the horizontal.     

The Ocular Hypertension Treatment Study: reproducibility of cup/disk ratio measurements over time at an optic disc reading center.

PURPOSE: To determine the reproducibility over time of visual estimates of the horizontal cup/disk ratio by trained technicians from optic disk stereophotographs. METHODS: Baseline optic disk stereophotographs are graded at entry and regraded annually in a masked fashion. The 1,636 participants in the Ocular Hypertension Treatment Study (OHTS) undergo stereoscopic optic disk photography at study entry and annually thereafter. Stereophotographs are graded independently by two technicians at the Optic Disc Reading Center. If the readers' estimates of horizontal cup/disk ratio differ by more than 0.2 disk diameters (DD), they attempt to reach a consensus; if they cannot, the horizontal cup/disk ratio is adjudicated by a glaucoma specialist. RESULTS: The percent of regradings differing by 0.2 DD or more from the estimate of horizontal cup/disk ratio made at entry was 4%, 6%, and 7%, respectively at years 1, 2, and 3. The percent differing by more than 0.2 DD was 1% or less at all years. Intraclass correlation coefficients were 0.93, 0.92, and 0.92, respectively. Estimates of horizontal cup/disk ratio from sequential full-frame photographs and simultaneous split-frame photographs appeared comparable and equally reproducible. Gradings by technicians were comparable to gradings by glaucoma specialists. CONCLUSIONS: High reproducibility between repeated gradings of baseline horizontal cup/disk ratio was achieved by trained technicians adhering to a rigorous protocol. Horizontal cup/disk ratio measurements in OHTS are sufficiently reproducible to provide information about the relationship of cup/disk ratio to the prognosis of individuals with ocular hypertension.     

Scanning electron microscopy of conjunctival surfaces in patients with ocular cicatricial pemphigoid

The conjunctival surfaces of ten patients with active, ocular cicatricial pemphigoid, three patients with drug-controlled ocular cicatricial pemphigoid, and six patients with normal conjunctivas were studied using scanning electron microscopy. A homogeneous granular sheet of amorphous mucin-like material was observed covering extensive areas of the conjunctiva in eight of ten patients with active ocular cicatricial pemphigoid. This sheet of amorphous material was absent on drug-controlled ocular cicatricial pemphigoid and normal conjunctival specimens. Our study demonstrates that patients with active ocular cicatricial pemphigoid possess ocular surface mucus that appears thicker and more continuous than normal ocular mucus when observed with scanning electron microscopy. This observation is in agreement with clinical observations of thick mucus strands in the inferior fornix of patients with active ocular cicatricial pemphigoid.     

Detection of submicroscopic lymph node metastases in patients with melanoma.

A cell culture technique was developed to investigate submicroscopic lymph node metastases in patients with stage 1 or 2 malignant melanoma. Lymph nodes were isolated from standard dissections and bivalved. Half of the node was evaluated by routine histopathologic examination, while the other half was processed and placed into tissue culture. Three hundred twenty-three lymph nodes were collected from 41 patients. The cell culture technique identified 155 of 323 lymph nodes containing micrometastases, while only 20 of 323 lymph nodes tested positive with routine histochemical processing. Nine patients were upgraded from stage 1 or 2 to stage 3 disease after micrometastases were identified in lymph node cultures. Identification of melanoma was confirmed by cytologic examination, immunohistologic staining, and the presence of GD3 ganglioside and 250-kd glycoprotein melanoma-associated antigens. This study provides evidence that the culture of lymph nodes is a sensitive method for the detection of micrometastases. In addition, this procedure may change prognosis and identify candidates for adjuvant therapies.     

Scintigraphic patterns in osteoid osteoma and spondylolysis

A retrospective review was performed of radionuclide bone scans and radiographs of 54 children with diagnoses of spondylolysis or osteoid osteoma/osteoblastoma. The findings indicate that skeletal scintigraphy shows imaging patterns that can be used to help distinguish these two conditions. Most cases of spondylolysis and all cases of osteoid osteoma or osteoblastoma demonstrated focally increased activity on the delayed skeletal scintigrams. Evaluation of the bone scan images obtained during the immediate postinjection period revealed intense activity with osteoid osteoma and osteoblastoma, but minimal or no abnormal activity in cases of spondylolysis. In addition, spondylolysis was the only condition that produced bilateral abnormalities in the pars interarticularis region in these children.     

Priorities, "street level bureaucracy" and the community mental health team

In the United Kingdom a combination of high profile incidents and reports personally critical of mental health policy in general and individual practitioners' actions in particular (Sheppard 1995) highlight the pressures which operate on mental health professionals in the community (Mechanic 1995a). These pressures are exacerbated by policy contradictions and resource limitations. Consequently community mental health practitioners (e.g. psychiatrists, community psychiatric nurses and social workers) can be sensitive to political and managerial agendas which may have a negative impact on their implementation of individual care programs (Marks et al. 1994). Using the concept of ‘street level bureaucracy’ (Lipsky 1980), this paper examines recent literature. It is argued that practitioners' reception and implementation of policy is influenced by the need to balance the tension between four elements: the political and policy imperatives, the agenda of local management, the professional and peer cultures in which practitioners operate and the balance of perceived personal advantage. It is further postulated that managers and policy makers may have a vested interest in not scrutinizing practitioners' implementation of policy too vigorously as a way of deflecting responsibility for its consequences. The ‘Care Programme Approach’ and recent legislative changes regarding community supervision (Department of Health 1995a) highlight the important and sometimes negative consequences for the service user that may result.