The chief medical residency in Canada: comparison of opinions between physicians-in-chief and chief medical residents.

We conducted a survey of physicians-in-chief (PCs) and chief medical residents (CMRs) in training programs throughout Canada to determine their attitudes toward the need for and role of CMRs in Canada and to rate the importance of CMR duties and attributes. Forty-three hospitals with 5 to 126 house staff in all eight provinces with medical schools were surveyed; 36 PCs (84%) and 29 CMRs (67%) returned a completed questionnaire. Compared with the CMRs the PCs preferred more prior training (p less than 0.03), estimated as significantly less the time spent by CMRs in required duties (p less than 0.05) and rated as more important the responsibilities of faculty-house staff liaison, house staff leader, house staff role model and teaching house staff (p less than 0.05) and the attributes of clinical judgement, medical knowledge, clinician model and research interests (p less than 0.03). All of the PCs and 97% of the CMRs rated the position as somewhat to very necessary; 83% of the PCs and 66% of the CMRs would not alter the present CMR roles. A total of 92% of the PCs felt that the position was very or somewhat advantageous with respect to a future private practice, compared with 67% of the CMRs (p less than 0.02). Increased administrative and committee duties, decreased teaching and future reductions in house staff were identified as major but reversible threats to the unique quality of the CMR position. We conclude that the CMR has a necessary, important and highly regarded role in Canadian university hospitals that could possibly be improved by regular review by the PC and CMR at each hospital to avoid the identified problems.     

Total anorectal reconstruction with a double dynamic graciloplasty after abdominoperineal reconstruction for low rectal cancer

PURPOSE: Total anorectal reconstruction with a double dynamic graciloplasty was performed after abdominoperineal reconstruction (APR) for low rectal cancer. In four patients an additional pouch was constructed to improve neorectal motility and capacity. The aim of this study was to evaluate the results in the first 20 patients and to report on the preliminary results of patients with an additional pouch. METHODS: Twenty patients with a mean age of 52 (range, 25–71) years and a rectal tumor at a mean of 3 (range, 0–5) cm from the anal verge were treated. In 14 patients the Miles resection, colon pull-through, and construction of a neosphincter were performed in one session. Six patients had the double graciloplasty at an average of 4.1 (range, 1.1–8.8) years after APR. In four patients a pouch was constructed with an isolated segment of distal ileum. RESULTS: After a mean follow-up of 24 (range, 1–60) months after APR, none of the patients developed local recurrence, whereas four patients developed distant metastasis. Fifteen of 20 patients were available for evaluation, and 5 patients were still in training. Of these 15 patients, 8 patients were continent (53 percent), 2 patients were incontinent, and in 5 patients the perineal stoma was converted to an abdominal stoma. Failures were attributable to necrosis of the colon stump (n=2) and incontinence (n=3). At 26 weeks mean resting pressure was 44 (standard deviation (SD), 28) mmHg, and mean pressure during stimulation was 90 (SD, 46) mmHg at a mean of 35 (SD, 1.2) volts at 52 weeks. Mean defecation frequency was three times per day (range, 1–5). Of the eight patients who were continent, six used daily enemas. Mean time to postpone defecation was 11 (range, 0–30) minutes. CONCLUSION: In experienced hands, the double dynamic graciloplasty is an oncologically safe procedure that can have an acceptable functional outcome in a well-selected group of patients. However, to improve the outcome, further modifications will be necessary. So far, the addition of a pouch has not resulted in improved outcome. Supported by the Profileringsfonds of the Maastricht University Hospital, The Netherlands, and by the Stichting Fondsenwervingsactie Volksgezondheid, Amsterdam, The Netherlands. Read in part at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 9 to 14, 1995.     

Heterogeneous proteolytic specificity and activity of the house dust mite proteinase allergen Der p I

Background Exposure of the skin or respiratory tract to proteinases is frequently associated with allergic sensitization. This is of particular significance in the domestic indoor environment where the proteolytic activity of Der p I, the group I allergen of the house dust mite Dermatophagoides pteronyssinus, may influence the allergenicity of mites. Using class-specific proteinase inhibitors and active-site affinity chromatography, we have previously shown that Der p I exhibits a mixed cysteine-serine proteinase activity. Measurement of the amount of cleavage, however, did not determine whether the inhibitors used were targeting exactly the same proteolytic mechanism. Objective To resolve this issue, we have examined whether the cleavage specificity of the cysteine and serine proteinase activities of Der p I was the same. Methods HPLC and mass spectrometry were used to analyse and identify the products of a Der p I-digested peptide substrate and thus identify the peptide bonds cleaved. Results Der p I cleaves different peptide bonds, depending upon the class of proteolytic mechanism used. In the model peptide substrate insulin B chain, the cysteine and serine proteinase activities of Der p I showed preference for glutamic acid and arginine respectively in the P1 position. Conclusion These data suggest the existence of more than one mechanistic form of the allergen immunologically identified as Der p I. If proteolytic activity is indeed a function of allergenicity, this information may have important implications for the pathogenicity of Der p I and the ability of innate antiproteinase defences in the respiratory tract to prevent immune sensitization.     

Identification of 12 novel mutations in the CFTR gene

Over 200 mutations, besides the deletion     

Successful treatment of concomitant pulmonary Nocardiosis and aspergillosis in an immunocompromised renal patient

A case is reported of rapid onset concomitant pulmonary infection withNocardia andAspergillus fumigatus in a patient six weeks after the institution of immunosuppressive therapy for renal vasculitis. Pulmonary lesions completely resolved on treatment with a combination of imipenem, cotrimoxazole and a prolonged course of itraconazole.     

Structural and geometrical isomers of carotenoids in human plasma

We have quantitatively analyzed human plasma for the following carotenoids: all-trans-lutein, all-trans-zeaxanthin, alpha-cryptoxanthin, beta-cryptoxanthin, the sum of all-trans-lycopene and its cis isomers, alpha-carotene and beta-carotene. In addition, we have tentatively identified and quantified 13-cis-lutein and 13-cis-zeaxanthin in human plasma. The latter two cis isomers are also apparent in samples of two common food items, spinach and corn meal. We have analyzed the ratios of all of the members of the beta, beta family of carotenoids (zeaxanthin, beta-cryptoxanthin and beta-carotene) to their corresponding beta, epsilon structural isomers (lutein, alpha-cryptoxanthin and alpha-carotene) in human plasma. There are marked differences in these ratios, with beta-carotene and beta-cryptoxanthin predominating in the carotene and monohydroxy-xanthophyll classes and lutein predominating in the dihydroxy-xanthophyll class. These differences could be attributable to dietary intake or to specific mechanisms in the way humans absorb and utilize these compounds.     

Stimulation of energy intake and growth by saccharin in rats

Rats fed wet diets containing saccharin consumed 12-14% more energy and gained 24-55% more weight than rats fed the same diets without saccharin. Saccharin-induced stimulation of intake was usually not so pronounced during the first week as during subsequent weeks of each experiment. Similar results were obtained using diets high in starch and fat. However, these effects could be obliterated by simply exposing the rats to unsweetened (plain) diet or to saccharin in water for several days before the sweetened diets were introduced. Furthermore, although stimulation of intake by saccharin was observed with diets containing 80% water, no such effect was observed with a diet containing 60% water. Rats given low-energy sweetened water in addition to their 80% water diet consumed substantially more fluid but not more or less energy than rats given unsweetened water. Preference tests suggest that saccharin increases diet palatability only very slightly; this finding is one of several observations suggesting that stimulation of intake by saccharin cannot be interpreted in terms of increased diet palatability. These results suggest that dietary hyperphagia results from the interaction between innate and learned responses to the taste of foods. Osmotic factors did not seem to exert a major influence in these experiments.