Factors associated with career longevity in residency-trained emergency physicians.

STUDY OBJECTIVE: To test the hypothesis that residency-trained emergency physicians who left the practice of emergency medicine do not differ significantly from those who continue to practice. DESIGN: A retrospective cohort study using a mailed questionnaire. TYPE OF PARTICIPANTS: Eight hundred fifty-eight emergency medicine residency graduates from 1978 through 1982. METHODS: A mailed questionnaire was used to obtain data from the study population. Individuals who did not respond to the first mailing were sent a second survey six weeks later. A sample of 10% of nonrespondents was contacted by telephone and compared with respondents on five variables. Respondents were divided into physicians who continued to practice emergency medicine and those who had elected to leave the specialty. The variables used to compare the two groups included personal and professional demographics, career satisfaction, and satisfaction with training. chi 2, Fisher's exact t-test, and logistic regression were used to analyze the data with an a priori level of significance set at .05. MEASUREMENTS AND MAIN RESULTS: There were 539 complete responses for a response rate of 62.8%. No statistical differences between responders and nonresponders were identified. The ten-year survival rate of respondents was 84.9%. Those who left emergency medicine were less likely to be board certified in emergency medicine (P less than .001), were more likely to be board certified in another field (P = .001), were less likely to work with residents during their emergency medicine practice (P = .009), and were more likely to report an annual gross income of less than $100,000 per year (P less than .001). Emergency physicians who have left the field were less likely to report being satisfied or very satisfied with their initial choice of emergency medicine as a specialty (P = .001). There was no difference in satisfaction with the quality of emergency medicine residency training (P = .183). CONCLUSION: Career longevity of residency-trained emergency physicians has been greater than early predictions. Interactions with residents, higher income, satisfaction with training decision, and board certification in emergency medicine are variables associated with a higher retention rate.     

Effect of atrioventricular synchrony on stroke volume during ventricular tachycardia in man.

The hemodynamic consequences of atrioventricular (AV) synchrony during ventricular tachycardia were evaluated during cardiac electrophysiologic testing. The relationship between stroke volume and the AV interval was investigated on a beat-by-beat basis in six patients during induced monomorphic ventricular tachycardia. Stroke volume was calculated either (1) in the right ventricle using impedance catheter method (four patients) or (2) in the left ventricle using Doppler measurement of aortic blood velocity (two patients). The impedance catheter method underestimated stroke volume by a factor of 4.2 +/- 2.4 compared with the thermodilution cardiac output method. However, there was a highly linear relationship between both methods for computing stroke volume (r greater than 0.9). Five patients had complete AV dissociation during ventricular tachycardia, and different AV intervals spanned the entire tachycardia cycle lengths. Largest stroke volumes were associated with optimal AV intervals within 120 and 230 msec, resulting in a 97 +/- 59% increase in stroke volume over ventricular tachycardia cycles not associated with atrial activity. Customized atrial pacing during ventricular tachycardia may provide a valuable means for artificially establishing the hemodynamically optimal AV interval and eliminating the ventricular tachycardia cycles not preceded by atrial activity.     

Expression of major histocompatibility complex class I antigens as a strategy for the potentiation of immune recognition of tumor cells.

Like many primary tumors, human adenovirus type 12 (Ad12)-transformed mouse cells express greatly reduced levels of the major histocompatibility complex (MHC) class I antigens and are highly tumorigenic in immunocompetent hosts. Expression of a transfected class I gene by these cells can abrogate their tumorigenicity. Both the K and the L class I genes can suppress the malignant phenotype. Previous studies showed that interferon can induce class I gene expression in certain Ad12-transformed cells and can suppress their tumorigenic phenotype. We now demonstrate that preimmunization of mice with a nontumorigenic dose of interferon-treated Ad12-transformed tumor cells can afford protection against a subsequent challenge by a tumorigenic dose of untreated Ad12-transformed tumor cells. Similar immunity can also be induced by using cells transfected with the K gene, and the observed protection appears specific to Ad12-transformed cells. Significant protection can be achieved even if immunization is provided subsequent to the tumor challenge. Since increasing numbers of human tumors have been found to have reduced levels of MHC class I antigens, the prospect of therapy by immunization with the parental tumor cells that have been manipulated to induce class I gene expression offers an attractive experimental model.     

Transduction of a bacterial gene into mammalian cells.

The transduction of an Escherichia coli gene into mammalian cells is described. A supressor tRNA gene was linked to a simian virus 40 (SV40) vector in vitro and the recombinant was used to transfect rat embryo cells and monkey kidney cells. The hybrid SV40 genome, SV40-su+ III, retained genetic information required for autonomous replication and cellular transformation and had a 1300-base-pair DNA segment in the late gene region (between the restriction endonuclease sits Hpa II at 0.735 and EcoRI at 0/1.0 on the SV40 genetic map) replaced by an 870-base-pair bacterial DNA segment containing the suppressor tRNA gene, su+ III (tRNATyrsu+III). The structure and fate of the SV40-su+III chimera were determined by DNA reassociation kinetic analysis and restriction enzyme cleavage of the total cellular DNA from transformed rat embryo cells and persistently infected monkey cells. Hybridization with radiolabeled probes specific for vector (SV40) or su+III DNA sequences revealed primarily nonintegrated or free hybrid genomes. In cloned lines of both cell types, the bacterial DNA segment was recovered intact, as judged by the length of the segment excised by restriction endonucleases and its ability to hybridize to the radiolabeled bacterial DNA probe and not to the SV40 probe.     

Familial antiphospholipid antibodies and acquired circulating anticoagulants

Familial clustering of elevated antiphospholipid antibody levels has been described, but the reports are heterogeneous with regard to the characterization of the antiphospholipid syndrome (APS), coexisting autoimmune diseases and clinical implications. We report a familial occurrence of APS in two patients, in the presence of SLE in the mother and absence of autoimmune diseases in the daughter along with acquired circulating inhibitors in both cases: platelet inhibitor and factor IX inhibitor, respectively.     

Prediction of coronary artery disease in a population of insulin-requiring diabetic patients: results of an 8-year follow-up study

To identify predictors of clinical coronary artery disease, 110 insulin-requiring diabetic patients with no symptoms suggestive of cardiac disease and with a normal resting ECG underwent metabolic and noninvasive cardiovascular screening including a history and physical examination, exercise ECG, M-mode echocardiography, and chemical laboratory testing. During a median follow-up interval of 100 months, 14 of these patients had clinical evidence of coronary artery disease consisting of acute myocardial infarction, sudden cardiac death, or anginal chest pain with angiographic documentation of occlusive coronary artery disease. Baseline variables that were univariately predictive of subsequent clinical coronary disease included age, peak treadmill heart rate, and retinal neovascularization. According to multivariate analysis the peak treadmill heart rate was the single most important predictor of subsequent development of clinical coronary disease. A treadmill ECG result that was either abnormal or inconclusive because of failure to achieve 90% of predicted maximal heart rate identified each patient in whom clinical coronary artery disease developed within 50 months after entry testing. Thus the entry treadmill ECG provided prognostic information not available from the history and physical examination results, but little further prognostic information was provided after the first 50 months of follow-up, suggesting the need for serial testing.     

Outcome of delayed primary internal fixation of distal radius fractures: A comparative study

Introduction and aim

Operative fixation of distal radius fractures using fixed-angle devices has become increasingly common. Although good to excellent results have been reported in acute fractures, little is currently known regarding the fixation of healing displaced distal radius fractures that were presented late. The aim of this study was to evaluate the results of internal fixation of distal radius fractures presented late (>21 days) as compared with an acute-care control group.

Methods

Forty patients operated on for displaced distal radius fractures, presenting more than 21 days after injury (delayed treatment (DT) group), were compared with 75 age-matched controls with acute fracture repair (≤21 days). The same surgical approach was used in both groups, together with dorsal soft-tissue and brachioradialis release. No osteotomy was required. Direct and indirect reduction aids were used. A fixed-angle device (DVR; Biomet Inc., Warsaw, IN, USA) was used in both groups. Mean follow-up was 3.4 years. Quick DASH (Disabilities of the Arm, Shoulder and Hand) and Short Form 12 scores were used to evaluate outcome, as well as radiographic analysis for Arbeitsgemeinschaft für Osteosynthesefragen(AO)/Orthopaedic Trauma Association(OTA) classification, volar tilt, radial inclination and radial length.

Results

Average age was 53 years in both groups and male to female (M/F) ratio was similar in the study groups. Mean time to surgery was 30 days in the DT group and 8 days in the control group. There were significantly more type C (91.5% vs. 67.5%) fractures in the control group. The average quick DASH score was 27.1 in the DT group as compared with 6.3 in the control group (p < 0.03); however, when controlling for two outlier cases with complications (hardware irritation and a sensory neuropathy) there was no significant difference. Volar tilt, radial inclination and length were similar in both groups and were within normal anatomical values.

Conclusions

Delayed primary operative fixation of displaced unstable distal radial fractures is a viable option for cases that were presented late, with predictable, favourable results. Neither extensile approaches nor formal osteotomies are required.