Country living,city income for rural practitioners by implementing the Rural Health Clinics Act

Rural medical practices have historically faced lower reimbursement than their urban counterparts. The relatively little-known Rural Health Clinics Act of 1976 permits a higher level of payment from Medicare and Medicaid through cost-based reimbursement. This article discusses the specifics and requirements of the Act and how practices can qualify and implement the change to rural health clinic participation.     

A novel behavioral model that discriminates between 5-HT2A and 5-HT2C receptor activation

2,5-Dimethoxy-4-iodoamphetamine (DOI), a serotonin (5-HT)2A/2C receptor agonist, elicits shaking behaviors in rodents, which have been reliably quantified as behavioral correlates of 5-HT2A receptor activation. Such studies are lacking in the rabbit. As part of our research examining the role of the 5-HT2 receptor in rabbits, we analyzed the behavioral effects of systemically administered DOI in rabbits. DOI (0.01-3 micromol/kg) or vehicle was injected, and two distinct behaviors, head bobs (vertical head movements) and body shakes (wet dog shakes), were counted for 90 min following the injection. DOI dose-dependently increased the number of head bobs and body shakes. The selective 5-HT2A receptor antagonist ketanserin (1-3 micromol/kg), 1 h before DOI (0.3 micromol/kg) challenge, significantly attenuated head bobs, but not body shakes. In contrast, the selective 5-HT2C receptor antagonists SDZ SER 082 (1-3 micromol/kg) and SB 206553 (1 micromol/kg) 30 min before challenge, significantly reduced body shakes but not head bobs produced by the same dose of DOI. This study establishes that, in rabbits, DOI mediates head bobs via 5-HT2A receptors and body shakes via 5-HT2C receptors. Thus, the rabbit provides a novel behavioral assay that discriminates between 5-HT2A and 5-HT2C receptor activation.     

Disseminated and disfiguring molluscum contagiosum in a child

We report widely disseminated and disfiguring lesions of molluscum contagiosum occurring in a 4-year-old girl secondary to a primary immunodeficiency disorder. The child, born of consanguineous parents, had multiple, asymptomatic, raised, skin-colored and whitish lesions since 2 years of age. On physical examination she had growth retardation features with grade II protein energy malnutrition. Cutaneous examination revealed numerous, widespread, skin-colored to translucent, firm, umbilicated papules of varying sizes (pinpoint to larger than 10 mm). They were distributed bilaterally over all four limbs, including the dorsum of the hands and feet, trunk, face (including lips), eyelids, auriculae, and perineal and gluteal areas. In places, they were linearly disposed and had coalesced to form plaques. A biopsy specimen from a representative skin lesion (arm) demonstrated lobulated epidermal growth consisting of keratinocytes with large intracytoplasmic eosinophilic inclusion bodies and a central crater. These findings were consistent with the diagnosis of molluscum contagiosum. Topical therapies with phenol and trichloroacetic acid were ineffective The child succumbed to a fulminant systemic infection at home, 2 months after discharge from the hospital. The extent and distribution of molluscum contagiosum in our patient was remarkably vivid and has been hitherto reported only rarely.     

A survey of deans and ADEA activities on dental licensure issues

A written survey on issues in clinical testing for licensure was sent to the deans of all dental schools in the United States. Response rate was 89 percent. Results indicate that administrative leaders of the country's dental schools think that third-party evaluation of graduates is appropriate, but they do not have confidence in current clinical tests for licensure. More than nine out of ten respondents indicated that change was needed in current testing procedures, and 82 percent thought the tests as currently conducted were not valid for decision purposes. Regional differences existed among the responses, with the least dissatisfaction occurring in the West. The highest-rated and most frequently mentioned reasons for dissatisfaction with clinical tests were the involvement of patients (human subjects) as currently done. Most respondents favored a national level for licensure tests, although the majority also approved of the recently enacted New York law that permits completion of a postgraduate year in an accredited program to substitute for clinical testing. Respondents indicated a belief that a national database on academic measures as compared to outcomes on clinical licensure tests would be useful, with overall grade point average or class rank as the favored academic measure. Informed by the recommendations of its representatives to the AADE-ADEA Innovative Testing and Educational Methodologies Committee and results of the survey of deans, ADEA is pursuing steps to foster change in the clinical licensure process.     

Advantages of normothermic perfusion over cold storage in liver preservation

BACKGROUND: To minimize the ischemia-reperfusion injury that occurs to the liver with the current method of preservation and transplantation, we have used an extracorporeal circuit to preserve the liver with normothermic, oxygenated, sanguineous perfusion. In this study, we directly compared preservation by the standard method of simple cold storage in University of Wisconsin (UW) solution with preservation by perfusion. METHODS: Porcine livers were harvested from large white sows weighing between 30 and 50 kg by the standard procedure for human retrieval. The livers were preserved for 24 hr by either cold storage in UW solution (n=5) or by perfusion with oxygenated autologous blood at body temperature (n=5). The extracorporeal circuit used included a centrifugal pump, heat exchanger, and oxygenator. Both groups were then tested on the circuit for a 24 hr reperfusion phase, analyzing synthetic function, metabolic capacity, hemodynamics, markers of hepatocyte and reperfusion injury, and histology. RESULTS: Livers preserved with normothermic perfusion were significantly superior (P=0.05) to cold-stored livers in terms of bile production, factor V production, glucose metabolism, and galactose clearance. Cold-stored livers showed significantly higher levels of hepatocellular enzymes in the perfusate and were found to have significantly more damage by a blinded histological scoring system. CONCLUSIONS: Normothermic sanguineous oxygenated perfusion is a superior method of preservation compared with simple cold storage in UW solution. In addition, perfusion allows the possibility to assess viability of the graft before transplantation.     

Improving the quality of kidneys from non-heart-beating donors,using streptokinase: an animal model

BACKGROUND: Non-heart-beating donors (NHBD) offer a promising potential to increase the cadaveric organ donor pool, especially for kidneys. However, almost half of NHBD kidneys are discarded after viability assessment. This wastage is costly in both human and monetary terms. Intravascular thrombosis at the time of donor death is an event leading to failure in the viability assessment. We have developed an animal model to investigate the effects of the addition of streptokinase to the in situ flush medium before transplant in an attempt to redress the situation. METHODS: Two groups of eight healthy young Landrace Yorkshire white pigs were entered into the study. Both groups were subjected to approximately 70 min warm ischemia. Both groups received an intravascular flush with 4 L of Marshall's solution with heparin (1000 IU/L); one group of pigs also had streptokinase (1.5 MIU/L) added. After donor nephrectomy, all kidneys were machine perfused for 4 hr. Data on perfusion characteristics were taken and samples of kidney effluent were assayed for tissue damage biomarkers, glutathione S-transferase (GST) and alanine aminopeptidase (Ala-AP). Wedge sections of porcine kidneys were taken at the end of perfusion, for histological analysis. RESULTS: Data on machine perfusion parameters (temperature, mean pressure index, resistance) indicate better cooling, lower resistance, and lower mean pressure index in the streptokinase-treated group of pigs. GST and Ala-AP levels were increased in the nonstreptokinase group perfusates. Histopathological analysis of porcine kidneys indicated more ischemic injury and tissue damage in the nonstreptokinase group. CONCLUSION: The use of streptokinase in this porcine NHBD model conferred benefits to donor kidneys when assessed by machine perfusion. Markers of biochemical injury indicated that less renal tissue damage occurred with the incorporation of streptokinase in the in situ flush medium.     

Prolonged survival of patients receiving active immunotherapy with Canvaxin therapeutic polyvalent vaccine after complete resection of melanoma metastatic to regional lymph nodes

OBJECTIVE: To determine whether adjuvant postoperative active specific immunotherapy with a therapeutic polyvalent vaccine (PV) called Canvaxin can prolong survival following complete resection of melanoma metastatic to regional nodes (American Joint Committee on Cancer [AJCC] stage III melanoma). SUMMARY BACKGROUND DATA: Despite complete lymphadenectomy, 5-year overall survival (OS) for patients with melanoma metastatic to regional lymph nodes is only 20% to 50%, depending on the number of tumor-involved nodes. In 1984, the authors began phase II trials of Canvaxin PV as postsurgical adjuvant therapy for AJCC stage III melanoma. METHODS: Patients who received PV between 1984 and 1998 were compared with patients who did not receive PV postsurgical therapy between 1971 and 1998. The seven covariates recently defined by the AJCC Melanoma Staging Committee (number of metastatic nodes, palpable status, ulceration, age, primary site, pT stage, and gender) were included by Cox regression in a multivariate model of OS. A computerized program matched PV and non-PV patients by these covariates. RESULTS: Of 2,602 patients who underwent complete lymphadenectomy for AJCC stage III melanoma with regional nodal metastases and were followed up by the same team of oncologists between 1971 and 1998, 935 received PV and 1,667 did not. Median OS and 5-year OS were significantly higher in PV than non-PV patients (56.4 vs. 31.9 months and 49% vs. 37%, respectively; P =.0001). When the non-PV patients were matched by the four most significant covariates, 447 matched pairs were formed between patients seen before or after January 1, 1985, and the OS was not different between the two time periods ( P=.789). However, when the PV patients were matched with non-PV patients by six covariates forming 739 pairs, the PV patients survived longer ( P=.0001). Detailed analysis of the 1,505 patients who were seen or who began vaccine therapy within 4 months after lymphadenectomy, and who had more complete data on the seven prognostic covariates showed that median OS and 5-year OS were higher in 445 PV patients than in 1,060 non-PV patients: 70.4 versus 31 months and 52% versus 37%, respectively (P =.0001). Multivariate Cox regression analysis identified six significant prognostic factors: number of metastatic nodes, size of metastatic nodes, pT stage, ulceration, age, and PV therapy. PV therapy reduced the relative risk of death to 0.64 (95% confidence interval, 0.55-0.76) ( P=.0001); sex and site of primary were of borderline significance. CONCLUSIONS: This large single-institution study independently confirmed the significance of prognostic covariates in the new AJCC staging system. By using modern statistical methods that controlled for all known prognostic factors, it also demonstrated PV's ability to significantly enhance OS. A multicenter phase III randomized trial is underway to validate the efficacy of PV as a postsurgical adjuvant.