On the genesis of heartburn

The primary function of the lower esophageal sphincter is to prevent reflux of acid gastric contents, and heartburn is the cardinal symptom of its failure. Standard meals of protein, carbohydrate, and fat have been shown to have significant effects on lower esophageal sphincter pressure. Most patients with heartburn relate their symptoms to certain foods, few of which contain pure protein, carbohydrate, or fat. We have studied the effects of some of these foods on the lower esophageal sphincter. Whole and nonfat milk were also studied because of their frequent use in heartburn therapy. Pressure in the lower esophageal sphincter was recorded continously in normal subjects using an infused open-tipped system. Test meals consisted of 240-cc quantities of water (control), whole milk, nonfat milk, orange juice, a mixture of tomato paste and water, and dilutions of chocolate syrup. Slight, but significant (P<0.05) decreases in lower esophageal sphincter pressure occurred after whole milk ingestion. By contrast, nonfat milk produced significant (P<0.05) increases in pressure. Orange juice and tomato both caused only transient decreases in pressure with gradual return to the baseline and considerable pressure variation and secondary contractions. Chocolate syrup (1.2% fat) produced immediate and sustained decreases in sphincter pressure (P<0.005) associated with symptomatic reflux in some subjects.     

How accurate are faculty evaluations of clinical competence?

Objective:To determine the degree and sources of variability in faculty evaluations of residents for the American Board of Internal Medicine (ABIM) Clinical Evaluation Exercise (CEX). Design:Videotaped simulated CEX containing programmed resident strengths and weaknesses shown to faculty evaluators, with responses elicited using the openended form recommended by the ABIM followed by detailed questionnaires. Setting:University hospital. Participants:Thirty-two full-time faculty internists. Intervention:After the open-ended form was completed and collected, faculty members rated the resident’s performance on a five-point scale and rated the importance of various aspects of the history and physical examination for the patient shown. Measurements and Main Results:Very few of the resident’s strengths and weaknesses were mentioned on the openended form, although responses to specific questions revealed that faculty members actually had observed many errors and some strengths that they had failed to document. Faculty members also displayed wide variance in the global assessment of the resident: 50% rated him marginal, 25% failed him, and 25% rated him satisfactory. Only for performance areas not directly related to the patient’s problems could substantial variability be explained by disagreement on standards. Conclusions:Faculty internists vary markedly in their observations of a resident and document little. To be useful for resident feedback and evaluation, exercises such as the CEX may need to use more specific and detailed forms to document strengths and weaknesses, and faculty evaluators probably need to be trained as observers. Received from the Fellowship Program in General Internal Medicine, Departments of Medicine, Walter Reed Army Medical Center, Washington, D.C., and the Uniformed Services University of the Health Sciences, Bethesda, Maryland. Presented at the Tenth Annual Meeting of the Society of General Internal Medicine, April 30, 1987, San Diego, California. Supported in part by the Department of Clinical Investigation, Walter Reed Army Medical Center. The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense.     

A 23187-stimulated calcium uptake and GABA release by cerebrocortical synaptosomes: effects of high pressure

Summary Guinea pig cerebrocortical synaptosome preparations were used to study the effect of compression to 62 ATA on⁴⁵Ca²⁺ uptake and [³H]GABA release using a calcium ionophore A23187, which bypasses the voltage-sensitive calcium channel. Pressure was found to exert a suppressive effect on the A 23187-induced release of [³H]GABA, while having no significant effect on A 23187-stimulated⁴⁵Ca²⁺ uptake. On the other hand, both depolarization-induced⁴⁵Ca²⁺ uptake and [³H]GABA release were inhibited by pressure exposure. These results suggest that pressure may suppress GABA release by affecting pre-synaptic events subsequent to calcium influx.     

Evaluation of the scalene lymph nodes in primary and recurrent cervical carcinoma

Open biopsy of the left scalene lymph nodes has been utilized to identify distant spread of cervical carcinoma in selected groups of patients who do not have other clinical evidence of disseminated disease. Twenty-one patients with primary cervical carcinoma and histologically proven para-aortic lymph node metastases and 10 patients with centrally recurrent tumors underwent scalene lymph node biopsy at Walter Reed Army Medical Center or the Naval Hospital, Bethesda, Maryland, between July 1, 1979 and June 30, 1985. All patients undergoing scalene node biopsy had clinically negative physical examinations. There were no surgical complications. All 31 biopsies were negative for metastatic tumor. Combined with previously reported data from this institution, 3 of 28 patients (11%) with primary cervical carcinoma and involved para-aortic nodes, and 6 of 35 patients (17%) with centrally recurrent disease had subclinical scalene node metastases. Patients with clinically suspicious scalene lymphadenopathy had fine needle aspiration cytology performed to document metastatic disease. The success of this technique has eliminated the need for open biopsy in these patients. Scalene node biopsy provides valuable prognostic information in patients with cervical cancer who have positive para-aortic lymph nodes. It also obviates surgical exploration in some patients felt to have resectable recurrent disease who actually have subclinical distant spread.