When, what and how South Australian pre-registration junior medical officers' career choices are made

OBJECTIVES: This study aimed to provide better understanding of how pre-registration junior medical officers (PJMOs) make their career choices by investigating when decisions are made, what factors impact on choices, and the role of experience in this process. METHODS: A third (n = 54) of PJMOs from the 2003 cohort at South Australian teaching hospitals participated in the current research. Inductive content analysis was used to discover themes in data gathered from semistructured interviews. RESULTS: Interviews revealed that although 26% (14/54) of participants had made their career decisions in their pre-registration year, 50% (27/54) had still to decide on a career choice. The factors identified as impacting on career choice were grouped into 5 main categories: job satisfaction; lifestyle; career path; training programme, and the wider environment. Depending on the demographic profile of the PJMO, different relative importance was assigned to these factors. The most important elements used to confirm or disconfirm PJMOs' potential career choices were the experiences they had of different specialty areas. DISCUSSION: This study allowed an in-depth exploration of the factors that affect the decision-making process of PJMOs. It also found that defined groups of PJMOs place different degrees of importance on these factors, which may have implications for medical workforce planning. It is clear that experience and role models are a crucial component of the career decision-making process. This has importance for specialties that are not incorporated into junior medical training.     

Medicare and cost-effectiveness analysis: time to ask the taxpayers

Maintaining Medicare's affordability for taxpayers and beneficiaries is becoming harder. Although cost containment strategies have been proposed, using cost-effectiveness analysis (CEA) to prioritize coverage decisions has not been among them. There is a widespread but largely untested perception that Americans are unwilling to accept limits in health care. We review existing evidence about the public's willingness to accept constraints and set health care priorities. We suggest that given the opportunity to weigh in on ethical and normative issues that surround CEA, members of the public are appropriate parties to engage in shaping Medicare's broadest resource allocation questions.     

Fecal Incontinence: Does Age Matter? Characteristics of Older <Emphasis Type="Italic">vs.</Emphasis> Younger Women Presenting for Treatment of Fecal Incontinence

Purpose The etiology of fecal incontinence is multifactorial. We hypothesize that women who seek treatment at different ages differ. We sought to determine which characteristics of women with fecal incontinence patients are associated with younger age at presentation. Methods We reviewed a database of 399 women with complete fecal incontinence evaluations from 2001 to 2006, selecting patients who were aged 49 and younger or aged 65 years and older, for a total of 246 patients. Data were obtained from self-report questionnaires on fecal incontinence frequency and associated symptoms, medical history, and results of anorectal physiology tests. Univariate and multivariate analyses were performed. Results The median ages of the two groups were 42 (range, 23–49) years and 72 (range, 65–89) years. Sphincter defects > 90 degrees and previous sphincteroplasty were associated with the younger age group. Previous hemorrhoid surgery and bilateral pudendal neuropathy were associated with the older age group. Younger women had more frequent incontinence to gas, mucus, and liquid stool. Conclusions In our cohort, fecal incontinence-related symptoms and medical conditions differed in older and younger women presenting with this condition. Younger women may be more likely to seek treatment for any degree of symptoms. The differing characteristics of fecal incontinence by age should be considered when developing a treatment strategy. Poster presentation at the meeting of The American Society of Colon and Rectal Surgeons, Seattle, Washington, June 3 to 7, 2006. Reprints are not available.     

A polarized multispectral imaging system for quantitative assessment of hypertrophic scars

Hypertrophic scars (HTS) are a pathologic reaction of the skin and soft tissue to burn or other traumatic injury. Scar tissue can cause patients serious functional and cosmetic issues. Scar management strategies, specifically scar assessment techniques, are vital to improve clinical outcome. To date, no entirely objective method for scar assessment has been embraced by the medical community. In this study, we introduce for the first time, a novel polarized multispectral imaging system combining out-of-plane Stokes polarimetry and Spatial Frequency Domain Imaging (SFDI). This imaging system enables us to assess the pathophysiology (hemoglobin, blood oxygenation, water, and melanin) and structural features (cellularity and roughness) of HTS. To apply the proposed technique in an in vivo experiment, dermal wounds were created in a porcine model and allowed to form into scars. The developed scars were then measured at various time points using the imaging system. Results showed a good agreement with clinical Vancouver Scar Scale assessment and histological examinations.OCIS codes: (110.0110) Imaging systems, (110.4234) Multispectral and hyperspectral imaging     

Platelet inhibition by aspirin 81 and 325 mg/day in men versus women without clinically apparent cardiovascular disease

Compared with men, women have greater platelet aggregation before and after low-dose aspirin. It is not known whether high-dose aspirin therapy brings residual platelet aggregation in women closer to that in men. Our objective was to compare inhibition of platelet aggregation in women and men after low- and high-dose aspirin. We enrolled healthy subjects (n=106) in a trial of 14 days of aspirin 81 mg/day followed by 14 days of 325 mg/day. Platelet function was measured at baseline and after the 2 aspirin doses. Women had greater baseline platelet activation measurements. After the 2 aspirin doses, men and women had near complete suppression of platelet aggregation to arachidonic acid in whole blood and in platelet-rich plasma (PRP), the direct cyclo-oxygenase-1 pathway affected by aspirin. For indirect pathways, women had significantly greater residual platelet activation to collagen and adenosine diphosphate (ADP) in whole blood after the 2 aspirin doses and in response to collagen and ADP in PRP after aspirin 325 mg/day only. After aspirin 325 mg/day, women continued to have greater residual platelet aggregation compared with men after aspirin 81 mg/day in response to collagen (p=0.016 in whole blood, p=0.037 in PRP), ADP (p<0.001 in whole blood, p=0.012 in PRP), and epinephrine (p=0.03 in PRP). Excretion of urinary thromboxane metabolite (urinary 11-dehydrothromboxane B2) decreased after aspirin to a similar extent in men and women. In conclusion, women continue to have greater residual platelet activity after high-dose aspirin compared with men treated with a lower dose of aspirin.     

Phospholipase C epsilon modulates beta-adrenergic receptor-dependent cardiac contraction and inhibits cardiac hypertrophy

Phospholipase C (PLC) epsilon is a recently identified enzyme regulated by a wide range of molecules including Ras family small GTPases, Rho A, Galpha(12/13), and Gbetagamma with primary sites of expression in the heart and lung. In a screen for human signal transduction genes altered during heart failure, we found that PLCepsilon mRNA is upregulated. Two murine models of cardiac hypertrophy confirmed upregulation of PLCepsilon protein expression or PLCepsilon RNA. To identify a role for PLCepsilon in cardiac function and pathology, a PLCepsilon-deficient mouse strain was created. Echocardiography indicated PLCepsilon(-/-) mice had decreased cardiac function, and direct measurements of left ventricular contraction demonstrated that PLCepsilon(-/-) mice had a decreased contractile response to acute isoproterenol administration. Cardiac myocytes isolated from PLCepsilon(-/-) mice had decreased beta-adrenergic receptor (betaAR)-dependent increases in Ca2+ transient amplitudes, likely accounting for the contractile deficiency in vivo. This defect appears to be independent from the ability of the betaAR system to produce cAMP and regulation of sarcoplasmic reticulum Ca2+ pool size. To address the significance of these functional deficits to cardiac pathology, PLCepsilon(-/-) mice were subjected to a chronic isoproterenol model of hypertrophic stress. PLCepsilon(-/-) mice were more susceptible than wild-type littermates to development of hypertrophy than wild-type littermates. Together, these data suggest a novel PLC-dependent component of betaAR signaling in cardiac myocytes responsible for maintenance of maximal contractile reserve and loss of PLCepsilon signaling sensitizes the heart to development of hypertrophy in response to chronic cardiac stress.     

A Blueprint of Pain Curriculum Across Prelicensure Health Sciences Programs: One NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) Experience

To improve U.S. pain education and promote interinstitutional and interprofessional collaborations, the National Institutes of Health Pain Consortium has funded 12 sites to develop Centers of Excellence in Pain Education (CoEPEs). Each site was given the tasks of development, evaluation, integration, and promotion of pain management curriculum resources, including case studies that will be shared nationally. Collaborations among schools of medicine, dentistry, nursing, pharmacy, and others were encouraged. The John D. Loeser CoEPE is unique in that it represents extensive regionalization of health science education, in this case in the region covering the states of Washington, Wyoming, Alaska, Montana, and Idaho. This paper describes a blueprint of pain content and teaching methods across the University of Washington’s 6 health sciences schools and provides recommendations for improvement in pain education at the prelicensure level. The Schools of Dentistry and Physician Assistant provide the highest percentage of total required curriculum hours devoted to pain compared with the Schools of Medicine, Nursing, Pharmacy, and Social Work. The findings confirm the paucity of pain content in health sciences curricula, missing International Association for the Study of Pain curriculum topics, and limited use of innovative teaching methods such as problem-based and team-based learning.     

Pharyngonasal reflux: spectrum and significance in early childhood

The radiographic and clinical findings of 57 infants and children demonstrating pharyngonasal reflux during barium swallow were reviewed. Pharyngonasal reflux is most frequent in the first 3 months of life and may occur in children with apneic episodes. Clinical symptoms in this group of children generally clear, even when reflux is severe. Pharyngonasal reflux may be associated with prematurity, neuromuscular disease, velopharyngeal incoordination, and other conditions but is usually of no consequence in very young infants.