Clerkship directors' perceptions of the impact of HCFA documentation guidelines.

PURPOSE: Chart notes are used to support billing codes under the evaluation and management guidelines of the Health Care Financing Administration (HCFA), in addition to serving as a record of the visit. To better understand the effect of the HCFA documentation guidelines, the authors collected data on how the guidelines affect participation by university- and community-based faculty in clinical education programs. METHOD: In 2000, the authors sent six copies of their questionnaire to the associate deans of the 125 U.S. medical schools and requested they distribute them to all core clerkship directors. The questionnaire consisted of multiple-choice and short-answer questions regarding documentation of medical visits, participation of community-based faculty, understanding of HCFA documentation guidelines, and effects on education programs. RESULTS: The response rate was about 50%. Most of the 379 clerkship directors who responded (77%) stated they were aware the HCFA documentation guidelines include specifications regarding the role medical students can play and documentation of medical visits, and 64% indicated they were concerned the guidelines would affect their educational programs. Concerns included the loss of student independence and active participation in the patient care environment (37), time constraints and the changing balance between education and service (16), loss of faculty and decreased morale (11), and decreased quality of care for patients (7). CONCLUSION: Leaders of medical education must work to modify these guidelines to protect the quality of patients' care, while maximizing students' educational opportunity and participation.     

Implantation response following clinical heart-lung transplantation

Implantation response has been a critical problem following heart-lung and lung transplantation. While the precise etiology of this problem remains unclear, improvements in organ preservation would be expected to have a beneficial effect on implantation response. The time-related profile of the implantation response was studied in 20 patients who underwent heart-lung transplantation between March 1984-March 1987. In 10 operations the donors had intravenous prostaglandin E-1 pretreatment while 10 had no vasodilatation before explantation of the organs. Otherwise lung preservation and early (2 weeks) immunotherapy were similar in both groups. The implantation response was evaluated by chest films and postoperative lung functions and mechanics. Roentgenographic implantation response was evident from the first postoperative day, was less evident at the seventh postoperative day and then gradually increased during the second postoperative week. There was a tendency towards less implantation response in the PGE-1 group than in the control group, but no statistical difference was observed. Patients with severe operative bleeding problems were excluded from the study. Only peak inspiratory pressures were significantly higher in the control group than in the PGE-1 group (p less than 0.01). Other lung function studies (alveolar-capillary pO2 difference, extubation time) were not different in the groups. This study supported the hypothesis that prostaglandin E-1 may have salutary effects on graft preservation and implantation response in heart-lung transplantation. Since 1986, we have performed 16 heart-lung transplantations using graft preservation with PGE-1 and flush perfusion. Thirty-day mortality is 0% and 13 of 16 patients are surviving.     

Recurrent carotid stenosis. Incidence and management

The actual incidence of recurrent carotid occlusive disease is not known. From January 1974 through December 1984, fifty-four patients underwent at least one second carotid endarterectomy or reconstructive procedure at St. Thomas Hospital in Nashville. Five patients required a third carotid operation. This retrospective study examines case reports, risk factors, patient presentation, interval of recurrence, and pathology involved. Surgical techniques and results are described. Complications occurred in six patients undergoing a total of 66 operations for an overall incidence of 9 per cent. Thrombosis was minimized by the use of antiplatelet drugs. Follow-up of patients ranged from one to 84 months. Four main causes for restenosis are discussed.     

Prelinguistic predictors of language outcome at 3 years of age.

PURPOSE: The purpose of this study was to examine the predictive validity of a collection of prelinguistic skills measured longitudinally in the 2nd year of life to language outcome in the 3rd year in children with typical language development. METHOD: A collection of prelinguistic skills was assessed in 160 children early (M = 14.31 months; SD = 1.36) and late (M = 19.76 months; SD = 1.16) in their 2nd year by using the Communication and Symbolic Behavior Scales Developmental Profile Behavior Sample (A. Wetherby & B. Prizant, 2002). The relation between the prelinguistic skills and the receptive and expressive language near the 3rd birthday was examined. RESULTS: Significant correlations were observed between many prelinguistic skills and language outcome. Regression analyses indicated that comprehension both early and late contributed unique variance to receptive and expressive language outcome. In addition, early in the 2nd year, inventory of conventional gestures contributed uniquely to receptive language outcome, and acts for joint attention contributed uniquely to expressive outcome. Late in the 2nd year, inventory of consonants contributed uniquely to expressive outcome. CONCLUSIONS: The findings demonstrate continuity between prelinguistic and linguistic skills and how individual differences in a number of prelinguistic skills contribute collectively and uniquely to language outcome in typically developing children.     

Ensuring data quality in a multicenter clinical trial: remote site data entry, central coordination and feedback

In an ongoing multicenter clinical trial, "Treatment Strategies in Schizophrenia," the five participating sites have the capacity to perform a variety of tasks or study functions independently. These tasks include (a) verification of diagnostic eligibility through the use of computerized decision algorithms; (b) assignment of patients to treatment based on prognostic indicators using a computerized randomization algorithm; (c) entry of data into a microcomputer using a clinical trial data management system that performs simple range and missing data item checks; and (d) regular transfer of all data to the central coordinating team. The clinical trial data management system employed allows for both independent site functioning and assurance of consistency across sites. The integration of a variety of software outside the main data management system provides the central coordinators with the tools to monitor critical data as it is collected, as well as the capacity to assess the flow, quality, and uniformity of the ongoing trial.     

Different modulation by histamine of IL-4 and interferon-gamma (IFN-γ) release according to the phenotype of human Th0, Th1 and Th2 clones

Histamine, an important inflammatory mediator in allergic diseases and asthma, has been reported to have modulator effects on T cells, suggesting that the bronchial microenvironment may regulate the function of resident T cells. We examined the effect of histamine on the release of the Th2-associated cytokines IL-4 and IL-5 and the Th1-associated cytokine IFN-γ by 30 CD4⁺ T cell clones from peripheral blood or bronchial biopsy of one atopic subject. Based on the IL-4/IFN-γ ratio, the clones were ascribed to the Th2 (ratio >1), Th0 (ratio 0.1 and 1) or Th1 (ratio <0.1) phenotype. Histamine inhibited IFN-γ production by Th1-like cells (P<0.02, Kruskall–Wallis), especially from bronchial biopsy, but had no effect on IL-4 release. Regarding Th0 clones, histamine inhibited IL-4 production (P<0.02) in a dose-dependent manner and slightly inhibited IFN-γ production, but had no effect on Th2-like cells. Histamine had a heterogeneous and insignificant effect on IL-5 production. The H₂-receptor antagonist ranitidine completely reversed the inhibition of IL-4 and IFN-γ production, whereas the agonist dimaprit mimicked this effect. In contrast, H₁- and H₃-receptor agonists and antagonists had no significant effect. These data demonstrate that histamine has different effects on IL-4 and IFN-γ release by T helper cells according to their phenotype via H₂-receptors. This study extends the immunomodulatory effects of histamine which may contribute to the perpetuation of airway inflammation in asthma.     

The role of size, sequence and haplotype in the stability of FRAXA and FRAXE alleles during transmission

Factors involved in the stability of trinucleotide repeats during transmission were studied in 139 families in which a full mutation, premutation or intermediate allele at either FRAXA or FRAXE was segregating. The transmission of alleles at FRAXA, FRAXE and four microsatellite loci were recorded for all individuals. Instability within the minimal and common ranges (0-40 repeats for FRAXA, 0-30 repeats for FRAXE) was extremely rare; only one example was observed, an increased in size at FRAXA from 29 to 39 repeats. Four FRAXA and three FRAXE alleles in the intermediate range (41-60) repeats for FRAXA, 31-60 for FRAXE) were unstably transmitted. Instability was more frequent for FRAXA intermediate alleles that had a tract of pure CGG greater than 37 although instability only occurred in two of 13 such transmissions: the changes observed were limited to only one or two repeats. Premutation FRAXA alleles over 100 repeats expanded to a full mutation during female transmission in 100% of cases, in agreement with other published series. There was no clear correlation between haplotype and probability of expansion of FRAXA premutations. Instability at FRAXA or FRAXE was more often observed in conjunction with a second instability at an independent locus suggesting genomic instability as a possible mechanism by which at least some FRAXA and FRAXE mutations arise.      

Primary cardiac neoplasms. Early and late results of surgical treatment in 42 patients

Forty-two patients underwent resection of primary cardiac neoplasms at Stanford University Medical Center and the Palo Alto Veterans Administration Medical Center between 1961 and 1986. A total of 27 atrial myxomas, seven benign nonmyxomatous tumors, and eight malignant tumors were resected. The mean age was 47 years (range 8 to 79) in 27 female and 15 male patients. The clinical presentations included congestive heart failure in 24 patients, palpitations in nine, neurologic symptoms in six, recurrent cardiac tamponade in three, vasculitis in two, and chest pain in two. Thirty-one of 34 benign lesions were completely resected, although one patient required cardiac transplantation to resect completely an "inoperable" benign tumor. All gross tumor was resected in four of eight patients with malignant lesions. All patients survived operation, but three with malignant disease died within 30 days. Late outcome was known for 41 of 42 (98%) patients. Total follow-up for the series was 200.1 patient-years, for an average of 4.7 years (range 1 month to 18 years). Excellent early and late results were obtained in patients with benign lesions, as there was no known tumor recurrence even if resection was incomplete. Effective palliation and local control of disease is possible with extensive resection of malignant primary tumors, but more effective adjuvant therapy will be necessary to improve long-term prognosis.     

Prostaglandins and cell-mediated immunity. The role of prostaglandin E1 in the induction of host-versus-graft and graft-versus-host reactions in mice

Based on studies in lymphocyte cultures it has been suggested that endogenous prostaglandins (PG), especially those of the E series (PGE), suppress cell-mediated immune reactions during their induction phase. We have tested this theory in experimental animals using local host-versus-graft (HVG) and graft-versus-host (GVH) reactions in mice. These reactions were suppressed in a dose-dependent manner by treatment of the animals with PGE1. If, however, endogenous PGE was neutralized through treatment of the animals with immune sera directed against PGE (APSE1) then inhibition of the development of HVG and GVH reactions was seen. This inhibition could be abrogated in "add back" experiments by treatment of the animals with PGE1. We suggest that the action of PGE1 during the induction phase of CMI responses is governed by a bell-shaped dose-response curve with a response-enhancing effect at low PGE1 and a suppressive effect at high PGE1 concentrations. APSE1 has proved to be very effective in inhibiting responses, and thus treatment with anti-PG antibodies may not only represent a valuable tool for the study of the role of PG in immunoregulation, but may become useful in therapeutic interventions with the immune system--e.g., after bone marrow transplantation.