A review of journal clubs in postgraduate medical education.

OBJECTIVE: To review the goals, organization, and teaching methods of journal clubs, summarize elements of successful clubs, and evaluate their effect on reading habits, and effectiveness in meeting teaching goals. Examples of clubs that utilize principles of adult learning are reviewed. DATA SOURCES: English language articles identified through a MEDLINE search (1966-1997) using the MeSH terms "internship" and "residency," and text words "journal club" and "critical appraisal." STUDY SELECTION: Articles on learning goals and organization were included if they represented national or regional surveys with a response rate of 65% or greater. Articles that evaluated teaching effectiveness were included if they used a controlled, educational design, or if they exemplified important adult learning principles. DATA EXTRACTION: Data were manually extracted from selected studies and reviews. DATA SYNTHESIS: A major goal for most clubs is to teach critical appraisal skills. Clubs with high attendance and longevity are characterized by mandatory attendance, availability of food, and perceived importance by the program director. Residents who are taught critical appraisal report paying more attention to the methods and are more skeptical of the conclusions, and have increased knowledge of clinical epidemiology and biostatistics, but studies have failed to demonstrate that these residents read more, or read more critically. Reading guidelines may be useful for teaching critical appraisal skills, and may be associated with increased resident satisfaction. CONCLUSIONS: Journal club formats are educationally diverse, can incorporate adult learning principles, and are an adaptable format for teaching the "new basic sciences."

Skin biopsy techniques for the internist.

OBJECTIVE: To review three commonly performed skin biopsy procedures: shave, punch, and excision. DATA SOURCES: English-language articles identified through a MEDLINE search (1966-1997) using the MeSH headings skin and biopsy, major dermatology and primary care textbooks, and cross-references. STUDY SELECTION: Articles that reviewed the indications, contraindications, choice of procedure, surgical technique, specimen handling, and wound care. DATA EXTRACTION: Information was manually extracted from all selected articles and texts; emphasis was placed on information relevant to internal medicine physicians who want to learn skin biopsy techniques. DATA SYNTHESIS: Shave biopsies require the least experience and time but are limited to superficial, nonpigmented lesions. Punch biopsies are simple to perform, have few complications, and if small, can heal without suturing. Closing the wound with unbraided nylon on a C-17 needle will enhance the cosmetic result but requires more expertise and time. Elliptical excisions are ideal for removing large or deep lesions, provide abundant material for many studies, and can be curative for a number of conditions, but require the greatest amount of time, expertise, and office resources. Elliptical excisions can be closed with unbraided nylon using a CE-3 or FS-3 needle in thick skin or a P-3 needle on the face. All specimens should be submitted in a labeled container with a brief clinical description and working diagnosis. CONCLUSIONS: Skin biopsies are an essential technique in the management of skin diseases and can enhance the dermatologic care rendered by internists.

Chronic venous insufficiency and venous ulceration.

OBJECTIVE: To review and summarize the literature on the normal venous circulation of the leg, and the epidemiology, pathophysiology, and treatment of chronic venous insufficiency (CVI). DATA SOURCES: English-language articles identified through a MEDLINE search (1966-1996) using the terms venous insufficiency or varicose ulcer and epidemiology, pathophysiology, diagnosis, and clinical trial (pt), and selected cross-references. STUDY SELECTION: Articles on epidemiology, pathophysiology, and treatment of CVI. Randomized, controlled studies were specifically sought for treatment efficacy. DATA EXTRACTION: Data were manually extracted from selected studies and reviews: emphasis was placed on information relevant to the general internist. DATA SYNTHESIS: Chronic venous insufficiency is a common primary care problem associated with significant morbidity and health care costs. The clinical spectrum of disease ranges from minor cosmetic concerns to severe fibrosing panniculitis and ulceration. Duplex Doppler ultrasonography may be the single best test to rule out deep venous thrombosis and other entities that can mimic CVI. Leg elevation and compression stockings are effective treatments for CVI; recalcitrant cases may require intermittent pneumatic compression. Topical antiseptics, antibiotics, enzymes, or growth factors offer no clear advantages in ulcer healing. Ulcer dressings remain a matter of convenience, cost, and physician judgment. The role of surgery in CVI appears to be limited. CONCLUSIONS: Chronic venous insufficiency is a recalcitrant, recurrent medical problem. This condition can be managed by primary care physicians with relatively inexpensive treatment modalities in association with lifestyle modification.

Resident research in internal medicine training programs.

OBJECTIVE: To determine how well medical residency programs are prepared to meet the new Accreditation Council of Graduate Medical Education (ACGME) accreditation guidelines for resident scholarly activity. DESIGN: Cross-sectional study using a mailed survey. PARTICIPANTS: Program directors of all ACGME-accredited internal medicine residency programs. MEASUREMENTS: Program directors were asked to list the scholarly activities and products of their residents and their programs' minimal expectations for resident research; available academic, faculty, technical, and personnel support for resident research; perceived barriers to resident research; and the desired educational and skill outcomes of resident research. The responses of university-based training programs were compared with those of non-university-based programs. RESULTS: 271 program directors returned the survey, yielding a response rate of 65%. Ninety-seven percent of all programs have established scholarly guidelines consistent with accreditation requirements. Although only 37% of programs reported having an organized, comprehensive research curriculum, 70% taught skills important to research. Technical support and resources were generally available for resident research; the most frequently cited barrier to resident research was lack of resident time. University-based and non-university-based training programs differed in important ways. Generally, non-university-based programs had more research activity and structure, and they exceeded university-based programs in the number of oral and poster presentations given at local, state, and national professional meetings. CONCLUSIONS: Most programs have in place the basic elements conducive to resident research. Program directors have identified and teach educational outcomes and skills that are likely to have lifelong benefits for most of their graduates.

Physicians' attitudes toward mandatory workplace urine drug testing.

BACKGROUND: Workplace drug testing programs are being increasingly implemented in both the public and private sectors, and health care workers are unlikely to be excluded from such testing. METHODS: A survey of attending physicians' attitudes toward mandatory hospital-based urine drug testing was undertaken in a medium-sized, midwestern county. RESULTS: Seventy-four percent (272/368) of the sample responded. Seventy-two percent of the subjects believed physician drug use to be a minor or nonexistent problem, 38% lacked confidence in the testing procedure, and 60% believed that testing infringed on the physician's right to privacy; yet 87% would submit to testing if required by a hospital. Forty-five percent of respondents agreed with the policy of mandatory testing for physicians with hospital privileges, 34% disagreed, and 21% were uncertain. Respondents were more supportive of mandatory testing of other health care and non-health care occupations than for themselves. Support for testing was greatest for illicit drugs. If implemented, physicians preferred mandatory testing to be performed by hospital medical staff independent of hospital administration. CONCLUSIONS: Further education and discussion within the physician community appears to be necessary before widespread mandatory workplace urine drug testing of physicians is implemented.

Case report: fatal overdose with sustained-release verapamil.

Verapamil is generally a safe and effective drug in the treatment of many vascular disorders. During the past 10 years, a number of serious poisonings have been attributed to verapamil overdose. A relatively new problem is toxicity with the sustained-release form of verapamil. Complications of verapamil overdose can be understood as simply an extension of its pharmacologic activity. Consistently effective therapy remains elusive. Specific calcium channel blocker antidotes are under investigation, but supportive therapy remains the mainstay for serious verapamil overdose.

Pseudoaneurysm of the abdominal aorta: a case report and review of the literature.

Pseudoaneurysm of the abdominal aorta is a rare finding, accounting for only 1% of all abdominal aneurysms. Abdominal pseudoaneurysms have been reported only in males, and two-thirds of the cases are the result of penetrating trauma. Pain, abdominal mass, and vascular occlusion are the most common presenting signs and symptoms. The interval between injury and rupture may range from hours to years, and accordingly, a high index of suspicion is needed to make the diagnosis.

Tanning salons: an area survey of proprietors' knowledge of risks and precautions.

An area survey of tanning salon proprietors was conducted in a medium-sized midwestern city. Proprietors reported they were in compliance with federal safety regulations, but not all had age, frequency, or duration restrictions. Similarly, proprietors were not uniformly informing patrons of potential tanning hazards, including the possibility of skin cancer, and were not knowledgeable about the risk and benefits of tanning. Some establishments reported selling psoralens to patrons to enhance tanning. More explicit guidelines regarding the use of tanning equipment and more accurate consumer information are needed.

Adult respiratory distress syndrome due to blastomycosis during pregnancy.

A 23-year-old healthy woman in her third trimester of pregnancy developed adult respiratory distress syndrome secondary to Blastomyces dermatitides. Pregnancy-related immunosuppression was believed to be responsible for the fungal infection. Following emergency delivery of the infant and a full course of amphotericin B therapy, the patient made an uneventful recovery. Although the fetal and maternal sides of the placenta demonstrated fungal spores, the child remained healthy. To our knowledge, this is the first report of blastomycosis-associated adult respiratory distress syndrome occurring during pregnancy.

Pulmonary hemorrhage in an immunocompromised, thrombocytopenic patient. How to make a difficult diagnosis.

Bilateral, diffuse infiltrates visible on chest radiographs of an immunocompromised patient suggest the possibility of infection, but occasionally other interesting conditions are responsible for the clinical picture. In this article, the authors describe a case in which special procedures were necessary to make the correct diagnosis.

Rapid evaluation of comatose patients.

Coma is a common, life-threatening medical problem encountered by primary care physicians. The principles of emergency management mandate that adequate oxygenation, blood flow, and supplementation with thiamine and glucose be given to the brain before a thorough diagnostic evaluation is undertaken. Knowledge of the usual causes of coma coupled with clues from the neurologic examination often aid in diagnosis and provide useful prognostic information.

Pancreatic carcinoma. An unusual presentation--inferior vena cava thrombosis.

The case reported here demonstrates the importance of considering the possibility of occult malignancy in young patients presenting with extensive or migratory thromboses in atypical locations that appear resistant to standard therapy. Suspicion for malignancy-related thrombosis is heightened by the absence of known precipitating causes and by a negative family history of thrombosis. The search for the responsible underlying neoplasm can be frustrating, but diagnosis and successful treatment of the tumor remain the keys to controlling the abnormal thrombotic state.

Self-poisoning: outcome and complications in the community hospital.

One hundred sixty cases of self-poisoning of patients aged 15 years and older were treated on the wards of the four community hospitals of Lansing, Michigan, in 1981. Most cases (91 percent) were intentional and represented suicide attempts. The complication rate was 13.8 percent and the overdose-related mortality rate 0.6 percent. Aspiration pneumonia was the most common complication, followed by respiratory failure and seizures. No patient with a level of consciousness stage 0 or 1 in the emergency room had a major overdose-related complication with permanent sequelae, and this group represented 80 percent of the cases. One possible guideline for managing the self-poisoner is level of consciousness in the emergency room.

Necrotizing cellulitis of the scrotum: a new complication of heroin addiction.

A drug addict experienced a necrotizing cellulitis of his scrotum and medial thigh after an injection of heroin into his left femoral artery. It is proposed that the arterial injection was directly responsible for producing the low tissue oxygen tension necessary for the synergistic growth of aerobic and anaerobic bacteria responsible for skin necrosis. The patient responded to wide surgical debridement and antibiotic therapy. To the best of our knowledge, this is the first report of necrotizing cellulitis associated with the intra-arterial injection of heroin.

Autoimmune polyglandular syndromes.

Autoimmune polyglandular syndromes are classified into three types. Type I occurs in childhood and is characterized by at least two of the following: chronic mucocutaneous candidosis, adrenal failure and hypoparathyroidism. There is also an association with chronic active hepatitis. Type II usually develops in adulthood and is characterized by adrenal failure plus hypothyroidism or diabetes mellitus, or both. Type III consists of thyroid disease and one other organ-specific autoimmune disorder. This classification has potential usefulness in patient management and family screening for autoimmune endocrine diseases.