Management of osteoarthritis of the knee by primary care physicians.

BACKGROUND: Most patients with osteoarthritis (OA) are treated by primary care physicians (in this article, primary care physicians are family physicians and general internists). OBJECTIVE: To describe and compare the self-reported practice patterns of family physicians and general internists for the evaluation and management of severe OA of the knee, including factors that might influence referral for total knee replacement. DESIGN, SETTING, AND PARTICIPANTS: A survey was developed and mailed to randomly selected community family physicians and general internists practicing in Indiana. MAIN OUTCOME MEASURE: Self-reported physician practice patterns regarding OA of the knee. RESULTS: Physical examination was the most common method of evaluating OA of the knee. Family physicians were more likely to examine for crepitation, joint stability, and quadriceps muscle strength than were general internists (P<.05). Patients with OA of the knee treated by family physicians were more likely to receive nonsteroidal anti-inflammatory drugs or oral corticosteroids and were less likely to receive aspirin, acetaminophen, or narcotics compared with patients treated by general internists. Six patient characteristics were rated as positive factors favoring a referral for possible total knee replacement, 8 characteristics were rated as negative, and 5 were rated as not a factor in the decision about referral. CONCLUSIONS: Results from this study suggest that additional research is needed to determine the evaluative techniques for OA of the knee that provide the most useful information for management decisions, the management techniques that maximize patient outcomes, and the criteria that should be used to select patients who would benefit most from referral for possible total knee replacement.

The carbohydrate sialyl Lewis(x) (sLe(x)) sulfated glycomimetic GM2941 attenuates glucan-induced pulmonary granulomatous vasculitis in the rat.

We examined the protective effects of GM2941, a sulfated glycomimetic of the complex carbohydrate sialyl Lewis(x), in a model of pulmonary granuloma development. This study was based on the rationale that formation of glucan-induced lung granulomas is dependent on neutrophils and that sialyl Lewis(x) glycomimetic (GM2941) interferes, in vitro, with P-selectin-dependent neutrophil-endothelial adhesive interactions. Infusion of particulate yeast cell wall glucan into rats results in the rapid (48 hr) formation of monocyte/macrophage-rich angiocentric pulmonary granulomas. Development of granulomas exhibits a temporal pattern characterized by the early, transient influx of neutrophils into blood vessel walls at sites of glucan embolization, followed by accumulation of monocytes and macrophages that constitute the definitive angiocentric lesions. Within 1 hr after the infusion of glucan, immunohistochemical analysis revealed up-regulation of blood vessel wall-associated P-selectin. Previous studies utilizing neutrophil-depleted animals have revealed that neutrophils, although not present in definitive lesions, are required for full granuloma development. The potential of GM2941 to inhibit neutrophil-endothelial cell adhesive interactions was demonstrated by the ability of the compound to inhibit P-selectin-mediated adhesion to histamine-stimulated HUVECs. Infusion of GM2941 retarded pulmonary granuloma development in a dose-dependent manner. Whole-lung myeloperoxidase activity, measured at the time of peak neutrophil accumulation, was significantly reduced in animals pretreated with GM2941 (30 mg/kg, 24 microM/kg), which suggests that this compound affords protection, at least in part, through impedance of neutrophil recruitment. These data indicate that GM2941 affords a significant degree of protection against granuloma formation associated with glucan infusion, probably through the interruption of neutrophil recruitment.

Tricompartmental knee replacement. A comparison of orthopaedic surgeons' self reported performance rates with surgical indications, contraindications, and expected outcomes. Knee Replacement Patient Outcomes Research Team.

The chance of a person with osteoarthritis of the knee receiving a knee replacement is highly variable. To understand better the reasons for this variation, all practicing orthopaedists in Indiana were surveyed about their management of severe knee osteoarthritis and their perception of tricompartmental knee replacement as a therapeutic option. Their perceptions of indications and outcomes of knee replacement were compared with the self reported annual number of patients for whom they performed (or referred to other surgeons for) tricompartmental knee replacements. A completed survey was returned by 220 (79%) of the 280 orthopaedists surveyed; analyses were limited to the 188 respondents who had cared for at least one patient with osteoarthritis of the knee in the prior 2 weeks (mean = 13). These surgeons reported performing (or referring patients for) a mean of 31 knee replacements in the prior year (SD 45, median 21, range 0-480 knee replacements). There was strong agreement (> 95%) among respondents for seven (21%) of 33 surgical indications and contraindications, and more general agreement (> 60%) for 21 (64%). In the five factors (15%) for which there was disagreement, there was no consistent relationship between opinions and self reported knee replacement performance rate. Surgeons reporting more knee replacements had significantly higher estimates of pain relief and functional improvement following surgery, and lower estimates of prosthesis infection and failure rates. When all responses were considered together, four decision factors correlated independently with the performance of more knee replacements, but these four factors explained only 24% of the variation in self reported knee replacement performance.(ABSTRACT TRUNCATED AT 250 WORDS)

Relationship of infant mortality to the availability of obstetrical care in Indiana.

BACKGROUND: Projects that are currently under way in Indiana to improve access to obstetrical care have not addressed the availability of these services in nonmetropolitan areas. This study was designed to identify all physicians who were providing obstetrical services in every county throughout the state to determine if there is a correlation between the availability of these services and the infant mortality rate in nonmetropolitan counties. METHODS: A state-wide physician profile maintained by the Indiana Academy of Family Physicians was cross-referenced with a telephone survey of all hospitals in the state to identify those physicians providing obstetrical services within each county in Indiana. The number of physicians in each county was then compared with the number of births per year by mothers from that county to determine whether nonmetropolitan counties had sufficient physicians to provide obstetrical services. Finally, these findings were compared with the most recent infant mortality rate for each nonmetropolitan county. RESULTS: A total of 610 family physicians, 311 obstetricians, and 75 general practitioners were providing obstetrical care in Indiana. There were 10 counties that did not have a physician who delivered babies practicing in that county. Thirty-two counties had more women who needed obstetrical care than the current number of physicians could serve. There was a negative correlation between physician availability and infant mortality in Indiana's nonmetropolitan counties (r = -.38; P less than .02). CONCLUSIONS: Access to care for pregnant patients is a major problem in rural Indiana and hampers Indiana's ability to reduce its current infant mortality rate.

Volume determinations of the encephalic ventricles with CT and MRI.

The volume of the encephalic ventricles was determined from magnetic resonance imaging (MRI) scans. Since there are many conditions in which the encephalic ventricles become enlarged such as Alzheimer's disease and hydrocephalus, accurate measurement of the ventricles provides a valuable and safe means of aiding the diagnosis of such conditions and also provides important follow-up information in affected patients. The objective was pursued in a three phase study. This paper presents the data obtained from the first phase. This first phase demonstrated the possibility of measuring fluid filled spaces by MRI in three phantom preparations (small, medium, and large "ventricles"). The results were compared with those obtained from computerized tomography (CT) scans of the same preparations. These volumetric calculations were done with the aid of a Calcomp 9,000 digital analyzer programmed to compensate for the scale factor and slice thickness of the images. The phantom study showed that the results obtained from the MRI scans were better than those obtained from the CT scans in measuring the volume of water-filled cavities (ventricles) in gelatin phantoms. The average percent difference between volumes obtained by an imaging procedure compared to the actual volume as determined by water displacement was 15.8% for CT scanning and a more impressive 8.3% for MRI.

Women in medical specialty societies. An update.

The question of whether women are joining medical specialty societies at the same rate as their male counterparts has not been studied. A questionnaire was mailed to 48 medical specialty societies representing the 37 specialties listed in the Physician Characteristics and Distribution in the U.S., 1986 Edition. The response rate was 79%. Twenty organizations were able to identify the sex of their members, including the 7 specialty societies that represent the 6 most frequently chosen specialties of women physicians. Only in the American Psychiatric Association and the American Academy of Family Physicians was the enrollment of potential female members equivalent to that of male members. If the medical specialty societies do not address the issue of women being underrepresented in their societies, they will lose a large potential resource of leadership, participation, and financial support. More important, the societies will not be truly representative of their specialties.

Family practice resident attrition: reasons and rates by sex.

A survey of all family practice residency programs in the country was done to determine resident attrition reasons and rate by sex. Of 383 programs mailed surveys, four returns were from programs too new to have data, and 238 returns were usable, for an effective response rate of 62.7%. The overall attrition rate was 12.4% (699/5,656), and varied by the type of residency program. The most frequent reason for attrition as identified by the survey respondent was switching specialties (41.0%), followed by private practice 16.4% and involuntarily released 11.9%. The remainder left for a variety of other reasons. There was a slightly higher attrition rate for women (14.2%) than men (11.9%). The odds ratio for this was 1.22 (95% confidence interval 1.03 to 1.41). Women were more likely to leave for childbearing or rearing, or spouse relocation, although overall these numbers were small, and men also left for these same reasons.