Lyme disease and post-treatment Lyme disease syndrome: the neglected disease in our own backyard.

OBJECTIVES: A survey was developed to assess experience and opinions about Lyme disease and post-treatment Lyme disease syndrome (PTLDS) among faculties in public health. No previous surveys of public health faculties have been found in the literature. STUDY DESIGN: This is a cross sectional study of public health school faculty members designed to measure knowledge and experience with Lyme disease and PTLDS using an internet survey instrument. METHODS: Participants were recruited using all the publicly available e-mail addresses of faculty members in all the 50 accredited Schools of Public Health in the United States. RESULTS: A 15% response rate was seen for the survey. 50% of respondents were from Lyme endemic states. Less than 5% of faculty members consider themselves expert in Lyme or PTLDS. Many faculty members had known someone with Lyme disease or PTLDS, but few had been diagnosed themselves. Most believe that PTLDS can be severe and chronic, is not easy to treat, and does not resolve on its own, but were uncertain about its aetiology. Most respondents also felt that the incidence of Lyme disease will increase and that more education is needed. CONCLUSIONS: The need for further understanding and communication presents an opportunity for public health research and education in Lyme disease and the sequelae of PTLDS.

Attitudes of faculty, housestaff, and medical students toward clinical practice guidelines.

PURPOSE: To examine attitudes of faculty, housestaff, and medical students toward clinical practice guidelines. METHOD: In a 1997 cross-sectional survey, a two-part, 26-item, self-administered questionnaire was mailed to all faculty, housestaff, and medical students in the department of internal medicine at Case Western Reserve University School of Medicine. The questionnaire asked for demographic information and attitudes toward clinical guidelines. RESULTS: Of 379 persons surveyed, 254 (67%) returned usable questionnaires: 56% of the medical students, 70% of the housestaff, and 73% of the full-time faculty. Medical students reported learning about guidelines predominantly during clerkships in internal medicine (71%) and pediatrics (68%). Overall, the respondents agreed most strongly that guidelines are "useful for the care of common problems," and least strongly that guidelines are "difficult to apply to individual patients" and "reduce physician options in patient care." Faculty were more likely to consider guidelines a "good educational tool" and less likely than were medical students and housestaff to agree that they promote "cookbook medicine." Of 11 influences on clinical decision making, the three groups together rated practice guidelines eighth or ninth. The use of guidelines for academic investigations was rated most appropriate, overall. In terms of their appropriateness, faculty consistently rated the use of guidelines more favorably except for use in malpractice suits. CONCLUSION: Faculty, housestaff, and medical students have significantly different perceptions of and attitudes toward clinical practice guidelines. Further studies are needed to explain the reasons for these differences. Considerable education and involvement must occur at all levels for practice guidelines to be successfully implemented and understood.

When doctors marry doctors: a survey exploring the professional and family lives of young physicians.

BACKGROUND: Soon, half of all physicians may be married to other physicians (that is, in dual-doctor families). Little is known about how marriage to another physician affects physicians themselves. OBJECTIVE: To learn how physicians in dual-doctor families differ from other physicians in their professional and family lives and in their perceptions of career and family. DESIGN: Cross-sectional survey. SETTING: Two medical schools in Ohio. PARTICIPANTS: A random sample of physicians from the classes of 1980 to 1990. MEASUREMENTS: Responses to a questionnaire on hours worked, income, number of children, child-rearing arrangements, and perceptions about work and family. RESULTS: Of 2000 eligible physicians, 1208 responded (752 men and 456 women). Twenty-two percent of male physicians and 44% of female physicians were married to physicians (P < 0.001). Men and women in dual-doctor families differed (P < 0.001) from other married physicians in key aspects of their professional and family lives: They earned less money, less often felt that their career took precedence over their spouse's career, and more often played a major role in child-rearing. These differences were greater for female physicians than for male physicians. Men and women in dual-doctor families were similar to other physicians in the frequency with which they achieved career goals and goals for their children and with which they felt conflict between professional and family roles. Marriage to another physician had distinct benefits (P < 0.001) for both men and women, including more frequent enjoyment from shared work interests and higher family incomes. CONCLUSIONS: Men and women in dual-doctor families differed from other physicians in many aspects of their professional and family lives, but they achieved their career and family goals as frequently. These differences reflect personal choices that will increasingly affect the profession as more physicians marry physicians.

Oral antibiotics in the nineties: new drugs and new challenges in primary care.

The primary care physician is faced with a bewildering array of new oral antimicrobials to treat common infections. These agents promise to be extremely effective as replacements for time-honored drugs, as prophylaxis, and for the treatment of infections previously requiring prolonged intravenous therapy. The overuse of the newer macrolides, quinolones, and beta-lactam beta-lactamase inhibitors may prove to be ecologically and economically costly. It is feared that the selective pressure from these broad spectrum agents may burden society with an even greater problem of multiply resistant community-acquired pathogens. The specific therapeutic and economic advantages and disadvantages of each class should be considered and the decision to employ these agents should be highly individualized.

Implementation of local guidelines for cost-effective management of hypertension. A trial of the firm system.

OBJECTIVE: To evaluate the effects of an intensive intervention to implement guidelines for cost-effective management of hypertension on medication use and cost, blood pressure control, and other resource use. DESIGN: Retrospective cohort trial based on the Cleveland Veterans' Affairs Medical Center Firm System. SETTING: General internal medicine teaching clinic in a large university-affiliated Department of Veterans Affairs Medical Center. PARTICIPANTS: All patients seen in the intervention firm (n = 1273) and control firm (n = 884) clinics in the 3-month period following the introduction of the guidelines. INTERVENTIONS: The control firm received guidelines and usual education for the cost-effective outpatient management of hypertension. The intervention firm received guidelines plus intensive guideline-based education and supervision. MEASUREMENTS AND MAIN RESULTS: The use of guideline medications was greater in the intervention firm as compared with the control. The intervention firm initiated more hydrochlorothiazide (HCTZ), 17.4% (95% confidence interval [CI] 14.8, 20.1) of patients versus 11.9% (CI 9.3, 14.8) in the control firm (p = .002). Atenolol was initiated in 7.2% (CI 5.6, 9.0) in intervention firm versus 4.7% (CI 3.2, 6.6) in the control (p = .03). In addition, the use of nonguideline medications was less in the intervention firm. The intervention firm initiated less long-acting nifedipine, 7.8% (CI 6.0, 9.8) versus 10.6% (CI 8.2, 13.5) in the control (p = .04). Blood pressure control demonstrated greater improvement in the intervention firm (p = .02). Use of guidelines was associated with decreased costs for antihypertensive medications in the intervention firm as a whole as compared with the control firm. There was no increased use in other measured resources in the intervention firm including the number of outpatient laboratory services obtained, clinic visits, emergency room visits, or hospitalizations. CONCLUSIONS: Intensive implementation of guideline-based education and supervision was associated with an increased use of guideline medications, decreased use of costly alternative agents, and no decrement in the measured outcomes of care.

Sarcoid myopathy in a patient with human immunodeficiency virus infection.

Although neither sarcoidosis nor HIV infection is rare, only eight patients with both diseases have been described. None of the eight had sarcoid myopathy. We describe a patient who had HIV infection and decreased CD4+ T-lymphocytes as well as sarcoidosis with muscle involvement. During 3 years of observation, primary sarcoidosis remitted and myopathic symptoms were controlled with prednisone. No opportunistic infections occurred during more than 3 years of prednisone therapy.

Interdisciplinary integration for quality improvement: the Cleveland Veterans Affairs Medical Center Firm System.

BACKGROUND: Many of the characteristics of Firm Systems lend themselves to the application of principles of continuous quality improvement (CQI). A Firm System is defined as two or more parallel practices organized on the principle of continuity of relationships between patients and an interdisciplinary group of health care professionals and trainees. Firm Systems are organized around the care of the patient or customer and emphasize access, continuity, and quality of care. CASE STUDY: The Firm System was implemented at the Cleveland Veterans Affairs Medical Center (VAMC) not as a CQI initiative per se, but as an effort to coordinate the processes involved in the delivery of patient care. The primary goals of this implementation were to improve the quality of patient care, medical education, and health care research. The main strategy to deal with problems caused by uncoordinated care were to move from a departmental approach to an integrated interdisciplinary approach. This approach represented a paradigm shift within the organization that extended to planning, documentation, and the general work environment. Most important, the institution had leaders who were committed to the Firm System and willing to authorize resources to ensure its success. CONCLUSION: VA hospitals are ideal settings for Firm Systems because they provide longitudinal, comprehensive care with a centralized, prepaid payment mechanism, and they have well-developed information systems that allow the random assignment of patients to Firms. Recommendations to others interested in implementing Firm Systems include creation of a written plan that can gain general support; identification of resources needed for successful implementation; remembering that the patient is the most important customer, as well as that complex systems have many customers; monitoring of performance; and the importance of randomizing patients and providers.

Glucocorticoids and infection.

Glucocorticoids alter the host response to both common and unusual infectious agents through widespread effects on immunity and the inflammatory process. Patients with ectopic ACTH syndrome or with exposure to high doses of exogenous glucocorticoids are at highest risk of infection. Care of these patients involves decreasing the levels of glucocorticoids whenever possible, preventing exposure to infectious agents, and aggressively evaluating patients with suspected infection.

Developing guidelines for local use: algorithms for cost-efficient outpatient management of cardiovascular disorders in a VA Medical Center.

Local use of practice guidelines requires paying close attention to the concerns of the patient within the framework of society, to the professional and educational needs of the provider, and to the realities of cost. One Veterans Affairs facility took the challenge of balancing these factors and developed their own algorithms for three cardiovascular disorders.

Amebiasis and "nonpathogenic" intestinal protozoa.

Infection with single or multiple species of intestinal protozoa is common in humans and can result in either asymptomatic colonization or symptoms of intestinal disease. Entamoeba histolytica serves as a paradigm for invasive colonic protozoal infection. The key to diagnosis and treatment of amebiasis is knowledge of the epidemiologic risk factors and clinical manifestations, a rational approach to diagnosis, and an understanding of the sites of action and uses of anti-amebic drugs. This knowledge of treatment provides a context for consideration of intestinal infection with less common protozoan pathogens such as Dientamoeba fragilis and Balantidium coli and 'nonpathogenic' protozoa such as Blastocystis hominis and Entamoeba coli.

Management of gallstones in diabetic patients.

The management of gallstones in diabetic patients has traditionally been considered problematic. Autopsy findings and uncontrolled studies have documented a higher prevalence of cholelithiasis in diabetics, and early reports showed dramatically increased perioperative morbidity and mortality for treatment of diabetics with acute cholecystitis. As a result, some authorities have recommended prophylactic cholecystectomy for diabetic patients with asymptomatic gallstones, which is in contrast to recommendations for nondiabetics. More recent investigators have shown comparable rates of operative morbidity and mortality for biliary surgery in diabetics when compared with the general population. Recent studies have questioned whether diabetes is an independent risk factor for gallstone formation. Decision analyses using these new data have shown that prophylactic cholecystectomy is not of clear benefit and should not be routinely recommended for diabetics with asymptomatic gallstones. We believe that available data, although limited, indicate that asymptomatic patients with diabetes do not benefit from screening for gallstones and that cholecystectomy should only be performed in cases of symptomatic cholelithiasis, as is the case in the general population.

The Cleveland Veterans Affairs Medical Center firm system.

Hospital-based "firms" provide a means for combatting the fragmentation experienced by both patients and caregivers in the modern teaching hospital environment. A "firm" is an academic group practice that includes attending physicians, physician trainees, nurses, other staff, and patients. Each person's relationship with a firm lasts throughout his or her association with a particular institution. This article describes the firm system that was recently implemented on the Medical Service of the Cleveland VAMC. This system incorporates both inpatient and outpatient general medical services and provides for unbiased assignment of patients, physicians, and nurses.

Characterization of calcium channel forming activity of Entamoeba histolytica in model biological membranes.

Entamoeba histolytica is an invasive enteric protozoan parasite whose cytolytic activity is associated with irreversible increases in target cell intracellular calcium. We studied the effect of homogenates of virulent E. histolytica on calcium permeability of bovine chromaffin granules and rat liver mitochondria, model membrane systems whose mechanisms of ion transport and permeability are well characterized. Treatment of chromaffin granules, with an extract of E. histolytica resulted in a dose-dependent increase in calcium uptake. These effects were similar to that seen with the calcium ionophore A23187 and indicate that the homogenate acts as a divalent cation ionophore. However, unlike what is observed with A23187, the Ca2+ uptake was greater in the presence of the permeable anion Cl- than in its absence. Also, in contrast to the calcium ionophore A23187, a homogenate of E. histolytica caused no calcium release from rat liver mitochondria but resulted in a dramatic increase in the rate of calcium accumulation. The amebic homogenate did not bind calcium in the absence of mitochondria. The increase in mitochondria calcium uptake occurred only in the presence of respiration and with normal state 3 and 4 oxygen consumption. Calcium accumulation occurred both in the presence and absence of 5 mM Pi. Substitution of NaCl or KCl for sucrose in the medium did not alter the enhanced mitochondria calcium uptake. Most data are consistent with the hypothesis that the E. histolytica homogenate is acting as a calcium ionophore transporting charged calcium electrophoretically across the chromaffin granules and the mitochondria inner membrane. This activity may contribute to the cytopathogenicity by E. histolytica.