A follow-up survey of alcohol consumption and knowledge in medical students.

We surveyed a medical school's students' drinking habits and knowledge 12 years after a previous survey. In this current survey from two academic years, final year students drank less than second year students did. Women in their second year drank as much as men. Overall, 28% of students drank more than the safe limits; 27% of students were problem drinkers, as measured by the CAGE questionnaire, and 52%, as measured by the AUDIT questionnaire. The proportion of students not drinking any alcohol rose from 6% in the previous survey to 27% in the current survey, possibly due to context and demographic changes. In spite of this difference, there have been no statistically significant reductions in either unsafe drinking levels or CAGE scores over 12 years. A third of students overestimated the safe levels of drinking. All medical schools should write and implement an alcohol policy.

The significance of ASCUS cytology in HIV-positive women.

OBJECTIVE: The aim of this study was to determine the incidence and severity of dysplasia associated with a cytologic diagnosis of atypical cells of undetermined significance (ASCUS) in women infected with the human immunodeficiency virus (HIV). METHODS: A cross-sectional analysis of cervical cytology, colposcopic impression, and cervical biopsy results was performed on 261 HIV-positive women diagnosed with ASCUS. The prevalence and grade of histologically documented cervical intraepithelial neoplasia (CIN) was determined. Patients with CD4 counts above and below 200 cells/mm(3) were compared using chi(2) analysis to determine any effect of worsening immunosuppression on the rates of associated dysplasia. RESULTS: Seven hundred sixty-one Pap smears were performed during the study period. Two hundred nine (27%) were diagnosed as ASCUS. All patients (pts) received colposcopic evaluation. The incidence of human papilloma virus (HPV) effect, low-grade CIN (I), and high-grade CIN (II, III, and carcinoma in situ) documented by cervical biopsy, cervical conization or endocervical curettings was 40, 17, and 15%, respectively. No cases of invasive cancer were found. These results are similar to those of previous cytohistologic studies of ASCUS in HIV-untested populations. There was no significant difference in frequency or severity of CIN in pts with severe immunosuppression (P = 0.4). CONCLUSION: A cytologic diagnosis of ASCUS in HIV-positive women identifies a group at significant risk for histologic abnormalities. The majority of pts will be diagnosed with HPV or low-grade CIN. HIV infection and severe immunosuppression do not appear to increase the frequency or severity of CIN associated with ASCUS. Given the 32% risk of associated CIN, all HIV-positive women with ASCUS cytology should undergo colposcopic evaluation.

The efficacy of cervical conization in the treatment of cervical intraepithelial neoplasia in HIV-positive women.

OBJECTIVE: The aim of this study was to evaluate the efficacy of cervical conization in the treatment of CIN in HIV-positive women. MATERIALS AND METHODS: Sixty-six HIV-positive women treated with cervical conization for CIN were stratified into four groups based on surgical margin and endocervical curetting (ECC) status (group 1: -margin/-ECC, group 2: +margin/-ECC, group 3: +margin/+ECC, group 4: -margin/+ECC). The rate of histologically proven recurrent CIN was calculated for each group and compared using chi(2) analysis. The effect of +margins, +ECC, degree of dysplasia, and CD4 count on the risk of recurrence was determined by logistic regression. RESULTS: Forty-nine percent of patients with negative margins and negative ECC experienced recurrence, most within 36 months. There was no significant difference in recurrence rate for patients with positive margins (69.2%, P = 0.19), positive ECC (50%, P = 0.97), or positive margins and ECC (66.7%, P = 0.41) when compared to patients with complete excision of dysplasia. No significant difference in the mean CD4 count of patients with and without recurrent dysplasia (316 vs. 390 cells/mm3, P = 0.37) was observed. Logistic regression showed only degree of dysplasia in the cone specimen to have a marginally significant linear relationship with recurrence. CONCLUSION: Cervical conization is not an effective method for eradicating CIN in HIV-positive women. Most patients will recur despite complete excision of dysplasia. Surgical margin status, ECC status, and CD4 count appear to have no effect on recurrence rate. Although multiple procedures were necessary in some patients, cone biopsy was effective in preventing progression to invasive cervical cancer in all cases.

Reflections on the medical deanship.

In 35 years, being dean of a medical school has changed dramatically. Thirty years ago, the dean's world was still the medical school and its affiliated hospitals, but soon this world was transformed by new emphasis on research (and the resources to conduct it) and the increase of specialty medicine. The medical school became larger and the affiliated hospital more complex. They consolidated into the modern academic medical center, which then became more diverse and self-contained and eventually became an island of special expertise and achievement in medicine, the biomedical sciences, and clinical care. Fifteen years, ago, the academic medical center began to be transformed again, this time by its competition with or incorporation into managed care and other health care delivery systems. The medical school dean now operates in an environment far different from that of the 1960s. Deans spend 90% of their time on five major issues: too few resources, isolation and division of activity within the institution, poor management, excessive traditionalism, and too few people with too much to do. In addressing these issues, the dean has several powerful levers, including the appointment and promotion of faculty, appointments to committees and task forces, assignments of budget and space, and controlling the agenda and leading the debate in the institution. Another but less tangible issue is the dean's attitude. Another but less tangible issue is the dean's attitude, which has enormous impact on what happens at the medical school and in its programs. The deanship will continue but in the new context of a health care delivery system-with variations on the same five problems and with the same ten levers available to address them. The responsibility is old; only the context is new.

Pigmented villonodular synovitis of the shoulder after anterior capsulolabral reconstruction.

Pigmented villonodular synovitis (PVNS) is a proliferative disorder of the synovium affecting joints, bursae, or tendon sheaths. PVNS is further classified into diffuse and localized forms and rarely affects the shoulder. We report a case of nodular synovitis of the shoulder after arthroscopic and open anterior capsulolabral reconstruction. The histopathology and treatment of a nodular form of PVNS of the shoulder is discussed.

Variability in BPRS definitions of positive and negative symptoms.

Reviewing Brief Psychiatric Rating Scale (BPRS) research indicates that combining items to form larger 'symptom factors' (e.g., depression, psychosis) has become the standard methodology. Unfortunately, a single symptom factor may be defined by different combinations of different BPRS items in different studies. To examine the potential impact of these differences, a number of different BPRS definitions of positive and negative symptoms in schizophrenia were culled from previous research. To compare these definitions, one hundred schizophrenics were interviewed with regard to current and recent symptomatology and rated on the BPRS, the Schedule for the Assessment of Negative Symptoms (SANS), and the Schedule for the Assessment of Positive Symptoms (SAPS). The four BPRS negative symptom definitions all correlated highly with one another and with the SANS. There were no differences in the amount that these different definitions of negative symptoms correlated with the SANS. Also, the nine definitions of positive symptoms all correlated highly with one another and with the SAPS. However, there were significant differences in how they correlated with the SAPS. Because of these differences, possible standard definitions for negative and positive symptoms of schizophrenia are proposed for future use of the BPRS in research.

The diffusion of medical technology: free enterprise and regulatory models in the USA.

The diffusion of technology in the US has taken place in an environment of both regulation and free enterprise. Each has been subject to manipulation by doctors and medical administrators that has fostered unprecedented ethical dilemmas and legal challenges. Understanding these developments and historical precedents may allow a more rational diffusion policy for medical technology in the future.

Business and managerial education in the medical school curriculum.

The need for medically related business and managerial training for medical students and physicians is an area of education that has been frequently discussed among physicians in private and academic practice. However, little has been done by physicians or in formal programs of medical or graduate medical education to address the need to introduce this type of training. This paper, based upon a survey of the medical students at Vanderbilt University, analyzes this need and proposes three new approaches in implementing medically related business and management education and training.

Combined paraesophageal and sliding hiatal hernia.

We have reported a case of a large paraesophageal herniation with a small sliding component. Abnormal positioning of the esophagogastric junction or the necessity for mobilizing it during repair requires the addition of an antireflux procedure to the standard reduction and repair. Elective repair of a paraesophageal herniation, even in the absence of limiting symptoms, is warranted, since complications of nonsurgical treatment may be sudden and severe.

Repair of aneurysms of the thoracic aorta: 12-year experience in a high-risk population.

We present our 12-year experience with surgical treatment of aneurysms of the thoracic aorta in a high-risk patient population. Of 52 patients with aneurysms, 36 patients, aged 19 to 80 years, had operation. In 24 of the 36, there were three or more associated major disease processes, such as chronic bronchitis, hypertensive cardiovascular disease, aortic valve disease, cerebrovascular disease, abdominal aortic aneurysm, and coronary artery disease. Eight patients with acute type A (ascending aorta) and seven with acute type B (descending aorta) aneurysms had emergency repair, with survival in four and seven, respectively. All patients with chronic type A or B aneurysms had elective repair, and all patients with acute or chronic type A aneurysms had surgical treatment. Four patients with acute type A and two with acute type B aneurysms had elective operation, with survival in three and one, respectively. Nine patients with chronic type A and six with chronic type B aneurysms had elective operation, and all survived. Twelve patients with chronic type B aneurysms did not have operation, and all were alive at early follow-up. Mortality for patients having acute type A aneurysms requiring emergency operation was greater than that after elective repair of acute or chronic type A aneurysms. Short-term survival for chronic type B aneurysms was similar whether the patient was treated medically or surgically.

Congenital absence of pericardium: an unusual cause of atypical angina.

Congenital defects of the pericardium are unusual. Patients may experience exertional chest pain, cardiac arrhythmias, syncope, sudden death, or incarceration of myocardium, or they may be entirely asymptomatic. We describe the case of a symptomatic pericardial herniation diagnosed by echocardiography and confirmed by cineangiography. Successful repair was accomplished using a polytetrafluoroethylene soft-tissue prosthesis.

The acting or interim leadership position: expectations, perceptions, realities.

The acting or interim leadership position has been neglected in terms of selection, role identification, and status. Individuals, programs, and organizations are paying a price for this inattention.

Impaired induction of ornithine decarboxylase activity following nerve crush in the streptozotocin-diabetic rat.

Ornithine decarboxylase activity was measured in the dorsal root ganglia from crushed and uncrushed contralateral sciatic nerve of control and streptozotocin-diabetic rats. A further group of diabetic rats was treated with insulin throughout the experiment. Ornithine decarboxylase activity in ganglia from uncrushed nerves was the same in diabetic and non-diabetic rats. A significant (greater than 4-fold) increase in mean levels of ornithine decarboxylase activity 72 h after crush injury was found in ganglia from crushed nerves in non-diabetic but not in diabetic rats. The enzyme activity in ganglia from diabetic rats treated with insulin resembled that in non-diabetic rats. Twenty-four hours after crush injury, ornithine decarboxylase activity in ganglia from crushed nerves was higher in non-diabetic than in diabetic animals. This may be responsible for the delayed and defective nerve regeneration known to occur in peripheral nerve of the streptozotocin-diabetic rat.