Dose response to nitric oxide in adult cardiac surgery patients.

STUDY OBJECTIVE: To determine the dose responsiveness to nitric oxide in adult cardiac surgery patients, especially in those patients with pulmonary hypertension. DESIGN: Prospective, randomized, nonblinded study. SETTING: University teaching hospital. PATIENTS: 62 consecutive cardiac surgery patients demonstrating pulmonary hypertension immediately before induction of anesthesia. INTERVENTIONS: Subjects were assigned by random number allocation to receive one of five doses of inhaled nitric oxide on termination of cardiopulmonary bypass (CBP; i.e., restitution of pulmonary artery flow). Subjects in Group 1 (n = 11) received 10 ppm of inhaled nitric oxide, Group 2 subjects (n = 12) received 20 ppm, Group 3 subjects (n = 12) received 30 ppm, and Group 4 subjects (n = 12) received 40 ppm. The fifth group (n = 15) received no nitric oxide. This fifth group served as a control and was treated with milrinone only. Those patients who were randomized to the milrinone group, had milrinone initiated by bolus administration (50 microg/kg) 15 min before separation from CPB. Milrinone was maintained at 0.5 microg/kg/min in the operating room thereafter. The conduct of anesthesia, surgery, and CBP were controlled. A therapeutic algorithm dictated the use of vasoactive substances for all patients. MEASUREMENTS: Heart rate, mean arterial pressure, pulmonary vascular resistance (PVR), peripheral vascular resistance, cardiac index, and right ventricular ejection fraction were monitored throughout the operative experience. MAIN RESULTS: There were no significant differences found in demographic data, baseline hemodynamic data, surgical treatment, conduct of CBP, or the use of inotropic or vasoactive drugs among the five treatment groups. The percentage decrease in PVR on treatment with nitric oxide as compared to baseline values was not significantly different among the groups (10 ppm = 38%, 20 ppm = 50%, 30 ppm = 44%, 40 ppm = 36%, milrinone = 58%, p = 0.86). CONCLUSIONS: Treatment with nitric oxide was associated with significant reductions in PVR in all groups. Dosages higher than 10 ppm were not associated with greater reductions in pulmonary vascular tone. In view of the fact that nitric oxide-related toxicity is dose-related, doses greater than 10 ppm do not appear to be justified in this patient population.

A survey of spinal and epidural techniques in adult cardiac surgery.

OBJECTIVE: To determine if a significant number of anesthesiologists are performing spinal and epidural techniques in adults undergoing cardiac surgery and if any neurologic injuries have been associated with these techniques. DESIGN: Anonymous survey of clinical practice. SETTING: Data collected via mail from members of the Society of Cardiovascular Anesthesiologists. PARTICIPANTS: Attending anesthesiologists. INTERVENTIONS: Anesthesiologists completed an anonymous survey of their use of spinal and epidural techniques in adult patients undergoing cardiac surgery. MEASUREMENTS AND MAIN RESULTS: Of 3974 anesthesiologists, 974 (24%) responded to the questionnaire; 892 are at institutions that perform cardiac surgery. Of the 892 responders, 68 (7.6%) reported they use spinal techniques, whereas 62 (7%) reported they use epidural techniques. Nine (1%) anesthesiologists reported they use both techniques. There were no reports of neurologic complications related to the use of spinal or epidural techniques performed by the anesthesiologists responding to the survey. CONCLUSIONS: A significant number of anesthesiologists are performing spinal and epidural techniques in adult patients undergoing cardiac surgery. Prospective, controlled trials should be performed to evaluate the benefits and risks of spinal and epidural techniques in this population.

The role of the coronoid process in elbow stability. A biomechanical analysis of axial loading.

BACKGROUND: The current treatment of coronoid process fractures of the ulna is based on the classification system of Regan and Morrey. We found no biomechanical studies that specifically addressed the role of the coronoid process in elbow stability. In the present investigation, the elbows of cadavera were tested before and after fracture of the coronoid process to assess the stabilizing contribution of the coronoid process under axial loading. METHODS: Six fresh-frozen cadaveric elbows were tested mechanically. All soft tissue surrounding the elbow, including the skin, was left intact. An axial load compressing the elbow joint was applied along the shaft of the forearm in the sagittal plane. A displacement of fifteen millimeters per minute was applied until a load of 100 newtons was attained. Each elbow was tested in 15, 30, 45, 60, 75, 90, 105, and 120 degrees of flexion. Next, less than 25 percent, 25 to 50 percent, or more than 50 percent of the coronoid process was fractured with an osteotome under radiographic guidance, and the testing was repeated. Each elbow served as its own control, and one elbow was used for two tests; therefore, a total of seven situations were investigated. The difference in displacements between the intact and osteotomized elbows was measured. RESULTS: There was no significant difference, at any flexion position, in posterior axial displacement between the intact elbows and the elbows in which 50 percent or less of the coronoid process was fractured (type I and type II) (p = 0.43). There were significant differences, across all flexion positions, in posterior axial displacement between the intact elbows and the elbows in which more than 50 percent of the coronoid process was fractured (type III) (p = 0.006). Specimens with a type-III fracture also showed a significant increase in displacement compared with specimens with a type-I or type-II fracture (p = 0.012). Specifically, from 60 to 105 degrees of flexion, a significant increase in posterior translation of up to 2.4 millimeters was found (p<0.05). CONCLUSIONS: In response to axial load, elbows with a fracture involving more than 50 percent of the coronoid process displace more readily than elbows with a fracture involving 50 percent or less of the coronoid process, especially when the elbow is flexed 60 degrees and beyond.

Lipid risk profile and weight stability after gastric restrictive operations for morbid obesity.

There are no longitudinal data that address weight loss stability and lipid levels in bariatric surgical patients. The goal of this study was to determine whether weight regain adversely affected reduction in lipid levels after gastric bariatric operations. Of 651 consecutive patients undergoing gastric restrictive surgery for morbid obesity, 227 (35%) had increased serum levels of total cholesterol (TC), triglycerides, or both preoperatively. High-density lipoprotein cholesterol (HDL-C) levels were subnormal (/=15% mean reduction in TC and a >/=50% mean reduction in triglycerides, both of which were significant in comparison with preoperative levels (P /=15% of their lost weight or lost less than 50% of excess weight (N = 37). Although mean excess weight loss and body mass index were significantly different between the two groups (P <0.0001) at 2 years, there was no difference in the lipid profile (TC/HDL) between the two groups at any interval through 5 years. These results show that abnormal lipid profiles can be permanently improved after gastric bariatric surgery and are not adversely affected by mediocre weight loss or regaining >/=15% of lost weight. DRY appears to be a superior operation for TC reduction in comparison with GP and RYGB.

Physician knowledge and practice patterns relating to diabetic nephropathy.

OBJECTIVE: To assess the knowledge and practice patterns of primary care physicians relating to the detection and treatment of diabetic nephropathy and to compare these findings with current standards of care. DESIGN: National survey. PARTICIPANTS: 1,000 randomly selected physicians. SETTING: Primary care. INTERVENTION: Mailed questionnaire consisting of a six-page "Diabetes Survey." RESULTS: Among the 1,000 primary care physicians, 950 were considered eligible for the survey. Sufficiently completed surveys were returned by 216 physicians, yielding an adjusted response rate of 22%. In general, patients with type 1 diabetes were monitored more intensively than those with type 2 diabetes. Primary care physicians were more likely to monitor patients for overt proteinuria (86%) than microalbuminuria (58%). Of the physicians who claimed to monitor patients for microalbuminuria, 39% chose inappropriate methods for detection, which lowers the percentage of physicians who correctly monitored for microalbuminuria to 37%. More than 95% of the respondents were aware of the benefits of angiotensin-converting enzyme inhibitors (ACEIs) in delaying the progression of diabetic nephropathy. Patients with proteinuria (86%) were more likely to be treated with an ACEI than were patients with microalbuminuria (79%). If a patient presented with proteinuria but without hypertension, the use of ACEIs fell to 75%. Rates of referral to a nephrologist were low at early stages of the disease (3% to 11%) and remained relatively low (28%) at later stages, even when serum creatinine was greater than 3 mg/dL. CONCLUSION: Further efforts directed toward education of primary care physicians about diabetic nephropathy have the potential to improve the care of patients with this disorder. These findings demonstrate a unique opportunity for pharmacists to become educators to physicians in their community.

Subtle differences in quality of life after breast cancer surgery.

BACKGROUND: Lumpectomy with axillary dissection (LAD) has taken its place alongside mastectomy (M) as the treatment of choice for stage I and II breast cancer. Its appeal is based on lessening disfigurement and thus improving quality of life. METHODS: We used the SF-36 Health Survey modified with ten questions relevant to breast cancer surgery to evaluate whether quality of life with LAD was better than with mastectomy in women with stage I and II disease. The additional questions addressed satisfaction with intimate relationships and sexuality, and explored impact on the way women dress, use bathing suits, hug people, are comfortable with nudity, and rate their sexual drive and sexual responsiveness. RESULTS: LAD was not associated with statistically significant better quality-of-life scores on any SF-36 questions, except vitality (P = .02). No differences were noted in the areas of intimacy and sexual satisfaction. LAD patients reported significant differences in matters of dress, use of bathing suits, hugging, comfort with nudity, and sexual drive compared to patients undergoing mastectomy. CONCLUSIONS: The SF-36 health survey detected few differences in quality of life measures between patients with LAD and those with mastectomy. However, LAD impacts favorably on the way women dress, on comfort with nudity, and on sexual drive.

Are vitamin B12 and folate deficiency clinically important after roux-en-Y gastric bypass?

Although iron, vitamin B12, and folate deficiency have been well documented after gastric bypass operations performed for morbid obesity, there is surprisingly little information on either the natural course or the treatment of these deficiencies in Roux-en-Y gastric bypass (RYGB) patients. During a 10-year period, a complete blood count and serum levels of iron, total iron-binding capacity, vitamin B12, and folate were obtained in 348 patients preoperatively and postoperatively at 6-month intervals for the first 2 years, then annually thereafter. The principal objectives of this study were to determine how readily patients who developed metabolic deficiencies after Roux-en-Y gastric bypass responded to postoperative supplements of the deficient micronutrient and to learn whether the risk of developing these deficiencies decreases over time. Hemoglobin and hematocrit levels were significantly decreased at all postoperative intervals in comparison to preoperative values. Moreover, at each successive interval through 5 years, hemoglobin and hematocrit were decreased significantly compared to the preceding interval. Folate levels were significantly increased compared to preoperative levels at all time intervals. Iron and vitamin B12 levels were lower than preoperative measurements and remained relatively stable postoperatively. Half of the low hemoglobin levels were not associated with iron deficiency. Taking multivitamin supplements resulted in a lower incidence of folate deficiency but did not prevent iron or vitamin B12 deficiency. Oral supplementation of iron and vitamin B12 corrected deficiencies in 43% and 81% of cases, respectively. Folate deficiency was almost always corrected with multivitamins alone. No patient had symptoms that could be attributed to either vitamin B12 or folate deficiency Conversely, many patients had symptoms of iron deficiency and anemia. Lack of symptoms of vitamin B12 and folate deficiency suggests that these deficiencies are not clinically important after RYGB. Conversely, iron deficiency and anemia are potentially serious problems after RYGB, particularly in younger women. Hence we recommend prophylactic oral iron supplements to premenopausal women who undergo RYGB.

Prophylactic iron supplementation after Roux-en-Y gastric bypass: a prospective, double-blind, randomized study.

OBJECTIVE: To determine whether prophylactic oral iron supplements (320 mg twice daily) would protect women from iron deficiency and anemia after Roux-en-Y gastric bypass. DESIGN: Prospective, double-blind, randomized study in which 29 patients received oral iron and 27 patients received a placebo beginning 1 month after Roux-en-Y gastric bypass. SETTING: Tertiary care medical center. PATIENTS AND INTERVENTIONS: Complete blood cell count and serum levels of iron, total iron binding capacity, ferritin, vitamin B12, and folate were determined preoperatively and at 6-month intervals postoperatively in 56 menstruating women who had Roux-en-Y gastric bypass. MAIN OUTCOME MEASURE: Incidence of iron deficiency and other hematological abnormalities in each treatment group. RESULTS: Hemoglobin, hematocrit, and vitamin B12 levels were significantly decreased compared with preoperative values in both groups. Conversely, folate levels increased significantly over time in both groups. Oral iron consistently prevented development of iron deficiency in the iron group. Ferritin levels did not change significantly in the iron group. However, in placebo-treated patients, ferritin levels 2 years postoperatively were significantly decreased compared with preoperative levels. There was no difference in the incidence of anemia between the 2 groups. However, the incidence of microcytosis was substantially greater (P=.07) in placebo-treated than iron-treated patients. CONCLUSIONS: Prophylactic oral iron supplements successfully prevented iron deficiency in menstruating women after Roux-en-Y gastric bypass but did not consistently protect these women from developing anemia. On the basis of these results we now routinely recommend prophylactic iron supplements to menstruating women who have Roux-en-Y gastric bypass.

Accuracy and reproducibility of blood lead testing in commercial laboratories.

OBJECTIVE: To assess the proficiency of commercial laboratories in analyzing lead in clinical blood samples from subjects without overt lead exposure. DESIGN: We submitted masked duplicate blood lead specimens to 8 masked laboratories. Each laboratory received blood aliquots immediately following drawing (time 1) and 2 weeks later (time 2) from 7 human subjects and 3 bovine blood samples with known lead levels of 0.26, 0.57, and 0.79 micromol/L (5.4, 11.8, and 16.4 microg/dL). Of the 8 laboratories, 5 were commercial laboratories, 1 was a state laboratory, 1 was a research laboratory, and 1 was the Centers for Disease Control and Prevention reference laboratory. OUTCOME MEASURES: Correlation coefficients were calculated, and differences within and between laboratories were assessed by analysis of variance. RESULTS: Results were obtained for all specimens, with all the human subjects' overall mean lead levels being less than 0.48 micromol/L (<10 microg/dL). Each laboratory reported all human blood specimens appropriately, as having lead levels less than 0.48 micromol/L (<10 microg/dL) and within 0.14 micromol/L (3 microg/dL) of the overall mean for that subject. All internal reproducibilities were very high (range, 0.92-1.00) except for one (0.60), possibly lower because of 1 pair of specimens. Mean differences between blood samples analyzed at time 1 and time 2 ranged from -1.4 to 1.2, with only 2 laboratories having significant differences (P<.01). CONCLUSIONS: Overall, there was strong reproducibility within and among laboratories, with no overall time trend or interlaboratory or intralaboratory variance. The storage conditions did not seem to affect the aggregate results. The data suggest that through implementation of the Centers for Disease Control and Prevention/Wisconsin Blood Lead Proficiency Testing Program, the Centers for Disease Control and Prevention's Blood Lead Laboratory Reference System, and mandated federal and state proficiency programs, laboratories in this geographic region have improved their performance as compared with previous published studies and an unpublished study.

The epidemiology of pediatric visits to New Jersey general emergency departments.

OBJECTIVE: To describe the epidemiology of pediatric visits to the emergency departments (EDs) of 10 general hospitals by age and gender. DESIGN: Review of ICD-9 codes from the billing database of a practice of emergency physicians. SETTING: Ten hospitals in north/central New Jersey. PATIENTS: All children <18 years treated by group physicians in EDs of study hospitals. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Diagnoses and visits. RESULTS: There were 319,430 diagnoses recorded for 241,839 children (18.9% of the 1,277,233 total visits by all ages). The number of visits was highest in the <2 and >14 years age groups, with males predominating in all age groups. The number of visits from trauma increased with age. Otitis accounted for over 3% of all ED visits in this sample, over 7000 visits. CONCLUSIONS: Children account for a significant portion of ED visits in general hospitals. EDs need to be equipped and staffed to handle this clientele.

Age-related differences in diagnoses within the elderly population.

The most common diagnoses of elderly patients in the emergency department (ED) were compared among three age subgroups: 65 to 74, 75 to 84, and 85 and older. The computerized billing records for patient visits to 10 northern New Jersey hospital EDs for the years 1985 to 1991 were retrospectively analyzed. The most frequently occurring ICD-9-CM codes for elderly patients were compared among the three age subgroups. Elderly persons comprised 174, 146 (14% of the total) patient visits. The 176,146 patient visits were assigned 259,440 ICD-9-CM codes. The most common ICD-9-CM codes for medical diagnoses included chest pain, cardiac dysrhythmias, congestive heart failure, syncope, abdominal pain, and dyspnea. Fractures, particularly of the lower limb and upper limb; contusions; open wounds, particularly of the head, neck, and trunk; and falls were among the most common trauma diagnoses. The proportions in the three age subgroups of each diagnosis were statistically significantly different, except for cardiac arrest and contusions of the trunk and of multiple sites. The diagnoses with clinically significant higher relative risks in older age subgroups were atrial fibrillation, congestive heart failure, syncope, hypovolemia/dehydration, gastrointestinal hemorrhage, dyspnea, pneumonia, pulmonary edema, cerebrovascular accident, septicemia, urinary tract infection, fractures, and open wounds of the head, neck, trunk, particularly the scalp, and falls. Clinically significant lower relative risks were found in older age subgroups for chest pain, acute myocardial infarction, hypertension, angina, chronic airway obstruction not elsewhere classified, epistaxis, contusions of the upper limb, and open wounds of the finger.

Follow-up study of risk factors in progressive supranuclear palsy.

The cause of progressive supranuclear palsy (PSP) is not known and has been little studied. The one previous controlled epidemiologic survey, performed at our center in 1986, found small-town experience and greater educational attainment as PSP risks, but, in retrospect, these results may have been produced by ascertainment bias. Since that time, several anecdotal reports have implicated heredity and various environmental exposures in the cause of some cases of PSP. To clarify the results of the previous study and to evaluate the more recently implicated candidate factors in a controlled fashion, we mailed a validated 69-item questionnaire to 91 personally examined patients with PSP and 104 unmatched controls with other neurologic conditions for which they had been referred to our tertiary neurologic center. We were able to match 75 subjects from each group by year of birth, sex, and race and subjected them to a separate matched-pair analysis. We allowed surrogates to supply any or all of the responses. Questions concerned hydrocarbon, pesticide, and herbicide exposure; urban/rural living; auto repair and other occupations; head trauma; educational attainment; maternal age; and family history of PSP, parkinsonism, dementia, and other neurologic conditions. A statistically significant finding was that patients with PSP were less likely to have completed at least 12 years of school (matched odds ratio = 0.35, 95% CI = 0.12-0.95, p = 0.022; unmatched odds ratio = 0.44, 95% CI = 0.21-0.89, p = 0.020). We hypothesize that this result may be a proxy for poor early-life nutrition or for occupational or residential exposure to an as-yet unsuspected toxin. Future studies should examine these potential risk factors in PSP.

Pharmacokinetics and immunomodulatory properties of intravenously administered recombinant human interleukin-10 in healthy volunteers.

Normal volunteers received single doses of recombinant human interleukin-10 (rhIL-10; n = 6 per group) or placebo (n = 3 per group) by intravenous injection to characterize pharmacokinetics, tolerability, and immunomodulatory effects. Dosages were 0.1, 0.5, 1.0, 2.5, 5.0, 10.0, 25.0, 50.0, and 100.0 micrograms/kg. Dose-related adverse effects consisted of a mild-to-moderate flu-like syndrome characterized by fever with chills, headache, and myalgias at the highest dose. The mean terminal phase t1/2 ranged from 2.3 +/- 0.5 to 3.7 +/- 0.8 hours. Dose-related effects of rhIL-10 included transient increases of circulating neutrophils and monocytes and decreases of lymphocytes. rhIL-10 markedly suppressed, in a time- and dose-dependent manner, the synthesis of the inflammatory cytokines IL-1 beta and tumor necrosis factor alpha by whole blood stimulated ex vivo with bacterial lipopolysaccharide. Circulating numbers of CD14+/HLA-DR+ cells at 24 hours after the dose were increased in a dose-dependent manner. Effects on expression of HLA-DR by CD14+ cells were variable. There was no apparent effect on HLA-DR expression by CD20+ cells. The immunomodulatory effects of rhIL-10 merit further clinical investigation.

Use of on-line medical command to randomize patients in a prehospital research study.

OBJECTIVE: To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment. DESIGN, SETTING, AND PARTICIPANTS: Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence. RESULTS: A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria. CONCLUSIONS: The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients.

Prospective, randomized trial of epinephrine, metaproterenol, and both in the prehospital treatment of asthma in the adult patient.

STUDY OBJECTIVE: To compare the effectiveness and incidence of adverse reactions with three treatment regimens for asthma in adults in the prehospital setting. DESIGN: Prospective, randomized clinical study. SETTING: Inner-city emergency medical service system providing basic and advanced life support and transport to 14 urban area hospital emergency departments. PARTICIPANTS: One hundred fifty-four adult asthmatic patients, 18 to 50 years old, who presented to paramedics with shortness of breath and wheezing. RESULTS: Eligible patients were randomly assigned by the base station physician to one of three treatment groups: subcutaneous epinephrine, nebulized metaproterenol, or subcutaneous epinephrine and nebulized metaproterenol. Peak expiratory flow rate (PEFR), blood pressure, heart rate, and respiratory rate were measured before and after treatment in each patient. During a 9-month period (October 1992 through June 1993), 154 patients were enrolled in the study; 53 (34%) received epinephrine, 49 (32%) received metaproterenol, and 52 (34%) received both. There were no significant differences in patient demographics, initial vital signs, or pretreatment PEFR among the three groups. The mean difference between pretreatment and posttreatment PEFR was 73 L/min and did not significantly differ among the treatment groups. Significant changes in vital signs were seen in no treatment group. CONCLUSION: Nebulized metaproterenol is as effective as subcutaneous epinephrine in the prehospital treatment of adult patients with acute asthma. The combination of these two treatments offered no additional clinical benefit in the patients we studied.

Arthrography of the wrist. Assessment of the integrity of the ligaments in young asymptomatic adults.

Fifty-two asymptomatic adults who were between twenty and thirty-five years old had arthrography of the wrist with use of a single injection into the radiocarpal joint. The purpose of the study was to evaluate the integrity of the triangular fibrocartilage, the scapholunate ligament, and the lunotriquetral ligament. Contrast medium was injected under fluoroscopic guidance, and posteroanterior and lateral radiographs of the wrist were made after the subjects had performed exercises of the wrist. No patient who had a history of trauma to the wrist, pain in the wrist, or inflammatory arthritis was included in the study. All of the subjects had an examination of both upper extremities that included measurement of the active motion of the wrist with a goniometer, strength-testing with a Jamar dynamometer, ballottement and testing for impingement, and palpation for tenderness. Plain radiographs were evaluated, and the ulnar variance was recorded. The arthrograms revealed an abnormal communication of the contrast medium in fourteen wrists (27 per cent), and four of the fourteen had multiple areas of communication. The abnormal communication was through the triangular fibrocartilage alone in six wrists, the scapholunate ligament alone in two wrists, the lunotriquetral ligament alone in two wrists, and in more than one of these areas in four wrists. A positive arthrogram was associated with a greater positive ulnar variance. All of the subjects had symmetrical motion of the wrists and grip strength, and none of them had tenderness in the wrist. There were no complications related to the arthrography. Perforation of a ligament in the wrist is common in young asymptomatic adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Gender concordance between family practice residents and diagnoses in an ambulatory setting.

BACKGROUND: Female physicians are more likely than male physicians to treat female patients. This study extends the scope of previous studies by scrutinizing gender concordance with specific diagnoses. METHODS: A total of 90,407 physician-patient encounters handled by 90 family practice residents from 1984-1993 in an ambulatory care setting were analyzed. In addition to genitourinary problems, the analysis included the 20 most frequently recorded diagnoses. RESULTS: Patients' encounters with residents differed between male and female residents. Female residents handled more encounters (P < .001) for vaginitis, prenatal care, menstrual disorders, menopausal symptoms, cervicitis, abnormal Pap smear, breast disease, breast lump, and general medical exam (female patient). Female residents handled a greater percentage (P < .001) of female patients within the 20 most frequent diagnoses. There was little difference with male patients. CONCLUSIONS: Gender concordance is suggested between male and female patients with specific diagnoses and their physicians. Educators must balance patient preferences and satisfaction with adequate exposure to the gamut of medical problems.