Practicing physicians' assessments of the impact of their medical-school clinical hospice experience.

BACKGROUND: The authors measured the impact of a clinical hospice experience in medical school on present medical practice by surveying former students after graduation. METHODS AND RESULTS: Of the graduates who apparently received anonymous questionnaires, 46 (71%) completed and returned them. Most were still in residency, and about a third were in private practice. Using a Likert scale, most gave the highest possible rankings in response to questions about how the experience had affected their present day-to-day communication with patients and their working knowledge of pain control, and the general question that asked about understanding quality-of-life issues. Written responses noted positive effects of the experience on the physicians' present practices, including improved knowledge of and attitudes towards dying patients, assessment of the effects of disease on patients and families, and quality-of-life. CONCLUSIONS: Although course work about death and dying is increasingly encountered in medical-school curricula, an intensive, focused clinical exposure is often lacking. This type of exposure has positive effects on physicians' self-assessments of their knowledge, attitudes, and skills in their present practices.

Rapid enzyme diagnosis of patients with acute chest pain reduces patient stay in the coronary care unit.

We have studied the effect of early exclusion of myocardial infarction using rapid biochemical diagnosis on the management of patients admitted to the coronary care unit of a district general hospital. Diagnosis was based on the rate of creatine kinase increase in serial samples obtained over the 8 h following admission. For an initial 3-month familiarization period serial creatinine kinase results were made available at the end of working day to supplement clinical management, supported by our traditional protocol of admission and daily enzyme determinations. Subsequently, for a 4-month period, the admission to 8 h serial values were provided by 1100 h each day and usually within 24 h of admission. There was a net reduction in length of stay on the coronary care unit to a median 2 days (n = 66) compared with 3 days (n = 41) for patients without further cardiac symptoms or electrocardiographic changes suggestive of ischaemia or infarction. This change was significant, P = 0.007, Mann-Whitney U test. Reversion to the original protocol of daily enzyme estimations resulted in an increase in the length of stay on the coronary care unit back to a median of 3 days for this patient group. Rapid diagnostic protocols, applied within routine clinical practice, have the potential for real reduction in coronary care unit stay.

Diagnosis of acute myocardial infarction from sequential enzyme measurements obtained within 12 hours of admission to hospital.

A prospective study was made of sequential changes in serum creatine kinase (CK) and CK-MB isoenzyme activity within the 12 hours following admission to the coronary care unit on 65 patients with recent chest pain. CK determinations were performed in the laboratory or in the coronary care unit using a dry reagent strip analyser. Slope values for log CK/hour and log CK-MB/hour were calculated, used to confirm or exclude the diagnosis of myocardial infarction, and compared with diagnosis by conventional means. Compared with retrospective diagnosis using all available information, the CK slope had a sensitivity of 100% and a specificity of 94%. This compared with a sensitivity of 94% and specificity of 90% for diagnosis using upper reference limits alone. Determination of CK slope permits very rapid and accurate biochemical confirmation or exclusion of myocardial infarction and the possibility of performing the measurements on the coronary care unit. It additionally offers the prospect of major cost savings resulting from early discharge or transfer from the coronary care unit.

Development of a radioimmunoassay for measuring gonadotrophin releasing hormone in patients receiving treatment.

A radioimmunoassay for the measurement of gonadotrophin releasing hormone (GnRH) in plasma and urine using readily available reagents was developed. The GnRH assay showed good precision, recovery, and parallelism over a wide range of GnRH concentrations with a sensitivity of 15 pg/ml. The assay was compared with a commercially available kit (Buhlmann Laboratories). Although the Buhlmann kit showed acceptable precision, recovery, sensitivity, and correlation with the developed GnRH assay for plasma samples, lack of parallelism of serially diluted plasma and urine samples was consistently observed, together with a poor correlation with the developed GnRH assay for urine, suggesting a matrix effect with the Buhlmann kit. The developed assay is suitable for measuring GnRH in samples obtained from patients receiving pulsatile infusions of GnRH. In contrast, the commercially available Buhlmann kit was unsuitable for measuring plasma GnRH as the kit had a top standard of only 160 pg/ml, well below the peak plasma concentration. It would not be possible to dilute samples for analysis because of the lack of parallelism of diluted samples compared with standards obtained with the Buhlmann assay.

Correlations between serum proteins modified by acetaldehyde and biochemical variables in heavy drinkers.

A strong and highly significant correlation was observed between serum aspartate transaminase (AST) activity and an index of the cytotoxic activity associated with serum proteins modified by acetaldehyde in a group of 24 heavy drinkers. A weaker but significant correlation (R = 0.564, p = 0.008) was found between total serum creatine kinase activity and this index of serum cytotoxicity. As it is likely that the concentration of circulating modified protein was largely determined by the quantity of free acetaldehyde generated in the liver and that the AST activity was mainly derived from damaged hepatocytes, the data indicate a correlation between hepatic acetaldehyde generation and hepatocyte damage. This correlation may indicate either that increased quantities of acetaldehyde are released by damaged hepatocytes or that acetaldehyde is hepatotoxic in vivo. As only the creatine kinase isoenzyme present in skeletal muscle (CK-MM) was demonstrable in the serum in all but one of our patients, the data also suggest that circulating modified serum proteins may be toxic towards skeletal muscle cells.

Benign Leydig cell tumour and germ cell carcinoma in situ in a young man with gynaecomastia.

A 21-year-old man presented with a 16-year history of recurrent pyrexial episodes and a 5-year history of gynaecomastia. Blood and urinary oestrogen levels were elevated and a mass was found in the upper pole of a retractile right testis. After orchidectomy, oestrogen levels fell, gynaecomastia regressed and the pyrexial episodes ceased. Histological examination of the right testis showed a benign Leydig cell tumour in the upper pole and a germinal cell carcinoma in situ in the remaining part of the testis. Thus a potentially lethal condition was detected at an early pre-malignant phase by virtue of a benign, endocrinologically active tumour. This would seem to be the first report of the co-existence of a Leydig cell tumour and germ cell carcinoma in the same testis.

Increased plasma pancreatic polypeptide in chronic alcohol abuse.

Post-prandial plasma gastrointestinal hormone profiles were measured in nine chronic alcoholics, one and fourteen days after complete alcohol withdrawal. Basal plasma pancreatic polypeptide concentration (PP--mean +/- SE mean) was significantly greater in alcoholics (control, 28 +/- 5 pmol/l; alcoholics, post-withdrawal day 1, 62 +/- 14 pmol/l, P less than 0.05; and post-withdrawal day 14, 89 +/- 17 pmol/1, P less than 0.005). The total integrated (TIR) PP response following a test breakfast was similarly elevated (control, 442 +/- 63 units; alcoholics, day 1, 1310 +/- 231 units, P less than 0.005; day 14,1066 +/- 66, P less than 0.005). Basal and TIR values for gastrin, gastric inhibitory peptide, insulin and glucagon were similar in alcoholics and controls. As PP has been shown to inhibit pancreatic exocrine enzyme secretion, these findings may help explain the abnormal pancreatic function seen frequently in alcoholics.

The value of ultrasound for monitoring ovarian responses to gonadotropin stimulant therapy.

Ultrasonic measurement of ovarian follicles was used in conjunction with conventional measurement of urinary oestrogen output to monitor responses in infertile women receiving gonadotrophin stimulant therapy. In the 21 women who conceived during the first 15 months, in which this combined monitoring was used, ultrasound proved superior to oestrogen measurement alone for assessing follicular maturity and hence deciding when to administer the ovulating dose fo chorionic gonadotrophin. The use of ultrasound imaging improves efficiency of treatment with gonadotrophin stimulant therapy, but is not predictive of multiple pregnancy or of hyperstimulation.

Abnormal suppression of plasma cortisol during the intravenous infusion of dexamethasone to alcoholic patients.

In some cases the oral administration of dexamethasone to alcoholic patients has failed to cause a normal depression of plasma cortisol levels. Although alcoholics often show signs of intestinal malabsorption, the possibility that the dexamethasone was not fully absorbed has not previously been considered. To eliminate any question of malabsorption, ten male alcoholic patients were infused intravenously with dexamethasone (1 mg/h). The plasma cortisol levels in blood samples withdrawn at half-hourly intervals during a 2-h infusion were compared with the values found in ten normal subjects similarly infused. Four of the alcoholics failed to show normal suppression of plasma cortisol levels, thus confirming that in some alcoholics there is a disturbance of pituitary-adrenal function similar to that found in Cushing's disease. In only one of the four cases was failure to suppress normally associated with the presence of clinical signs of Cushing's disease.