Immune response of the tammar wallaby (Macropus eugenii) to sperm antigens.

In the present study, male and female tammar wallabies were immunised with whole tammar wallaby sperm in adjuvant. An assay for sperm antibodies using a live sperm ELISA has been developed to detect sperm surface antigens and used to validate an assay using a 3-[(3-cholamidopropyl) dimethylammonio]-1 propanesulfonate (CHAPS) membrane extract of whole tammar wallaby sperm. The tests were used to monitor the immune response to whole sperm in both male and female tammar wallabies. Antisera with a limited array of specificities were generated, with those locating to the midpiece region of the sperm appearing the most likely candidates for targets for fertility perturbation based on immunofluorescence of fixed and non-fixed sperm. These systemically generated antibodies were demonstrated to have access to both the female and male tammar reproductive tracts and were found on ejaculated sperm and antibodies from female sera and follicular fluid-labelled fresh ejaculated sperm from non-immunised males. Preliminary sequencing of these proteins has identified some possibilities for further investigation.

Porcine zonae pellucidae immunization of tammar wallabies (Macropus eugenii): fertility and immune responses.

This study looked at the feasibility of targeting the zona pellucida for a contraceptive vaccine as a possible alternative method of control for overabundant macropods. Tammar wallabies, as a model for other macropods, were immunized with porcine zonae pellucidae (PZP) and were found to achieve significant concentrations of antibody to PZP in sera and reproductive tract fluids. Wallabies immunized with PZP exhibited lower ovarian weight with reduced numbers of antral follicles when compared with control animals. Wallabies were placed in a natural mating trial followed by an artificial insemination trial. None of the PZP-immunized wallabies produced offspring in the natural mating trial compared with 67% of control animals. To further assess fertility, a sub-sample of the wallabies were superovulated and artificially inseminated. This resulted in all control wallabies producing fertilized ova and all PZP-immunized wallabies failing to ovulate. These results suggest that immunocontraception based on targeting antigens of the zona pellucida may be an effective strategy for fertility reduction in macropods.

A complete stylohyoid bone with a stylohyoid joint.

Different clinical entities are associated with elongation of the styloid process or ossification of the stylohyoid ligament. Although partial ossification of the stylohyoid ligament is not uncommon, complete ossification is rare. We present a rare case of complete ossification of the stylohyoid ligament. This case may represent the extreme end of the spectrum of entities known as cervicopharyngeal pain syndrome, which includes Eagle's syndrome, stylohyoid syndrome, and pseudostylohyoid syndrome.

The role of endoscopic sinus surgery in chronic sinonasal sarcoidosis.

The aim of this study was to define a role for endoscopic sinus surgery (ESS) in the treatment of chronic sinonasal sarcoidosis. All patients seen for sinonasal sarcoidosis in an otolaryngology practice in a tertiary care center from 1991 to 2000 were reviewed. Of 86 patients, 6 were treated with ESS for an operative rate of 7%. Surgeries were performed on those patients with significant sinonasal anatomic blockage. This included nasal obstruction from nasal polyposis and chronic and recurrent acute sinusitis from granulomatous lesions of the ostiomeatal complex. Patients remained symptom free for years after surgery on a nasal steroid regimen. Endoscopic sinus surgery is a viable treatment for those few patients with nasal obstruction or chronic sinusitis due to anatomic blockage from sinonasal sarcoidosis. Although it does not eradicate the disease or prevent recurrence, it does markedly improve quality of life by relieving severe symptoms and reducing the need for systemic steroids. This is the first study to advocate a role for surgery in sinonasal sarcoidosis beyond biopsy and management of complications. Although it may not be the appropriate approach for every patient, ESS certainly should be considered in the treatment options.

Home health nurse clinical assessment of neonatal jaundice: comparison of 3 methods.

OBJECTIVE: To compare 3 methods of clinical assessment of jaundice in newborns by home health nurses. DESIGN: Prospective clinical trial. SETTING: Homes of newborns living within 10 miles of a 340-bed community hospital where they were delivered. PARTICIPANTS: Home health nurses and newborn patients (< or =2 weeks old). INTERVENTIONS: The nurses examined the newborns and documented whether they detected jaundice. In newborns thought to have jaundice, the nurses estimated bilirubin levels, documented the extent of caudal progression of the jaundice, and determined the Ingram (Cascade Health Care Products, Salem, Ore) icterometer readings from the newborns' noses. Total serum bilirubin tests were obtained from all newborns studied. OUTCOME MEASURES: Nurse assessment of the presence of jaundice and its caudal progression, nurse estimates of bilirubin levels, icterometer readings, and bilirubin levels. RESULTS: The nurses determined that 82 (50%) of the 164 newborns had jaundice. Their estimates of bilirubin levels were most highly correlated with serum bilirubin levels (Pearson correlation, 0.61). All 3 newborns with bilirubin levels greater than or equal to 291 micromol/L (> or =17 mg/dL) were recognized by the nurses as having jaundice. These newborns had icterometer readings greater than or equal to 3.5 and had estimated bilirubin levels of greater than or equal to 274 micromol/L (> or =16 mg/dL). CONCLUSIONS: The method of evaluation that each nurse was accustomed to using was the most accurate in determining the severity of newborn jaundice. These results suggest that postpartum home health nurses can effectively evaluate newborns for the presence and severity of jaundice.

Meta-analysis of tympanostomy tube sequelae.

OBJECTIVE: To estimate the incidence of tympanostomy tube sequelae based on systematic review of published case series and randomized studies. DATA SOURCES: English-language MEDLINE search from 1966 through April 1999 with manual reference search of proceedings, articles, reports, and guidelines. STUDY SELECTION: Cohort studies with otitis media as the primary indication for tube placement. DATA EXTRACTION: Two reviewers independently extracted data from 134 articles. DATA SYNTHESIS: Transient otorrhea occurred in 16% of patients in the postoperative period and later in 26%; recurrent otorrhea occurred in 7.4% of patients and chronic otorrhea in 3.8%. Sequelae of indwelling tubes included obstruction (7% of ears), granulation tissue (5%), premature extrusion (3.9%), and medial displacement (0.5%). Sequelae after tube extrusion included tympanosclerosis (32%), focal atrophy (25%), retraction pocket (3.1%), cholesteatoma (0.7%), and perforation (2.2% with short-term tubes, 16.6% with long-term tubes). Meta-analysis showed that long-term tubes increased the relative risk of perforation by 3.5 (95% CI, 1.5 to 7.1) and cholesteatoma by 2.6 (95% CI, 1.5 to 4.4). Similarly, intubation increased the relative risk of tympanosclerosis by 3.5 (95% CI, 2.6 to 4.9) and focal atrophy by 1.7 (95% CI, 1.1 to 2.7) over nonintubated control ears (baseline tympanosclerosis and atrophy rates of 10% and 14%, respectively). CONCLUSIONS: Sequelae of tympanostomy tubes are common but are generally transient (otorrhea) or cosmetic (tympanosclerosis, focal atrophy). Nonetheless, the high incidence suggests a need for ongoing otologic surveillance of all patients with indwelling tubes and for a reasonable time period after tube extrusion. Long-term tubes should be used on a selective and individualized basis.

Physician gender and psychosocial care for children: attitudes, practice characteristics, identification, and treatment.

OBJECTIVE: To examine differences by physician gender in the identification and treatment of childhood psychosocial problems. DESIGN: Survey of patients (n = 19,963) and physicians (n = 366) in primary care offices in 2 large, practice-based research networks. Multivariate regressions were used to control for patient, physician, and visit characteristics, with a correction for the clustered sample. SUBJECTS: Children ages 4 to 15 years seen consecutively for nonemergent care. MEASURES: Physician report of attitudes, training, practice factors, and identification and treatment of psychosocial problems. Parental report of demographics and behavioral symptoms. RESULTS: Compared with male physicians, female physicians were less likely to view care for psychosocial problems as burdensome. They were more likely to see children who were female, younger, black or Hispanic, in single-parent households, enrolled in public or managed health plans, and with physical health limitations. Children seen by male physicians had higher symptom counts. Male physicians were more likely to report having primary care responsibility for their patient and that parents agree with their care plan. Female physicians spent more time with patients. After controlling for these differences, female physicians did not differ from male physicians in identification or treatment of childhood psychosocial problems. CONCLUSIONS: Male and female physicians see different kinds of children for different visit purposes and have different kinds of relationships with their patients. After controlling for these factors, management of childhood psychosocial problems does not differ by physician gender. Improving management of psychosocial conditions depends on identifying modifiable factors that affect diagnosis and treatment; our work suggests that characteristics of the practice environment, physician-patient relationship, and patient self-selection deserve more research.

Liquid medication dosing errors.

BACKGROUND: Our goal was to examine the following issues relevant to the use of liquid medications: (1) which liquid medication dosing devices are commonly owned and used; (2) the ability of potential patients to accurately measure liquids using 3 different dosing devices; (3) their ability to correctly interpret a variety of dosing instructions; and (4) their ability to correctly interpret a pediatric dosing chart. METHODS: One hundred thirty volunteers from the waiting areas of 3 primary care clinics in the St. Paul, Minnesota, area were interviewed. Participants were shown 7 liquid dosing devices and were asked which they had in their homes and which they had ever used. The participants were tested and scored on their ability to measure liquid medicines and interpret dosing instructions accurately. The total performance score was determined, with a maximum obtainable score of 11. RESULTS: A household teaspoon was the device most frequently used for measuring liquid medication. Women and participants with more education had higher total performance scores. Common errors included misinterpreting instructions, confusing teaspoons and tablespoons on a medicine cup, and misreading a dosage chart when weight and age were discordant. CONCLUSIONS: Clinicians need to be aware that many people continue to use inaccurate devices for measuring liquid medication, such as household spoons. They should encourage the use of more accurate devices, particularly the oral dosing syringe. Clinicians should always consider the possibility of a medication dosing error when faced with an apparent treatment failure.

Choosing a family physician. What do patients want to know?

What type of information do patients find valuable when choosing a family physician? At a suburban Midwestern clinic, 221 adults rated the value of 12 demographic items and eight attributes pertaining to physicians. Of the demographic information, board certification was most valued by respondents; all personal attributes listed were rated very highly. Although 44% of women preferred a female physician, 93% of women agreed that, in general, male and female family physicians are equally competent. In summary, a physician's personal attributes and characteristics are of most importance to consumers when choosing a family physician. With the exception of board certification status, information about a physician's training or demographics is of much less value to patients. In addition, the information identified as most important in the survey is not typically provided by managed care organizations.

Evaluation and management of newborn jaundice by midwest family physicians.

BACKGROUND: Recognition and management of newborn jaundice is controversial and even more challenging with the early discharge of newborns. The purpose of this study was to describe the jaundice management patterns of family physicians in Minnesota and Wisconsin and compare them with American Academy of Pediatrics recommendations. METHODS: Forty-two members of the Practice-Based Research Group of the Wisconsin Research Network and of the Minnesota Academy of Family Physicians Research Network recorded information on study cards about the care they provided to healthy full-term newborns for 6 months. RESULTS: Data was collected on 335 infants, 30% of whom were jaundiced. Physicians ordered limited laboratory testing on selected jaundiced infants. Infants with jaundice were more frequently breast-fed, and had longer hospital stays. Jaundice was commonly managed by phototherapy (17%), home sunlight (28%), and increased breast-feeding (44%). Twenty-six percent of the physicians used a formal phototherapy guideline. The timing of the first follow-up visit did not differ for infants discharged before or after 48 hours of age. CONCLUSIONS: Family physicians identified and managed newborn jaundice relatively infrequently in our study. Their practice patterns were consistent with most aspects of the American Academy of Pediatrics jaundice guideline, although few of them used it to guide phototherapy use. The study physicians did not generally follow recommendations for follow-up of infants discharged early. Until a large-scale clinical trial of newborn jaundice management is performed, a variety of practices should continue to be acceptable.

Use of a structured encounter form to improve well-child care documentation.

OBJECTIVE: To determine if a structured encounter form for well-child care improves documentation of well-child care. DESIGN: Retrospective medical record review of a before-and-after trial. SETTING: Family practice residency clinic serving a primarily low-socioeconomic urban population. PATIENTS: Children younger than 6 years receiving well-child care visits. INTERVENTION: Detailed checklists were developed and implemented in 1994 for each of 12 well-child examinations for the assessment of children aged 2 weeks to 5 years based on recommendations from the American Academy of Pediatrics and the US Preventive Services Task Force. MAIN OUTCOME MEASURES: Documentation of multiple aspects of well-child care, including developmental assessment, safety and nutrition counseling, and laboratory tests for 6-month periods in 1993 and 1994, before and after implementation of the structured encounter form. RESULTS: A total of 842 well-child visits were reviewed. Documentation improved significantly with the use of the encounter form for 19 of the 23 aspects of well-child care that were studied. Screening test rates were less than optimal despite the encounter form. CONCLUSIONS: The structured encounter form was very effective in improving documentation of almost all aspects of well-child care. However, effective communication is needed among physicians, nurses, and parents to ensure optimal screening test rates.

Facial nerve stimulation from cochlear implants.

OBJECTIVE: To evaluate the incidence of facial nerve stimulation from cochlear implants and to better define the segment of nerve being stimulated and the causes of stimulation. STUDY DESIGN: Retrospective patient case review and a temporal bone dissection study. SETTING: A tertiary care setting. PATIENTS: All patients given a cochlear implant at the Hospital of the University of Pennsylvania. This encompassed only adult patients. INTERVENTION: All patients had surgical insertion of either a 3M single channel, Nucleus 22-channel, or CLARION multichannel cochlear implant. MAIN OUTCOME MEASURES: Demonstration of facial nerve stimulation with a cochlear implant and determination of affected electrodes; measurement of electrode location and distances between the labyrinthine segment of the facial nerve and the cochlea in temporal bone dissections: and determination of the relationship between the labyrinthine facial nerve and the cochlea using computed tomography evaluation. RESULTS: The overall incidence of facial nerve stimulation using all three devices was 14% (8 of 58). Otosclerosis and otosyphilis appear to be predisposing conditions to stimulation. The mid-cochlear electrodes, located near the labyrinthine facial nerve, appear to cause stimulation of the VIIth nerve most commonly. Computed tomographic evaluation of the bone between the labyrinthine fallopian canal and the cochlea may provide some indication of potential facial nerve problems. CONCLUSION: Facial nerve stimulation from the use of cochlear implants is more prevalent in patients with otosclerosis and otosyphilis. The labyrinthine segment of the facial nerve is the most likely area being stimulated in most patients. Preoperative computed tomographic evaluation may be beneficial in determining the possibility of this problem.

A clinic system to improve preschool vaccinations in a low socioeconomic status population.

OBJECTIVE: To determine if a clinic system to assess and vaccinate preschool-age children at every clinic visit can improve vaccination rates. DESIGN: A nonequivalent control group design contrasting an intervention clinic with a comparison clinic. SETTING: Two urban St Paul, Minn, clinics. The intervention clinic is a family practice residency clinic, and the comparison, clinic is a community health center clinic. PATIENTS: Primarily a low socioeconomic status white population. INTERVENTIONS: A clinic-wide system to identify and vaccinate children at all clinic visits. Appointment personnel, medical assistants, and physicians all had roles in the intervention protocol. MAIN OUTCOME MEASURES: Percentage of children at the 2 clinics who were up-to-date for a primary vaccine series at age 24 months and also at the end of the study collection periods, preintervention and postintervention. RESULTS: The intervention clinic improved the percentage of children up-to-date for a primary vaccine series at age 24 months from 42% to 56% (P = .02), while the percentage at the comparison clinic did not change significantly (P = .81). Similarly, the intervention clinic improved the percentage of children up-to-date for age at the end of the study periods from 49% preintervention to 63% postintervention (P = .02), while the percentage at the comparison clinic did not improve significantly (P = .45). The system was especially useful for children with few visits to the intervention clinic. CONCLUSIONS: Although the intervention clinic resulted in a substantial improvement in vaccination rates for preschool-age children, rates remained well below national goals. A combination of clinic, community, and national initiatives may be needed to ensure appropriate vaccination rates for this challenging patient population.

Effectiveness of a nurse-based intervention in a community practice on patients' dietary fat intake and total serum cholesterol level.

OBJECTIVE: To evaluate the effect of a nurse-based intervention for patients with high total cholesterol (TC) levels in a community practice. DESIGN: Clinical trial without a control followed by a nonrandomized control trial. SETTING: Suburban primary care practice. PATIENTS: White patients with TC higher than 6.21 mmol/L (240 mg/dL). In the initial trial, 82 patients with a mean TC level of 6.80 mmol/L (263 mg/dL). Fifty-three preponderantly female patients in the nonrandomized control trial with a mean TC level of 6.83 mmol/L (264 mg/dL). INTERVENTION: Counseling by office nurses using the Eating Pattern Assessment Tool and handouts with brand-specific food advice. In the initial study, patients attended up to 5 nurse counseling visits. In a follow-up study, intervention patients attending 2 or more counseling sessions were matched with other patients in the practice. MAIN OUTCOME MEASURES: Eating Pattern Assessment Tool scores in the initial study and TC levels in both trials. RESULTS: Mean Eating Pattern Assessment Tool scores at baseline in both studies demonstrated that intervention patients were already following a diet consistent with the National Cholesterol Education Program Step I Diet. In the initial study, mean TC levels of the patients declined 2% (P < .05) and mean Eating Pattern Assessment Tool score improved from 23.4 to 20.4 (P < .001). In the follow-up study, the mean TC level of all patients improved significantly (P = .002). However, the improvement of the intervention patients was no better than that of the comparison patients. CONCLUSION: The nurse counseling intervention was not effective in patients already following a Step I Diet.

Recognition of the presence and severity of newborn jaundice by parents, nurses, physicians, and icterometer.

OBJECTIVE: To determine how well parents, nurses, physicians, and an Ingram icterometer can detect the presence and the severity of jaundice in newborns. SETTING: Normal newborn nursery in a 340-bed teaching hospital. PATIENTS OR OTHER PARTICIPANTS: Nurses and physicians caring for nursery infants and parents of the infants. INTERVENTIONS: Physicians and nurses examining newborns documented whether they detected jaundice in the infants and, if so, the estimated bilirubin level and the extent of cephalocaudal progression of the jaundice. An assistant taught the parents how to examine the infants for jaundice and determine its cephalocaudal progression. The assistant also obtained icterometer readings. Bilirubin testing was performed according to usual clinical practice. OUTCOME MEASURES: Nurse and physician estimates of bilirubin levels; parent, nurse, and physician assessment of the presence of jaundice and its cephalocaudal progression; icterometer readings; bilirubin levels. RESULTS: There was moderate agreement about the presence of jaundice in the infants (pairwise kappa, 0.48) However, all infants with bilirubin levels >12 mg/dL were correctly identified as jaundiced by all examiners. The parents' assessment of cephalocaudal progression and the icterometer readings were most highly correlated with serum bilirubin levels (adjusted Pearson correlations, 0.71 and 0.57, respectively). CONCLUSIONS: Many parents can be taught to accurately assess cephalocaudal progression of jaundice in the hospital. The icterometer is a useful tool for assessing jaundice severity. Both parent assessment and the icterometer were more highly correlated with bilirubin levels than physician and nurse estimates in this study. Additional research is needed to determine how accurate these methods of clinical assessment are at the higher bilirubin levels that typically occur after hospital discharge.

Gay and lesbian physicians in training: family practice program directors' attitudes and students' perceptions of bias.

BACKGROUND: Disclosure of homosexual orientation by medical students or physicians has generally been regarded as having dire professional consequences. We surveyed family practice residency directors to determine how knowledge of homosexual orientation might affect a residency applicant's ranking. We then surveyed gay and lesbian medical students to better understand their attitudes and beliefs about disclosure of orientation during residency application. METHODS: A survey was mailed to all family practice residency directors and a convenience sample of third- and fourth-year gay and lesbian medical students. RESULTS: The program director response rate was 73%. Of these respondents, 67% showed accepting attitudes toward homosexuality, 25% were neutral, and 8% had negative views. One of four directors admitted they "might rank" or "most certainly" would rank an applicant known to be gay lower than a heterosexual one. The medical student response rate was 81%. When choosing a specialty, 42 students (71%) considered how other physicians might accept them as a lesbian or gay provider. Psychiatry and family practice were perceived as the most accepting specialties. Thirty-one student respondents (52%) agreed that at most residency programs, an applicant known to be gay or lesbian would be ranked lower than an applicant assumed to be heterosexual. CONCLUSIONS: Most family practice residency directors have accepting attitudes toward gays and lesbians in general, but 25% of directors express hesitation in matching openly gay residents. Gay and lesbian medical students want to match in residency programs where they will be welcomed and respected but fear discrimination if they disclose their orientation.

Diagnosis and management of complications of self-injection injuries of the neck.

When IVDUs who lose peripheral access turn to their necks, they invite a spectrum of unique complications that require particular management and treatment. While many of these complications are infectious, other possibilities include vocal cord paralysis and needle fragment foreign bodies. Work-up of these patients must include a very thorough history and physical exam, particularly of the head and neck, complete with a laryngeal exam. All patients should undergo imaging studies, including plain films, CT or MRI of the neck, and other studies as appropriate. Laboratory studies should include HIV and hepatitis serologies. Because of the risks to the surgical team, neck explorations, when indicated, should be performed under general anesthesia with strict adherence to universal precautions. Further management includes early referrals to methadone clinics, although unfortunately poor patient compliance is usual. Public campaigns aimed at prevention are useful, although limited, and should be encouraged.