Standardized patients' perceptions about their own health care.

BACKGROUND: There have been detailed descriptions on standardized patients (SP) programs' effects on students, curricula, and faculty, yet little attention has been paid to the consequences of participating on the SP's. PURPOSE: This study explored the perceptions of SPs toward their own health care in the context of having served as SPs. METHOD: All 180 SPs participating in Department of Medicine programs at 5 medical schools were surveyed. They completed the survey during SP activities, or it was mailed to them. SPs indicated their level of agreement or disagreement with 11 attitude statements related to their own health care after serving as an SP using a Likert scale, with 1 reflecting the most positive attitude and 5 the least positive. RESULTS: Responses to the attitudinal questions were obtained from 164 SPs (91%). SPs perceived that because of their participation as SPs they had a better understanding about medical history taking and physical examinations (1.9 +/- 0.9), communicated more effectively with their health care provider (1.8 +/- 0.9), and were more comfortable with both health care visits and physical examinations (2.2 +/- 0.9). There were no significant differences in results based on gender, age, race, or school. CONCLUSIONS: As a consequence of their participation, the SPs indicated a change in attitudes about their personal health care. They perceived improved understanding and ability to communicate and comfort with their own health care. Participation in SP programs seems to influence SPs by improving perceptions about their own health care interactions.

The responsibilities and activities of internal medicine clerkship directors.

PURPOSE: To characterize the responsibilities, activities, and scholarly productivity of internal medicine clerkship directors (CDs). METHODS: In 1999, internal medicine CDs from 122 U.S. medical schools and one Canadian medical school were surveyed. The instrument asked about the CDs' demo-graphics, workloads, clerkship characteristics, and scholarly productivity. RESULTS: The response rate was 89%; 72% of the respondents were men. Mean age was 45 years, mean time as CD was 6.5 years, and 58% of the CDs had completed fellowship training. The CDs spent 28% of their professional time on the clerkship, three half days weekly in clinic, and three months on inpatient services. The CDs had published a mean of 2.2 (range 0-20) articles and received a mean of 0.7 (range 0-4) grants. Similar factors were associated with publishing articles and receiving grants; gender (men), < or = three clinic half days weekly, fellowship training, having a faculty development program, teaching other courses, and discussing expectations with their department chairs. In a multivariate analysis, fellowship training, clinic half days, teaching other courses, and discussing expectations explained 22% of the variance for papers published. For grants received, a model with gender, clinic half days, a faculty development program, discussing expectations, and teaching other courses explained 35% of the variance. CONCLUSIONS: An internal medicine CD invests significant effort administering the clerkship and contributing to clinical and educational activities. The factors associated with successful scholarship may be useful for fostering CDs' academic careers.

Fumonisin b1 carcinogenicity in a two-year feeding study using F344 rats and B6C3F1 mice.

Fumonisin B1 (FB1) is a mycotoxin isolated from Fusarium fungi that contaminate crops worldwide. A previous study demonstrated that FB1 promoted preneoplastic foci in initiated rats and induced hepatocellular carcinomas in BD IX rats at 50 parts per million (ppm), but fundamental dose-response data were not available to assist in setting regulatory guidelines for this mycotoxin. To provide this information, female and male F344/N/Nctr BR rats and B6C3F1 Nctr BR mice were fed for two years a powdered NIH-31 diet containing the following concentrations of FB1: female rats, 0, 5, 15, 50, and 100 ppm; male rats, 0, 5, 15, 50, and 150 ppm; female mice, 0, 5, 15, 50, and 80 ppm; male mice, 0, 5, 15, 80, and 150 ppm. FB1 was not tumorigenic in female F344 rats with doses as high as 100 ppm. Including FB1 in the diets of male rats induced renal tubule adenomas and carcinomas in 0/48, 0/40, 9/48, and 15/48 rats at 0, 5, 15, 50, and 150 ppm, respectively. Including up to 150 ppm FB1 in the diet of male mice did not affect tumor incidence. Hepatocellular adenomas and carcinomas were induced by FB1 in the female mice, occurring in 5/47, 3/48, 1/48, 19/47, and 39/45 female mice that consumed diets containing 0, 5, 15, 50, and 80 ppm FB1, respectively. This study demonstrates that FB1 is a rodent carcinogen that induces renal tubule tumors in male F344 rats and hepatic tumors in female B6C3F1 mice.

Compensatory regeneration as a mechanism for renal tubule carcinogenesis of fumonisin B1 in the F344/N/Nctr BR rat.

Fumonisin B1(FB1) is a fungal metabolite of Fusarium verticillioides (= F. moniliforme), a fungus that grows on many crops worldwide. Previous studies demonstrated that male BD IX rats consuming diets containing 50 ppm fumonisin B1 developed hepatocellular carcinomas. In our recent studies, diets containing FB1 at 50 ppm or higher concentrations induced renal tubule carcinomas in male F344/N/Nctr BR rats and hepatocellular carcinomas in female B6C3F1/Nctr BR mice. The carcinogenicity of FB1 in rats and mice is not due to DNA damage, as several laboratories have demonstrated that FB1 is not a genotoxin. FB1 induces apoptosis in cells in vitro. Including FB1 in the diets of rats results in increased hepatocellular and renal tubule epithelial cell apoptosis. In studies with F344/N/Nctr BR rats consuming diets containing up to 484 ppm FB1 for 28 days, female rats demonstrated more sensitivity than male rats in the induction of hepatocellular apoptosis and mitosis. Conversely, induction of renal tubule apoptosis and regeneration were more pronounced in male than in female rats. Induction of renal tubule apoptosis and hyperplasia correlated with the incidence of renal tubule carcinomas that developed in the 2-year feeding study with FB1 in the F344/N/Nctr BR rats. The data are consistent with the hypothesis that the induction of renal tubule carcinomas in male rats could be partly due to the continuous compensatory regeneration of renal tubule epithelial cells in response to the induction of apoptosis by fumonisin B1.

Production of recombinant human type I procollagen trimers using a four-gene expression system in the yeast Saccharomyces cerevisiae.

The expression of stable recombinant human collagen requires an expression system capable of post-translational modifications and assembly of the procollagen polypeptides. Two genes were expressed in the yeast Saccharomyces cerevisiae to produce both propeptide chains that constitute human type I procollagen. Two additional genes were expressed coding for the subunits of prolyl hydroxylase, an enzyme that post-translationally modifies procollagen and that confers heat (thermal) stability to the triple helical conformation of the collagen molecule. Type I procollagen was produced as a stable heterotrimeric helix similar to type I procollagen produced in tissue culture. A key requirement for glutamate was identified as a medium supplement to obtain high expression levels of type I procollagen as heat-stable heterotrimers in Saccharomyces. Expression of these four genes was sufficient for correct assembly and processing of type I procollagen in a eucaryotic system that does not produce collagen.

Coumadin necrosis of the skin: report of four patients.

Necrosis of skin and soft tissue as a complication of oral anticoagulation therapy is a rare condition with approximately 200 cases documented in the world. Coumadin-induced skin necrosis is a painful skin lesion, sudden, localized, initially erythematous or hemorrhagic, that becomes bullous and eventually culminates in gangrenous necrosis. It develops mainly in women around 50 years of age who are usually obese and have been treated for thrombophlebitis or pulmonary embolism. There seems to be a marked predilection for areas with increased subcutaneous fat content, such as breasts, thighs, and buttocks. The injury is so significant that plastic surgery is frequently required to repair the damaged tissue. The authors present four clinical cases of Coumadin necrosis, observed in two different institutions, and perform a literature review on the mechanisms that trigger the development of the disease. This condition still remains a diagnostic-therapeutic challenge.

Cystic hygroma of the chest wall: a rare condition.

Cystic hygroma of the chest wall is a very rare condition. A review of the literature showed only 15 cases reported worldwide. The authors report a case of cystic hygroma of the chest wall in a male infant 2 months of age that was successfully treated with surgical excision in one stage. The diagnosis was made by physical examination with transillumination and by its typical sonographic pattern. The diagnosis was confirmed by histopathological examination and there is no evidence of recurrence after 24 months of follow-up. A review of the literature, updating the embryology, classification, and treatment of the disease, is also presented.

Diagnosing and treating congenital melanocytic nevus simulating malignant melanoma.

Many cases reported as malignant melanomas arising in benign congenital melanocytic nevi in the neonatal period have not shown evidence of metastases after several years of follow-up. These lesions were probably pathologically misdiagnosed, thus creating a controversy regarding the precise incidence. This article describes the case of an infant with a giant melanocytic nevus simulating malignant melanoma to illustrate the proper criteria for diagnosis of this condition so extensive and unnecessary therapy procedures can be avoided.

The versatility of double-Z rhomboid plasty.

The versatility of the double-Z rhomboid plasty is demonstrated in the closure of excisional wounds in the face and extremities following resection of skin tumors. The degree of distortion resulting from the double-Z rhomboid, simple rhomboid, and direct closure are compared in foam rubber models. The original design as described by Cuono is compared with modifications suggested by Katoh. The indications for the double-Z rhomboid repair are reviewed and the technical aspects to maximize the results are described.

Acute periodontal abscess associated with an immediate implant site in the maintenance phase: a case report.

This article describes a complication that occurred with root-form implants: an acute periodontal abscess associated with an implant during the maintenance phase. The clinical treatment is outlined, as are the results achieved.

Mohs micrographic surgery.

Mohs micrographic surgery has been highly successful in treating skin cancers that grow in a contiguous manner. The technique requires removal of involved tissue in thin layers and histographic mapping to pinpoint residual tumor. This process is repeated until all of the tumor is resected. This allows 100 percent of all margins to be examined and is very tissue conservative, attributing to its unsurpassed cure rates and excellent cosmetic results. Since it is done as an outpatient procedure under local anesthetic, it also is safe and efficient.

Interventional treatment in evolving myocardial infarction.

Residual myocardial function has been shown by many investigators to be a key factor in determining survival following acute myocardial infarction. In light of this, much effort has been undertaken to develop means of preserving myocardium in the setting of acute myocardial infarction. Acute revascularization has been approached as a logical method to reach this end. The development of more effective thrombolytic agents, better catheter dilatation systems, and improved surgical techniques have now made acute intervention possible, safe, and practical. Because of the marked clinical variability of patient presentation, as well as variability of available medical and surgical resources, a rational and logical system of approach must be developed, such that patients presenting with acute myocardial infarction can receive the most appropriate interventional therapy in any given setting.

Surface electrocardiogram in the detection of transmural myocardial ischemia during coronary artery occlusion.

To examine whether coronary occlusion causing transmural ischemia was accurately reflected by ST-segment elevation on routine electrocardiograms, intracoronary and surface electrocardiograms were simultaneously recorded during percutaneous transluminal coronary angioplasty (PTCA). The study group consisted of 54 patients who had intracoronary ST-segment elevation during transient coronary occlusion (left anterior descending [LAD]: 25 patients, left circumflex [LC]: 19 patients, right coronary artery: 12 patients). Elevation of the ST segment on the surface electrocardiogram (greater than or equal to 0.1 mV) was recorded in 84% of patients during LAD dilatation, in 32% of patients during LC dilatation (p less than 0.01 vs LAD and right), and in 92% of patients during right coronary dilatation (not significant vs LAD). The magnitude of intracoronary ST elevation was 1.10 +/- 0.8, 1.68 +/- 1.2 and 0.8 +/- 0.6 mV for the LAD, LC and right occlusions, respectively (not significant). Thus, despite the comparable magnitude of intracoronary ST elevation, LC occlusion resulted in ST-segment elevation on the surface electrocardiogram in significantly fewer patients than did LAD or right occlusion. During LC occlusion, 9 patients had no electrocardiographic changes and 4 had only precordial ST depression. Thus, in patients with transmural ischemia during right or LAD occlusions, concordant ST elevation on the surface electrocardiogram is common. In contrast, ST-segment elevation is an insensitive marker of LC occlusion. In patients with ongoing ischemic symptoms and isolated precordial ST depression or no repolarization abnormalities, LC occlusion should be considered in the differential diagnosis.