Physician Scientist Training in the United States: A Survey of the Current Literature.

The declining number of physician scientists is an alarming issue. A systematic review of all existing programs described in the literature was performed, so as to highlight which programs may serve as the best models for the training of successful physician scientists. Multiple databases were searched, and 1,294 articles related to physician scientist training were identified. Preference was given to studies that looked at number of confirmed publications and/or research grants as primary outcomes. Thirteen programs were identified in nine studies. Eighty-three percent of Medical Scientist Training Program (MSTP) graduates, 77% of Clinician Investigator Training Program (CI) graduates, and only 16% of Medical Fellows Program graduates entered a career in academics. Seventy-eight percent of MSTP graduates succeeded in obtaining National Institute of Health (NIH) grants, while only 15% of Mayo Clinic National Research Service Award-T32 graduates obtained NIH grants. MSTP physician scientists who graduated in 1990 had 13.5 ± 12.5 publications, while MSTP physician scientists who graduated in 1975 had 51.2 ± 38.3 publications. Additionally, graduates from the Mayo Clinic's MD-PhD Program, the CI Program, and the NSRA Program had 18.2 ± 20.1, 26.5 ± 24.5, and 17.9 ± 26.3 publications, respectively. MSTP is a successful model for the training of physician scientists in the United States, but training at the postgraduate level also shows promising outcomes. An increase in the number of positions available for training at the postgraduate level should be considered.

Tobacco control in Vietnam.

OBJECTIVES: To investigate the use of tobacco in Vietnam. STUDY DESIGN: Review study. METHODS: Data were collected through a review of tobacco-related literature in Vietnam. Grey literature and web content from agencies such as the World Health Organization and the US Centers for Disease Control and Prevention were consulted. RESULTS: Tobacco smoking is still common in Vietnam, although numerous policies have been issued and implemented over the last two decades. Based on the most recent data (2010), the prevalence of smoking among adults aged >15 years was 23.8%, with a higher percentage among males (47.4%) than females (1.4%). The prevalence of smoking among students aged 13-15 was 3.8% (2007), with a similar gender pattern. The prevalence of exposure to secondhand smoke is of concern, with 73.1% and 55.9% of adults reporting exposure to secondhand smoke at home and at work or other places, respectively. Of the adult respondents, 55.5% believed that smoking may cause lung cancer, stroke and heart disease. Most students (93.4%) and adults (91.6%) had seen anti-smoking media messages. Of the students, 56.4% had seen pro-cigarette advertisements on billboards, 36.9% had seen pro-cigarette advertisements in newspapers or magazines, and 8.2% had been offered free cigarettes by tobacco company representatives. The price of cigarettes decreased by approximately 5% between 1995 and 2006, whereas gross domestic product per capita increased by more than 150%. On average, smokers smoked 13.5 cigarettes per day, and spent US$86 on cigarettes per year. Despite such high levels of tobacco exposure in Vietnam, the total tax on cigarettes remains at 45% of the retail price. Furthermore, only 29.7% of smokers had been advised to quit by a healthcare provider in the past 12 months. CONCLUSION: Strong enforcement and evidence-based regulations which rounded on MPOWER are needed to help protect current smokers and non-smokers from the devastating effects of tobacco.

Medical education in Vietnam.

BACKGROUND: Vietnam is one of the most populous countries in Southeast Asia, yet it displays an unsettling lack of doctors. AIMS: Medical education is an important factor contributing to this issue, yet little is known about the system currently in place in Vietnam. METHODS: Through an extensive literary search of medical schools' and Ministry of Health's data, we have examined the current medical education system in Vietnam. RESULTS: At present, there are 12 medical universities, and the general curriculum at each university follows a national framework but tends to vary from university to university. Medical training lasts either 4 or 6 years, with competitive graduates attending residency programs following graduation. While examinations are required to graduate, the lack of a national licensing exam makes it difficult to ensure that a nation-wide standard of quality exists, both at the medical universities themselves as well as amongst the doctors graduating from them. CONCLUSIONS: The development and institution of a national exam would introduce a standard of training throughout Vietnam's medical education system. Further, a substantial portion of a doctor's education is in subjects that are loosely related to medicine. When looking forward it will be important to evaluate whether or not these non-medical subjects detract from the quality of medical training.

Cost-effective imaging approach to the nonbilious vomiting infant.

OBJECTIVE: To develop a cost- and time-effective algorithm for differentiating hypertrophic pyloric stenosis (HPS) from other medical causes of emesis in infants referred from community-based pediatricians and family practitioners to the imaging department of a tertiary children's care facility. METHODS: Eighty-nine vomiting infants (22 females, 67 males) between the ages of 11 and 120 days (mean, 43.5 days) had received nothing by mouth for at least 1 hour before the study. Each child was assessed for duration of vomiting, status of body weight, time and volume of last ingestion, and time of last emesis. A #8 French (Sherwood Medical, St Louis, MO) nasogastric feeding tube was placed in the child's stomach. The contents were aspirated and measured to determine likelihood of HPS. An aspirated volume >/=5 mL implicated gastric outlet obstruction, and ultrasonography (US) was performed. If this study was positive for HPS, the patient was referred for surgery. If US was negative, an upper gastrointestinal series (UGI) was performed. An aspirated stomach contents volume <5 mL suggested a medical cause for the emesis, and UGI was performed. Pediatric surgeons with no knowledge of the volume results palpated the abdomens of 73 of 89 infants (82%). RESULTS: Twenty-three of 89 patients (25%) had HPS. The aspirate criteria for HPS had a sensitivity of 91%, a specificity of 88%, and an accuracy of 89%. Of the false-positive studies (total = 8), six were related to recent significant ingestion (within 2 hours of the study), and two were attributable to antral dysmotility. The surgeons palpated the mass in 10 of 19 patients (53%). Sensitivity and specificity were 53% and 93%, respectively. Only 6 of 89 infants (7%) required both US and UGI to determine the etiology of the nonbilious vomiting. By performing the UGI in 66 patients, it was also found that 14% had slow gastric emptying and 79% had gastroesophageal reflux. Eighty-one percent of the gastroesophageal reflux was significant. CONCLUSION: The volumetric method of determining the proper imaging study is cost- and time-effective in the evaluation of the nonbilious vomiting infant for pyloric stenosis. If US was performed initially in all patients referred for imaging, two studies would have been performed in 68 of 89 patients (76%) to define the etiology of the emesis. Because we used the volumetric method, 62 fewer imaging studies were performed, representing a savings of $4464 and 30 hours of physician time. If children are given nothing by mouth for 3 to 4 hours before gastric aspiration, the specificity of the volumetric method improves to 94%, and the accuracy improves to 96%.

Bone scintigraphy in the detection of chronic recurrent multifocal osteomyelitis.

UNLABELLED: In this study, we describe the importance of the whole-body bone scan in diagnosing the multifocality of chronic recurrent multifocal osteomyelitis (CRMO) and in distinguishing it from unifocal acute hematogenous osteomyelitis. MATERIALS: The medical records and two-phase, whole-body bone scans of 14 patients (mean age 10.5 yr) with the diagnosis of CRMO, were retrospectively reviewed. The diagnosis of CRMO was based on bone biopsy in 9 patients and clinical course/laboratory findings in 5. Bone scans were evaluated for geographic and anatomic locations of their lesions. Correlative radiographs of areas of abnormal uptake were performed to assess the radiographic appearance of the lesions. RESULTS: The presentation of the disease was localized to one painful, tender and swollen periarticular site 86% of the time. The number of lesions detected by bone scan varied from 1-18 (mean 6). Most lesions were metaphyseal, proximal or distal tibial lesions. Purely sclerotic or mixed (sclerosis and lysis) lesions were found on radiographs. Bilateral lesions were seen in 64% of patients. Biopsies were negative for organisms in all patients and exhibited subacute or chronic histologic changes in most instances. Complications of chronic hyperemia included marked overgrowth (5), diffuse demineralization (1), angular deformity (1) and length discrepancy (1). CONCLUSION: The identification of the multifocal configuration of the disease process by two-phase (soft-tissue and delayed) whole-body bone scintigraphy results in appropriate diagnosis and therapy of CRMO. Additional sites for possible bone biopsy become apparent for exclusion of other diagnoses. Supportive (nonsteroidal, anti-inflammatory medication) instead of antimicrobial therapy can be initiated with significant cost savings.

Nuclear medicine in pediatric orthopedics.

In this presentation, the common clinical pediatric problems (appendicular growth aberrations, hip pain, back pain, some aspects of trauma, and inflammatory and infectious processes that can be addressed by nuclear imaging will be discussed. The accurate interpretation of bone scintigraphy in the evaluation of pediatric orthopedic conditions depends on the use of appropriate radiopharmaceuticals and imaging techniques specific for the pediatric population, a knowledge of physiologic changes in the growing skeleton, as well as the different disease processes peculiar to each age bracket. The physes (growth-plates) will be discussed in detail because they are the most active portion of the pediatric skeleton. Their activity (potential for growth) can be altered by physiologic, developmental aberrations (varus and valgus) and pathologic conditions (trauma, infection, etc.).

The use of the salivagram in the evaluation of severe and chronic aspiration.

Chronic salivary aspiration may be responsible for a significant percentage of pneumonia in the neurologically impaired child. The radionuclide salivagram (RS), a simple investigative study, can document salivary aspiration as the source of pulmonary contamination. The purpose of this study was to determine if the results of the RS would accurately identify children with severe and chronic salivary aspiration who would benefit from laryngotracheal separation (LTS). We reviewed 30 records of children with chronic aspiration pneumonitis who underwent LTS between 1988 and 1996. We recorded the number of inpatient days required for respiratory infections before and after LTS. This number was compared with the number of inpatient days for respiratory infection from children (n = 27) who underwent the RS during a ten-month period but who were never referred for LTS. Fifteen children who underwent LTS had a preoperative RS. The RS documented salivary aspiration in 11 of these children. Aspiration was effectively controlled by LTS for this group. There were three studies that failed to show either aspiration or progression of the Technetium 99m sulfur colloid (Tc 99m SC) into the esophagus This finding was felt to represent significant swallowing dysfunction and, therefore, was also considered a positive finding. There was a significant difference in the number of inpatient days for children who had a negative RS and were never referred for LTS when compared with the number of inpatient days for those children who had a positive RS and were referred for LTS. We feel that the RS is an effective tool to document salivary aspiration as the source of recurrent pneumonia. A modification of the technique and interpretation of RS is suggested.

Imaging techniques in childhood arthritis.

Technological advances in imaging have given physicians caring for children with arthritis a greater opportunity to detect abnormalities early in the course of a disease and better methods for monitoring chronic changes. Indications for using radiography, bone densitometry, nuclear medicine, ultrasound, CT scanning, and MR imaging are discussed in this article. In this era of managed care, the practicing clinician is urged more than ever to consult with the radiologist in selecting the study or sequence of studies to be used in particular case. In this way, evaluation can be limited to the most effective strategy from both the clinical and cost perspectives.

Economic issue in pediatric nuclear medicine: cortical scanning of acute pyelonephritis.

Pediatric nuclear medicine, in order to survive, must be innovative in finding ways of competing with other pediatric imaging subspecialties for the health care dollars. Newer radiopharmaceuticals and imaging methods that are time-effective in answering clinical problems and cost-effective in attracting the health care providers are ways of accomplishing this difficult task. Renal cortical scanning for the diagnosis of acute pyelonephritis is presented as an example of an existing nuclear medicine study that is accurate and cost-effective, but has not yet taken a major place in the imaging armamentarium. In this discussion, the cortical scan is endorsed as the primary imaging tool for children presenting with acute urinary infection.

The renal axes in spina bifida: issues of confusion and fusion.

The occurrence of horseshoe kidneys in myelodysplasia has been suggested to be overestimated because of the concurrent prevalence of kyphotic spine in the spina bifida population. Pseudohorseshoe kidneys result from the actual medial migration and apposition of the lower renal poles in the deep fossa created by the gibbus deformity. The presence of a lumbosacral kyphosis, however, does not imply there is not a true horseshoe kidney. In our myelodysplasia population of 189 patients, occurrence of true horseshoe kidneys (13 patients) and pseudohorseshoe kidneys (14 patients) was increased. The finding of lumbosacral kyphosis was twice as common in the pseudohorseshoe population as in the true horseshoe population. True horseshoe kidneys were three times more commonly seen in association with congenital vertebral anomalies cephalad to the dysraphic spine. Diagnosis in this study was predominantly based on renal cortical scintigraphy with the posterior pin-hole magnification technique.

Hypervitaminosis A as a complication of treatment for neuroblastoma.

A case of hypervitaminosis A (HVA) as a complication of therapy for stage-IV neuroblastoma is presented. The patient was randomized to a trial of 13-cis -retinoic acid (a vitamin A-related compound) after completing routine chemotherapy. This acid was given as a means of maturing potential minimal residual disease. A routine follow-up bone scan revealed areas of increased activity, initially along the midshaft of the right ulna and subsequently bilaterally, which were ultimately found to be due to HVA. Hypervitaminosis A has not been previously reported in this setting, and awareness of the condition is important in centers where this treatment is contemplated.