The primary care specialties working together: a model of success in an academic environment.

In today's environment of decreasing resources and increasing competition among clinical delivery systems, survival and ultimate success require interdisciplinary cooperation and, if possible, integration. Academic leaders at the University of California, Irvine (UCI), have developed a collaborative model in which faculty in family medicine, general internal medicine, and general pediatrics cooperate extensively in education, research, and patient care. Generalist faculty jointly administer and teach both a four-year "doctoring" curriculum for medical students and an array of integrated curricula for primary care residents, including a communication skills course. Several primary faculty jointly developed a collaborative unit for health policy and research, now an active locus for multidisciplinary research. Other faculty worked together to develop a primary care medical group that serves as a model for interdisciplinary practice at UCI. Recently, the university recruited an associate dean for primary care who leads the new UCI Primary Care Coalition, reflecting and promoting this interspecialty cooperation. This coalition does not represent a step toward a generic primary care specialty; UCI's generalist disciplines have preserved their individual identities and structures. Yet interdisciplinary collaboration has allowed primary care faculty to share educational resources, a research infrastructure, and clinical systems, thus avoiding duplicative use of valuable resources while maximizing collective negotiating abilities and mutual success.

Periconception care.

If we are to provide periconception care to all American men and women of reproductive age, we must consider it all "routine visits." For prevention of birth defects, all reproductive-age women should be counseled about folic acid supplementation and rubella immunity. Many clinicians consider risk reduction and anticipatory activities important in periconception care. This includes counseling families about avoiding tobacco and substance abuse, using passenger restraints, avoiding teratogens, seeking appropriate genetic counseling and early prenatal care, and a variety of other periconceptional health issues. Reproductive-age women with underlying medical problems should be identified and counseled about pregnancy risks.

Yesterday a learner, today a teacher too: residents as teachers in 2000.

Resident physicians spend numerous hours every week teaching medical students and fellow residents, and only rarely are they taught how to teach. They can, however, be taught to teach more effectively. Teaching skills improvement initiatives for residents are taking a more prominent place in the educational literature. Limited evidence now suggests that better resident teachers mean better academic performance by learners. A small but important body of research supports selected interventions designed to improve residents' teaching skills, but not all studies have demonstrated significant educational benefits for learners. An increasing number of valid and reliable instruments are available to assess residents' clinical teaching, including objective structured teaching examinations and rating scales. In all specialties, rigorous research in evidence-based teacher training for residents will help prepare academic medical centers to meet the diverse and changing learning needs of today's physicians-in-training.

Common peripartum emergencies.

Peripartum emergencies occur in patients with no known risk factors. When the well-being of the fetus is in question, the fetal heart rate pattern may offer etiologic clues. Repetitive late decelerations may signify uteroplacental insufficiency, and a sinusoidal pattern may indicate severe fetal distress. Repetitive variable decelerations suggesting umbilical cord compression may be relieved by amnioinfusion. Regardless of the etiology of the nonreassuring fetal heart pattern, measures to improve fetal oxygenation should be attempted while options for delivery are considered. Massive obstetric hemorrhage requires prompt action. Clinical signs, such as painless bleeding, uterine tenderness and nonreassuring fetal heart patterns, may help to differentiate causes of vaginal bleeding that may or may not require emergency cesarean delivery. The causes of postpartum hemorrhage include uterine atony, vaginal or cervical laceration, and retained placenta. The challenge of managing shoulder dystocia is to effect a rapid delivery while avoiding neonatal and maternal morbidity. The McRoberts maneuver has been shown to be the safest and most successful technique for relieving shoulder dystocia. Eclampsia responds best to magnesium sulfate, supportive care and supplemental hydralazine or labetalol as needed for severe hypertension.

Immunolocalisation of intermediate filament proteins in porcine meat. Fibre type and muscle-specific variations during conditioning.

Two intermediate filament proteins, desmin and vinculin, were immunofluorescently localised in porcine longissimus dorsi(∗∗) and iliocostalis muscles up to 7 days post mortem. Changes in tenderness of the m. longissimus and the water-holding capacity of both muscles were also monitored throughout this storage period. Longissimus muscle shows a rapid decline in the overall intensity of labelling for both desmin and vinculin. In contrast to the vinculin labelling, desmin labelling is preferentially lost from type IIB muscle fibres in the longissimus muscle. In the redder iliocostalis muscle, the loss of desmin and vinculin labelling was less rapid and did not show an obvious relation to muscle fibre type. In one sample with very high water loss, there were indications of greater extracellular space development and delayed loss of intermediate filament labelling. The time course of diminishing intermediate filament labelling is consistent with previous suggestions that degradation of these proteins is involved in post-mortem conditioning. The variations within and between muscles shown here may explain some of the variability in their mechanical properties. Additionally, it is suggested that intermediate filament integrity is necessary for the expulsion of water from the muscle cells during drip formation.

Controversies in women's health maintenance.

Because the health care system has become more cost-conscious, and because professional organizations vary in their recommendations for women's health maintenance, it is more important than ever to use an evidence-based approach for selecting health maintenance interventions wisely. The Papanicolaou smear is a gold standard for cancer screening if women undergo regular testing; however, data conflict on how often women should be screened and how risk factors for cervical cancer should be interpreted. Postmenopausal estrogen replacement therapy slows osteoporotic bone loss and may decrease a woman's relative risk of coronary artery disease. The relationship of hormone replacement therapy (estrogen plus progestin) to the risk of breast cancer still remains unclear. Although new data suggest that screening mammography may reduce breast cancer mortality by 20 percent or more in women over 40 years of age, its use in women who are 40 to 49 years of age is still controversial. Family physicians, as advocates for women's health, are ideally positioned for leadership roles in the policy making that may ultimately find solutions to these controversial issues.

The development of articular cartilage: I. The spatial and temporal patterns of collagen types.

Articular cartilage is both morphologically and biochemically heterogeneous. Its susceptibility to degenerative diseases such as arthritis and its limited repair capacity have made cartilage the focus of intense study; surprisingly, little is known of its development. Using a panel of specific antibodies, we have documented the temporal and spatial patterns of collagen types I, II, III, VI and X in the developing knee cartilage of the marsupial Monodelphis domestica from parturition to adulthood. Type I collagen was initially detected in the presumptive articular cartilage of the epiphyses in addition to the perichondrium. By 14 d postparturition, type I collagen was not detectable in the epiphyseal cartilage apart from insertion sites of ligaments and tendons of the joint. Similarly, type III collagen was detected at insertion sites of the major ligaments and tendons and within the perichondrium/periosteum but was never detected in the cartilage per se. Type II collagen was predictably distributed throughout the cartilage matrix and was also detected in the perichondrium. Type VI collagen was widely distributed throughout the cartilage matrix at parturition, but during development became restricted to a pericellular location particularly towards the presumptive articular cartilage, i.e. the epiphysis. Interestingly, generalised matrix immunopositivity was only retained in the hypertrophic cartilage of the secondary centre of ossification. After the formation of the secondary centre, type VI collagen became localised pericellularly in the deeper regions of the articular cartilage but was absent in the cartilage of the growth plate. Type X collagen showed a novel distribution pattern. In addition to being synthesised by hypertrophic chondrocytes, this collagen type was also expressed transiently by some cells at the presumptive articular surface. Furthermore, these surface chondrocytes also stained histochemically for alkaline phosphatase, suggesting that they were terminally differentiated. The fate of these terminally differentiated cells is unknown.

The development of articular cartilage: II. The spatial and temporal patterns of glycosaminoglycans and small leucine-rich proteoglycans.

Articular cartilage is both morphologically and biochemically heterogeneous. Its susceptibility to degenerative diseases such as arthritis and its limited repair capacity has made cartilage the focus of intense study; surprisingly, little is known of its development. Using a panel of specific antibodies, we have documented the temporal and spatial patterns of the small leucine-rich proteoglycans fibomodulin, decorin and biglycan in the developing knee cartilage of the marsupial South American opposum (Monodelphis domestica) from parturition to adulthood. The major proteoglycan of cartilage, aggrecan, can be substituted with a variety of isomers of chondroitin sulphate (CS) and keratan sulphate (KS) glycosaminoglycans. Consequently, we have used monoclonal antibodies to determine the distribution of the chondroitinase generated epitopes of CS isomers (delta di-6S and delta di-4S oligosaccharide 'stubs'). Other monoclonal antibodies (3B3[-], 7D4) were used to investigate temporal changes in the expression of specific sulphation patterns within native chondroitin sulphate chains in addition to keratan sulphate chains (5D4). We found the distributions of the small proteoglycans (PGs) to be highly dynamic during development. Both fibromodulin and biglycan appeared to specifically label early articular cartilage as opposed to epiphyseal or growth plate cartilage. All 3 small PGs become preferentially distributed to the upper half of the adult articular cartilage depth. Similarly, delta di-6S, delta di-4S oligosaccharide 'stubs', KS and epitope 7D4 were variably distributed during development but all were again preferentially located to the upper depth of the mature tissue. The epitope recognised by antibody 3B3[-] was extensively distributed in the neonate, but became more restricted to hypertrophic chondrocytes by day 19. It was not detected in the adult tissue. These data suggest that in Monodelphis, proteoglycans are preferentially synthesised and elaborated in the upper half of the tissue depth and contrasts with the patterns observed in eutherian mammals. The data also pose questions as to the functional significance of these molecules within the tissues and to the idea that global patterns of matrix components exist in mammalian articular cartilages.

Novel articular cartilage structure in the South American opossum, Monodelphis domestica.

Articular cartilage provides smooth surfaces for low-friction, unrestricted movement of opposing skeletal elements. The surface topography of articular cartilage has been the subject of numerous studies and, with few exceptions, is considered to be smooth (at least at the light microscopic level). Some studies have reported 'humps' on the articular surface which have been related to underlying chondrocytes residing very close to the surface. Here we report on a highly nodular form of articular cartilage in the distal limb joints of the South American opossum, Monodelphis domestica. Unlike previous reports, these articular 'humps' are visible under a dissecting microscope. Each 'hump' or 'nodule' represents the surrounding matrix of single or sometimes paired rounded chondrocytes. Flattened chondrocytes normally associated with mammalian articular cartilage were absent from these joints. Interestingly, the articular cartilage of the more proximal limb joints such as the knee showed more typical features of articular cartilage including flattened superficial chondrocytes.

Measuring proliferation in routine fine needle aspirates. Immunocytochemical detection of bromodeoxyuridine incorporation and Ki-67 expression in breast aspirates.

Two simple quantitative means of measuring tumour proliferation which can be applied to cytological material are described. One method involves immunocytochemical staining of cytological smears prepared from breast aspirates with the monoclonal antibody Ki-67. The other method involves incubation of aspirated material with 5-Bromo-2-deoxyuridine (BrdU). Direct measurement of the S phase of the cell cycle is feasible in breast fine needle aspirates by Bromodeoxyuridine incorporation and subsequent immunocytochemical detection. The proliferation indices obtained correlate with those derived from Ki-67 staining. This technique is suitable for routine use in the assessment of tumour proliferation.