Academic survival through mission-based management.

This article summarizes the DeLisa lecture and 3-day course of the same name offered at the 2001 Annual Association of Academic Physiatrists Educational Conference, in Hilton Head, South Carolina. The authors briefly discuss the historical school of medicine management approach and the rationale behind mission-based management. The three components of mission-based management are then reviewed along with issues pertaining to their development, implementation, and utilization. Finally, potential operational and political obstacles related to mission-based management are discussed, and recommendations for avoiding political difficulties are presented.

Major U.S. disability and compensation systems graphically compared.

This article offers the reader a "bullet" overview of the principal systems of disability determination. The reader is referred to other sources for more in-depth coverage and a detailed historical background and overview of these systems.

Goniometric techniques for range-of-motion assessment.

The authors hope that this article promotes greater understanding of the methodology available for measuring and recording joint ROM and fosters movement towards the eventual adoption of a single integrated goniometric system for the evaluation and recording of musculoskeletal impairment and disability. Towards this end, the authors have focused on applications of the Neutral-Zero Measuring Method and SFTR documentation and Recording System, and have highlighted the advantages of this system when compared to more conventional approaches. Examination and recording procedures have been described briefly, and examples of appropriate instruments and their applications have been illustrated. The reader is referred to more extensive discussions elsewhere of the measurement techniques themselves.

Impairment rating and disability evaluation of the pulmonary system.

An increasing number of patients are being seen by physicians for impairment and disability of the pulmonary system, partially because of the increasing prevalence of chronic obstructive pulmonary disease and increased awareness of industrial and environmental hazards to the respiratory system. As legislative efforts and social expectations towards entitlement and compensation become more permissive, an increasing number of individuals with respiratory impairment are claiming disability and seeking compensation. Consequently, the physician whose practice includes pulmonary rehabilitation may be expected to evaluate and rate impairment and disability of the pulmonary system. Fortunately, for respiratory disorders, excellent objective measures of pulmonary function exist that are readily applicable to the process of disability assessment. This article highlights the diagnostic procedures and assessment criteria of choice for pulmonary disability determination.

[Importance of dermatologic screening within the frame work of a general cancer prevention program]. / Importanza di uno screening dermatologico nell'ambito di un programma di prevenzione oncolologica generale.

BACKGROUND: Skin tumours represent about 11% of all the malignant neoplasms and their frequency is increasing annually. Skin tumours (melanoma, basal and squamous cell carcinoma, etc.) can be used for a good screening activity, but in relation to breast or cervix uteri cancer needs to be better defined. A test on a population of selected patients against skin malignant neoplasms has been carried out in our Centre. All of them had skin lesions and further checks were necessary. METHODS: The diagnostic protocol used in our Centre for Oncological Prevention uses the collection of anamnestic data and an objective examination. Between 1996 and 2000, 222 patients between the ages of 18 and 80 have been selected. All of them had suspected skin lesions. The patients were selected by the oncologist, particularly for pigmentation, asymmetry, irregular borders and heterogeneous colour of their skin lesions. Subsequently, the patients were sent for a further examination to the dermatologist oncologist, who on the basis of the objective dermatological examination with possible dermatoscopy, made a clinical diagnosis of the skin injuries or suggested surgical removal for the histological control of the same. RESULTS: Requested consultations: 222. Exami-nations made: 195. Patients considered: 190. Skin injuries examined: 190. The following skin lesions were identified: melanoma: 4 (2.1%) [2: I Clark level; 2: II Clark level]; basal cell carcinoma: 14 (7.37%); dermatofibrosarcoma: 1 (0.53%); keratoacanthoma: 1 (0.53%); dysplastic nevus: 4 (2.1%); actinic keratosis: 7 (3.68%); benign lesions: 159 (83.68%). CONCLUSIONS: These data were obtained by a screening program and it is therefore not a random study. This study shows interesting results because tumoral skin lesions and in particular melanoma were recognised at early stages. This is more than enough for us to create a specific screening program for skin lesions to cut down the rate of morbidity and mortality.

CLAR1, a novel gene that exhibits enhanced expression in advanced human prostate cancer.

The molecular events involved in prostate cancer progression are, at present, poorly understood. Using a differential display technique, we identified a cDNA fragment that is present in greater abundance in stage D prostate tumors compared to stage B tumors. Northern analysis was used to confirm that transcripts for this gene are expressed at higher levels in prostate tumors of later pathological stage and higher Gleason grade compared to tumors of earlier stage and lower grade. These transcripts were also expressed at high levels in all four human prostate cancer cell lines, the neonatal prostate cell line FNC 267beta1, and in a variety of other normal human adult and fetal tissues. The cDNA fragment obtained by differential display was used as a probe to clone the full-length cDNA for this gene from a human heart cDNA library. DNA sequence analysis confirmed that the cDNA was novel, and we have named this gene CLAR1. The gene displays two transcripts of 2.6 and 2.0 kb in all tissues examined. CLAR1 maps to chromosome 19q13.3 and appears highly conserved among mammals. The deduced amino acid sequence of CLAR1 encodes a proline-rich protein that contains several SH3-binding domains and a serine phosphorylation site. The presence of these motifs suggests a possible role for CLAR1 in one or more signal transduction pathways. The enhanced expression of this novel gene in more advanced forms of prostate cancer and its potential role in signal transduction both argue that this gene should be further investigated.

Impairment and disability rating in low back pain.

This "how-to" guide for the examination of impairment and disability resulting from low back pain examines Workers' Compensation, Social Security, The Americans with Disabilities Act, and the American Medical Association's Guides to the Evaluation of Permanent Impairment. The medicolegal interface is addressed, and specific recommendations are made to assist the physician involved in an independent medical evaluation.

Joint moments in minor limb length discrepancy: a pilot study.

A biomechanical analysis was performed to determine if a minor limb length discrepancy alters lower extremity joint mechanics significantly and in a manner that could contribute to the development of joint abnormalities. Ten healthy subjects with equal limb lengths were recruited. Gait analysis was performed for both left and right sides to determine the maximum moments at the hip, knee, and ankle joints. A minor limb length discrepancy was simulated by adding a shoe lift of 1.25 cm to the left leg. After a period of acclimation, the gait was reanalyzed. Differences for maximum joint moments at the hip, knee, and ankle before and after simulation were nonsignificant. An additional 10 healthy, asymptomatic patients with actual limb length discrepancies ranging from 1 cm to 2 cm were also recruited. Gait analysis for maximum joint moments before and after correction of the limb length discrepancy was performed. Side-to-side differences in joint moments before correction were nonsignificant. After correction of the limb length discrepancy, side-to-side joint moment differences were significantly increased (P = 0.02) and may suggest acute overcompensation to the presence of the corrective shoe lift. Consequently, this study did not find an association between minor limb length discrepancies and predictable changes in lower extremity joint kinetics that might potentially lead to joint abnormalities.

Industrial rehabilitation medicine. 1. Why is industrial rehabilitation medicine unique?

This self-directed learning module is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Industrial rehabilitation medicine encompasses injuries and illnesses that occur in the workplace and are covered under workers' compensation. The central thesis of this article is that industrial rehabilitation medicine is a unique area because the workers' compensation system influences the behavior of injured workers. The article is divided into three sections. The first briefly reviews the history of workers' compensation in the United States, and describes eight key features of compensation systems. The second explores several hypotheses to explain why injured workers frequently have less favorable outcomes than noncompensation patients with similar medical conditions. Some explanations focus on dysfunctional psychologic reactions such as "compensation neurosis" and "disability syndrome." Others focus on contextual factors, including return to work policies by employers and financial incentives or disincentives for return to work. The third section outlines reasons why the physiatrist is often the "preferred provider" in industrial rehabilitation medicine. One crucial consideration is that many of the most important disabling work injuries are those with which physiatrists are familiar. Also, physiatric training and philosophy prepare the physician to focus on function, to work with a rehabilitation team, and to be sensitive to psychologic factors that might impede an injured worker's recovery. All of these skills are important in the treatment of injured workers.

Industrial rehabilitation medicine. 2. Case studies in occupational low back pain.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. The evaluation and management of patients presenting with low back pain are skills that practicing physiatrists need to acquire. This chapter gives a step-by-step format, along with the thought processes involved, for managing patients with three types of low back pain presentations.

Industrial rehabilitation medicine. 3. Case studies in upper extremity cumulative trauma disorders.

This self-directed learning module highlights new advances in this topic area. It is part of the chapter on industrial rehabilitation medicine in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section contains three case studies discussing nerve, joint, and soft tissue pathology and work disability due to upper extremity pain. New areas of interest covered in this section include the controversy regarding the work causality of upper extremity disorders, a detailed review of the impact of upper quadrant postural dysfunction on symptom perpetuation, and the assessment and nonsurgical management of thoracic outlet syndrome.

Industrial rehabilitation medicine. 4. Strategies for disability management.

This self-directed learning module provides a practical overview of the general rehabilitative management of work disability. It is the fourth of four articles on the topic of industrial rehabilitation medicine for the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. This section includes an algorithm to highlight strategies for early involvement of the physiatrist in the comprehensive management of injured workers. It also examines the broader role of the physiatrist as independent medical examiner. Finally, it explores the complexities surrounding case closure for the chronically disabled injured worker.

Androgen receptor variants with short glutamine or glycine repeats may identify unique subpopulations of men with prostate cancer.

The androgen receptor (AR) contains glutamine (CAG) and glycine (GGC) repeats that are each polymorphic in length. We screened clinically localized prostate cancers for somatic mutations in the length of the CAG and GGC repeats in the AR gene and characterized the length of these repeats in the germ-line AR gene. Somatic mutations were rare, and the range of germ-line repeat lengths in men with prostate cancer was within the range of normal in the general population. Most allele frequencies in Caucasian men with clinical prostate cancer were remarkably comparable to those in the general Caucasian population. However, a subpopulation of the men with clinical prostate cancer had a substantially higher frequency of AR alleles with 16 or 17 CAGs (6 of 59 men, 10%) than did the general population (6 of 370 alleles, 1.6%), and a different subpopulation of the men with prostate cancer had a higher frequency of AR alleles with 12 or 13 GGCs (7 of 54 men, 13%) than did the general population (1 of 110 alleles, 0.9%). Of the men with prostate cancer who had an AR gene with 16 or 17 CAGs, 83% had lymph node-positive disease, despite the lack of clinical evidence of metastatic spread. This suggests that a short AR CAG allele may be a risk factor for the development of clinically unsuspected lymph node-positive prostate cancer among men undergoing radical prostatectomy and raises the question of whether this short repeat length played an active role in the development of aggressive prostate cancer. The odds of having a germ-line AR gene with a short CAG repeat (

Increased glyceraldehyde-3-phosphate dehydrogenase gene expression in late pathological stage human prostate cancer.

Glyceraldehyde-3-phosphate dehydrogenase (GAPDH) is a multifunctional enzyme best known to many investigators as a 'housekeeping' gene used as a loading control on northern blots. Prior studies, however, have shown that GAPDH RNA levels vary greatly among different prostate cancer cell lines. We undertook this study to determine the level of GAPDH gene expression within primary human prostate tumors and to determine the validity of using GAPDH as a loading control for northern analysis of human prostate cancer specimens and normal human organs. We found that GAPDH expression was significantly higher in specimens from patients with pathological stage C and D prostate cancer than those with stage B disease. Within the human prostate cancer cell lines TSUPr1, DU145, LNCaP and PC-3 and a normal neonatal prostate epithelial cell line FNC 267beta1, LNCaP cells expressed the highest level of GAPDH but all cell lines, including the normal neonate prostate cell line had very strong GAPDH gene expression. GAPDH RNA levels were highly variable among 16 normal human adult organs and four human fetal organs examined. We conclude that GAPDH RNA levels in human prostate tumors correlate with pathologic stage and that GAPDH should not be used as a loading control in northern blot experiments. Other controls, such as beta-actin or 28s ribosomal RNA, would be more suitable for such purposes.

A simulation of hand impairments: effects on upper extremity function and implications toward medical impairment rating and disability determination.

OBJECTIVES: To determine whether simulation of significant impairment of the hand will have a predictable impact on degree of functional loss at the wrist and hand. DESIGN: Single subject repeat measures using before-after trial comparisons and healthy volunteer subjects. SETTING: Occupational therapy section of a large academic medical center. OTHER PARTICIPANTS: Twenty adult volunteer student subjects from an occupational therapy education (OTE) department were included. All were between ages 18 and 43 years, right hand dominant, and in excellent general health. There were 19 women and 1 man, reflecting gender distribution of the OTE student body. INTERVENTION: A simulated fusion of the carpometacarpal (CMC) joint of the thumb was achieved by immobilization in an individually fabricated splint designed to maximally restrict motion at the first CMC joint. Impairment ratings (baseline vs splinted) according to the AMA Guides were obtained by Greenleaf testing, and upper extremity function was quantitatively assessed before and after splinting. MAIN OUTCOME MEASURES: Measures of upper extremity function included grip and pinch strength, wrist torque, and speed of performance on the Valpar Small Tools test, Jebsen Hand Function test, and an exploratory measure, the Functional Life Activity Test (FLAT). RESULTS: Significant impairments were achieved for all subjects after splinting and according to Greenleaf testing. Splinting resulted in significant reductions in grip and pinch strength, wrist torque, and significant slowing of performance on the Valpar, Jebsen, and FLAT tests. Regressions of degree of impairment on degree of functional loss after splinting, and according to each of the above measures, were not significant. CONCLUSIONS: Impairment of the hand was simulated to a mild-to-moderate degree as measured according to the AMA Guides. This imposed significant reductions in motion at key joints of the wrist and hand as well as significant reductions in grip and pinch strength and wrist torque. A corresponding and significant slowing of performance on a variety of measures of upper extremity function of an industrial and nonindustrial nature was also seen. However, and for the first time, correlation and regression reveals that it is not possible to predict degree of functional loss attributable to degree of impairment for the hand. It thus appears that, for mild-to-moderate clinical impairments, the associated impairment rating is a poor estimator of functional loss at the hand and should be used cautiously, if at all, as a criterion for disability determination.

Androgen-receptor gene structure and function in prostate cancer.

Androgen-receptor (AR) gene mutations have been found in clinical prostate cancer, both prior to hormonal therapy and in hormone-refractory disease that persists despite androgen-ablative therapy. Thus, mutations that are present in late-stage disease might arise prior to therapy rather than as a result of therapy. A common feature of mutations in untreated prostate cancer and in hormone-refractory prostate cancer is that the AR retains activity as a ligand-dependent transcription factor. Some AR mutations in prostate cancer show broadened ligand specificity, such that the transcription-factor activity of the AR can be stimulated not just by dihydrotestosterone (DHT) but also by estradiol and other androgen metabolites that have a low affinity for the AR. The activation of mutant AR by estrogen and weak androgens could confer on prostate cancer cells an ability to survive testicular androgen ablation by allowing activation of the AR by adrenal androgens or exogenous estrogen. Such mutations might confer an advantage even prior to androgen ablation, since prostate cancer has lower levels of 5 alpha-reductase and, therefore, of DHT, than normal. Thus, AR mutations that occur prior to therapy may characterize a more aggressive disease. A large percentage of tumors appear to have no AR gene mutation. In tumors without an AR gene mutation, AR function might be affected via other mechanisms (e.g., AR gene amplification, which could increase the amount of AR activity at a given DHT level). Importantly, the apparent absence of AR gene mutations in the majority of earlystage tumors indicates that the role of androgen in the development of clinical prostate cancer is mediated predominantly by a normal AR gene. There are actually multiple alleles of the normal AR gene; these allelic variants differ in glutamine and glycine repeat length in the transactivation domain of the protein, and they may differ in signal-transducing activity. The glutamine and glycine repeat length may thereby modulate the effect of androgen on tumor-cell proliferation that occurs during clonal expansion.

The role of ovarian hormones, age and mammary gland development in polyomavirus mammary tumorigenesis.

Polyomavirus infection of adolescent athymic female mice causes a high incidence of mammary adenocarcinomas. We have examined the role of ovarian hormones, age and mammary gland developmental stage at infection on subsequent tumor induction, viral replication and gene expression. Ovariectomy (OVX) of adolescent mice 1 week before infection decreased mammary tumor incidence and number, and significantly increased tumor incidence and number, and significantly increased tumor latency. Reduction in tumorigenesis was observed to a lesser degree if mice were OVX at the time of or after infection, indicating that ovarian hormones are mainly required for tumor initiation. Tumor incidence was also reduced with increasing age; OVX prior to infection at older ages drastically reduced tumor development. Treatment of OVX adult mice with estrogen + progesterone for 1-3 weeks prior to infection was unable to restore tumorigenesis to the level observed in intact mice. Thus, in contrast to adolescent mice, the continued presence of ovarian hormones after infection was required for maximal tumorigenesis in adult mice. The decreased tumorigenesis observed in older animals is not likely due to increased differentiation since late pregnant mice with well differentiated mammary glands remained highly susceptible to tumorigenesis. At 10 days post infection, the levels of viral genomes were moderately high and similar in all experimental groups. Early viral protein and middle T-associated kinase levels were undetectable in infected tissues in all experimental conditions. However, high levels were found in tumors, perhaps reflecting a high dosage requirement for oncogenesis.

Structured research training in residency training programs. The impact on the level of resident research activity.

A survey was conducted to construct a profile of structured resident research training and experience in physiatric residency training programs. Resident research activity was quantified, and factors that may influence the level of resident research activity were examined. Questionnaires were sent to all 72 residency training program directors, of which 87% responded. To construct the profile of structured training and experience in research that currently exists, descriptive analyses were applied to the survey responses. Resident research activity was quantified according to projects per resident per year over the last 3 yr. Resident research activity was assigned to level I activity (> or = 0.25 projects/resident/year) or level II activity (< 0.25 projects/resident/year). This point of discrimination was chosen because it represents one project per resident per 4-yr graduate medical education cycle. Nonparametric, univariate analyses were used to evaluate the impact of each characteristic in the research training profile on resident research activity. The following characteristics were found to be statistically significant (P < 0.05): (1) the use of mentors outside of the physical medicine and rehabilitation department; (2) the provision of guidelines to residents for choosing a mentor; (3) the provision of responsibility guidelines to mentors; (4) the presence of a classroom curriculum. Mentorship outside of the department, however, had a negative impact on resident research activity, although the other three characteristics had positive impacts. A multivariate analysis using stepwise logistic regression was applied to further determine the capacity of each characteristic to predict independently the level of resident research activity. Only one characteristic simultaneously and independently remained significant (P < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)