The Bell Commission: ethical implications for the training of physicians.

In 1989, the New York State Legislature enacted New York State Code 405 in response to the death of a patient in a New York City hospital. Code 405 was the culmination of a report (the Bell Commission Report) that implicated the training of residents as part of the problem leading to that tragic death. This paper explores the consequences of the regulatory changes in physician training. The sleep deprivation of house officers was considered a major issue requiring correction. There is little evidence to support the claim that sleep deprivation is a serious cause of medical misadventures. Nevertheless, the changes in house officers' working hours and responsibilities have profound implications. Changes in the time allotted to teaching, the ability to learn from patients admitted after a shift is over, and the increasing loss of continuity, all may have a negative impact on physician training. It is not clear that trainees are being realistically prepared for the actual practice of medicine - physicians often work extended hours. The most serious concern that has been raised is the loss of professionalism by physicians. Residents are now viewing themselves as hourly workers, and the State has intervened in an area of training formerly left to the profession to manage. We are now training doctors in New York State who will be comfortable working in an hourly wage setting, but not in the traditional practice of medicine as it has been in the United States during this century. We are concerned that this may sever the bond between doctor and patient - a bond that has been the bedrock of our conception of a physician.

An integrated program for evidence-based medicine in medical school.

To provide optimal care for their patients, clinicians must be able to locate and interpret the most current literature. Teaching the necessary skills to medical students is essential, if we wish to train clinicians to be able to keep up with the expansion of biomedical knowledge for their entire working lives. In this paper, we describe our school's four-year curriculum in evidence-based medicine and the performance of three senior classes on the summative evaluation exercise devised to measure the program's success.

Efficacy of salvage therapy containing ritonavir and saquinavir after failure of single protease inhibitor-containing regimens.

OBJECTIVE: To assess the efficacy of salvage therapy containing ritonavir and saquinavir after failure of indinavir- or nelfinavir-containing regimens, and to determine correlates of success or failure. DESIGN: Retrospective chart review. SETTING. The Moore Clinic - the HIV clinic of Johns Hopkins Hospital. PATIENTS: Forty-one HIV-infected patients were identified through physician contacts, referrals from other providers, and review of a comprehensive clinical database. MAIN OUTCOME MEASURES: To determine response to salvage therapy, HIV-1 viral RNA (absolute and log10-transformed) was measured using the Roche Amplicor quantitative HIV-1 RNA assay after initiation of the salvage regimen. Potential correlates of response included: viral RNA at the time of switch; viral RNA at the time of switch as a percentage of baseline viral RNA; magnitude of decline in viral RNA; and the interval between virologic failure of single protease inhibitor therapy and switch to the salvage regimen. RESULTS: Thirteen (56.5%) of 23 patients failing indinavir responded to salvage therapy (HIV RNA < 400 copies/ml) with persistence throughout the follow-up period (median of 37 weeks; range 18-67 weeks). Mean absolute viral RNA at the time of switch was 20 238 copies/ml (median, 9281) compared with 42 953 copies/ml (median, 24 650) for the 10 non-responders. Mean log10 viral RNA at switch was 3.804 for responders versus 4.405 for non-responders (P = 0.040). Among four responders who had failed nelfinavir, mean viral RNA was 9634 copies/ml and mean log10 viral RNA was 3.749 at the time of switch. Two non-responders had a mean viral RNA of 21 551 and a mean log10 viral RNA of 4.037 at switch. CONCLUSIONS: In contrast with previous reports, salvage regimens containing ritonavir and/or saquinavir can be effective and durable following the failure of combination regimens containing either indinavir or nelfinavir. Salvage therapy may be more likely to succeed when it is initiated early in failure at low viral loads.

Medical education grand rounds.

The primary goal of Medical Education Grand Rounds is to enhance the overall educational mission of the Mount Sinai School of Medicine. This editorial describes the first four years of this unique and innovative educational program, and serves as a prelude to a new feature of The Journal.

Efficacy of lufenuron against developmental stages of fleas (Ctenocephalides felis felis) in dogs housed in simulated home environments.

Twenty-four, adult, female Beagles were arranged by body weight from greatest to least and allocated to 2 groups of 12 dogs, using random numbers. Dogs were housed collectively in 2 adjacent metal buildings, each divided into 4 rooms measuring 2.1 x 3.7 m. Each room was paneled and carpeted and had an access door to the outside with a connecting run that measured 2.1 x 9.1 m. Each run had a surface consisting of 5 cm of pea gravel overlaying 5 cm of sand, and was partially covered by an awning that provided shade at its proximal end. For placement in room/run units, dogs in each of the treated and control groups were alloted to 4 subgroups of 3 dogs each. Each subgroup of dogs was placed in a separate room/run unit. Units containing treatment or control subgroups were alternated to avoid placing identically treated subgroups adjacent to each other. Dogs of subgroups A, C, E, and G were treated with lufenuron monthly at a minimal target dosage of 10 mg/kg of body weight; those of subgroups B, D, F, and H were treated with excipient tablets. Dogs were treated on study days 7, 37, 68, and 98. Each dog was infested with 100 newly emerged, unfed, insectary-reared, adult Ctenocephalides felis on each of study days 0 and 2. Thereafter, infestations on all dogs were dependent on continued development of fleas either in the indoor or outdoor environment. Numbers of fleas on each of the treated and control dogs were determined, using a nondestructive counting technique on days 6, 14, 21, 28, 35, 56, 70, 84, 98, 112, and 119.(ABSTRACT TRUNCATED AT 250 WORDS)

Incubating syphilis in an adolescent female rape victim.

The risk of infection after rape is believed to be low. The use of presumptive treatment is, therefore, controversial. Some experts recommend treatment of all patients, and others suggest treatment if the doctor suspects infection, if the patient requests it, if follow-up examination of the victim cannot be ensured, or if the assailant has a known infection. No regimen will cover all possible pathogens. The Centers for Disease Control's empiric regimen for victims of sexual assault is effective against gonorrhea, chlamydia, and, most likely, syphilis. We present a case of incubating syphilis following rape, that did not respond to ceftriaxone.

Absence and atonic seizures induced by piperazine.

A previously healthy 2-year-old girl, who presented with transient neurologic dysfunction manifested mainly by absence and atonic seizures, was treated with large doses of the antihelminthic piperazine hexahydrate. The role of piperazine salts and piperazine-containing compounds in producing neurotoxic side effects is discussed. We suggest that these drugs be considered as a possible cause of transient encephalopathy and nonepileptic seizures in previously healthy individuals.