The formation and dynamics of proton wires in channel environments.

By virtue of an accurate interaction model, the equilibrium and dynamical properties of an excess proton in aqueous systems are studied, in which the water and excess proton are confined to hydrophobic cylindrical channels. Solvation structures of the excess proton and its mobility along the channel are considered as a function of the channel radius. It is found that when the aqueous proton systems are sufficiently constricted there is a substantial increase in the diffusion of the excess proton charge accompanied by a decrease in the diffusion of water molecules along the channel. Such systems present clear evidence for the possible existence of "proton wires."

Employment profiles in neuromuscular diseases.

Consumer and rehabilitation provider factors that might limit employment opportunities for 154 individuals with six slowly progressive neuromuscular diseases (NMD) were investigated. The NMDs were spinal muscular atrophy (SMA), hereditary motor sensory neuropathy (HMSN), Becker's muscular dystrophy (BMD), facioscapulohumeral muscular dystrophy (FSHD), myotonic muscular dystrophy (MMD), and limb-girdle syndrome (LGS). Forty percent were employed in the competitive labor market at the time of the study, 50% had been employed in the past, and 10% had never been employed. The major consumer barrier to employment was education. Other important factors were type of occupation, intellectual capacity, psychosocial adjustment, and the belief by most individuals that their physical disability was the only or major barrier to obtaining a job. Psychological characteristics were associated with level of unemployment. However, physical impairment and disability were not associated with level of unemployment. There also were differences among the types of NMDs. Compared with the SMA, HMSN, BMD, and FSHD groups, the MMD and LGS groups had significantly higher levels of unemployment, lower educational levels, and fewer employed professional, management, and technical workers. Nonphysical impairment factors such as a low percentage of college graduates, impaired intellectual function in some individuals, and poor psychological adjustment were correlated with higher unemployment levels in the MMD group. Unemployment in the LGS group was correlated with a failure to complete high school. Major provider barriers to employment were the low level of referrals to Department of Rehabilitation by physicians and the low percentage of acceptance into the State Department of Rehabilitation. The low rate of acceptance was primarily attributable to the low number of referrals compounded by a lack of counselor experience with individuals with NMD. Both consumer and provider barriers may contribute to the lack of interest in obtaining a job.

Influences upon reported health promotion by family physicians.

Disease prevention and the promotion of healthy life-styles have received increasing attention over the past two decades. The purpose of this study was to determine the current level of health promotional activity as reported by family physicians. In addition, the study addressed various factors which may influence the level of physician promotion of healthy life-styles. This was accomplished by means of a survey of 815 active members of the American Academy of Family Physicians. A total of 521 questionnaires was returned, providing a 64 percent response rate. The results of this survey indicate that the level of physician personal health activity tends to influence their reported professional promotion of healthy habits. In addition, residency faculty and physicians working for health maintenance organizations were significantly more likely to report offering a higher frequency of health promotional activity than physicians in private practice. Finally, age and family practice residency training appear to have no influence on self-reported physician health promotional activity.

Interactive, mathematical, and sequential consultative methods in diagnosing renal masses on excretory urograms.

Using the clinical setting of diagnosing renal masses on excretory urograms, we compared the diagnostic efficacy and costs resulting from different consultative methods. These included face-to-face interactive consultation, mathematical combination of a fixed number of radiologists' confidence judgments, and computerized sequential decision making. This last method mathematically combines a variable number of individual judgments into an aggregate diagnosis based on diagnostic certainty. Six radiologists interpreted 42 proven urograms individually, with face-to-face consultation for selected cases, and interactively in groups of three. Individual diagnostic probability estimations were mathematically combined for the mathematical and sequential models. All models of consultation resulted in both higher diagnostic accuracy and lower costs than individual radiologists interpreting urograms alone. While the sequential model provided the highest diagnostic efficacy, it was only slightly more accurate than the other models tested. Radiologists interactively consulting on cases they considered difficult was the least costly method, approximating the projected costs of sequential decision making. Interactive consultation among radiologists is a cost-effective practice; sequential decision-making is a promising technique for improving diagnostic efficacy and reducing costs, and further evaluation is warranted.

The practicing doctor's perspective on the surgical curriculum.

The purpose of this study was to identify deficiencies of surgical clerkship and residency curricula in the training of family physicians. Responses to a survey from 202 practicing family practitioners were analyzed. Orthopedics, otolaryngology, urology, neurosurgery, and cardiovascular surgery were surgical specialty areas where more than 40 percent of the respondents thought they had spent too little time. Learning objectives were either not presented or were used ineffectively, according to the majority of respondents. Fifty percent believed that indicating a career interest in family medicine resulted in a negative bias toward them during the surgery clerkship. Over 45 percent thought they were moderately or totally unprepared at the completion of their training to perform several basic surgical procedures. The results of this survey indicate the need for an increased allocation of curricular time to several surgical specialties and an augmented emphasis on outpatient experiences within the surgical curriculum.

Blue toe syndrome: treatment with anticoagulants and delayed percutaneous transluminal angioplasty.

The spontaneous onset of a painful unilateral blue toe is usually caused by fibrinoplatelet microemboli arising from an upstream stenotic or occlusive lesion of the iliac or femoral artery. This constellation of findings is referred to as the blue toe syndrome (BTS). In 12 patients who experienced 14 spontaneous episodes of BTS, angiography demonstrated 15 proximal atherosclerotic arterial lesions, which were presumed to be the source of the microemboli. Fourteen of the 15 lesions were short-segment stenoses or occlusions distal to the aortic bifurcation. Six lesions were treated with antiplatelet or anticoagulant drugs followed by delayed percutaneous transluminal angioplasty (PTA) 6-12 weeks later. Three lesions were treated with surgical bypass, three with long-term anticoagulation, and one with transcatheter clot aspiration and immediate PTA. Two were treated with immediate thrombolytic therapy and had embolic complications. Antiplatelet and anticoagulant therapy followed by delayed PTA may be an effective alternative to surgery for treating BTS.

Orthopaedic teaching: the practicing family doctor's perspective.

Two hundred and two family doctors in practice responded to a survey that identified orthopaedics as a surgical specialty in which they would have benefited from more training. Forty percent felt unprepared to apply casts or manage fractures. Learning objectives were either not used or used ineffectively, according to the majority of respondents. Fifty percent reported that indicating a career interest in family medicine resulted in a negative bias toward them during surgery clerkship. The results indicate the need for an increased allocation of curricular time to orthopaedics and an augmented emphasis on outpatient experiences.

The effect of an inpatient chemical dependency rotation on residents' clinical behavior.

The effect of a rotation in a chemical dependency unit on subsequent resident diagnoses in the family practice clinic was investigated by clinic audit. A significant increase in diagnoses of alcoholism (56 vs. 18, P less than .05) and chemical dependency (114 vs. 49, P less than .001) was found in the year following initiation of the rotation. An inpatient rotation immediately increases resident recognition of addictive illness in the model clinic.

Intravesical bacillus Calmette-Guerin therapy and associated granulomatous renal masses.

We report a case of clinically symptomatic renal granulomas occurring during intravesical and intracutaneous bacillus Calmette-Guerin therapy for bladder cancer. The patient responded to antituberculous triple therapy. We emphasize the rarity of such extravesical infectious complications and discuss the possible routes of renal inoculation.

Protean manifestations of pylethrombosis. A review of thirty-four patients.

Thirty-four adult patients with portomesenteric venous occlusion (PVO) were reviewed. In 11 with hepatic cirrhosis, PVO was usually heralded by worsening ascites often with varix hemorrhage; mortality was high. Four with isolated portal block had varix hemorrhage without ascites. All of these patients survived despite recurrent hematemesis when portal decompression was not feasible in two patients. Eight others (5 agnogenic and 3 with hypercoagulability), experienced sudden abdominal pain with a clot typically propagated into mesenteric tributaries with ileojejunal infarction; survival was related to the promptness of operation and the extent of bowel ischemia. Of five patients with intraabdominal sepsis and pylephlebitis, only one survived. In the final six patients, PVO occurred with intraabdominal carcinoma. Five had progressive ascites, cachexia, and an early death. Imaging techniques included plain and contrast roentgenograms, ultrasonography, and for definitive diagnosis direct portography (operative or splenoportogram), indirect portography (splanchnic arteriovenogram), and computed tomography. Thirteen of 34 patients had ascites, and in nine of 11 patients examined, protein concentration of ascitic fluid was extremely low (less than 0.6 g/dl). Clinical presentation of PVO varies, depending on acuteness and extent of visceral venous blockade, severity of portal hypertension, auxiliary venous collateralization, and regional lymph flow. Inciting factors include endothelial damage and blood hypercoagulability from trauma, infection, stagnant circulation, blood dyscrasia, and malignancy. Improved imaging now allows early diagnosis.