Thyroid hormone and thyromimetics inhibit myelin and axonal degeneration and oligodendrocyte loss in EAE.

We have previously demonstrated that thyromimetics stimulate oligodendrocyte precursor cell differentiation and promote remyelination in murine demyelination models. We investigated whether a thyroid receptor-beta selective thyromimetic, sobetirome (Sob), and its CNS-targeted prodrug, Sob-AM2, could prevent myelin and axonal degeneration in experimental autoimmune encephalomyelitis (EAE). Compared to controls, EAE mice receiving triiodothyronine (T3, 0.4 mg/kg), Sob (5 mg/kg) or Sob-AM2 (5 mg/kg) had reduced clinical disease and, within the spinal cord, less tissue damage, more normally myelinated axons, fewer degenerating axons and more oligodendrocytes. T3 and Sob also protected cultured oligodendrocytes against cell death. Thyromimetics thus might protect against oligodendrocyte death, demyelination and axonal degeneration as well as stimulate remyelination in multiple sclerosis.

Nosocomial infections in hand surgery.

The active and experienced hand surgeon should have enough knowledge to recognize both common and uncommon hand infections. Control of hospital-acquired infections, including surgical site infections, requires a knowledge of potential personal risk factors and ongoing surveillance systems to aid in prevention and early detection. Current national trends may soon require that surgical-site infections be diagnosed by specific criteria that will allow comparisons of data from various locations. Although most hand surgery procedures are now performed on an ambulatory basis, it is important for the hand surgeon to be aware of current methodologies for the prevention, control, surveillance, and treatment of hospital-acquired infections. These intriguing aspects of hospital-acquired infections are reviewed in this article.

Carpal tunnel syndrome in the work place.

The management of patients with the CTS that appears to be related to occupational tasks is a complex issue. At this time, there is no definite evidence to show that any job is the sole cause of an individual worker's symptom complex. Management of patients in this situation requires surgical restraint coupled with an understanding of the worker's overall lifestyle. The most effective outcomes for all concerned appear to occur when there is cooperation among the patient, the physician, and the employer or his or her representatives. The recent prospective study by MacDougal that attempted to correlate job classifications with surgical outcome may be a very positive step in this direction.

The small group consensus process for changing physician practices: influenza vaccination.

OBJECTIVE: To evaluate the effectiveness of a small group consensus process in enhancing compliance with guidelines for influenza vaccination among older HMO members. DESIGN: A controlled study of the practice of primary care physicians, with pre/post comparisons and a 2-year follow-up. SETTING: An 84,000 member prepaid staff model HMO group practice. PARTICIPANTS: Primary care clinicians (N = 36) practicing in a staff model HMO. INTERVENTION: A small-group process, including opinion leader, feedback, and group decision making. MAIN OUTCOME MEASURE: Percentage of patients in a given physician-panel who received influenza immunization. RESULTS: Improvement in vaccination rate from 60.8% to 72.35% (with further increases over 2 successive years), in the intervention group as compared with improvement in the control from 60.7% to 65.93%. CONCLUSION: In this model, the small group consensus process resulted in an alteration in physician practice pattern, yielding a significant improvement in immunization rates above the already-established level of 60%.

Enhancing physician adoption of practice guidelines. Dissemination of influenza vaccination guideline using a small-group consensus process.

BACKGROUND: A dissemination intervention to facilitate adoption of a preventive practice guideline (influenza vaccination for older adults) in group practices was developed and evaluated. The intervention, small-group consensus process, started with a physician expert presenting the guideline and followed with the group participating in a structured discussion of ways to implement the guideline that culminated in a public commitment (ie, "buy in") to adopt the guideline. METHODS: Thirteen group practices and their primary care physicians (mean size, 5) were assigned randomly to intervention or control arms. In each group practice, physicians in the intervention arm met for 1 hour. Control physicians participated in an unrelated discussion (non-steroidal drug use). Guideline adoption was determined by changes in physicians' vaccination rates that were obtained through prechart and postchart reviews of 51 physicians. Prequestionnaires and postquestionnaires measured influenza knowledge and prevention attitudes. RESULTS: Using analysis of covariance, the small-group consensus process was found to increase physician vaccination rates by 34% compared with the control arm (F (1,48) = 19.49). All intervention arm physicians increased vaccination rates from before to after compared with 54% of control arm physicians. Attitudes and knowledge did not change and were unrelated to increased vaccination rates. CONCLUSIONS: A case is made for the small-group consensus process as an effective utilization-focused dissemination method. Interventions based on group dynamics and sensitive to local practice contexts can be useful in facilitating adoption of guidelines by physicians in group practices.

Geriatric issues in the diagnosis and management of patients with rheumatic disorders.

The musculoskeletal diseases account for the most frequent complaints among older persons. Rarely is it possible to provide the patient with complete symptomatic relief. Instead, the patient needs to be taught good health habits, good concepts of preventive care, the value of rehabilitation, the gains to be achieved through non-pharmacologic therapy, and a recognition that symptoms reflect emotional problems as well as diseased musculoskeletal tissue. Most important, the patient needs to be taught that he or she can live a full exciting life despite the limitations imposed by the musculoskeletal disease. Encouragement of this attitude and institution of any and all measures that will enhance the patient's ability to retain independence are the major components of ongoing care for this growing segment of our population.

Cardiovascular, neuromuscular, and metabolic alterations with age leading to frailty.

As members of our society live longer, a greater percentage of the population will be older. These demographic changes will stress our social and medical delivery system, unless interventions can alter the course leading to frailty. Maximal aerobic power decreases with age, due to a decrease in cardiac output, and is exacerbated by cardiovascular disease. Asymptomatic aging does not reduce cardiovascular function to an extent that would lead to loss of function. Metabolism, endurance, and contraction velocity and muscle strength remain relatively high until 40, 50, and 60 years of age, respectively. After age 60, there are dramatic decreases (approximately 10% per year) which lead to loss of function and independence. The loss of muscle function leads to an increase in the likelihood of falls (approximately 4-fold). Exercise programs utilizing "aerobic" exercise activities do not lead to an increase in muscle function, whereas programs designed specifically for muscle can increase function and, presumably, reduce the risk of falls and injuries.

Gender of physicians and patients and preventive care for community-based older adults.

BACKGROUND: This study was undertaken to determine whether the gender of patients and physicians is a significant factor in deciding which older adults are offered preventive care. METHODS: A survey of medical records of ambulatory patients older than 60 years was performed in the practices of 210 physicians. Documentation of influenza vaccine, rectal examination, fecal occult blood test, Papanicolaou smear, pelvic examination, breast examination, mammogram, and pneumococcal vaccine was recorded, and rates of compliance were evaluated by sex of patient and physician. RESULTS: The medical records of 3327 patients were surveyed. Men were given influenza and pneumococcal vaccines more frequently than women. Among physicians, women physicians were more likely to give influenza vaccine (P = 0.003) and to check for fecal occult blood (P < 0.001). No significant difference was found between men and women physicians in the frequency of doing Papanicolaou smears, breast examinations, rectal examinations, and mammograms. CONCLUSIONS: While a difference in practice patterns was found between men and women physicians, most of the variance in compliance with preventive care guidelines was unexplained by the gender of physicians and patients. Matching of physician and patient by sex did not predict improved preventive care, indicating that other factors are involved in the failure to provide adequate primary preventive care to the ambulatory elderly.

Forequarter amputation wound coverage with an ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flap in patients undergoing palliative shoulder-girdle tumor resection.

Closure of massive soft-tissue defects in patients undergoing forequarter amputation for shoulder-girdle tumors may present a daunting challenge. This report describes two patients whose forequarter amputations were closed using ipsilateral, lymphedematous, circumferential forearm fasciocutaneous free flaps.

Curricular variations in combined baccalaureate-M.D. programs.

The authors review curricular characteristics of combined baccalaureate-M.D. programs at 28 U.S. medical schools from 1961, when the first programs started, until 1991-92. Initially, in the 1960s, these programs were created (1) to offer talented high school graduates an accelerated track leading to the baccalaureate and M.D. degrees, (2) to reduce educational expenses, (3) to improve education in the humanities, and (4) to attract outstanding students into careers in medicine. In the 1970s these objectives were modified to address national health care needs, particularly the need to graduate more physicians more quickly, especially primary care physicians for underserved areas. In the 1980s the objectives were broadened to achieve more diverse goals, including emphases on the humanities, community medicine, and biotechnology, in addition to the continued stress on the education of primary care physicians.

Predictors of black medical student success.

This study identifies those variables, cognitive and noncognitive, that relate significantly to the successful completion of the combined BA/MD degree program. The study sample included 69 black students who entered at year one, directly from high school, between 1972 and 1981. The Student's t-test identified statistically significant differences in the means of selection variables of successful and nonsuccessful black students. Single order correlations between predictor variables and the criterion of graduation were determined. This was followed by a stepwise regression procedure. The same predictor variables were correlated with grade point average (GPA) at the end of year one, and a further analysis added year one GPA to the predictors of graduation in a stepwise regression procedure. The same statistical analyses were carried out on a stratified sample of 69 nonminority students. Predictors of graduation for black students were parents' level of education, admission test score, self-evaluation, and council index (average vote of all committee members on an applicant). Year one GPA was a strong predictor of success for both cohorts of students. This study supports the inclusion of noncognitive information when considering black applicants for medical school. In particular, parents' levels of education and applicants' self-appraisals, along with admission test scores, showed a significant relationship to graduation 6 years later with the MD degree.

Women medical students' ratings of the required surgery clerkship: implications for career choice.

This study examined the ratings of their required surgery clerkship by 150 women and 202 men students. The authors hypothesize that a positive, highly rated curricular experience will have a statistically significant relationship to performance in surgery and to selection of that specialty for further training. Women students rated 12 of the 15 aspects of the clerkship and the overall evaluation lower than their male peers did. Men students scored significantly above the women on objective examinations, but women were rated significantly higher than the men on the clerkship, and there was no significant difference in their performance as first-year residents. The women who entered surgery residencies (half as many women as men) rated the clerkship higher than the women who entered other specialties. Recognizing that experiences on a clerkship are but one influence on a student's eventual specialty choice, the authors nonetheless conclude that more women would select careers in surgery if their initial contact with the specialty provided more relevant work, more patient responsibilities, and more skill development, all conveyed with a more positive staff attitude.

Muscle rehabilitation: its effect on muscular and functional performance of patients with knee osteoarthritis.

Muscle function and functional performance are limited in patients with osteoarthritis (OA). Although aerobic exercise can increase aerobic power and reduce fatigue, it does not appear to improve muscle function. The purpose of this study was to demonstrate the effect of a muscle rehabilitation program on muscle strength, endurance, speed, and function for patients with OA of the knees. Fifteen men (67.6 +/- 6.1 years) with OA of the knees underwent a four-month exercise program, three times per week. Muscle strength, endurance, and speed were 50% less in OA patients than in controls. After rehabilitation, there was a significant increase in strength (35%), endurance (35%), and speed (50%). Deficiencies and improvements in the muscles were greater at longer muscle lengths. Increases in muscle function were associated with decreased dependency (10%), difficulty (30%), and pain (40%). The average increase in all measured parameters was 10% and 25% after two and four months of rehabilitation, respectively. Improvements were sustained for eight months after rehabilitation. The muscle rehabilitation program was designed specifically to improve function; the improved muscle function was translated into improved functional performance.

Muscle rehabilitation in impaired elderly nursing home residents.

Based on observations of changes in muscle function associated with aging, and the exacerbation of these changes with frailty, a program of muscle strengthening has been developed to correct specific defects in muscles. This pilot study was undertaken on 18 functionally impaired nursing home residents (age range 60 to 90 years) with markedly deteriorated muscle function (50%) secondary to age, disuse, and multiple chronic illnesses. Fourteen of the subjects completed the six-week program without adverse effects. In 75% of the patients, there was improved muscle function, with endurance, strength, and speed increasing 35%, 15%, and 10%, respectively. After the program, many subjects increased their spontaneous activity and decreased their dependency. The improvements were still evident four months after rehabilitation. These results suggest that it may be possible, through a carefully supervised, short-term program of muscle rehabilitation, for nursing home residents to achieve an enhanced level of physical functioning.

An assessment of the student partnership program at the University of Missouri-Kansas City School of Medicine.

The partnership program at the University of Missouri-Kansas City (UMKC) School of Medicine pairs less experienced students with more experienced students to work together during the last four years of a six-year curriculum. The present study has explored how the partnership program is supposed to work, whether in reality it does work, what function it actually serves, and under what circumstances it operates best. In 1986 and 1987, the authors analyzed information from formal school documents, created and used questionnaires for the students and faculty, conducted semistructured interviews with selected students, and used the results of an annual survey, begun in 1978, of supervisors of first-year students who graduated from UMKC. The students and docents were found to favor the partnership system and reported that most partnerships worked well. The system's chief outcome is seen to be teaching teamwork: learning from and working together with student partners. The characteristics of the students, docents, and setting that contributed to successful partnerships are identified. The authors conclude that the partnership system at UMKC does achieve its objectives, which are described.