How do Australian doctors with different pre-medical school backgrounds perform as interns?

AIM: To assess whether there is any advantage to be gained with respect to performance in the first year of postgraduate medical training (internship) by selecting medical school candidates with different educational backgrounds. Specifically, we were interested in comparing the performance ratings of interns who entered medical school with secondary (directly from high school) or tertiary (at least one year of a university degree) level educational backgrounds. FOCUS: We compared the performance ratings of interns according to the subjects or degree undertaken at a secondary or tertiary level, respectively. The effects of age and gender were also examined to determine their influence on performance ratings. METHOD: All graduates (N=235) from the University of Newcastle Medical School, Australia who commenced their intern year in the state of New South Wales from 1993 to 1996 inclusive were eligible for the study. The outcome measure was a score derived from a valid and reliable clinical supervisor rating scale. Independent variables were level of previous educational experience (secondary or tertiary entry), and subjects studied by secondary level entrants (predominantly science or equal proportions of humanities and science) and degree undertaken by tertiary level entrants (arts or science or allied health or nursing). RESULTS: The records of 173 (73% of eligible sample) were included in the analyses. There were no significant differences between the mean ratings of interns with respect to previous educational background, subjects studied at secondary school or degree undertaken. Age and gender did not significantly affect performance ratings.

Severe skin rash in two consecutive patients treated with 2-chlorodeoxyadenosine for hairy cell leukaemia at a single institution.

Although hairy cell leukaemia was first described 40 years ago, it is only in the last decade that newer therapeutic agents have enabled effective treatment. The purine nucleoside analogue, 2-chlorodeoxyadenosine (2-CdA) is currently considered as first-line therapy with a very high rate of complete remission. Although adverse events with 2-CdA are increasingly recognized, severe cutaneous reactions have been reported rarely. We describe two consecutive patients treated with 2-CdA for hairy cell leukaemia who both suffered extremely severe cutaneous reactions, one of which was life-threatening.

Effect on cell kill of addition of multidrug resistance modifiers cyclosporin A and PSC 833 to cytotoxic agents in chronic lymphocytic leukaemia.

Expression of P-glycoprotein (Pgp), the drug efflux pump which mediates multidrug resistance (MDR), has been widely reported in chronic lymphocytic leukaemia (CLL) and improved accumulation of daunorubicin has been reported using the MDR reversing agent cyclosporin A (CSA). We have investigated the effects on cell kill of the addition of CSA and its analogue PSC 833 to daunorubicin, doxorubicin, idarubicin, mitozantrone and fludarabine in samples from 51 patients with CLL using an MTT [3(4,5-dimethylthaizol-2-yl)-2,5-diphenyltetrazolium bromide] assay. Pgp expression was assessed by immunocytochemistry using the JSB-1 monoclonal antibody. Of the 51 samples, 10 (20%) were Pgp positive and all of these samples were from treated patients. With the exception of mitozantrone, the addition of CSA and PSC 833 to cytotoxic agents failed to significantly improve cytotoxicity, even in the Pgp positive group. With mitozantrone significant responses were seen in both Pgp positive and negative groups suggesting that the responses were due to direct cytotoxicity of the cytotoxic-modifier combination rather than reversal of MDR. Both CSA and PSC 833 showed significant direct cytotoxicity (P = 0.004 and 0.04 for PSC 833 at 1000 ng/ml and 500 ng/ml respectively; P < 0.001 for both concentrations of CSA). The responses were disappointing compared to the highly significant improvements in cytotoxicity seen using cells from the Pgp positive CEM VLB 100 acute myeloid leukaemia cell line, and it was not possible to demonstrate the superiority of PSC 833 over CSA which is also seen in cell lines. Our data do not support a role for Pgp modifiers in CLL. Further studies using larger numbers of Pgp positive CLL cells and higher doses of PSC 833 would be useful.

Delayed diagnosis and unnecessary percutaneous biopsies in cases of myeloma presenting as chest wall tumours.

We report on five cases of myeloma presenting at a single institution over an 8-year period between 1988 and 1996. All presented with bony pain and a chest wall mass arising from a rib on chest X-ray. Myeloma was not confirmed until 22, 25 and 50 days after admission in three of the cases who each suffered a potentially hazardous percutaneous chest wall biopsy which was undiagnostic. A fourth case did not suffer diagnostic delay as his biopsy showed sheets of plasma cells although, as in all five cases, evidence of myeloma was clearly present on serum/urine electrophoresis, skeletal survey and marrow aspirate, making chest wall biopsy unnecessary. The only case who suffered no diagnostic delay and no percutaneous chest wall biopsy was the only case to have a comprehensive chest X-ray report listing myeloma as a differential diagnosis and suggesting a haematology referral.

Persistence of RAR alpha-PML fusion mRNA detected by reverse transcriptase polymerase chain reaction in patients in long-term remission of acute promyelocytic leukaemia.

Acute promyelocytic leukaemia (APL) is characterized by t(15;17), which results in the formation of two chimaeric genes, PML-RAR alpha and RAR alpha-PML. PML-RAR alpha transcripts have been detected in all cases of APL whilst those of RAR alpha-PML have been detected in only about 67% of cases. We have used reverse transcriptase polymerase chain reaction (RT-PCR) to detect both fusion transcripts serially in 18 patients in remission of APL after chemotherapy and bone marrow transplantation. All patients were negative for PML-RAR alpha, whereas in six patients (remission 3-9 years) RAR alpha-PML was consistently detected. Only one patient at remission showed the 5' breakpoint RAR alpha-PML, with the rest showing the 3' breakpoint 144 bp RAR alpha-PML. The level of sensitivity for detecting RAR alpha-PML was some 10-fold higher than that for PML-RAR alpha. Serial negative tests for PML-RAR alpha have been correlated with durable remissions, suggesting possible eradication of residual leukaemia in APL. Our results, however, show persistence of t(15;17) cells expressing RAR alpha-PML fusion mRNA in patients in long-term remission of APL. They indicate that patients considered clinically 'cured' of APL still have molecular evidence of minimal residual disease and also provide further insight into the biology of acute myeloid leukaemia.

The medical care programs of the Farm Security Administration, 1932 through 1947: a rehearsal for national health insurance?

At a time of renewed interest in universal health insurance, an examination of earlier periods when society grappled with the link between socioeconomic status and health is fruitful. Between 1935 and 1947, the federal government sponsored a comprehensive medical care program for low-income farmers, sharecroppers, and migrant workers under the auspices of the Farm Security Administration (FSA). Despite the strong opposition of the American Medical Association, humanitarian and economic concerns at the local level often promoted physicians' participation in the program's group prepayment plans. Many FSA leaders clearly saw the program as a model upon which national health insurance might advance. However, in the wake of World War II, the FSA program declined as physicians' income improved, the rural population declined, and traditional ideological objections to federal intervention in medical care resurfaced. The FSA experience illuminates the complex ideological, economic, and humanitarian motivations of American physicians in the face of health care reform.