Effects of developmental age, ambient temperature, and dietary alterations on delta(12) desaturase activity in the house cricket, Acheta domesticus.

Double bond formation in polyunsaturated fatty acids (PUFA) is mediated by desaturase enzymes. Certain insect species have been found to possess a Delta(12) desaturase, previously thought to occur exclusively in plants. We have begun to characterize this enzyme to determine its relatedness to those found in plants and animals. Desaturase activity can be altered significantly by a number of environmental factors in protozoa, cyanobacteria, plants, fish, and rats. We present evidence here that Delta(12) desaturase activity in Acheta domesticus is affected by developmental stage, starvation, dietary alterations, and fluctuations in ambient temperature. Highest activity is observed during the middle of the penultimate instar and 3 to 6 days after adult emergence. Starvation markedly decreases Delta(12) activity, whereas resumption of feeding on fat-free or low fat diets increases activity.

Intra-arterial 5-fluorouracil and intravenous folinic acid in the treatment of liver metastases from colorectal cancer.

OBJECTIVE: To compare two regimens of intra-arterial chemotherapy for the treatment of hepatic metastases from colorectal cancer. DESIGN: Open study. SETTING: Teaching hospital, UK SUBJECT: 57 patients with unresectable metastases confined to the liver, and an indwelling catheter in the hepatic artery. INTERVENTIONS: The first 33 patients had a 24-hour intra-arterial infusion of 5-fluorouracil (5-FU) 1500 mg/m2, together with folinic acid 200 mg/m2 intravenously for the first and last two hours of the 5-FU infusion. This was repeated at weekly intervals for six weeks followed by a two-week gap before the next cycle. The remaining 24 patients had a two-weekly regimen in which folinic acid 200 mg/m2 was infused intravenously over 2 hours followed by an intra-arterial loading dose of 5-FU 400 mg/m2 over 15 minutes; 5-FU 1600 mg/m2 was then given by intra-arterial infusion over 22 hours. This was repeated on day 2 and then at two-weekly intervals. MAIN OUTCOME MEASURES: Response rate and toxicity. RESULTS: Median follow-up was 21 months, and estimated median survival 19 months. 29 patients (51%) have responded, 5 completely. There are no significant differences between the groups. Sites of progression were liver alone 26 (53%), lung alone 9 (18%), liver and lung 3 (6%), and the remainder in local or regional nodes (n = 7) or bone (n = 4). Six patients experienced WHO grade 3 or 4 toxicity. CONCLUSION: The two regimens have high response rates and cause little systemic toxicity. Intra-arterial chemotherapy for hepatic metastases from colorectal cancer is currently being compared with conventional systemic chemotherapy in a randomised controlled trial.

The physician's role in a world of technology.

Technology has come to dominate the medical world over the past 100 years. Some of this technology has come from science and some has been imported from the world of business. Some technology exists in the form of physical objects; other technology takes the form of systems and organization. Technology to manage information has played a particularly critical role in changing how medicine is practiced. Those who choose to apply the latest technologies to patient care do so in ways that are not merely a reflection of some "objective" set of scientific data. Rather, the use of technology transforms both the clinical encounter and the technology itself, and in so doing reflects the values of those who created and those who use the technology. Despite the many ways that technology has come to be used for medical care over the course of the past century, the role of the physician has remained central.

Evaluation of a follow-up programme after curative resection for colorectal cancer.

Frequent liver imaging can detect liver metastases from colorectal cancer at an asymptomatic stage.

Making a medical practice in an uneasy world: some thoughts from a century ago.

A century ago medical trainees in the United States faced many of the same sorts of issues that confront trainees today. For practical advice in setting up their practices, many of those trainees turned to a book by physician David Cathell called The Physician Himself, which was first published in 1882 and was reprinted many times thereafter. This paper explores the advice Cathell offered in his book as well as parallels with events of the recent past, discussing Cathell's opinions on physician overcrowding, medical education, new technology such as the telephone and the automobile, and the sensitive ethical issues that physicians must deal with. The paper concludes that because being an excellent physician in both Cathell's time and today requires more than good science, Cathell's book helps to remind us of the social world in which medicine is practiced.

Infusion pumps for systemic and intra-arterial chemotherapy of colorectal liver metastases.

Over a 12 month period, we prospectively evaluated the use of an ambulatory infusion pump for intra-arterial and intravenous chemotherapy in patients with colorectal liver metastases. In all, 274 separate infusions were given with minor complications occurring on six occasions. Administering treatment on an outpatient basis rather than as an inpatient has resulted in savings of over Pounds 17000 in the first year.

A phase II study of regional 2-weekly 5-fluorouracil infusion with intravenous folinic acid in the treatment of colorectal liver metastases.

Forty patients with unresectable colorectal metastases confined to the liver were evaluated in a phase II study. 5-Fluorouracil (5-FU) was delivered via a surgically placed hepatic artery catheter. Patients received folinic acid (200 mg m-2) intravenously over 2 h followed by a loading dose of intra-arterial 5-FU (400 mg m-2) over 15 min, then 5-FU (1600 mg m-2) by intra-arterial infusion over the following 22 h. This was repeated on day 2 and the whole schedule was repeated every 2 weeks. Response was assessed after six treatments. The median follow-up was 17 months. Overall response rate was 46% with 8% complete response. Estimated median survival is 19 months. Site of progression was the liver alone in 55%, liver and lung in another 16% and 29% in other sites. Eight patients experienced grade 3 or 4 toxicity. The response rate of this regimen compares favourably with reported trials of intra-arterial FUDR, and our schedule is currently being compared with a similar schedule of intravenous 5-FU and folinic acid in a randomized Medical Research Council trial (CR05).

Creating university hospitals: rationales and realities.

This article analyzes the reasons given for the founding of three early university hospitals: those at the University of Michigan, the University of Pennsylvania, and Johns Hopkins University. The hospital at the University of Michigan was founded to ensure medical students' access to clinical instruction. The University of Pennsylvania's desire to have not only access to but control over hospital affairs provided the impetus to build a university hospital. Johns Hopkins University, building upon the examples of Michigan and Pennsylvania, firmly joined the hospital and medical school and introduced research as a link between these institutions. The early histories of these three institutions demonstrate how each created a different mission for its university hospital. Today, as in the past, university hospitals must choose which of their multiple roles to emphasize. The meaning of "university hospital" has always been ambiguous, and this ambiguity can provide useful flexibility to institutions responding to a changing environment.

Medical history in the undergraduate medical curriculum.

History has long played a role in the education of American physicians, but the uses of medicine's past have changed over time. In the late nineteenth century, some physicians taught medical history to their students to supply a sense of continuity with professional traditions in times of rapid and bewildering change. Other physicians believed that instruction in medical history would impart a sense of refinement to medical practitioners. In the late twentieth century, medical history is increasingly viewed as a significant dimension of the professional, intellectual, and humanistic development of medical students. Further, it is one of the principal means by which recent, radical changes in health care can be given needed perspective. The knowledge that medicine and the medical sciences are fundamentally social enterprises is an important lesson for medical students. Through exposure to the history of health care, students also learn that medical knowledge is itself subject to change and is acquired in specific contexts. In the 1990s, medical history is taught in a variety of settings. In some schools, history is integrated into the teaching of medical humanities. Where medical history is institutionally distinct from the humanities, courses in medical history may be either elective or required. In order to reach students at every stage of their medical education, historians and clinicians can join forces to teach history in innovative and flexible programs.

Histories of academic medical education.

The author discusses the ways in which the history of medicine has changed in recent times, from an emphasis on celebrating past events to a focus on elucidating the nature of changes in medical care. Characteristic historical methodologies are described, including a tendency to use multiple types of sources. The importance of education in medical history and the potential utility of the study of history for contemporary medical practice are emphasized. The author gives examples of the many ways in which the history of medical education might be conceptualized.

Resident-patient interactions: the humanistic qualities of internal medicine residents assessed by patients, attending physicians, program supervisors, and nurses.

BACKGROUND: The patient-physician relationship is central to medical practice. Increasingly, educators and certifying bodies seek to assess trainees' humanistic qualities. METHOD: The humanistic qualities of first-year internal medicine residents were rated in 1987-88 and 1988-89 by patients hospitalized on the general internal medicine and pulmonary services of the University of Michigan Hospital. Attending physicians (for 1988-89 only), program supervisors (program directors and chief residents), and nurses (for 1988-89 only) rated the same residents, and these ratings were compared with those of the patients. RESULTS: A total of 625 patient questionnaires for 70 residents were analyzed, with a mean of nine patient evaluations per resident and a range from four to 24. Analysis showed that more than 50 patients would need to rate each resident to achieve desired levels of reproducibility. Large numbers of attending physicians (20 to 50) would also be required to obtain a reproducible assessment; the attending physicians' ratings correlated only moderated well (r = .26) with the patients' ratings. Ratings from smaller numbers of program supervisors (five to ten) and nurses (ten to 20) would be needed for reproducible assessments. However, only the nurses' ratings showed a moderately strong relationship (r = .35) with the patients' ratings. CONCLUSIONS: Patients, attending physicians, program supervisors, and nurses view differently the humanistic attributes of residents as they interact with patients. Large numbers of patients and attending physicians would be needed to obtain reproducible ratings. Nurses' and program supervisors' ratings are much more reproducible, but nurses' perceptions correlate more closely to those of patients.

The storage of tetanus vaccine in accident and emergency departments: a postal survey.

The aim of this study was to assess the quality of storage of tetanus vaccine in accident and emergency (A&E) departments and also of the awareness of Department of Health guidelines. A postal questionnaire was sent to 50 randomly selected major A&E departments in the British Isles, enquiring about awareness of Department of Health guidelines (Department of Health, 1990). Forty (80%) A&E departments responded. Only 14 were aware of the Department of Health guidelines and in only 18 was there a member of staff taking responsibility for vaccine storage. The study found that safe storage of vaccine, and therefore guarantee of efficacy, is not occurring in the majority of A&E departments. Unnoticed failure of refrigerators could be exposing patients to the risk of tetanus infection.

Patterns of alcohol use and abuse among aging Civil War veterans, 1865-1920.

Given the extent of alcoholism among elderly people, it is remarkable how little is known about the biomedical and social dimensions of alcohol use and abuse in late life. In the absence of compelling longitudinal data drawn from contemporary sources, a historical perspective may help to illuminate the incidence and consequences of alcohol abuse among the elderly. Based on a study of 370 case histories drawn from the National Military Home in Dayton, Ohio, which around the turn of the century was the nation's largest old-age home, it appears that alcohol's social ramifications were more important than its pathological or physiological manifestations in late 19th-century America. Drinking habits among aging Civil War veterans varied considerably: moderate consumption was acceptable; too much of a good thing caused problems.