Natural history of asymptomatic gallstones in family practice office practices.

BACKGROUND: Improved access to less invasive testing has resulted in more Americans being diagnosed with asymptomatic gallstones. The family physician has had to rely on community-based or referral patient studies to advise their office-based patients about treatment options. OBJECTIVE: To understand the natural history of asymptomatic gallstones discovered through a routine patient care process in a rural, office-based research network of 9 family physician practices. PARTICIPANTS AND METHODS: Nine family physician practices agreed to comb their records for medical records of patients found to have asymptomatic gallstones during their routine primary care practice. Medical records were then reviewed annually for 5 years for evidence of gallstone-related problems Results were compared with previous English-language literature studies. RESULTS: Asymptomatic gallstones were found in 32 patients (19 women [59%] and 13 men [41%] with an average age of 59.5 years). Symptoms developed in 8 patients (25%) after an average latency period of 3 years 5 months. Seven patients underwent cholecystectomy; there was no gallstone-related mortality in this group. One patient who developed a ruptured gallbladder required an emergency procedure. CONCLUSIONS: Routine office practice is detecting only a small percentage of the asymptomatic gallstones expected by community-based screening studies. While more of these patients became symptomatic than in general population studies, most patients with asymptomatic gallstones required no treatment. Those patients in family practice offices who are serendipitously found to have gallstones can generally be followed up conservatively.

Rural training tracks in four family practice residencies.

The use of rural training tracks (RTTs) in family practice residencies is a new strategy (beginning in the late 1980s) to increase the number of residents selecting rural careers. The authors describe the four residencies (in Washington, Nebraska, New York, and Kentucky) that have established RTTs. The first residency year is completed in an urban tertiary care center, and the second and third years are completed in a distant rural community wherein the primary faculty are the members of a rural family practice group. Inpatient experience for the residents is provided by community hospitals that offer obstetrics, emergency room care, and first-line critical care. The residents' training is supplemented by specialty faculty practicing in the rural communities. The curricula are highly structured and are evaluated to ensure training experiences of high quality. The RTTs' financial support comes from state initiatives, hospital reimbursement, recruitment budgets, and outpatient care revenues. The authors conclude that the RTT concept has the potential to lessen the shortage of rural physicians.

Size distribution of fine particles from coal combustion.

Measurements of the particle size distribution at the outlets of six coal-fired utility boilers showed a peak at a particle diameter near 0.1 micrometer. This submicrometer mode appears to be a general feature of coal combustion that results from a volatilization-condensation process in the boiler. At the boilers tested, the submicrometer mode contained 0.2 to 2.2 percent of the total fly ash mass. The importance of this mode is greater than its small quantity suggests because particles in the submicrometer size range are often much more difficult to collect with conventional particulate control devices than larger particles. Thus, the submicrometer mode may significantly influence the design and selection of future power plant emission controls. The particle mass in the submicrometer mode was correlated with the nitric oxide concentration in the flue gas. This correlation suggests that control of nitric oxide by modification of the combustion conditions may reduce the generation and emission of submicrometer particles.