Contribution of education to cost-effective care of microcytic, hypochromic anemia.

Through a handbook, a seminar, and multiple opportunities for reinforcement in clinical settings, faculty in family medicine conducted an educational program that presented cost-effective practice standards for the care of anemia patients to resident physicians. A comparison of the quality and cost of anemia care by the residents before and during the program ascertained its value. The quality of patient care by residents rose significantly during the program. In addition, the residents' utilization of tests, therapy, and clinic visits and attendant costs reached more appropriate levels. These results should encourage faculty to respond to the current national need for the development of educational materials on cost-effective care of patients with common health problems.

"Effort thrombosis" of the subclavian vein associated with oral contraceptives.

We report a case of "effort thrombosis" of the subclavian vein in a 33-year-old woman with several thrombotic risk factors, including the use of oral contraceptives. The signs and symptoms associated with this syndrome, as well as concepts concerning diagnostic techniques and management, are discussed.

PIP: A case of "effort thrombosis" of the subclavian vein which occurred in a young woman with severe thrombotic risk factors is reported. The manifestations of this syndrome are summarized, and recent concepts regarding the management of subclavian vein obstruction are discussed. The 33 year old woman was admitted with a 3 day history of rapidly increasing pain and swelling of her right upper extremity and right breast. She recalled no previous trauma but did indicate that her vocation required frequent exertion of her right (dominant) arm. The involved extremity exhibited easy fatigability with intermittent "tingling numbness" of the hand. She had been taking oral contraceptives (OCs) for 4 years. On admission she was smoking 2-3 packs of cigarettes daily with a 15 year smoking history. She had essential hypertension of 14 years duration which was treated with a thiazide diuretic. On physical examination, the patient's right breast was found to be twice the size of the left and exhibited tenderness, peau d'orange appearance, and superficial venous prominence. The right upper extremity exhibited venous prominence and mottled cyanosis and was edematous with an upper arm circumference that was 2.5 cm greater than the left. The involved axilla was tender, with no palpable venous "cord" or enlarged lymph nodes. Adson's maneuver was negative. Noninvasive impedance plethysmography showed no evidence of obstruction to venous outflow in the upper or lower extremities, but venography taken with the arms abducted to 45 degrees showed complete thrombotic obstruction of the right subclavian vein (shown in a figure). At first the patient was treated conservatively with bedrest, arm elevation, discontinuation of OCs, and heparinization. She became asymptomatic during the ensuing week, but a repeat venogram after 7 days of heparin therapy displayed complete obstruction of the right subclavian vein. The patient was discharged on warfarin sodium therapy which was continued for 5 months, during which time antithrombin 3 levels rose to 100% activity. During the year following hospitalization, the patient has experienced monthly episodes of mild aching in her right arm, unaccompanied by swelling or discoloration, following exertion of the extremity. Due to the fact that the etiology of effort thrombosis is now considered to be related to thoracic outlet compression, more emphasis is being placed on the use of phlebography to demonstrate compression points along the subclavian vein. Conservative management with anticoagulants continues to be the mainstay of therapy, but surgical treatment with early thrombectomy promises to decrease the chronic morbidity so common to this condition.

The docent system: an alternate approach to medical education.

There are many applications of the docent system for schools in which students are older and engaging in more conventional educational approaches. There are advantages in bringing students from different classes together over a prolonged period of time, starting with their entrance into the program. Advisors in docent roles can contribute much to such groups. Pairing of more-advanced with less-advanced students, at least informally, may offer some of the advantages described by students at UMKC in their partnerships. Women students may find it much easier to establish helpful relationships with male and female peers and teachers in organized group settings. Faculty may come to experience the advantages for themselves of close personal interaction with students. Better relationships between male and female faculty members can lead to more successful recruitment of excellent female faculty members, which is important with the increased number of women medical students. The concept offers a personalized approach to undergraduate medical education that is worthy of continued study and evaluation.