Opportunities and challenges in educating community-responsive physicians.

Medical educators, funders, and policy makers are placing greater emphasis on educating physicians-in-training to provide community-responsive care and to participate in community-focused health-promotion and disease-prevention efforts. The MCP [symbol: see text] Hahnemann School of Medicine requires all first-year students to work in the community on projects involving health education, needs and resource assessment, advocacy, outreach, and other community health skills. The Department of Community and Preventive Medicine at MCP [symbol: see text] Hahnemann directs these required courses, as well as other elective programs that provide students the opportunity to develop community health competencies. This article summarizes key elements of these educational activities and discusses challenges we have encountered developing and implementing these activities and our responses. Finally, we suggest some issues and questions deserving further exploration.

The adequacy of screening, documenting, and treating the diseases of substance abuse.

In a large inner-city teaching hospital, only 28 percent of over 1000 consecutive hospital admissions received proper screening for diseases of substance abuse. Although the CAGE questions are currently considered the best screening test for quickly assessing an alcohol abuse history, not a single CAGE question was documented during our 23 day study. Of the 1010 patients in the study, 160 or 16% were found to be substance abusers. Of these, 57 (37%) were properly screened by the physician team and 8 (5%) received adequate follow-up treatment for their substance abuse by way of social service or psychiatric consultation, or documented counselling by their physician. Physicians are not adequately screening for the diseases of substance abuse, and are not appropriately evaluating and referring patients who are known to be substance abusers. Meaningful training of medical students and physicians is necessary to increase awareness and produce positive behavior change.

Quantitative gait analysis in unilateral and bilateral total hip replacements.

By qualitative and quantitative analysis of gait we evaluated the outcomes in 41 patients after total hip arthroplasty for degenerative arthritis. Patients with unilateral and bilateral degenerative hip disease were evaluated in an effort to characterize preoperative and postoperative gait characteristics. Patients were evaluated using a subjective hip-rating scale and a gait-evaluation mat. Data were compared with those obtained from a control group of 91 patients. All patients showed a marked improvement in both subjective ratings and measured quantitative gait parameters. Patients with unilateral hip disease improved to a greater extent than those with bilateral disease after arthroplasty. We have concluded that total hip arthroplasty can greatly improve the gait characteristics of patients with degenerative arthritis, and that this improvement can be quantified, documented, and followed by using a system of gait evaluation.

Quantitative gait analysis after unilateral or bilateral total knee replacement.

Using a gait mat, we characterized the functional results for thirty-five patients before and after a total knee replacement for the treatment of degenerative arthritis. Preoperatively, we studied three distinct populations of patients. Group I consisted of sixteen patients who were scheduled to have a unilateral total knee replacement and who had no signs or symptoms of arthritis in the contralateral knee. Group II consisted of twelve patients who were scheduled to have a unilateral total knee replacement but who had asymptomatic degenerative arthritis in the contralateral knee. Group III consisted of seven patients who had bilateral arthritis that was to be managed by total knee replacement. The gait mat allowed us to measure stance time, step length, double-support time, swing time, swing-to-stance ratio, and velocity. A knee-rating scale was used to measure pain. The data were compared with those obtained from an age-matched control group of ninety-one subjects. Postoperatively, the gait evaluation revealed marked improvement in all of the patients. However, the patients in Group II did not improve as much as those in Groups I and III did. We concluded that even asymptomatic arthritis can impair gait, that bilateral total knee replacement can yield excellent results, and that patients tend to use the lower limbs in as symmetrical a way as possible. Gait analysis can be an important source of objective information, and it is easily performed by using a gait mat.

CT diagnosis of broncholithiasis.

Computed tomography clearly demonstrated broncholithiasis rather than suspected malignancy as the cause of segmental atelectasis of the right middle lobe. Possible technical limitations as a source of error are presented.

Clinical significance of anti-double-stranded DNA antibodies detected by a solid phase enzyme immunoassay.

A solid phase enzyme immunoassay (EIA) detected anti-double-stranded (ds) DNA antibodies in 88% of sera from patients classified clinically as having active systemic lupus erythematosus (SLE) without renal symptoms and 93% with renal disease. Fifty-six percent of sera from patients with inactive SLE were EIA positive for anti-dsDNA antibodies. The EIA had a sensitivity and specificity comparable to radioimmunoassay (RIA) and hemagglutination for patients with active SLE with or without renal disease, but it detected anti-dsDNA antibodies more frequently in patients with inactive SLE than the latter procedures. Precipitating antibodies detected by counterimmunoelectrophoresis (CIE) were less common in patients with renal disease (23% incidence) than clinically active patients without renal disease (79% incidence). Twenty-four SLE sera with elevated levels of C1q binding showed a 96% concordance for a positive EIA for anti-dsDNA antibodies in contrast to 66% concordance by RIA or hemagglutination. These findings suggest that the EIA is a sensitive and specific method for detection and measurement of anti-dsDNA antibodies. Several clinical applications of the EIA are discussed.

Study of two acetylcholine analogs with fixed conformations.

Two acetylcholine analogs, compound M (4,4-dimethyl-2-morpholonium) and compound P (1,1-dimethyl-3-acetoxypiperidinium) which contain the N-C-C-O group of acetylcholine fixed in the gauche and trans conformations, respectively, were tested for activity on the terminal ileum of the rat, the rectus abdominis muscle of the frog, and the superior cervical ganglion of the cat. It was found that compound M stimulates the ganglion but has no affinity for receptors in either the ileum or the rectus muscle, while compound P stimulates cholinergic receptors in the ileum and in the fast fibers of the rectus muscle but acts neither on the slow fibers of the rectus muscle nor on the ganglion.