Joining forces to improve point-of-care testing

Point-of-care (POC) testing takes a "laboratory" test directly to the patient's bedside. Although bedside testing is not new, the compliance standards are relatively new. Regulations ensure that all personnel are trained to properly perform the test. The central laboratory and nursing of this hospital merge the best skills of both units to create a successful POC testing program.

Hemangioma of the umbilical cord mimicking an omphalocele

A hemangioma of the umbilical cord was misdiagnosed as an omphalocele both antenatally and immediately after birth. The girl was full term and had no other anomalies. Complete resection, including an intraabdominal component, was performed on the first day of life. This rare anomaly and its possible pitfalls are discussed, and the literature is reviewed.

Purine and pyrimidine nucleotide metabolism of vascular smooth muscle cells in culture

1. Cultures of vascular smooth muscle cells accumulate extracellular breakdown products of purine and pyrimidine nucleotides that, over 9 hr, represent 60 +/- 7 and 78 +/- 17%, respectively, of the intracellular nucleotide content. 2. The accumulation is stimulated during contracture with 20 mM KCl or 70 microM carbachol, consistent with the notion that both pyrimidine and purine nucleotides are involved in the energetics of smooth muscle contracture. 3. Because the intracellular levels of pyrimidine and purine nucleotides remain constant, it appears likely that rates of synthesis match the rates of release. 4. Ectonucleotidases are present that can degrade ATP, UTP, and CTP. High-energy nucleotides may be the primary products released.

Serum from women with polycystic ovary syndrome inhibits fertilization and embryonic development in the murine in vitro fertilization model

OBJECTIVE

To study the effects of serum collected from women with polycystic ovary syndrome (PCOS) on the fertilization and early embryonic development of the murine oocyte.

DESIGN

Sera from women with anovulation were used as a supplement in a murine IVF model.

SETTING

Tertiary care academic medical center.

PATIENTS

Four fertile, four hypothalamic amenorrheic, seven PCOS (three with elevated LH and four with elevated T), and three anovulatory women with normal hormone levels.

RESULTS

When compared with serum from fertile women, serum from women with PCOS reduced fertilization rates (60% versus 42%) and subsequent early embryonic development rates (87% versus 31%). Serum from women with PCOS and elevated T levels had the lowest fertilization rates (22%). Polycystic ovary syndrome serum with elevated T or LH levels significantly decreased early embryonic development rates in comparison to fertile women (22%, 41% versus 87%).

CONCLUSIONS

Serum from women with PCOS inhibited fertilization and blastocyst development. Because both T and LH caused inhibited blastocyst development, these data have implications regarding low pregnancy rates and live birth rates during ovulation induction in women with anovulation. These data also raise questions regarding the use of serum during IVF.

Evaluation of serum CA 125 concentrations as predictors of pregnancy with human in vitro fertilization

OBJECTIVE

To determine if CA 125, a product of human endometrium, may be an indicator of early endometrial function. To test this hypothesis we examined CA 125 concentrations before oocyte retrieval in IVF cycles.

DESIGN

Retrospective data analysis of 111 consecutive IVF cycles.

SETTING

Tertiary care academic medical center.

PATIENTS

All women who received luteal leuprolide acetate (LA) suppression followed by hMG for IVF and had sera available for analyses were entered into the study.

MAIN OUTCOME MEASURE

Serum CA 125 was measured in the previous luteal cycle, day 7 of hMG, day before, and day of hCG administration. Twelve other variables were analyzed.

RESULTS

Fifty-six cycles (47 women) qualified for evaluation and included 25 pregnant cycles (45%) and 31 nonpregnant cycles. Higher serum CA 125 concentrations were associated with pregnancy in both endometriosis and nonendometriosis subgroups. CA 125 values on the day of hCG administration were the best predictors of pregnancy, with levels > or = 16 U/mL having a sensitivity of 72%, specificity of 97%, and a positive predictive value of 95% for pregnancy. The other variables were not predictive of pregnancy.

CONCLUSIONS

With a LA and hMG stimulation protocol, increased CA 125 concentrations before retrieval are associated with very high pregnancy rates. The source(s) of the serum CA 125, although as yet undertermined, may be of endometrial origin. The study supports further evaluation of CA 125 concentrations in IVF as a preretrieval predictor of pregnancy.

Pituitary response to early follicular-phase minidose gonadotropin releasing hormone agonist (GnRHa) therapy: evidence for a second flare

PURPOSE

Our purpose was to determine the pituitary response to minidose follicular-phase GnRHa and see if a second flare can be achieved.

METHOD

A prospective, consecutive series of 12 couples with tubal-factor infertility underwent 14 cycles of minidose GnRHa. Women were given a 25- or 50-migrograms dose of leuprolide acetate (LA) on cycle days 2 and 5. On cycle days 3 and 4 no LA was given but 2 ampoules of pure follicle stimulating hormone (FSH) was administered. Beginning day 6, a combination of LA and FSH was administered.

RESULTS

Following a dose of only 25 micrograms of LA on cycle day 2, mean FSH, LH, and E2 levels were significantly elevated over the baseline levels. Following no LA on cycle day 3 or 4, a repeat dose of 25 micrograms LA caused a second flare of LH and E2 on cycle day 6. Of the 14 cycles, 6 were canceled because of poor stimulation. Two of the eight patients who underwent retrieval delivered a live birth.

CONCLUSIONS

This is the first study to examine both the pituitary response and the recovery time from minidose follicular-phase GnRHa. An extremely small dose of LA is needed to cause a pituitary flare of gonadotropins. Following a flare from 25 micrograms of LA on cycle day 2, the pituitary is able to recover and respond with a repeat flare on cycle day 5.

The effect of serum from infertile women with endometriosis on fertilization and early embryonic development in a murine in vitro fertilization model

OBJECTIVE

To evaluate the effect of serum from infertile women with endometriosis on fertilization and embryonic development in a murine IVF model.

DESIGN

Pretreatment and post-treatment comparison of murine oocyte fertilization and early embryonic development with the addition of serum supplements from infertile women with endometriosis.

SETTING

Tertiary care academic medical center.

PATIENTS

Sera from 10 fertile women without endometriosis and 28 infertile women with endometriosis both before and after laser laparoscopy.

RESULTS

When compared with serum from fertile women, serum from infertile women with endometriosis inhibited fertilization rates (51% versus 81%) and subsequent embryonic development rates (46% versus 79%). The inhibitory effect was greater as the stage of endometriosis increased. Treatment of endometriosis by laser laparoscopy improved both fertilization (51% versus 56%) and early embryonic development rates (46% versus 58%).

CONCLUSIONS

Serum from infertile women with endometriosis inhibits both fertilization and early embryonic development in the murine IVF model. Inhibition of fertilization and early embryonic development rates increases as the stage of endometriosis increases. Improved fertilization and early embryonic development rates are observed after treatment of endometriosis by laser laparoscopy.

Clinical evaluation of CA-125 concentrations as a prognostic factor for pregnancy in infertile women with surgically treated endometriosis

OBJECTIVE

To extend and confirm earlier observations that serial CA-125 determinations appear to have prognostic value in some infertile women with surgically treated endometriosis using a new automated enzyme immunoassay.

DESIGN

A prospective consecutive case series.

SETTING

A university-based tertiary practice.

PATIENTS

Of 342 women having a laparoscopy for infertility, 123 (36%) had endometriosis. Fifty-six of 123 (45%) infertile women with endometriosis had preoperative CA-125 values > or = 16 U/mL and were followed for 12 months with serial CA-125 determinations.

MAIN OUTCOME MEASURE

Proportion of women achieving a pregnancy within 12 months from surgery.

RESULTS

Mean preoperative CA-125 concentrations were not statistically different for women conceiving, but mean postoperative CA-125 values were significantly lower for women achieving a pregnancy. Univariate analyses indicated that preoperative CA-125 values between 16-25 U/mL and postoperative CA-125 values < 16 U/mL were associated with significantly higher pregnancy rates. Multivariate analyses of 10 covariables indicated only postoperative CA-125 concentrations to be associated with pregnancy even after controlling for all covariables.

CONCLUSION

Using a newly developed assay for CA-125, the study confirms and extends earlier observation that CA-125 concentrations have prognostic value for pregnancy in infertile women with surgically treated endometriosis. The findings provide additional support for the clinical use of CA-125 concentrations in selected women with endometriosis.

Interpretation of abnormal lumbosacral spine radiographs. A test comparing students, clinicians, radiology residents, and radiologists in medicine and chiropractic

STUDY DESIGN

Controlled comparison of radiographic interpretive performance based on training and experience.

OBJECTIVES

This study compared each of these groups in medicine and chiropractic by testing abilities to interpret abnormal plain film radiographs of the lumbosacral spine and pelvis.

SUMMARY OF BACKGROUND DATA

Low back pain is a common and costly problem that is evaluated and treated primarily by medical physicians, orthopedists, and chiropractors. Although radiology is used extensively in patients with low back pain, the radiographic interpretations of students, clinicians, radiology residents, and radiologists have never been compared.

METHODS

Four hundred ninety-six eligible volunteers from nine target groups completed a test of radiographic interpretation consisting of nineteen cases with clinically important radiographic findings. The nine groups included 22 medical students, 183 chiropractic students, 27 medical radiology residents, 13 chiropractic radiology residents, 66 medical clinicians (including 12 general practice physicians, 25 orthopedic surgeons, 21 orthopedic residents, and 8 rheumatologists), 46 chiropractic clinicians, 48 general medical radiologists, 55 chiropractic radiologists, and 36 skeletal radiologists and fellows.

RESULTS

The test established a high level of internal consistency reliability (0.880) and revealed that, in the interpretation of abnormal plain film radiographs of the lumbosacral spine and pelvis, significant differences were found among professional groups (P < 0.0001). Post hoc tests (P < 0.05) revealed that skeletal radiologists achieved significantly higher test results than did all other medical groups; that the test results of general medical radiologists and medical radiology residents was significantly higher than those of medical clinicians; that test results of medical students was significantly poorer than that of all other medical groups; that the performance of chiropractic radiologists and chiropractic radiology residents was significantly higher than that of chiropractic clinicians and chiropractic students; that no significant differences was revealed in the mean values of performance of chiropractic clinicians and chiropractic students; that the test results of chiropractic radiologists, chiropractic radiology residents, and chiropractic students was significantly higher than that of the corresponding medical categories (general medical radiologists, medical radiology residents, and medical students, respectively); that no significant difference in test results was identified between chiropractic radiologists and skeletal radiologists or between chiropractic and medical clinicians; and that the length of time in practice for clinicians and radiologists was not a significant factor in the test results.

CONCLUSIONS

These data demonstrate a substantial increase in test results of all radiologists and radiology residents when compared to students and clinicians in both medicine and chiropractic related to the interpretation of abnormal radiographs of the lumbosacral spine and pelvis. Furthermore, the study reinforces the need for radiologic specialists to reduce missed diagnoses, misdiagnoses, and medicolegal complications.

Neomorphic agouti mutations in obese yellow mice

Several dominant mutations of the mouse agouti coat colour gene have pleiotropic effects that include obesity and a yellow coat. The Ay allele is caused by a large deletion that affects the expression of several contiguous genes. We show that three other obesity-associated agouti mutations, Aiy, Asy and Avy, are due to different molecular alterations that result in ubiquitous expression of a chimaeric RNA that encodes a normal agouti protein. The Aiy and Avy alleles are caused by insertion of an intracisternal A particle element 1 kb or 100 kb, respectively, upstream of agouti coding sequences. These results provide a model for other genes that show allele-specific imprinting, and demonstrate that molecular mechanisms typically responsible for activation of proto-oncogenes can also lead to other disease phenotypes.

Differences in dorsal and ventral pigmentation result from regional expression of the mouse agouti gene

The agouti coat color gene encodes a paracrine signaling molecule that controls the production of yellow and black pigment by melanocytes within hair follicles. Some agouti alleles affect the dorsum and ventrum independently, which has provided the basis for speculation that agouti gene action in different regions of the body is controlled by distinct genetic loci that are closely linked. Using a combination of cDNA cloning and RNA expression studies, we find that alternative isoforms of agouti mRNA contain different noncoding first exons located 100 kb apart, whose patterns of expression indicate independent control by regulatory elements that are either ventral specific or hair cycle specific. These results demonstrate that the apparent genetic complexity of the agouti locus is explained by the existence of multiple regulatory elements exerting control over a single coding sequence and provide a conceptual basis for understanding differences in dorsal and ventral hair coloration in many mammalian species. The ventral-specific agouti isoform represents an example of a transcript whose expression is restricted to ventral skin and provide an approach to investigate the mechanisms by which dorsal-ventral differences in gene expression are established and maintained.

Establishing an internal medicine practice: a model to determine economic feasibility

To make informed career decisions, physicians must acquire a basic knowledge in medical management and health care economics as they evaluate the potential survival and growth of a primary care practice. Health care providers considering a specific community and local leaders and hospital administrators attempting to recruit internal medicine physicians need a method by which they can evaluate a community's potential for supporting a first or additional primary care physician. To develop this method, we conducted a detailed survey of nonmetropolitan internal medicine generalists and primary care physicians. Data collected from internal medicine physicians and their administrative staff reflected the volume of ambulatory and hospital visits and the direct and indirect costs of the practice over the previous 24 months. Using the fixed and operating cost data, as well as number of patient visits and patient care revenue, we designed a model to project the economic feasibility of establishing an internal medicine practice in a specific community. This model can be used to project the number of adult primary care visits a community can generate for a prospective physician, as well as to estimate the direct and indirect costs, annualized capital costs, gross revenue, and net income of the practice.

Influence of cell density and receptor number on the binding and distribution of cell surface epidermal growth factor receptors

Previous studies have shown that cell density influences the expression of receptors for at least four growth factors. The data presented in this report demonstrate that epidermal growth factor receptors are regulated differently on cells expressing over a million receptors as opposed to cells expressing approximately fivefold fewer receptors. Specifically, we show that BT-20, MDA-468, and A-431-R1 cells, which exhibit a large number of epidermal growth factor receptors, preferentially down-regulate the high affinity class of these receptors as cell density increases. In addition, we show that these cells express cell surface epidermal growth factor receptors that are localized predominantly to the periphery of the cells. In contrast, A-549 and BSC-1 cells, which exhibit fewer cell surface epidermal growth factor receptors and which reduce all affinity classes of epidermal growth factor receptors as cell density increases, exhibit a diffuse cell surface distribution of these receptors at both low and high densities.

Long-term outcome of patients with acute myelogenous leukemia: the role of maintenance therapy, consolidation therapy and the predictive value of two in vitro assays

Three successive strategies used to treat acute myelogenous leukemia (AML) patients who entered complete remission are compared with respect to their long term efficacy (> 5 years). Additionally, the ability of two in vitro assays to identify patients who would be long term remitters was assessed. With respect to the proportion of patients in long term remission, 5 years of maintenance therapy, intensive consolidation therapy plus 3 years of additional therapy, and 4 courses of consolidation therapy produced equivalent results with 18 to 22% of patients in remission at 7 years. Patients whose leukemia cells retained high levels of cytosine arabinoside triphosphate (araCTP) and who received maintenance therapy were less likely to experience early relapse than comparably treated patients whose leukemia cells failed to retain araCTP. The failure of leukemia cells to clone in vitro was also associated with a lower early relapse rate for patients who received maintenance therapy. Neither the ability of leukemia cells to retain araCTP nor their ability to clone in vitro were of prognostic significance for patients treated with 4 courses of intensive consolidation therapy.

Localization and synthesis of entactin in seminiferous tubules of the mouse

Localization and synthesis of entactin in seminiferous tubules of mouse testis was studied by immunocytochemistry. Frozen sections from adult mice testes were subjected to anti-entactin and anti-laminin immunofluorescence. Both entactin and laminin were localized within the seminiferous tubule basement membrane and intertubular region of the testis. The addition of excess amount of entactin (but not fibronectin), premixed with anti-entactin antiserum, abolished the immunostain. Western blotting showed that a protein extract from a seminiferous tubule basement membrane preparation was recognized by anti-entactin anti-serum and comigrated with recombinant entactin. Enriched fractions of isolated primary Sertoli cells and peritubular myoid cells cultured for 6 days on a glass coverslip were able to synthesize and secrete entactin as detected by immunofluorescence microscopy. Entactin was also produced by TM3 (Leydig-like) and TM4 (Sertoli-like) cell lines as detected by both immunofluorescence and Western blotting. The distribution of entactin vs. laminin within both the cultured primary cells and the TM3 and TM4 cell lines differed. Entactin appeared mainly localized extracellularly. In contrast, laminin was mainly localized intracellularly. The above findings suggested that 1) entactin existed in the seminiferous tubule basement membrane and intertubular region of adult mice testis, co-localized with laminin; 2) entactin was synthesized by the cultured primary Sertoli cells and peritubular myoid cells and the TM3 and TM4 cell lines; 3) entactin was exocytosed with little intracellular accumulation, in contrast to an intracellular accumulation of laminin.

Clinical program renovation management

The day-to-day management of medical practice is so heavily influenced by tactical imperatives that few physicians have the time to think strategically. Traditionally, the difference between tactics and strategy is not a major concern of most physician executives. The realm of tactics is the short run, when managers must make do with the fixed resources at hand. Strategy addresses the long run, when all resources and markets are variable. A tactical focus is understandable, maybe even acceptable, in industries where nothing challenges traditional approaches to production of an established product or service. However, medical care in the 1990s is changing so fast that a physician executive must devote an incredible amount of time and effort just to stay confused about what is going on.

Significance of sludge and thickened wall in ultrasound evaluation of the gallbladder

Ultrasonography is reliable in detecting the presence of cholelithiasis. Isolated findings of a thickened gallbladder wall or intraluminal sludge (echogenic bile), or both, are regarded as less reliable in the diagnosis of primary gallbladder pathologic factors and are often thought to be indicators of some other pathologic or physiologic process. A retrospective analysis of 72 patients with isolated findings of sludge or thickened wall was performed. Thickened wall remains a non-specific finding. The presence of sludge on ultrasound, when coupled with normal liver function and amylase test results and right upper quadrant pain, correlated with a significant incidence of intrinsic pathologic findings of the gallbladder.

Dorsal penile nerve block in neonatal circumcision: chloroprocaine versus lidocaine

Dorsal penile nerve blocking (DPNB) has been used with success in decreasing neonatal stress during circumcision. This study was designed to confirm the effectiveness of lidocaine in DPNB and to demonstrate that chloroprocaine, a shorter acting anesthetic, is as effective in blocking circumcision stress as lidocaine, but, because of its shorter plasma elimination half-life and time of onset of action, is safer. Five groups of 15 neonates were matched for weight, age, and Apgar scores and randomly assigned to a control group, one lidocaine group and three chloroprocaine groups with 2-, 3- and 5-minute postinjection waiting periods. Each neonate was subjected to six events during circumcision for which heart rate, tissue oxygenation, and cry duration were recorded. We found that, as in previous investigations, DPNB with lidocaine was effective in reducing neonatal stress, as was evident from decreased excursion from baseline heart rate, tissue oxygenation, and cry duration when compared with the control group (nonblocked). Furthermore, chloroprocaine DPNB approximates the effectiveness of lidocaine, as was evident from decreased change from baseline cry duration, tissue oxygenation, and heart rate during the most stressful events, particularly in the 3-minute wait chloroprocaine group. This more rapid onset of regional anesthesia decreases DPNB circumcision time and benefits patients, parents, and physicians.

Adolescent blood pressure survey: Tulsa, Oklahoma, 1987 to 1989

The study goals were to document the incidence of elevated blood pressure (BP) values in public high school students in Tulsa, Oklahoma; to determine whether age and sex are risk factors; and to encourage adolescents with abnormal screening BP values to seek medical care. Over a 2-year period, 5537 adolescents aged 14 to 19 years were evaluated by a mass screening method. Blood pressure was measured once between 8:30 and 9:30 AM, with the students seated. Korotkoff phases 1 and 5 were recorded as systolic and diastolic BP. According to the criteria of the Second Task Force on Hypertension in Children and Adolescents, 334 students had elevated BP values (either systolic, diastolic, or both) (an incidence of 6%). Boys had an incidence of elevated systolic BP of 5.8%, while girls had a 2.8% incidence, a difference that might have been expected because of the generally higher incidence among men in the adult population. The incidence of elevated diastolic BP was 2.8% in boys and 2.1% in girls. Statistically significant differences between boys and girls mean systolic and diastolic elevations were found, but were not considered clinically significant. An instructional mailing was done in an effort to stimulate follow-up medical care for those with abnormal findings, but its effect was not measured.

Expression of fibroblast growth factor receptors by embryonal carcinoma cells and early mouse embryos

We have previously shown that differentiation of embryonal carcinoma (EC) cells leads to both increased binding of FGF (fibroblast growth factor) and suppression of k-FGF expression. In the current study, we examined the expression of FGF receptors by EC cells, EC-derived differentiated cells and early mammalian embryos using the technique of reverse transcription-polymerase chain reaction (RT-PCR). We determined that both mouse, F9, and human, NT2/D1, EC cells as well as their differentiated counterparts express transcripts for two forms of FGF receptors, bek (bacterially expressed kinase) and flg (fms-like gene). In addition, we determined that mouse blastocysts express flg transcripts. The presence of FGF receptor transcripts in early embryos and the previous finding of FGF-related activity in medium conditioned by mouse blastocysts argue that the FGF family plays important roles during early mammalian development.

Moderate and severe reactions in blood donors

During the period April 1985 to March 1986, 217 blood donors were found to have moderate (syncopal) to severe (convulsive) reactions. This population was compared to 5630 randomly selected donors who did not have reactions. An examination of demographic, physical, and societal/emotional factors was conducted to determine if any were predictive of reactions in donors. The results of the research supported the hypothesis that first-time donors have a higher frequency of reactions (1.7%) than do repeat donors (0.19%). A review of the above predictive factors documented that, with regard to demographic factors, 1) the number of prior donations was inversely proportional to the risk of reaction; 2) the gender of the donor was not predictive; and 3) youth was a predictor of reactions. An analysis of the physical factors revealed that donors who reacted were of lower weight (mean, 153.7 lb) than those who did not (mean, 166.4 lb) and that systolic blood pressure was slightly lower in the group with reactions. Although the difference was significant (3 torr), it was not thought to be significant clinically. In a comparison of a group with systolic blood pressure ranging from 80 to 100 torr and a group with systolic blood pressure ranging from 120 to 140 torr, the first group had a 70-percent higher risk of reaction. Finally, with regard to the last category of societal or emotional factors, the research demonstrates 1) that the ingestion of caffeinated beverages was associated with a reduced risk of reactions; 2) that the food intake of donors who reacred was significantly different from that of those who had no reaction, but this difference was not thought to be clinically significant; and 3) that the duration between registration and the onset of phlebotomy was directly predictive of reaction status. The research indicates that first-time donor status and several specific demographic, physical, and societal or emotional factors are predictors of donor reactions.

Tissue factor antigen in senile plaques of Alzheimer's disease

Tissue factor (tissue thromboplastin) is the primary initiator of the extrinsic coagulation pathway, triggering a proteolytic cascade when exposed to circulating coagulation factors. In this study, the distribution of tissue factor was examined immunohistochemically in Alzheimer's disease (AD) and control brains. Tissue factor was expressed diffusely in the neocortex, but in AD there was enhanced immunoreactivity in senile plaques. Although tissue factor might potentially contribute to the formation of senile plaques, it could also accumulate in the plaques as a secondary response to other biochemical perturbations.

Establishing a family practice: a model to determine economic feasibility

The availability of adequate health care is a major concern of urban and rural citizens. Community leaders and hospital administrators attempting to recruit family physicians and health care providers considering a specific community need a method by which they can evaluate a community's potential for supporting a first or additional primary care physician. To develop this method, a detailed survey of family practices geographically dispersed throughout Oklahoma was conducted in 1989. Data collected from family physicians and their administrative staff reflected the volume of ambulatory and hospital visits and the direct and indirect costs of the practice over the previous 12 months. Using the fixed and operating cost data, as well as number of patient visits and patient care revenue, we designed a model to project the economic feasibility of establishing a family practice in a specific community. This model can be used to project the number of visits a community can generate for a prospective family physician, as well as the direct and indirect costs, gross revenue, and net income of the practice.

Economic feasibility of a primary care practice

To make informed career decisions, the new physician must acquire basic skills in medical management and health care economics and learn how to evaluate the potential survival and growth of a primary care practice. The authors have developed a model designed to aid physicians in determining the economic feasibility of establishing a practice in a specific community or joining an established practice.

A model to determine the feasibility of a pediatric practice

A major concern of urban and rural citizens of the United States is the availability of adequate pediatric health care in their community. Community leaders attempting to recruit health care providers and pediatricians considering locating their practice in a specific community need a method by which they can evaluate a community's potential for supporting a new primary care practice. A detailed survey was conducted in early 1988 of pediatric practices geographically dispersed throughout the state of Oklahoma. Data collected from the physicians and their administrative staff reflected the volume of office and hospital visits and practice costs over the prior 12 months. Using the capital costs and direct operating cost data with information obtained on the number of patient visits and revenue generated collected in this survey, we designed a model to project the economic feasibility of establishing a pediatric practice in a specific community. This model can be used to project the number of annual pediatric primary care visits a community can generate, the direct and indirect costs to establish and maintain a clinic, and the gross revenue and net income of the practice.

Late recurrence (33 years) of a gastric epithelioid stromal tumor (leiomyoblastoma) with low malignant potential

A recurrence of a gastric epithelioid stromal tumor (leiomyoblastoma) 33 years after incomplete resection and radiation therapy is reported. The original tumor involved the posterior gastric wall and presented with intraperitoneal hemorrhage. A tumor recurrence was found attached to the stomach with invasion through the wall of the splenic flexure of the colon. The histologic features of the tumor had not significantly altered, except for a slight increase in mitotic rate. Neither the original tumor nor the recurrence exhibited smooth-muscle differentiation on ultrastructural or immunohistochemical examination, suggesting an origin from an undifferentiated or primitive mesenchymal cell. The term leiomyoblastoma, although established in the literature, should be reserved for epithelioid tumors in which myoid differentiation can be established. The long interval to recurrence supports the suggestion that all of these tumors have at least a low-grade malignant potential.

Whole body hyperthermia (41-42 degrees C): a simple technique for unanesthetized mice

A technique for accomplishing 41-42 degrees C whole body hyperthermia (WBH) in unrestrained, unanesthetized mice using a simple apparatus is reported. This method combines a radiant heat technology with monitoring of individual rectal temperatures at 10-min intervals. In 66 heating sessions, involving 116 AKR mice and a total of 619 WBH treatments, the mortality rate was less than 1%. Treatment at 41-42 degrees C for periods of up to 120 min were accomplished. Relationships of several variables of mouse temperature-time profiles were studied including (1) initial core temperature, (2) rate of heating, (3) whole body irradiation, and (4) the presence of tumor (transplanted AKR leukemia). Sham treatments produce a consistent temperature-time profile showing about a 1 degree C rise. Between-mouse variability, as well as between-treatment variability in individual animals was estimated. Thermal mapping of the device demonstrates a range from 32-38 degrees C of the air temperature in the zone with the mice to a high of 47 degrees C near to the radiant heating surface at the top of the apparatus.

Aortic regurgitation in scleroderma

Two cases of scleroderma with isolated aortic regurgitation are described. Other known causes of aortic regurgitation were not apparent. None of the patients gave a history of rheumatic fever. It appears likely that aortic regurgitation is related to scleroderma in these two patients. Aortic regurgitation in scleroderma is, however, rare.

Adolescent pregnancy: a combined obstetric and pediatric management approach

During the past decade, the relative increase in adolescent pregnancy has forced physicians and other health professionals who provide services to teenagers to be aware of the factual data relating to teenage pregnancy and the pertinent social issues in order to serve as advocates for both the parent and the child. In this article, we review the existing demographic data regarding adolescent pregnancy in conjunction with current approaches to intervention programs for the maintenance of a stable environment and optimal development of the parent and the child.

Rubella susceptibility in an adolescent female population

A survey of 1,008 adolescent girls was performed to characterize adolescent rubella immunity, and susceptibility was defined as a hemagglutination antibody titer of less than 1:8 (the definition used by the Minnesota State Health Department and the pediatric literature). The incidence of rubella susceptibility was 9.1% in the study population and was evenly distributed with regard to current age, age at time of vaccination, and source of vaccination. In subjects with a history of rubella vaccination, 7.4% were susceptible, whereas in the unvaccinated population, the susceptibility rate was 31.7%. Because rubella is a relatively benign disease except when acquired by the fetus during pregnancy, and adolescents are not only approaching the traditional age of motherhood but also experiencing pregnancy in increasing numbers, it is important for physicians to substantiate the rubella susceptibility status of their adolescent female patients.

Theophylline compliance in adolescent patients with chronic asthma

Twenty-one chronic asthma patients ages 12 to 17 years were studied to determine their compliance in taking medication. Serum theophylline concentrations were determined and theophylline dosage (milligrams per kilogram body weight per day) was calculated in participants who had allegedly followed their medication regimen. Although the theophylline dosage followed the guidelines in the literature, only 10% of the patients had serum levels in the therapeutic range. This study suggests that noncompliance among adolescent asthmatics is similar to the noncompliance found in adolescents with other chronic illnesses and that physicians should use drug levels in designing optimal short- and long-term management programs. Further, it emphasizes the need for physicians to educate their patients as to the therapeutic actions of the medication they are taking and the necessity of medication compliance.

Child abuse and neglect

Family physicians annually see a large number of children at risk for child abuse and neglect. Because of the family physician's orientation toward a vision of the family constellation as a whole rather than a grouping of individual members, and because of trained sensitivity and gravitation toward a generally humanistic approach to clinical problems, the family physician is well equipped to identify child abuse and neglect. An appropriate assessment and management scheme includes a well-documented history, a complete physical examination, clinical laboratory evaluation, utilization of consultation services, selection of a diagnostic category, and choice of disposition. The family physician's primary function rests in his ability to coordinate and facilitate the process of problem resolution while simultaneously supporting the family as an intact unit.

Primary fibromyalgia (fibrositis): clinical study of 50 patients with matched normal controls

Detailed clinical study of 50 patients with primary fibromyalgia and 50 normal matched controls has shown a characteristic syndrome. Primary fibromyalgia patients are usually females, aged 25-40 yr, who complain of diffuse musculoskeletal aches, pains or stiffness associated with tiredness, anxiety, poor sleep, headaches, irritable bowel syndrome, subjective swelling in the articular and periarticular areas and numbness. Physical examination is characterized by presence of multiple tender points at specific sites and absence of joint swelling. Symptoms are influenced by weather and activities, as well as by time of day(worse in the morning and the evening). In contrast, symptoms of psychogenic rheumatism patients have little fluctuation, if any, and are modulated by emotional rather than physical factors. In psychogenic rheumatism, there is diffuse tenderness rather than tender points at specific sites. Laboratory tests and roentgenologic findings in primary fibromyalgia are normal or negative. Primary fibromyalgia should be suspected by the presence of its own characteristic features, and not diagnosed just by the absence of other recognizable conditions. This study has also shown that primary fibromyalgia is a poorly recognized condition. Patients were usually seen by many physicians who failed to provide a definite diagnosis despite frequent unnecessary investigations. A guideline for diagnosis of primary fibromyalgia, based upon our observations, is suggested. Management is usually gratifying in these frustrated patients. The most important aspects are a definite diagnosis, explanation of the various possible mechanisms responsible for the symptoms, and reassurance regarding the benign nature of this condition. A combination of reassurance, nonsteroidal antiinflammatory drugs, good sleep, local tender point injections, and various modes of physical therapy is successful in most cases.

Family studies with HLA typing in Reiter's syndrome

Twelve consecutive patients with Reiter's syndrome, nine with the B27 antigen (B27 positive) and three without (B27 negative), and their 45 first degree relatives were studied clinically and with HLA typing. Two of the four adult male first degree relatives with the B27 antigen had classic Reiter's syndrome. In addition, one of two B27 positive adult male second degree relatives studied in one family had classic Reiter's syndrome. The data, although limited, suggest that the familial occurrence of Reiter's syndrome is higher than previously recognized, especially in adult male first degree relatives with the B27 antigen, and is similar to the degree of familial aggregation reported in ankylosing spondylitis.