Endometrial morphology and hormonal profiles in in vitro fertilization patients

Endometrial biopsy was performed in 27 infertile women participating in the IVF program. Their mean age was 31.8 years, 33% of the women being over 35 years old. The average duration of infertility was 6.9 years. The superovulation protocol consisted of hMG/hCG in 5 cases, of combined GnRH analog/gonadotropin therapy in 20 women, and 2 patients received combined contraceptive pill/gonadotropin treatment. Judging by hormonal profiles, follicular growth rate and number of oocytes retrieved, the response to stimulation was normal. The mean estradiol (E2) levels increased from 132.7 pg/ml on day -5 (SEM = 9.67) to 1272 pg/ml (SEM = 103.7) on the day of hCG administration and to 1813 pg/ml (SEM = 209.6) 1 day later. One day before the hCG application, the mean progesterone and LH levels were 1.34 ng/ml and 8.38 IU/ml, respectively. Only one patient had clinical hyperstimulation syndrome. Ova were harvested in all women, the mean number of oocytes being 7.7 (SEM = 0.83) per patient. In all 27 cases lack of fertilization or faulty ovum cleavage were observed. Thus, an endometrial biopsy (EB) was performed 72 h after oocytes retrieval. The mean estrogen and progesterone levels on the EB day were 610.9 pg/ml (SEM = 78.44) and 45.4 ng/ml (SEM = 7.53), respectively. Histologic examination of the endometrium showed normal secretory endometrium consistent with day 16-17 of spontaneous ovulatory cycle. Two women who received combined contraceptive pills/gonadotropin therapy showed inactive endometrium with subnuclear vacuoles and decidual reaction in the stroma similar to that observed in women on estrogen-progestin birth control medication.(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin-tumour interrelationships in thymoma bearing mice. Effects of dietary glucose and fructose

Control (C) or Thymoma (T) implanted male C57BL/6J mice received a basal diet containing 16.5% glucose (G) or fructose (F). Compared to the C-G group, the C-F mice consumed more food and less water, and gained more weight. The blood glucose, insulin and triglyceride levels were higher in the C-F than in the C-G mice. Thymoma implantation into the right flank caused a transient decrease in body weight followed by a steady increase due to tumour growth. Tumours were detected earlier and tumour size was greater in the T-F group than in the T-G mice. Tumour chemical composition was similar in both groups. Blood analysis showed that the T mice had lower glucose and higher insulin and triglyceride levels than the C group. Carcasses from the T groups contained more water and ash and less fat than their C counterparts, but the type of sugar did not affect the body composition of the C or T groups. The results suggest that dietary fructose may enhance the growth of tumour via its hyperinsulinaemic action.

Oral colon lavage solutions containing polyethylene glycol may interfere with ELISA detection of tumor-associated antigens in colonic effluent

Immunologic methods for detection of colorectal neoplasia based on examination of stool or colonic effluent are being developed. Most current oral lavage preparations contain polyethylene glycol (PEG), and if PEG adversely interferes with immunologic testing these tests may become less useful. We describe a decrease in sensitivity of ELISA for tumor-associated antigens (TAA) when effluent samples are diluted in PEG-electrolyte lavage solution, equivalent to a commonly used oral lavage solution based on PEG. Radioisotope-labeled antigen binding to plastic plates was decreased by dilution in the PEG lavage solution. Antigen binding, present in colonic effluent collected by the laxative purge method, was absent in effluent collected by PEG oral lavage from the same patient. We conclude that PEG and PEG-containing lavage solutions interfere with ELISA detection of TAA in colonic effluents. We speculate that the in vitro, and possibly the in vivo, effect occurs at the level of antigen binding to the plate either by a steric effect or alteration of charge by the nonpolar properties of PEG.

Screening recommendations for the elderly

BACKGROUND

Studies have documented the potential contributions of preventive health care programs. Yet little is known about which screening tests should be included in public health programs for older persons. This study offers recommendations regarding these tests.

METHODS

The recommendations come from synthesizing the findings of the US Preventive Services Task Force, the literature, and the consensus of experts in geriatrics, gerontology, and health policy research. The literature was evaluated to identify methodologically sound studies of the prevalence of selected disorders and benefits and availability of screening procedures for those disorders. Experts from various fields specializing in the care of the elderly formed panels to assist in evaluating the literature and providing further information from gerontological and public health perspectives.

RESULTS

We recommend vision testing for refractive error; inspection of the skin surface for fungal infection and skin cancer, drug eruptions, and xerosis; a history for symptoms of xerosis; audiometric testing for presbycusis; surveys for hearing loss; otoscopic inspection for cerumen impaction; dental examination for caries; measurement of blood pressure for hypertension; and breast examination and mammography for cancer.

CONCLUSIONS

Our study suggests that these screening procedures are useful for public health screening programs. More information is needed on the effects of screening services on the health and functioning of older persons.

Geriatrics faculty in the United States: who are they and what are they doing?

Despite increases in geriatrics training at all levels of medical education, there is a nationwide shortage of geriatrics faculty. This shortage may be due in part to demands for clinical responsibilities that preclude adequate time for teaching and research. To learn about the professional activities of geriatrics faculty, we conducted a national survey of a 50% sample of all medical schools and their affiliated residency programs that focused on physician and non-physician geriatrics faculty in internal medicine, family practice, psychiatry, neurology, and physical medicine and rehabilitation. Although we found minor differences across specialties, in general, approximately one-third of physician faculty time is spent in teaching, the majority of which is clinical teaching. Less than 15% of physician faculty time is spent in research, and fewer than 10% of physician geriatrics faculty devote over half of their time to research. The percentage of time that non-physician faculty (other than "Research Only" faculty) spend in research is only slightly higher. These findings suggest that efforts to increase geriatrics education at all levels and promote research advances will be limited unless geriatricians devote substantially more of their time to these responsibilities.

Failure of physicians to recognize functional disability in ambulatory patients

OBJECTIVE

To assess the ability of internists to identify functional disabilities reported by their patients.

DESIGN

Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function.

SETTING

A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California.

SUBJECTS

Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients.

MEASUREMENTS AND MAIN RESULTS

Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability.

CONCLUSIONS

Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.

Insulin-tumour interrelationships in EL4-lymphoma or thymoma-bearing mice. II. Effects of dietary omega-3 and omega-6 polyunsaturated fatty acids

Male C57BL/65 mice received a basal diet supplemented with 4% soya-bean oil, linseed oil or fish oil, in which the major polyunsaturated fatty acids were linoleic acid, alpha-linolenic acid and long chain omega-3 fatty acids, respectively. Groups of animals were injected into the right flank with EL4-lymphoma cells, others with thymoma cells. Tumour implantation caused a gradual decrease in food consumption with both types of tumour, while body weight increased, especially in the EL4-bearing animals receiving the soya-bean diet. The weight gain was due to body water accumulation and was accompanied by decreases in body fat and minor changes in carcass protein and ash contents. The dietary treatments did not produce significant differences in tumour incidence and mortality, but tumour size was decreased by diets supplying omega-3 fatty acids: in the EL4 mice tumour weight was markedly depressed by linseed oil, compared to soya-bean oil, whereas thymoma tumour weight was lowest in mice receiving fish oil and highest in the soya-bean oil group. Both types of tumour caused pronounced hypoglycaemia and hyperinsulinaemia in the hosts, and the effect was modulated by the diets in the EL4 but not in the thymoma animals: the plasma glucose level was especially low in the linseed oil group and relatively highest in the soya-bean oil treatment. The degree of hyperinsulinaemia depended on the diet only in the thymoma-bearing mice, with linseed and fish oils producing higher insulin levels than soya-bean oil. A slight hyperinsulinaemia was also observed in linseed and fish oil-fed control mice. Serum triglycerides were elevated in tumour-bearing animals, without consistent differences between dietary treatments. Although no clear pattern emerged concerning total cholesterol and LDL levels, HDL values were strongly affected by the type of oil: in the control animals linseed oil caused an increase in HDL-cholesterol compared to the other two oils. The thymoma-bearing mice responded to the linseed and fish oil diets with greatly elevated HDL-cholesterol levels. The results point to important differences in the responses of the two implanted tumours and hosts not only to the omega-6 and omega-3 fatty acids, but also to the type of dietary omega-3 fatty acids, namely alpha-linolenic acid and long chain fish oil polyunsaturated fatty acids.

Adult respiratory distress syndrome: roles of leukotriene C4 and platelet activating factor

The relationship between leukotriene C4 (LTC4), platelet activating factor (PAF), and adult respiratory distress syndrome (ARDS) was studied in nine patients and 84 control subjects. A leukocyte adherence inhibition (LAI) assay induced by each of the ligands was used to monitor the subjects for 3 consecutive days or until clinical recovery was noted. LAI was considered to be positive if the nonadherence index (NAI) was greater than 30 for LTC4 or greater than 20 for PAF. LAI was negative in all healthy subjects using both ligands. LTC4-induced LAI was positive in all nine ARDS patients and reverted to negative after recovery from the syndrome, while three (33.3%) of nine patients responded to PAF. In contrast, of the 84 control subjects, LAI was induced by LTC4 in only three (3.3%) and by PAF in five (5.9%). The mean NAI (52.2 +/- 18) of LTC4-induced LAI in ARDS patients was significantly (p less than .05) higher when compared with the control group (-5 +/- 6.4), whereas that of PAF-induced LAI was less than 20 in both groups, indicating that LTC4 is a more specific ligand than PAF. All three patients in whom ARDS was caused by sepsis responded to both LTC4 and PAF, but results of specific receptor-antagonist experiments indicated that each compound acted independently. The mean NAI for LTC4 (58.5 +/- 10) and PAF (49.1 +/- 12) in patients with septic ARDS were significantly (p less than .05) higher when compared with those of patients with sepsis alone (0.5 +/- 9.9 and 4.4 +/- 17, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Leukotriene C4 decreases the activity of respiratory cilia in vitro

In the present study we assessed the effect of leukotriene C4 on ciliary beat frequency in vitro. Chicken tracheas were sliced into thin rings and ciliary activity was viewed microscopically. Ciliary beat frequency was measured through an optical fibre by a fast Fourier transformer analyser and recorded on an oscilloscope. Ciliary beat frequency was measured at one fixed point during 30 min at room temperature in RPMI-HEPES medium alone and in medium containing leukotriene C4 at a range of concentrations (10(-6)-10(-9) M). Our results demonstrate that leukotriene C4 (10(-7) and 10(-8) M) caused a significant decrease in ciliary beat frequency in all tracheal rings tested (mean decrease of 24%). The specificity and Ca2(+)-dependency of leukotriene C4 activity was elucidated by the ability of FPL 55712 (SRS-A specific antagonist), Ca2(+)-free medium, calcium channel blockers (nifedipine and verapamil) and the calmodulin inhibitor trifluroperazine to abrogate its effect on ciliary beating.

A comparison of implicit and explicit methods of process quality assurance for blunt trauma patients

We compared explicit (objective) and implicit (subjective) methods of process quality assurance to understand how the findings of each method are related. The charts of 100 blunt trauma patients who were admitted to the ICU, underwent surgery, or died in the emergency department were reviewed for compliance with six explicit process-of-care criteria previously established by the ED faculty. The results of this explicit review were compared with the results of an ongoing quality assurance program that uses implicit review. In the implicit review, a faculty member reviewed patients' charts and responded to three questions regarding the process of care. All blunt trauma patients who met the admission criteria were to be included in this review. Only 44 of the 100 charts were subjected to implicit review. Of these, 26 were judged satisfactory by both methods, two were judged unsatisfactory by both methods, two failed only the implicit review, and 14 failed only the explicit review. The null hypothesis, that the two methods were equivalent, was rejected (McNemar's test, P less than .003). These results suggest that process-of-care assessments of the quality of care must be interpreted with caution as they are method dependent and may not correlate with patient outcomes.

Insulin-tumour interrelationship in EL4 lymphoma or thymoma-bearing mice. I. Alloxan-diabetic or non-diabetic mice

A study has been carried out in which a comparison was made between EL4 lymphoma (assumed to be an insulin-producing secreting tumour) and thymoma (an insulin-dependent tumour). Tumour development and incidence, 3H-thymidine incorporation and insulin content in tumours, the host's food intake, blood insulin, glucose and cholesterol were determined in non-diabetic and alloxan-diabetic mice. Whereas no significant differences were observed between the diabetic and non-diabetic EL4 tumour-bearing mice, the diabetic, thymoma tumour-bearing mice showed reduced tumour growth and lower tumour incidence as compared with their non-diabetic counterparts. Insulin administration to diabetic tumour bearing mice, enhanced 3H-thymidine incorporation in the thymoma tumour cells only, and the insulin content of the EL4 tumours was found to be higher than that of the thymoma tumours. Rapid diabetes remission was observed in the diabetic, EL4 tumour-bearing mice as compared with the thymoma tumour-bearing mice.

[Screening for colorectal neoplasms]

We screened groups at high risk for colorectal neoplasms, determining the efficacy of the leukocyte adherence inhibition test (LAI) for early detection, in comparison with that of the fecal occult blood (Hemoccult) test and sigmoidoscopy or colonoscopy. Those screened included 549 first-degree relatives of patients with colorectal cancer, 190 patients with a past history of colorectal adenoma or carcinoma and 67 with a past history of breast or gynecological cancer or inflammatory bowel disease. 146 normal volunteers served as controls. In 782 of those fully screened during a 3-year period, 121 had adenomas (15.5%) and 5 had invasive cancer (0.6%). The LAI test was positive in 21% of those at high risk and in 7.5% of the controls. The hemoccult test was positive in only 4.8%, but in 1/3 of them neoplasms were found. This predictive value of 33% compares with only 16% for the LAI test. That most of the neoplasms found were adenomas and not invasive cancer may be due to the relative youth of most of those screened. We conclude that the groups studied were indeed at high risk. The LAI test is not sensitive enough to identify benign adenomas but might serve as another risk-market for colorectal neoplasms. Long-term follow-up of those at high-risk with positive LAI tests may prove that we have identified a subgroup truly at risk.

Improving patient function: a randomized trial of functional disability screening

STUDY OBJECTIVES

To test whether a 34-item functional status questionnaire measuring physical, psychological, and social function can be used by physicians in practice to help improve their patients' outcomes.

DESIGN

Prospective randomized trial.

SETTING

Community internal medicine practices.

PATIENTS

Five hundred and ten continuing patients with functional disabilities who saw their physicians at least four times a year. PHYSICIANS: Seventy-six UCLA clinical volunteer faculty who are internists in community office practices.

INTERVENTIONS

Physicians and their patients were randomly assigned to the experimental or the control group. Experimental group physicians attended a 2-hour multimedia educational session and received four functional status reports on each of their study patients over a 1-year period. Control group physicians received no education and no functional status feedback. Control group and experimental group patients were tested for functional status with the functional status questionnaire every 4 months for 1 year. Both groups also completed monthly diaries that measured use of health services. Experimental group physicians answered an anonymous evaluation questionnaire at 6 months after study entry.

MEASUREMENTS AND MAIN RESULTS

Forty-three percent of experimental group physicians reported that they had used the functional status questionnaire to change therapy. Ninety-five percent reported that it was useful and accurate. Patient diaries did not show any difference between experimental group patients and control group patients in number of medications used, visits to physicians or other health professionals, equipment purchased, diet, or exercise programs. There were no significant differences between experimental and control group patients at exit from the study on any functional status or health outcome measure.

CONCLUSION

A more powerful intervention than a 2-hour educational session and the regular provision of functional status information is needed to help office-based internists improve patient outcomes.

Assessment of a self-contained solid phase enzyme linked immunoassay (ImmunoComb) for the determination of serum total IgE

A semiquantitative method (ImmunoComb) for measuring total serum IgE is described and compared with a standard radioimmunoassay (PRIST). ImmunoComb, based on a solid-phase enzyme-linked immunoassay, is self-sufficient and does not require any expensive laboratory equipment. Comparison of these two assays revealed an almost absolute agreement between them (correlation coefficient = 0.95). Furthermore, the ImmunoComb assay also demonstrated its rapidity and temperature independence while maintaining a recovery of 90% to 102%.

Physician ratings of appropriate indications for three procedures: theoretical indications vs indications used in practice

We previously reported substantial disagreement among expert physician panelists about the appropriateness of performing six medical and surgical procedures for a large number of theoretical indications. A recently completed community-based medical records study of about 4,500 patients who had one of three procedures--coronary angiography, upper gastrointestinal endoscopy, and carotid endarterectomy--shows that many of the theoretical indications are seldom or never used in practice. However, we find that there is also substantial disagreement (5, 25, or 32 per cent for angiography, endoscopy, or endarterectomy, respectively) about the appropriateness of indications used in actual cases if disagreement is defined by first discarding the two extreme of nine ratings, then looking for at least one rating near the bottom (1 to 3) and one near the top (7 to 9) of the 9-point scale. Patients should know that a substantial percentage of procedures are performed for indications about which expert physicians disagree.

The condition of the literature on differences in hospital mortality

The quiescent interest in understanding the variations in the quality of hospital care has been revitalized recently with the government's release of hospital-specific mortality data. The authors reviewed all published studies that either named hospitals and gave their death rates or explored which of their characteristics explained the differences in their rates. The literature is only in fair condition. It is sparse and flawed, and, before the government's release, did not identify an individual hospital's mortality experience by name. Twenty-two studies were analyzed; only five (23%) met criteria for validity. Seventeen (77%) focused on in-hospital mortality. Data were collected for a short time, were not gathered uniformly, and came from a sample of local hospitals. Researchers identified and explained limitations in their studies and were particularly concerned with their inability to measure differences in patients that might affect death rates. Several characteristics of hospital care were found to be associated with lower inpatient mortality: communication among and commitment of staff, clinical experience and performing operations frequently, board certification, size, and teaching status. The authors urge caution in applying the literature's findings to evaluations of hospital quality and offer suggestions for researchers. Improved research is critically important in facilitating current policy discussions regarding the use of mortality as a measure of hospital quality.

Randomized clinical trials: issues for researchers

The clinical trial is a randomized prospective study of human subjects in which the effectiveness of an intervention is compared against a control. Such a trial is considered to be a critical test of an innovative therapy. Trials require careful design and planning to be scientifically valid and clinically pertinent. In this review the clinical trial and its role in research are defined, and major ethical, methodological, and feasibility issues associated with trial design and organization are described.

Anti-tumor immunity in breast cancer evaluated by a computerized tube leukocyte adherence inhibition (LAI) assay

Seventy-four women admitted for breast biopsy were monitored before surgery for anti-tumor cell-mediated immunity using a computerized tube leukocyte adherence inhibition (LAI) assay. Spent medium from breast, lung and colon adenocarcinoma cell lines was used as the source of organ-specific neoantigens for standardization of the assay. Peripheral blood leukocytes from 25/40 (62.5%) patients diagnosed after surgery as breast cancer responded to spent medium with a positive non-adherence index (NAI). A positive NAI was inversely related to tumor mass because only 7/18 (38.8%) of those with Stage III or IV had a positive NAI; while 18/22 (81.8%) of those with Stage I or II were positive. Cross-reactive antigenicity was not observed when spent medium from breast cancer was incubated with leukocytes from patients with several other solid tumors nor when leukocytes from breast cancer patients were incubated with spent medium from lung or colon carcinoma cell lines. The antigenic material in the spent medium appears to be an organ-specific neoantigen because only 1/34 patients with benign breast disease had a positive NAI and all normal healthy control individuals were negative. The results of this study show that spent medium of a breast carcinoma cell line is more reliable than crude cancer extracts for use in LAI to detect specific anti-tumor cellular immune responses. The improved method presented in this report can be a useful tool in the early diagnosis of breast cancer and for monitoring of patients with this disease.

The role of acupuncture in asthma: changes in airways dynamics and LTC4 induced LAI

A cohort of nine extrinsic asthma patients were treated by means of acupuncture. Patients were followed up for changes in medical treatment, spirometry, skin reactivity to immediate type reactions, total serum IgE levels and reactivity of their leukocytes to leukotriene C4 challenge (LTC4 induced leukocyte adherence inhibition (LAI) assay). Our results show that after acupuncture, treated patients were able to reduce bronchodilator and taper completely corticosteroid therapy. No change in skin reactivity or in IgE levels were noted. However, acupuncture treatment was able to negate, in 66.6%, the positive LTC4 induced responses.

Allergen-induced leukotriene production by nasal mucosa and peripheral blood leukocytes

The relationship between release of leukotriene C4 (LTC4) from nasal mucosa in vivo and from peripheral blood leukocytes (PBLs) in vitro was examined in 18 patients with untreated rhinitis allergic to the house dust mite, Dermatophagoides pteronyssinus, and in 20 nonallergic control subjects following challenge with the specific allergen. Allergic patients were subjected to intranasal and PBL challenge with D pteronyssinus and a nonrelevant allergen, Artemisia vulgaris. In all allergic patients, intranasal challenge by D pteronyssinus, but not by A vulgaris, resulted in a release of substances from the nasal mucosa that reacted in a radioimmunoassay with antiserum to LTC4. Dermatophagoides pteronyssinus challenge in vitro of PBLs from the same patients, but not A vulgaris challenge, induced release of the same immunoreactive material into the supernatant. By comparison, the nonallergic subjects challenged with D pteronyssinus showed significantly lower LTC4 levels in their nasal secretions and PBL supernatants. The results show that, following specific allergen challenge, the release of LTC4 by the allergic nasal mucosa is similar in extent and nature to that of PBLs, indicating that these procedures can be used as tools to measure the efficacy of topically and systemically administered antiallergic drugs.

Effects of elevated intranasal temperature on subjective and objective findings in perennial rhinitis

The effects of elevated intranasal temperature on symptoms and signs of perennial rhinitis were studied in 78 patients by a double-blind, randomized, placebo-controlled clinical trial. Patients were subjected to two treatments separated by a 1-week interval. Each treatment consisted of three 30-minute sessions, during which the patient's intranasal temperature was raised by inhalation of saturated hot air (42 degrees C to 44 degrees C). Subjective response was recorded on a daily symptom score card during the week following treatment. Nasal patency was determined before and after treatment by measuring maximal nasal expiratory and inspiratory airflow and by measuring the area covered with vapor formed by the exhaled air on a plate. Highly reproducible results were obtained by using these three objective methods. Elevation of intranasal temperature resulted in amelioration of rhinitis symptoms and in objective evidence of increased nasal patency in a significant percentage of patients compared to the placebo-treated group.

Measuring the clinical appropriateness of the use of a procedure. Can we do it?

Increasing attention is being paid to data on geographic differences in population-based rates of use of medical and surgical procedures. To understand these differences and to determine what level of use is appropriate, a method is needed to judge the clinical appropriateness of services. We recently developed and tested such a method in two large, urban geographic areas. Eighty-one medical records from a randomly selected sample of 30 billing entities (46 physicians) who performed upper gastrointestinal endoscopy (UGIE) on Medicare patients were abstracted. Ninety-four percent of physicians who were asked agreed to participate. Reliability testing showed 99% agreement on items abstracted from a subset of records independently reviewed by two abstractors. Based on the abstractions, each patient could be assigned at least one (mean 2.2) specific clinical indication for which UGIE was performed. Using ratings derived from a previously held panel meeting, it was possible to evaluate the appropriateness of the indications for each UGIE.

The effect of comorbidity on appropriateness ratings for two gastrointestinal procedures

We evaluated the effect of patients' comorbidity on the appropriateness of performing esophagogastroduodenoscopy or cholecystectomy. A nine-member national physician panel rated 1118 brief clinical scenarios for patients without comorbidity. Ratings were then repeated for patients with increasing degrees of comorbidity. As comorbidity changed from none to medium, 60% of those scenarios that were originally rated as appropriate for endoscopy and cholecystectomy remained appropriate. As high comorbidity was introduced, only 13% of such scenarios remained appropriate for endoscopy, while 33% remained appropriate for cholecystectomy. These findings suggest that, although clinical reasons for performing procedures are a powerful determinant of when they should be used, comorbidity is also important and needs to be included in any assessment of the appropriateness of procedure use.

Does inappropriate use explain geographic variations in the use of health care services? A study of three procedures

We studied the appropriateness of use of coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy and its relationship to geographic variations in the rates of use of these procedures. We selected geographic areas of high, average, and low use of these procedures and randomly sampled Medicare beneficiaries who had received one of the procedures in 1981. We determined the indications for the procedures using a detailed review of medical records and used previously developed ratings of appropriateness to assign an appropriateness score to each case. Differences among sites in levels of appropriateness were small. For example, in the high-use site for coronary angiography, 72% of the procedures were appropriate, compared with 81% in the low-use site. Coronary angiography was performed 2.3 times as frequently in the high-use site compared with the low-use site. Under the conditions of this study, we did find significantly levels of inappropriate use: 17% of cases for coronary angiography, 32% for carotid endarterectomy, and 17% for upper gastrointestinal tract endoscopy. We conclude that differences in appropriateness cannot explain geographic variations in the use of these procedures.

Obtaining clinical data on the appropriateness of medical care in community practice

We sought the voluntary cooperation of a randomly selected sample of community physicians and hospitals in five states for a study of how appropriately they performed coronary angiography, carotid endarterectomy, and upper gastrointestinal tract endoscopy. Ninety percent of 913 sampled physicians (n = 819) consented to a review of up to 20 of their 1981 Medicare patients' records. These physicians represented seven different specialties and subspecialties and performed 4988 procedures, 92% of the desired sample. Only three of 230 hospitals did not participate. We attribute our method's success primarily to the formation of a network to connect the branches of the profession, respect for office and hospital practice routine, confidentiality, and the development of carefully designed medical record abstraction systems. We conclude that, with effort, cooperative research among disparate segments of the medical community can become a reality even if the topic studied is relatively sensitive.

Sufficiency of clinical literature on the appropriate uses of six medical and surgical procedures

We reviewed the English-language clinical literature on carotid endarterectomy, cholecystectomy, upper gastrointestinal endoscopy, colonoscopy, coronary angiography and coronary artery bypass graft procedure to identify the appropriateness of using these procedures in 1981. Most of the 803 relevant articles and textbooks were published after 1975; about 10% of the 571 research studies were randomized, controlled trials, while two thirds were retrospective studies. Incomplete or contradictory information was available on the indications for and efficacy of using the procedures; almost no data were available on costs and use; data on complications failed to specify patients' symptoms or the relationship between complications and reasons for doing the procedure.

Assuring the quality of health care for older persons. An expert panel's priorities

To select topics for quality assurance activities focusing on older patients, we convened a 14-member panel of physicians and experts in quality assurance. In two rounds of ratings, panelists rated 42 medical conditions (eg, pneumonia) in terms of their effects on patient outcomes, the availability of beneficial interventions, and the health benefits from improving current quality. They rated 27 health services (eg, adult day-care) on similar dimensions. The feasibility of doing quality assurance work on each condition and service also was rated. Using the ratings, the conditions selected for quality assurance work were congestive heart failure, hypertension, pneumonia, breast cancer, adverse effects of drugs, incontinence, and depression. Health care services selected were hospital discharge planning, acute inpatient care for the frail elderly, long-term-care facilities (intermediate-care facilities and skilled nursing facilities), home health care services, and case management.

Allergen-specific leukocyte adherence inhibition (LAI) assay: sensitivity, specificity and mechanism

An allergen-specific tube leukocyte adherence inhibition (LAI) assay has been developed in order to study the mechanism by which leukocytes lose their normal property of adherence to glass. Peripheral blood leukocytes (PBL) from 27 individuals allergic to Dermatophagoides farinae (DF), 10 with seasonal rhinitis not induced by DF and 49 non-allergic healthy volunteers were challenged in vitro with DF and a non-relevant allergen, Artemisia vulgaris (AV) and then assayed for the ability to adhere to glass tubes. Challenge by DF, but not by AV, resulted in loss of adherence by PBL from patients allergic to DF, but not in those of normal controls. The specific LAI response was dose-dependent and occurred only when a critical dose of 0.5 X 10(3) was employed. Following in vitro challenge with DF, radio-immunoassay using an antiserum to LTC4 detected immunoreactive material in supernatants of PBL from DF-allergic individuals. When highly enriched mononuclear cells from non-allergic individuals were armed with cytophilic allergen-specific IgE and challenged with the specific allergen, they lost the property of glass adherence and released a substance that was immunoreactive with LTC4. The results suggest that the chain of events leading to the LAI response in PBL from allergic individuals involves primary recognition of the allergen by specific IgE antibodies bound to receptors on mononuclear cells. The cells are thus triggered to synthesize cysteinyl-containing leukotrienes which mediate the LAI phenomenon. The results suggest that this assay may be used to study allergen-antibody interaction and the subsequent events leading to the clinical picture of atopic diseases.

Providing primary general medical care in university hospitals: efficiency and cost

Data on efficiency, costs, and profits of 15 internal medicine outpatient group practices in university hospitals were collected for 9 months from interviews, a time-motion study, observations, and reviews of bills. Charges for a follow-up visit were about 25% higher than Medicare's allowable charges, but differed threefold across practices. Physicians spent more than half their allocated patient care or supervision time in other activities and 14% of nursing time was used for direct patient care. Visits to second- and third-year residents cost one half of those to faculty. Faculty supervision of second- and third-year residents was limited; it was, on average, 2 minutes per follow-up visit. Despite these inefficiencies, bad debts, and educational costs, practices appeared to break even financially. We conclude it is financially feasible for university hospitals to provide primary care to disadvantaged populations.

Educating physicians and treating patients in the ambulatory setting. Where are we going and how will we know when we arrive?

We evaluated 15 group practices in general internal medicine in university hospitals with regard to access to and quality of care, patients' satisfaction with that care, and quality of residency education provided. We used these data to speculate about potential changes in ambulatory care programs in university teaching hospitals. All 15 practices participated for 4 years. One third of their patient population had no medical insurance. Practice patients had twice as many chronic illnesses as did the general population, and two fifths of patients stayed at least 2 years in the practice. Few faculty members spent more than 14 hours weekly in the practices, and housestaff worked an average of 4 hours per week. Patient waiting times did not meet ideal standards, but patient satisfaction was higher than in a general population. Compliance with quality of care criteria was not exceptional; for example, 10% of eligible patients received an annual influenza vaccination. Housestaff assigned a relatively low ranking to their educational experience in the practices. We recommend the institution of additional experimental programs in ambulatory care and housestaff education to improve the quality of care in the ambulatory setting.

The appropriateness of using a medical procedure. Is information in the medical record valid?

Understanding the clinical appropriateness of a procedure's use may be critical in explaining geographic variations in its use. Little is known, however, about whether data on appropriateness can be obtained from a medical record. A national panel of physicians formulated a list of 300 mutually exclusive, detailed clinical indications for performing coronary angiography. Using this list, we compared the reasons physicians perform coronary angiography as revealed in medical records with those given in interviews with the physicians who actually did the procedure. Thirty-five of 47 eligible billing entities (74%) from two Los Angeles Professional Standards Review Organization areas participated. These physicians practiced in 14 hospitals and accounted for 81% of all angiographies performed on Medicare patients in the two areas. Sixty-six records (approximately two per physician) were reviewed; physician interviews were conducted by two trained data collectors who were blinded to each other's results. Ninety-one percent agreement was reached on the specific indication for performing coronary angiography when information from the record review and interview was compared. We conclude that medical records yield valid information on why coronary angiography is performed and that they are a suitable source to use in judging the appropriateness of that use.

Derivation of clinical indications for carotid endarterectomy by an expert panel

We used a two-round consensus panel method to derive and rate the appropriateness of comprehensive sets of detailed clinical indications for performing carotid endarterectomy. Before meeting, nine nationally influential physicians rated 675 indications; after review and discussion, they rated 864. The method did not force unanimity; our purposes were not only to encourage agreement but also to uncover areas of disagreement concerning the procedure's appropriate use. The panelists agreed on the level of appropriateness for 54 per cent of the final 864 indications and disagreed on 18 per cent. Ratings were reliably reproduced six to eight months after the completion of the process. The physicians' indications and ratings were consistent with those in the literature, and statistical analysis demonstrated that they followed logical clinical rationale. We conclude that consensus methods that do not force agreement can be used with panels of physicians to produce detailed, reliable, and valid indications. They can also identify medically controversial reasons for using a procedure that can serve as a starting point for a research agenda.

Use of carotid endarterectomy in five California Veterans Administration medical centers

Although carotid endarterectomy is a controversial and frequently performed surgical procedure, little is known about the clinical appropriateness of its use in actual practice. Are the majority of procedures performed for highly accepted clinical reasons? We studied the clinical appropriateness of 107 procedures performed on 95 patients in 1981 in five Veterans Administration teaching medical centers. Standards for judging appropriate use were based on the recommendations of a multidisciplinary panel of nine physicians. Fifty-five percent of the procedures studied were judged clearly appropriate, 32% equivocal, and 13% clearly inappropriate. The rate of serious operative complications was 5.6%. These results suggest that carotid endarterectomy is overutilized within at least some segments of the Veterans Administration population.

Organ specific neoantigens reactive in the leukocyte adherence inhibition assay: affinity purification of human colon carcinoma antigen and its cross-reactive protein using monoclonal antibodies

A monoclonal antibody (mAb) was prepared against a semipurified preparation of an organ specific neoantigen (OSN) reactive in the leukocyte adherence inhibition (LAI) assay. The mAb (LC20.1) induces a positive LAI response when incubated with leukocytes of normal individuals in the presence of OSN derived from either human colon or lung carcinoma cell lines. Absorption of crude OSN preparations from these cell lines on immobilized LC20.1 mAb eliminates all the LAI reactive material suggesting that the mAb recognizes a common determinant on OSN from both colon and lung carcinomas. The LC20 mAb was used to affinity purify the colon cancer OSN as well as a cross-reactive normal protein from the urine of colon cancer patients and healthy donors, respectively. The colon cancer OSN and normal cross-reactive protein display an apparent molecular weight of 29,000, have a similar linear tryptic peptide map, and are indistinguishable by isoelectric focusing analysis. Regardless of the molecular similarity, only the colon cancer OSN preparation could induce a positive LAI when incubated with leukocytes of colon cancer patients. Seven additional anti-colon cancer OSN mAbs were prepared against purified material. These mAbs can be divided into three groups, each of which recognizes a distinct antigenic determinant that is shared by the colon cancer neoantigen and its cross-reactive normal protein.

Ketotifen, disodium cromoglycate, and verapamil inhibit leukotriene activity: determination by tube leukocyte adherence inhibition assay

Peripheral blood leukocytes (PBL) from asthmatic individuals lose their former ability to adhere to glass when incubated with leukotriene C4 (LTC4). A modified leukotriene-induced leukocyte adherence inhibition (LAI) assay was therefore used to study the ability of anti-asthmatic drugs to abrogate such activity. Ketotifen, disodium cromoglycate, Verapamil, and dimethpyridene, all at concentrations of 2 X 10(-6) M, were co-cultured with 2 X 10(-7) M LTC4 and their effect on the LTC4-induced LAI determined. Verapamil, Ketotifen, and disodium cromoglycate all inhibited the LTC4 activity while the H1 antagonist, dimethpyridene, did not. These results suggest that the beneficial effect of Verapamil, Ketotifen, and disodium cromoglycate in bronchial asthma is probably as calcium antagonists that cause the inhibition of leukotriene activity.

Physician ratings of appropriate indications for six medical and surgical procedures

We convened three panels of physicians to rate the appropriateness of a large number of indications for performing a total of six medical and surgical procedures. The panels followed a modified Delphi process. Panelists separately assigned initial ratings, then met in Santa Monica, California where they received reports showing their initial ratings and the distribution of the other panelists ratings. They discussed the indications and revised the indications lists, then individually assigned final ratings. There was generally better agreement on the final ratings than on the initial ratings. Based on reasonable criteria for agreement and disagreement, and excluding one outlying procedure, the panelists agreed on ratings for 42 to 56 per cent of the indications, and disagreed on 11 to 29 per cent.

The isolation of colon cancer organ specific neoantigen by the use of the leukocyte adherence inhibition assay and monoclonal antibodies

The LAI reactivity of a colon organ specific neoantigen (OSN) was recovered from the urine of advanced colon cancer patients. In this study three physico-chemical steps were employed; precipitation by 80% ammonium sulfate, ion exchange, and molecular sieve chromatography. Each isolate was tested for activity and specificity by the direct tube leukocyte adherence inhibition (LAI) assay employing leukocytes from colon and breast cancer patients. The OSN enriched isolate was then used to generate monoclonal antibodies (Mab). Hybridomas were screened by ELISA. One hybridoma designated Bac 18.1 reacted preferentially with colon OSN and not with the urine from normals or patients with breast cancer. Affinity purification of colon OSN was achieved and it was shown to consist of a single band in SDS-PAGE with an apparent molecular weight of 30,000. The eluted polypeptide was specifically reactive in ELISA as well as in the LAI assay.

The Functional Status Questionnaire: reliability and validity when used in primary care

A comprehensive functional assessment requires thorough and careful inquiry, which is difficult to accomplish in most busy clinical practices. This paper examines the reliability and validity of the Functional Status Questionnaire (FSQ), a brief, standardized, self-administered questionnaire designed to provide a comprehensive and feasible assessment of physical, psychological, social and role function in ambulatory patients. The FSQ can be completed and computer-scored in minutes to produce a one-page report which includes six summated-rating scale scores and six single-item scores. The clinician can use this report both to screen for and to monitor patients' functional status. In this study, the FSQ was administered to 497 regular users of Boston's Beth Israel Hospital's Healthcare Associates and 656 regular users of 76 internal medicine practices in Los Angeles. The data demonstrate that the FSQ produces reliable sub-scales with construct validity. The authors believe the FSQ addresses many of the problems behind the slow diffusion into primary care of systematic functional assessment.

Work satisfaction and career aspirations of internists working in teaching hospital group practices

This paper presents data on the characteristics, work activities, job-related stress, work satisfaction, and career aspirations of 150 faculty and 595 housestaff physicians who regularly provide continuous primary care in 15 teaching hospital-based group practices. The faculty were young, board-certified generalists; they had been recruited from local training programs and spent the majority of their time seeing patients and supervising housestaff. Job satisfaction among faculty and housestaff was generally high. Dissatisfaction occurred most often with aspects of work over which physicians had little control. Although work-related stress was common, it was not related to job satisfaction. Compared with housestaff in traditional residency programs, housestaff enrolled in special Primary Care Training Programs reported significantly greater job satisfaction. For all housestaff, satisfaction with work in the group practice was consistently associated with decreased interest in subspecialty training.

Variations in the use of medical and surgical services by the Medicare population

We measured geographic differences in the use of medical and surgical services during 1981 by Medicare beneficiaries (age greater than or equal to 65) in 13 large areas of the United States. The average number of Medicare beneficiaries per site was 340,000. We found large and significant differences in the use of services provided by all medical and surgical specialties. Of 123 procedures studied, 67 showed at least threefold differences between sites with the highest and lowest rates of use. Use rates were not consistently high in one site, but rates for procedures used to diagnose and treat a specific disease varied together, as did alternative treatments for the same condition. These results cannot be explained by the actions of a small number of physicians. We do not know whether physicians in high-use areas performed too many procedures, whether physicians in low-use areas performed too few, or whether neither or both of these explanations are accurate. However, we do know that the differences are too large to ignore and that unless they are understood at a clinical level, uninformed policy decisions that have adverse effects on the health of the elderly may be made.

Leukocyte adherence inhibition assay in the diagnosis and follow-up of colorectal cancer patients

Antitumor immune response to colorectal cancer extract was tested by the tube leukocyte adherence inhibition (LAI) assay. Of 70 colorectal cancer patients, 38 (54%) were LAI-positive. In contrast, 15 of 159 (9%) healthy individuals and 2 of 28 (7%) patients with nonmalignant diseases were positive. The LAI activity disappeared a few months after surgery and remained negative in patients with no evidence of disease as well as in patients with disseminated progressed disease. A change of LAI from negative to positive during the follow up period correlated in some cases with the recurrence of the disease, but was observed also in cases with no clinical evidence of disease.

Diagnostic value of the computerized tube leukocyte adherence inhibition (LAI) assay for human colorectal, breast and lung cancers

We have tested by the computerized tube leukocyte adherence inhibition (LAI) assay, 319, 100 and 342 patients and controls for the presence of antitumor immunity to colorectal, breast and lung cancers. The assay was standardized and its sensitivity increased by using, as a challenging antigen, spent medium of human carcinoma cell lines and by the addition of prostaglandin E2 (PGE2). By large, the sensitivity of the assay (after the addition of PGE2) was inversely related to tumor burden, namely, it was 82.7, 78.9, and 88.6% as compared to 57.1, 33.3, and 29.6% for the early and late stages of colorectal, breast and lung cancers, respectively. Calculating the frequency of disease in the population studied and in comparison with known frequencies of the same in the general population, the positive and negative predicting values (PVpos, PVneg) were obtained. Our results demonstrate that the LAI assay cannot be applied for mass screening since its low PVpos would impair its effectiveness. However, its application to a population at high risk for developing a particular malignancy or as a second-line modality to more conventional screening methods would increase its cost-effectiveness and favor its applicability.

Setting standards of performance for program evaluations: the case of the teaching hospital general medicine group practice program

Program evaluation is like research in its use of the scientific method. An important difference is that evaluations result in judgments of merit. What are the standards for making the judgments? Little attention has been paid to their selection and use. This article reports on how standards were set in an evaluation of the structure of fifteen of the nation's university hospitals who participated in the Teaching Hospital General Medicine Group Practice Program (sponsored by the Robert Wood Johnson Foundation). Many sources were used to select standards including a review of the literature, expert advice and actual data from two years of the programs's performance. Also, the standard-setting process was a participatory one in which all potentially competing views were provided with a forum for discussion. Finally, standards were set in advance of the collection of information, facilitating the selection of study designs and analysis techniques. Almost all project directors stated that the process helped them in program planning and gave them ideas for research and evaluation. Because standard-setting has mutual benefits, we recommend that it take place during program planning.

A method for the detailed assessment of the appropriateness of medical technologies

The standard way to assess medical technologies is to conduct a randomized clinical trial. Patients are randomly assigned to groups receiving alternative treatments, and outcomes are monitored over a long period of time. For example, some victims of left main coronary artery disease may undergo coronary artery bypass surgery, and others may receive medical treatment with nitroglycerine and beta blockers. Comparison of five-year mortality and morbidity in the two groups helps to determine the relative appropriateness of the two procedures. In addition, information about quality of life and cost can also be collected and compared.

Is common variable hypogammaglobulinemia linked to HLA? A family study

Two patients with common variable hypogammaglobulinemia (CVH) and their families, who came from different ethnic backgrounds, were surveyed for the level of immunoglobulins (Ig) and HLA genotypes. Six of 10 siblings and the mother in one family had a decreased level of one of the major classes of Ig (IgA in 5, IgM in 1 and IgG in the mother). A similar decrease was found in three of six siblings in the other family (IgG in one, IgA in one and IgM in one). HLA genotyping disclosed that affected and nonaffected family members had identical genotypes, suggesting that hypogammaglobulinemia in CVH is not linked to a specific HLA genotype.

Physician and patient satisfaction as factors related to the organization of internal medicine group practices

The present study compares patient satisfaction scores with job satisfaction scores of the physicians providing their care in 16 general internal medicine teaching hospital group practices. Practice sites with more satisfied patients were also more likely to have more satisfied housestaff and faculty physicians. Additionally, higher satisfaction scores for both physician groups and patients were consistently associated with a greater percentage of patients experiencing continuity of care, lower patient no-show rates, more efficient use of ancillary staff in providing direct patient care, and more reasonable charges for a routine follow-up visit. These findings suggest that improving physician and patient satisfaction may have economic as well as psychological and social benefits.