Management of giant cell arteritis and polymyalgia rheumatica

Giant cell arteritis and polymyalgia rheumatica are closely related disorders that affect persons more than 50 years of age and cause substantial morbidity. Patients with giant cell arteritis typically have a localized headache, nonspecific systemic symptoms, temporal artery tenderness and a high erythrocyte sedimentation rate (ESR). The diagnosis is confirmed by characteristic pathologic findings on temporal artery biopsy. Patients with polymyalgia rheumatica usually have similar nonspecific systemic symptoms, proximal muscle pain and stiffness, and an elevated ESR. The diagnosis is based on the clinical findings. Both disorders are treated with corticosteroids: high dosages for giant cell arteritis (prednisone in a dosage of 40 to 60 mg per day) and lower dosages for polymyalgia rheumatica (prednisone in a dosage of 10 to 20 mg per day). Symptom relief in response to treatment is rapid and reinforces the diagnosis. After normalization of the ESR, the corticosteroid is tapered, with the patient monitored closely for symptom recurrence. Most patients require corticosteroid therapy for two to three years and experience one or more treatment complications.

Management of bacterial endocarditis

Most cases of bacterial endocarditis involve infection with viridans streptococci, enterococci, coagulase-positive staphylococci or coagulase-negative staphylococci. The choice of antibiotic therapy for bacterial endocarditis is determined by the identity and antibiotic susceptibility of the infecting organism, the type of cardiac valve involved (native or prosthetic) and characteristics of the patient, such as drug allergies. Antibiotic therapies discussed in this report are based on recommendations of the American Heart Association. Treatment with aqueous penicillin or ceftriaxone is effective for most infections caused by streptococci. A combination of penicillin or ampicillin with gentamicin is appropriate for endocarditis caused by enterococci that are not highly resistant to penicillin. Vancomycin should be substituted for penicillin when high-level resistance is present. Resistance of enterococci to multiple antibiotics including vancomycin is becoming an increasing problem. Native valve infection by methicillin-susceptible staphylococci is treated with nafcillin, oxacillin or cefazolin. The addition of gentamicin for the first three to five days may accelerate clearing of bacteremia. Infection of a prosthetic valve by a staphylococcal organism should be treated with three antibiotics: oral rifampin and gentamicin and either nafcillin, oxacillin, cefazolin or vancomycin, depending on susceptibility to methicillin. Vancomycin is substituted for penicillin in patients with a history of immediate-type hypersensitivity to penicillin.

Student performances on Step 1 and Step 2 of the United States Medical Licensing Examination following implementation of a problem-based learning curriculum

PURPOSE

To examine students' performances on Step 1 and Step 2 of the United States Medical Licensing Examination (USMLE) following the implementation of a problem-based learning curriculum.

METHOD

Performances on Step 1 of the USMLE for four classes at the University of Missouri-Columbia School of Medicine that completed a new problem-based learning curriculum (1997, 1998, 1999, and 2000) were compared with those of the last two classes to learn in the traditional curriculum (1995 and 1996). Performances on Step 2 of the USMLE for the classes of 1997, 1998, and 1999 were also compared with those of the classes of 1995 and 1996. The authors analyzed matriculation data (GPAs and MCAT scores) for all six classes. They compared all data with those of U.S. and Canadian first-time USMLE takers.

RESULTS

The mean scores were higher on USMLE Step 1 for classes in the problem-based learning curriculum than for classes in the traditional curriculum. The mean scores for Step 2 were above the national mean for classes in the revised curriculum and below the national mean for classes in the traditional curriculum. The admission profiles of these classes were essentially the same before and after the change in curriculum.

CONCLUSIONS

Major PBL revisions of the curriculum did not compromise the performances of medical students on the licensing examinations; in fact, they may have contributed to higher scores.

A clinical trial of hypertonic saline nasal spray in subjects with the common cold or rhinosinusitis

OBJECTIVE

To determine whether hypertonic saline nasal spray relieves nasal symptoms and shortens illness duration in patients with the common cold or acute rhinosinusitis.

DESIGN

Randomized trial with 2 control groups.

SETTING

Two family practice clinics.

PARTICIPANTS

One hundred forty-three adult patients with a cold or sinus infection. Patients with allergic rhinitis, symptoms for more than 3 weeks, or other respiratory diagnoses were excluded, as were those who had used topical decongestants.

INTERVENTION

Hypertonic saline or normal saline spray 3 times a day or observation. Subjects completed a 7-day symptom checklist that included a well-being question ("Do you feel back to normal?").

MAIN OUTCOME MEASURES

Nasal symptom score (sum of scores for nasal congestion, rhinorrhea, and headache) on day 3 and day of well-being (day of symptom resolution).

RESULTS

Data were collected for 119 subjects. No difference was found in either primary outcome when hypertonic saline was compared with either normal saline or observation. Mean day of well-being was 8.3 (95% confidence interval [CI], 6.9-9.7), 9.2 (95% CI, 6.9-11.43), and 8.0 (95% CI, 6.7-9.3) days in the hypertonic saline, normal saline, and observation groups, respectively. Day 3 mean nasal symptom score was 3.8 (95% CI, 3.0-4.5) for hypertonic saline, 3.7 (95% CI, 2.9-4.5) for normal saline, and 4.1 (95% CI, 3.5-4.7) for observation. Only 44% of the patients would use the hypertonic saline spray again. Thirty-two percent noted burning, compared with 13% of the normal saline group (P = .05).

CONCLUSION

Hypertonic saline does not improve nasal symptoms or illness duration in patients with the common cold or rhinosinusitis.

Modifying the culture of medical education: the first three years of the RWJ Generalist Physician Initiative

The Generalist Physician Initiative (GPI) was created by The Robert Wood Johnson Foundation to help medical schools increase the number of predoctoral and residency graduates entering generalist careers. The underlying assumption of the GPI is that more medical graduates will become generalists if schools select candidates whose personal characteristics are compatible with generalist careers and if schools provide for them an educational environment that values generalist careers in the same manner it has valued specialist careers. In essence, the GPI is helping schools modify the culture in which medical education occurs so that they may increase their production of generalists. Fourteen grants for six years of support were made to 16 U.S. medical schools in 1994. These schools are developing institution-wide efforts that span the continuum from the recruitment and selection of students through their medical school and residency education to their entry into practice, and include support of the practice. Most schools have developed external partners (e.g., state legislatures, managed care organizations, area health education centers) to assist in achieving their goals. The project is now (1997) at its halfway mark. This article describes the conceptual bases for the program (e.g., changes in admission criteria to favor applicants oriented to generalism), identifies common approaches to intervention chosen by the participating schools (e.g., establishing longitudinal, generalist-oriented clinical experiences throughout the four years of medical school), and explores issues being faced by the schools as they implement change (e.g., difficulties in decentralizing clinical education to include community physicians as teachers and role models).

Patients' attitudes about gifts to physicians from pharmaceutical companies

BACKGROUND

Little is known about patients' awareness of and attitudes about gifts to physicians from pharmaceutical companies.

METHODS

During a 7-week period in summer 1994, we surveyed adults (18 years of age and older) in the waiting rooms of two family practice centers in central Missouri. Four-hundred eighty-six adults (83 percent participation rate) responded to a self-administered questionnaire that assessed awareness of and attitudes about representative gifts.

RESULTS

Rates of awareness of specific gifts were 87.0 percent for free drug samples, 55.3 percent for ballpoint pens, 34.6 percent for medical books, 28.6 percent for baby formula, 22.4 percent for dinner at a restaurant, and 13.8 percent for a coffee maker. Of the 486 respondents, the following percentages were reported that "it is not all right" for physicians to accept specific gifts: dinner at a restaurant, 48.4 percent; baby formula, 44.2 percent; coffee maker, 40.7 percent; ballpoint pens, 17.5 percent; medical books, 16.9 percent; drug samples, 7.6 percent. In addition, 32.5 percent did not approve of their physicians accepting payment by a pharmaceutical company of medical conference expenses and from 28.0 percent to 43.4 percent disapproved of their physicians attending specific social events sponsored by pharmaceutical companies at a medical conference. Seventy percent of the subjects believed that gifts sometimes or frequently influence a physician's prescribing of medication; 64.0 percent believed that gifts to physicians increase the cost of medication. Beliefs that gifts influence prescribing behavior and beliefs that gifts increase medication costs were strongly associated with disapproval of each gift except for drug samples.

CONCLUSIONS

Respondents distinguished between particular gifts; approval rates were high for gifts generally considered to be trivial or that have potential value to patient care; disapproval rates were relatively high for gifts that have some monetary value but have little or no benefit for patients. Opinions about gifts were related to perceptions of their effects on prescribing behavior and costs.

Cervical inflammation and preterm delivery in pregnant women with a history of preterm delivery

BACKGROUND

A previous preterm delivery is a risk factor for preterm delivery in a subsequent pregnancy. We tested the hypothesis that evidence of inflammation on a Papanicolaou smear obtained during pregnancy is a risk factor for preterm delivery for women with a history of preterm delivery.

METHODS

We studied women who had two singleton deliveries at a university hospital during an 8-year period. Women eligible for our study were those whose first delivery was preterm (< 37 weeks of gestation) and for whom a Papanicolaou smear was obtained during the second pregnancy. These smears were examined for evidence of inflammation by a cytopathologist. Information about the second pregnancy was obtained by chart review.

RESULTS

The cytopathologist reviewed Papanicolaou smears from 92 study pregnancies and found evidence of cervical inflammation on 34 smears (37 percent). Preterm delivery ended 24 (26.1 percent) of the second pregnancies. The incidence of preterm delivery in women with inflammation on Papanicolaou smear was 41.2 percent compared with an incidence of 17.2 percent in women without inflammation (relative risk of 2.40 with a 95 percent confidence interval of 1.19 to 4.83). This association remained significant after controlling for potential confounding variables. A stratified analysis found that the association of cervical inflammation with preterm delivery was limited to women who had systemic exposure to an antibiotic during pregnancy.

CONCLUSION

Among pregnant women with a history of preterm delivery, evidence of inflammation on Papanicolaou smear was associated with an increased risk of preterm delivery. If replicated in other studies, this finding might have implications for the management of pregnancies in women with a history of preterm delivery.

Patterns of comorbidity in elderly patients with multiple sclerosis

This study explored the prevalence of comorbid conditions in hospitalized patients with multiple sclerosis (MS) who were 65 years of age or older. Using 1989 data from the Quality of Care Medicare Provider Analysis and Review (MEDPAR) file, hospitalized MS patients were compared with respect to discharge diagnoses to an age- and sex-matched group of hospitalized patients without MS. As expected, the following discharge diagnoses were more common (P < 0.05) for MS patients: urinary tract infection, pneumonia, septicemia and cellulitus. In contrast, MS patients were less likely (P < 0.05) to have discharge diagnoses of acute myocardial infarction, heart failure, hypertension, angina pectoris, cerebrovascular disease, diabetes mellitus and chronic obstructive pulmonary disease. Possible explanations include under-reporting of certain comorbid conditions on discharge records of MS patients, a protective effect of MS or its treatment, reduced prevalence of risk factors, disproportionate mortality in younger MS patients with comorbidity and the benefits of medical surveillance.

Publication patterns of presentations at the Society of Teachers of Family Medicine and North American Primary Care Research Group annual meetings

BACKGROUND AND OBJECTIVES

The annual meetings of the Society of Teachers of Family Medicine (STFM) and the North American Primary Care Research Group (NAPCRG) are important peer-reviewed venues for family medicine academicians to present their research. However, a relatively small number of individuals actually hear each presentation. In order to permanently share their research with a large number of peers, these presenters need to take the next step and publish completed manuscripts. This study examined the frequency with which presentations at these meetings are eventually published.

METHODS

All abstracts from the 1987 and 1988 meetings of NAPCRG and the PEER and research sections of STFM were followed by performing a Medline computer search for the presenting author. Publications that matched the presentations were identified, and information was recorded about the elapsed time between presentation and publication, and the journal where publication occurred.

RESULTS

Just under half (48%) of all the presentations were published within 4 or 5 years. There was no difference between 1987 and 1988 presentations, nor between NAPCRG and the combined STFM presentations. However, 69% of STFM research presentations were published compared to 31% of the peer presentations (X2 = 20.6, df = 2, P < .001). The STFM research publications also tended to be in print sooner than other presentations. Fifty-six percent of the publications occurred in family practice journals, with Family Medicine and the Journal of Family Practice being the most common journals.

CONCLUSIONS

Approximately half of the presentations at STFM and NAPCRG annual meeting are published within 4 to 5 years. This is consistent with publication rates found for other specialty meetings. The reasons for not publishing are numerous and need to be better elucidated to help family medicine academicians complete the research loop and disseminate their findings to the scientific community.

Update and rationale for the inverted functional foot orthosis

The inverted orthotic technique, also known as the Blake functional foot orthosis, is a prescription variable that allows for greater control of abnormal foot function. This article describes the indications for this prescription and the specific stability changes this technique produces. The authors conclude that it is crucial for laboratories to be brought into the process of orthosis development so that new techniques can be incorporated easily into therapy.

Posterior tibial tendinitis. A literature review with case reports

Overuse posterior tibial tendinitis is caused by the increased stress placed on the tendon as it tries to compensate for the increased subtalar joint pronatory movement and velocity during physical activity. The stress can cause microtrauma and rupture of some of the fibers of the tendon. This leads to an inflammatory process and the classical clinical signs and symptoms. Therapy is directed at reducing the inflammation, minimizing the fibrosis buildup, re-strengthening the weakened tissue, and controlling the pronatory force. The two case reports illustrate typical clinical signs, symptoms, and treatment for this injury.

Correlation between limb length discrepancy and asymmetrical rearfoot position

Ten subjects with a known limb length discrepancy were filmed with the two-dimensional Motion Analysis Foot Trak System; eight were filmed running and walking and two were filmed walking only. A control group of ten subjects with no measured limb length discrepancy was filmed in the same manner (eight walking and running and two walking only). The calcaneus-to-vertical angle was recorded for the entire stance gait cycle (heel contact to toe-off). Analysis of the data between the short and long side showed a significant difference in calcaneal position between the two sides at midstance, with the longer side being more everted by 3 degrees or greater than the short side in most cases. There was no significant difference in the calcaneus-to-vertical angle at heel contact between the long and short side. There was no significant difference between the calcaneus-to-vertical angles of the right and left sides of the ten control subjects, either walking or running.

Walking and hiking injuries. A one year follow-up study

Injury patterns associated with walking and hiking activities were examined for all patients presenting to the clinic over a 1-year period. Among the patient group, the authors found that most injuries were unilateral, resulting from overuse, and occurred in the lower extremity, particularly in the foot, ankle, and knee. There are limited studies investigating walking and hiking injury rates in the general population. The results can be applied only to a small specific sample of the population.

Effect of extrinsic rearfoot posts on rearfoot position

Twenty runners displaying abnormal subtalar joint pronation were selected for this study, the purpose of which was to investigate the effects of extrinsic rearfoot posted orthoses on frontal plane rearfoot and tibial position. Numerous temporal events were measured and compared for three different conditions: acrylic post, Birko post, and no post. The results suggested that rearfoot posts have a somewhat limited function in foot orthotic therapy and that the choice of posting material is of limited functional value.

Does problem-based learning work? A meta-analysis of evaluative research

The purpose of this review is to synthesize all available evaluative research from 1970 through 1992 that compares problem-based learning (PBL) with more traditional methods of medical education. Five separate meta-analyses were performed on 35 studies representing 19 institutions. For 22 of the studies (representing 14 institutions), both effect-size and supplementary vote-count analyses could be performed; otherwise, only supplementary analyses were performed. PBL was found to be significantly superior with respect to students' program evaluations (i.e., students' attitudes and opinions about their programs)--dw (standardized differences between means, weighted by sample size) = +.55, CI.95 = +.40 to +.70 - and measures of students' clinical performance (dw = +.28, CI.95 = +.16 to +.40). PBL and traditional methods did not differ on miscellaneous tests of factual knowledge (dw = -.09, CI.95 = +.06 to -.24) and tests of clinical knowledge (dw = +.08, CI.95 = -.05 to +.21). Traditional students performed significantly better than their PBL counterparts on the National Board of Medical Examiners Part I examination--NBME I (dw = -.18, CI.95 = -.10 to -.26). However, the NBME I data displayed significant overall heterogeneity (Qt = 192.23, p < .001) and significant differences among programs (Qb = 59.09, p < .001), which casts doubt on the generality of the findings across programs. The comparative value of PBL is also supported by data on outcomes that have been studied less frequently, i.e., faculty attitudes, student mood, class attendance, academic process variables, and measures of humanism. In conclusion, the results generally support the superiority of the PBL approach over more traditional methods. Acad. Med. 68 (1993):550-563.

The motion analysis system for dynamic gait analysis

The research value of the Motion Analysis System, within its scope of limitations, is large and may allow the podiatrist to lend scientific data to support many areas that have been previously held to be of a theoretic or anecdotal basis. The whole concept of rearfoot control with orthoses is perhaps the most important of these. Podiatrists have been aware of the role of orthoses for years, but now there is the means to demonstrate these findings to other medical professions. The ability to compare a number of clinical variables is another truly useful feature. The Motion Analysis System and other similar equipment are not designed to replace or make obsolete the biomechanical examination and "trained human eye;" rather, they act to compliment these skills and to help bring the realm of podiatric biomechanics and orthotic therapy into the scientific arena.

The pregnancy-related dreams of pregnant women

BACKGROUND

This study examined the frequency and nature of pregnancy-related dreams in pregnant women in a family practice center and assessed the extent such dreams were discussed with providers of prenatal care.

METHODS

Pregnant women 18 years of age or older who were receiving prenatal care at the University of Missouri-Columbia Family Medical Care Center responded to a two-page self-administered questionnaire. The major variables measured were frequency of pregnancy-related dreams, frequency of frightening dreams, content of dreams, and discussion of dreams. Health professionals providing prenatal care to these women were also surveyed.

RESULTS

Eighty-eight pregnant women, 41 family physicians, and 3 nurse practitioners participated in the study. Dreams about their pregnancy or baby were reported by 59 (67 percent) of 88 pregnant women, of whom 22 had experienced at least one frightening dream. Seventeen women reported being upset by a dream. The frequency of dreams increased with advancing gestational age. The content of the most common dream involved conflict with the father of the baby. Most women had talked to another person about their dreams, usually the baby's father. Only 2 women told their physicians about the pregnancy-related dream. One-half of the providers of prenatal care reported discussing pregnancy-related dreams with a pregnant patient at least once during their careers.

CONCLUSION

Dreams about their pregnancy or baby occurred frequently in pregnant women and could be a neglected source of information about the psychological state of the patient.

Does evidence of inflammation on Papanicolaou smears of pregnant women predict preterm labor and delivery?

BACKGROUND

Preterm delivery is the most common cause of neonatal morbidity and mortality in the United States. There is evidence that cervicovaginal infection could predispose to preterm labor. This study explored a possible association of evidence of inflammation on an otherwise normal Papanicolaou smear obtained during pregnancy with subsequent preterm labor and preterm delivery.

METHODS

Using a retrospective matched cohort design, we studied women who gave birth to live singleton infants at the University of Missouri Hospital and Clinics during a 21-month period. Papanicolaou smears were obtained from 1 to 8 months before delivery and were interpreted in the same cytopathology laboratory. Data pertaining to outcome variables and potential confounding variables were collected from hospital charts.

RESULTS

Incidence rates were 14.4 percent for labor < 37 weeks' gestation (preterm labor), 12.3 percent for hospitalization for preterm labor, 9.9 percent for delivery < 37 weeks (preterm delivery), 2.6 percent for delivery < 34 weeks, and 7.5 percent for birth weight < 2500 g. On univariate and multivariate analyses, there were no significant differences in any outcome between the 293 women with inflammation and the 284 women without inflammation on Papanicolaou smear. Results were unchanged when the analysis was limited to the 412 women who received no antibiotics during pregnancy. Among the 38 women with a history of preterm labor or preterm delivery, those with cervical inflammation had a higher rate of preterm labor than those without inflammation.

CONCLUSIONS

In the sample as a whole, there was little evidence that findings of inflammation on Papanicolaou smear constituted a risk factor for preterm labor or preterm delivery. The data suggest that inflammation could be associated with an increased risk in a subgroup of women at higher risk by virtue of their obstetric history.

Inflammation on the cervical Papanicolaou smear: the predictive value for infection in asymptomatic women

BACKGROUND

The clinical significance of inflammation on the cervical Papanicolaou (Pap) smear of asymptomatic women is unknown. This study assessed the possible association between inflammation on Pap smears with the presence of cervical/vaginal pathogens.

METHODS

A questionnaire was given to 290 asymptomatic women seen for routine gynecologic examination, including Pap smear, in a primary care setting. The women were tested for the presence of Candida species, Trichomonas vaginalis, Gardnerella vaginalis, Neisseria gonnorrhoeae, and Chlamydia trachomatis.

RESULTS

Recovery of Chlamydia and Trichomonas was more frequent in women with inflammation on Pap smear than in women without inflammation, but the positive predictive value of inflammation was only 7% for Chlamydia and 14% for Trichomonas. Seventy-one percent of the women with inflammation had no evidence of any of the organisms. After a 6-month follow-up period, women with inflammation on Pap smear were no more likely than their matched counterparts without inflammation to return for a clinic visit with symptoms of vaginitis.

CONCLUSIONS

In this study, inflammation on Pap smear had a relatively low predictive value for the presence of vaginal pathogens in asymptomatic women.

Extrinsic rearfoot posts

The addition of an extrinsic rearfoot post to an orthotic device allows the podiatric practitioner to modify the function of the device. Specifically, rearfoot posts are used to allow for a more inverted heel position at contact, to provide greater resistance to abnormal frontal plane motion of the calcaneus and to provide for motion for shock absorption. The authors present nine prescription variables that each provide for a specific functional change to be incorporated into the orthotic device.

The os trigonum syndrome. A literature review

The os trigonum syndrome, a musculoskeletal ankle disorder causing posterior ankle pain, is an entity that may present as numerous disorders. To accurately diagnose and treat the syndrome, its anatomy, origin, nomenclature, and biomechanics must be thoroughly understood. For this purpose, a review of recent literature is presented.

Limb length discrepancies

Examining for a possible limb length discrepancy is an important part of the podiatric biomechanical examination. The authors present a review of the literature pertaining to the definition of and examination for a limb length discrepancy. They present a typical rationale for lift therapy in the treatment of this pathology.

Biomechanical analysis of running with 25 degrees inverted orthotic devices

The purpose of this study was to evaluate the effectiveness of two different rigid foot orthotic devices in controlling subtalar joint subluxation and pronation. A high-speed video analysis system was used to record, store, and analyze data from seven runners: 1) barefoot, 2) shoes only, 3) shoes and vertical orthoses, and 4) shoes with 25 degrees inverted orthotic devices. The results indicate the need for suitable studies, on a larger population group, to evaluate the effect of a variety of orthotic devices on running biomechanics.

Foot orthosis for the severe flatfoot in sports

The control of excessively pronating feet in athletes can be a prolonged and frustrating experience for both the doctor and the patient. The inverted orthotic technique has previously been described for making a device that has two basic applications: to control excessive subtalar joint pronation, especially where a Root or modified Root device cannot, and to invert the entire lower limb for such problems as medial knee pain. The authors present two case histories that highlight the indications of this orthotic device for the athletic population.

Achilles tendon rupture. A protocol for conservative management

The authors discuss surgical versus conservative management of closed Achilles tendon ruptures. They favor a conservative approach in most cases and present arguments to support this preference. They present a protocol for conservative management of closed Achilles tendon ruptures, which has been developed at the Center for Sports Medicine, Saint Francis Memorial Hospital, San Francisco.

TL-61 versus Rohadur orthoses in heel spur syndrome

The authors present the subjective responses of 40 patients with heel spur syndrome or plantar fascitis to orthotic treatment. Twenty patients had Rohadur orthoses and 20 patients had TL-61 orthoses. These data show no difference in the response to or problems created by either TL-61 or Rohadur orthoses. The authors recommend TL-61 as one alternative to Rohadur, now that that latter is unavailable.

The myth of running limb varus

Even though the authors believe that there are many flaws in treadmill-based video analysis, they do believe that this study shows that running limb varus is not as important a concept as previously discussed by many authors. The FootTrak system is the first system available to give biomechanical researchers the ability to document the tibia-to-vertical angle with computerized digitation. The clinician with a knowledge of biomechanics understands that functional orthotic devices are more effective on primary calcaneal motions and positions than motions and positions produced by extrinsic tibial, knee, or hip factors. Thus, functional foot orthoses tend to work better in controlling varus during running that is produced by the calcaneus, rather than the tibia.

Salicylate poisoning from enteric-coated aspirin. Delayed absorption may complicate management

Acute salicylate poisoning with enteric-coated aspirin may result from accidental ingestion, a suicide attempt, or a complication of long-term therapy. Because absorption of enteric-coated aspirin is delayed, use of the Done nomogram to determine toxicity may lead to underestimating the severity of the poisoning. Treatment options include induction of emesis or diuresis, gastric lavage, administration of activated charcoal, and surgery.

Social stressors, social supports, and self-esteem as predictors of morbidity in adults with chronic lung disease

Psychosocial correlates of morbidity and functional status were examined in 44 white adults with chronic lung disease. Demographic characteristics, functional status, stressful life changes, social supports, and self-esteem were assessed at baseline by a self-administered questionnaire. Hospital days, bed-disability days, restricted-activity days, and physician visits were then measured prospectively by mailed questionnaire over the next 6 months. There were no cross-sectional associations of psychosocial variables with demographic characteristics. Better functional status (measured by the Sickness Impact Profile) was associated with a lower 12-month life-change score (measured by the Social Readjustment Rating Scale), with stronger social supports (measured by a 13-item index), and with higher self-esteem (measured by the Rosenberg Scale). On bivariate analysis, higher life-change score predicted higher levels of all four morbidity variables; low social supports predicted increased bed days, restricted-activity days, and physician visits; and low self-esteem predicted high restricted-activity. After controlling for demographic characteristics and baseline function by multivariate analysis, low social supports continued to predict higher rates of physician visits, but the other associations of psychosocial variables with morbidity were no longer statistically significant. The results suggest that patients with weak social supports have increased use of physician services.

A randomized controlled evaluation of a psychosocial intervention in adults with chronic lung disease

The effect of a stress management program on morbidity and psychosocial and physical function in patients with chronic lung disease was assessed. Adults attending either a VA pulmonary clinic or university hospital pulmonary rehabilitation clinic who met criteria for obstructive or restrictive pulmonary disease were randomly assigned to receive the intervention or to a control group. The intervention was provided by a nurse and included one to three teaching sessions, reading material, audiotapes, and telephone follow-up. The program focused on stress management techniques such as cognitive restructuring, progressive relaxation, breathing exercises, and visual imagery. The 45 experimental subjects were similar to the 49 controls with respect to baseline characteristics. Experimental and control subjects had similar rates of mortality, hospital days, bed-disability days, restricted-activity days, and physician visits during the 12-month follow-up. There were no differences between the two groups in physical or psychosocial function at six months or in levels of stressful life changes, social supports, and self-esteem at six and 12 months. Intervention recipients had better function at 12 months, suggesting a possible benefit of the intervention.

Design and Characterization of X-Ray Multilayer Analyzers for the 50-1000 eV Region

This report describes a synthesis of more than 10 years of this program's development and application of multilayer analyzers for absolute Bragg spectrometry in the low-energy x-ray region of 50-1000 eV. Multilayers, denned here as systems of periodic layered structures parallel to the analyzer surface, have been applied principally in the diagnostics and application of the new, intense sources of synchrotron and high-temperature plasma x radiation. Detailed absolute reflectivity characterizations are presented for selected examples of these multilayers which have been semiempirically determined for mica, potassium acid phthalate, and the fabricated Langmuir-Blodgett and sputtered multilayer analyzers with d-spacings in the 10-200 Å range. Design requirements for absolute spectrometry are established. Efficient analytical multilayer reflectivity models are derived and parameterized (based upon a modification of the Darwin-Prins model for the low-energy x-ray region), including, for the sputtered multilayers, parameters for defining interface structure. The dependence of the reflectivity characteristics, high-order Bragg diffraction suppression, and overall efficiency upon the model parameters is analyzed. A special spectrograph and procedure for the absolute measurement of the relevant reflectivity characteristics are described. Detailed measurements and semiempirical characterizations are presented. Programs for small laboratory computers have been developed that allow rapid and flexible spectral analysis, transforming measured spectra to absolute Spectra.

Epidemiologic inquiry: observational studies

A major objective of epidemiologic investigation is to determine whether or not an association between an exposure and a condition exists in a human population. The presence of such an association cna be explored using three distinct strategies, the cohort, the case-control, and the cross-sectional approaches. This paper describes each of these research designs and discusses their advantages and disadvantages.

The life space drawing as a measure of social relationships

The life space drawing was prospectively assessed as a predictor of 12-month morbidity in 27 white female participants of a clinical trial. Women who subsequently experienced a high rate of self-reported morbidity (greater than or equal to 3 restricted-activity days per month) had a higher proportion of interpersonal relationships characterized by poor communication than did women with less than or equal to 2 restricted activity days per month. The quality of the relationship with a spouse/significant other appeared to be a particularly strong predictor of morbidity in this small self-selected group of women.

Acute pancreatitis

Acute pancreatitis is most often secondary to prolonged excessive alcohol intake or biliary tract disease. The diagnosis is based on a combination of physical, laboratory, and radiologic findings. Differentiation from intra-abdominal processes that require surgical intervention is important. Treatment involves restoration of intravascular volume, correction of hypoxemia and metabolic derangements, and resting the gastrointestinal tract. Prognostic indicators are useful in identifying severe cases that may benefit from more aggressive monitoring, peritoneal lavage, antibiotic therapy, and surgical intervention. The recovery period may be complicated by sequellae of pancreatic necrosis and by sepsis.

The effects of stress and social support on health: a research challenge for family medicine

Family physicians frequently encounter patients who have recently experienced stressful life changes and who have weak social supports. Since an accumulation of evidence indicates that these psychosocial profiles are associated with health impairment, further investigation of these factors is of importance to family medicine. This paper reviews conceptual and methodologic issues involved in the assessment of the health effects of stress and social support and identifies particular questions and directions appropriate for family medicine research. The ultimate goal of research inquiry in this area is to develop effective clinical and public health strategies that prevent or minimize adverse health consequences.

A point-source epidemic of leptospirosis. Description of cases, cause, and prevention

Leptospirosis is a zoonotic disease that consists of fever, headache, myalgias, and multiple organ involvement, has varying clinical severity and morbidity, and can occur in epidemic form. Diagnosis is based on culture or serologic demonstration of recent infection. There is evidence that doxycycline therapy started early in the course of the disease favorably affects duration and severity. Antibiotic therapy is often initiated because of a strong suspicion of the disease, before bacteriologic or serologic confirmation of the diagnosis is completed. Public health measures play an important role in minimizing the incidence of leptospirosis.

Rational theophylline use in older asthmatics

In the sick adult, the variability of clearance from patient to patient may be greater than 50%. A given dose of theophylline that is predicted to result in a serum concentration of 15 micrograms/ml may result in an actual range of serum concentrations from 6.6 to 33 micrograms/ml. Respiratory infections, both acute and chronic, seem to have an adverse effect on theophylline clearance. Studies in adults with acute viral upper respiratory infections, pneumonia, and chronic obstructive pulmonary disease show a significant decrease in clearance.