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The Department of Veterans Affairs (VA) is undergoing change in the way it delivers health care. Forces underlying this change include demographics of its population, new fiscal constraints, and the requirements of its academic affiliates. The benefit to the medical school affiliates will be the availability of patients in a structure useful for outpatient teaching of medical students and houseofficers. Barriers to effective delivery of ambulatory health care and education in VA facilities are (1) the historic focus on episodic, inpatient care, (2) continuous changes in eligibility requirements, (3) increases in patient care responsibilities for affiliated faculty, and (4) concomitant withdrawal of resources from the VA at a time when costs of health care and education are increasing. The VA medical centers will be increasingly forced to investigate innovative models for patient care delivery and education in the ambulatory setting.

Systemic antibiotics are a valuable therapeutic modality in the burned patient when properly used. Injudicious use, however, may not only fail to be beneficial to the patient but also may produce harmful effects--either through direct toxicity or by contributing to the emergence of resistant strains of micro-organisms. General guidelines and principles for systemic antibiotic use include the following: The burned patient, despite all efforts, will be exposed to microorganisms. No single agent or combination of agents can destroy all the organisms to which the burned patient is exposed. Treatment involves first identifying the organism responsible for clinical sepsis, then choosing appropriate agents. Combinations of antibiotics are not always synergistic or even additive in effect. Multiagent therapy may have the untoward effect of predisposing to superinfection by yeast, fungi, or resistant organisms. Antibiotics should be used for a long enough period to produce an effect, but not long enough to allow for emergence of opportunistic or resistant organisms. Dosages must be adjusted based on serum concentrations when serum assays are available. In general prophylactic systemic antibiotics are indicated in only a few clinical situations including the immediate preoperative and postoperative periods associated with excision and autografting, and possibly in the early phases of burns in children. The penetration of systemic antibiotics into burn eschar remains an area not fully studied; hence, they cannot be the only therapeutic modality used to treat burn wound infection. Systemic dosages of antibiotics in burns will require alteration depending on the clinical status of the patient. The choice of agent requires a thorough knowledge of side effects, toxicity, and potential benefit. Above all, active surveillance and monitoring of the burned patient and the environment in which he or she is being treated is mandatory for effective treatment. The increasing number of new antimicrobial agents has presented a new dilemma to the practicing clinician because many of these agents have not been evaluated thoroughly in the burned population. With further studies, the armamentarium of the burn treatment team will inevitably increase. It is in this manner only that so many of the unanswered questions will be solved, and that infection will start to decline as the major cause of death in the burned population.

Two infections by swine influenza virus, antigenically similar to A/New Jersey/76 (H1N1) virus, were detected during community epidemics with other influenza viruses. The swinelike viruses were obtained during virological surveillance of acute respiratory illnesses, and the clinical symptoms of these two patients were similar to those caused by other respiratory viruses. Both patients reported contact with swine a few days before onset of illness, but in one case it was brief. Serological studies suggested that one patient may have transmitted the virus to his roommate, but spread into the community was not indicated.

P hysicians and medical industrial representatives (pharmaceutical, medical service, medical product, surgical instrument) are strange bedfellows. At one extreme, significant diagnostic and therapeutic contributions to the health care of patients have occurred consequent to the mutual cooperation between these two groups. Medical industry is a vigorous scientific and financial supporter of basic and applied research, a consideration of increased significance in the context of curtailed governmental research support. And at the other extreme, aggressive marketing programs by medical industrial representatives in an atmosphere of a free enterprise system can foster inappropriate and biased utilization of those products. Exemplary of these extremes, the dichotomy of which poses an ethical dilemma, is the relationship between physicians and pharmaceutical representatives. Physicians are constantly confronted with a corpus of rapidly expanding and evolving medical knowledge and with the availability of a plethora of pharmaceutical agents. In that context, continuing medical education is essential to physicians if they want to maintain their expertise. What role should pharmaceutical representatives, occasionally themselves licensed pharmacists, play in the provision of information regarding any specific product? The sale of pharmaceutical products is unique mainly because it is indirect. Pharmaceutical advertising campaigns for prescription compounds are rarely directed toward the consumer (patient), but rather toward the intermediate dispenser (physician). When pharmaceutical companies have directed advertising campaigns toward patients, physicians, governmental agencies, and consumer advo cacy groups have raised a vast hue-and-cry reaching even lay periodicals (Should prescription drugs be advertised to consumers? Consumer Reports 1984; 49; 392-393). How should physicians respond to solicitation by pharmaceutical representatives in the form of “curb side” consultations, “free samples,” professional journal advertising, and invitations to attend and participate in pharmaceutical company-sponsored symposia? How impartial and unbiased are any of these modes of interaction? In answer to the questions just posed, it is imperative for physicians to adopt and employ critical analytic skills when evaluating medical industrial products. Adaptation of a scientific methodologic approach to analyses of refereed journal articles, balanced seminars, and personal empiric observations is essential if the health care needs of patients are to be best served. Medical school educators bear significant responsibility in this regard in fostering, demanding, and exemplifying the use of critical analytic techniques, mitigating partial and biased solicitations. It would be naive for physicians to presume that they are immune to the blandishments of “free” samples, books, meals, trips, symposia, et cetera. Equally naive is the view that medical ir&strial representatives are always pernicious and biased, representing a monolithic enterprise motivated solely for profit. Somewhere be tween the quixotic joust against windmills and an uncritical quotidian embrace lies the ethically responsible and appropriate course for a sentient physician.

The efficacies of two dosage regimens (2.0 g and 1.5 g each day for four days) of rosaramicin were compared in 40 men with acute uncomplicated gonococcal urethritis. After treatment 39 (97%) of 40 patients were asymptomatic and had negative cultures. Gastrointestinal side effects were reported for 12 (28%) of 43 patients; however, only two patients (5%) discontinued therapy because of side effects.

The abdominal left ventricular assist device (ALVAD) is an order of magnitude more effective than conventional intra-aortic balloon pumping (IABP) in unloading and providing circulatory support to the failing left ventricle. This is a report of a unique case which demonstrates that in the absence of pulmonary vascular obstruction or constriction, the ALVAD can substitute for both left and right heart function. A 21-year-old patient with a congenital bicuspid aortic valve developed acute valvular endocarditis which rapidly progressed to congestive heart failure. An operation was undertaken, the mitral and aortic valves were excised and replaced by porcine heterografts, and a fistula from the right sinus of Valsalva to the right ventricle was closed. When coronary circulation was restored, irreversible ischemic contracture of the left ventricle, or "stone heart" syndrome, developed and emergency ALVAD or partial artificial heart implantation was effected. This device functioned as a total artificial heart for nearly six days, while a donor heart was sought. The patient then underwent removal of the ALVAD and cardiac and renal allografting. The transplanted heart functioned well, but the patient expired fifteen days later from gram-negative sepsis.

The Argyll Robertson pupil, a miotic pupil that fails to react to direct light, has been described for more than a century. Originally associated with tabes dorsalis, the sign has now been found in a number of conditions with lesions in the area of the nucleus of Edinger-Westphal. Magnetic resonance imaging studies have localized the lesion in patients with sarcoidosis and multiple sclerosis. With the declining incidence of neurosyphilis, the sign is increasingly likely to indicate another cause, although an assiduous search for lues should also be undertaken.

Systemic sepsis resulting from invasive infection remains the leading cause of death among patients hospitalized with major thermal injury. Prevention of infection and death in burn patients requires a thorough knowledge of the multiple predisposing factors involved and expert application of appropriate diagnostic, supportive, and therapeutic modalities. The improved survival in this population is a result of all these factors, not any one. It is this principle and the adherence to a treatment program that encompasses all the modalities which are so essential in the care of burn patients if continuing progress is to be made in this field. This article describes the current management of infection and infection control in burn patients. The burn wound and pulmonary system remain the major foci for infection in this population. Less common types of infection include suppurative thrombophlebitis, suppurative chondritis, bacterial endocarditis, urinary tract sepsis, sinusitis, intra-abdominal sepsis, and infections of the eyes. Prophylaxis protocols involve proper control of the environment and an anticipation of bacterial colonization. A number of specific monitoring and treatment guidelines have evolved that have proved effective over the years in minimizing morbidity and mortality.

The prophylactic effect of low doses of human leukocyte interferon (HuIFN-alpha) against infection with rhinovirus was measured in double-blind, placebo-controlled studies with volunteer subjects. An antihistamine (chlorpheniramine) was given before administration of single or multiple doses of HuIFN-alpha but saturated cotton pledget or by aerosol; volunteers were then challenged with rhinovirus. When the results for all groups were combined, a lower frequency of respiratory illness was demonstrated in the HuIFN-alpha-treated volunteers (20 of 39 vs. 11 of 38, P less than 0.05). A significant improvement in mean symptom scores was found only in the volunteers who received HuIFN-alpha by cotton pledget. The total numbers of isolates of rhinovirus and seroconversions were similar for HuIFN-alpha-treated and control volunteers. No significant side effects were noted in the HuIFN-alpha-treated volunteers. Higher concentrations or improved methods of delivery of HuIFN-alpha will be necessary for improving the clinical efficacy of HuIFN-alpha against viral infections in the respiratory system.

A patient with acute bacterial endocarditis in whom ischaemic contracture of the left ventricle (stone-heart syndrome) developed during aortic and mitral valve replacement had an emergency implantation of an intracorporeal partial artificial heart (an abdominal left-ventricular assist device of ALVAD). This device functioned as a total artificial heart for nearly 6 days, while a donor heart for transplantation was sought. The ALVAD was then removed, and the patient received allografts of a heart and a kidney. The transplanted heart functioned well, but the patient died 15 days later from gram-negative sepsis. There was no evidence of cardiac or renal allograft rejection.

Current methods for monitoring exercise exertion rely upon heart rate monitors, which represent a crude and lagging indicator of conditioning. The rationale for the present study is that both systemic and local metabolic mechanisms are responsible for physical performance, and therefore they should be simultaneously quantified to achieve an objective assessment of human conditioning. We propose a compact, wearable near-infrared spectroscopy (NIRS) device integrated with electrocardiography (ECG) and photoplethysmography (PPG) to simultaneously assess the cardiovascular and local response to exercise. The system was tested on subjects performing a graded maximal exercise by comparing our readings with metabolic variables measured with respiratory gas analysis. We found strong correlations between local deoxyhemoglobin concentration [HHb], heart rate and oxygen uptake, as well as between oxyhemoglobin concentration [HbO(2)] and stroke volume. This study shows that combined NIRS, ECG and PPG measurements yield useful information to understand the interplay between systemic and local muscular responses to exercise.

Background Formulation and evaluation of public health policy commonly employs science-based mathematical models. For instance, epidemiological dynamics of TB is dominated, in general, by flow between actively and latently infected populations. Thus modelling is central in planning public health intervention. However, models are highly uncertain because they are based on observations that are geographically and temporally distinct from the population to which they are applied. Aims We aim to demonstrate the advantages of info-gap theory, a non-probabilistic approach to severe uncertainty when worst cases cannot be reliably identified and probability distributions are unreliable or unavailable. Info-gap is applied here to mathematical modelling of epidemics and analysis of public health decision-making. Methods Applying info-gap robustness analysis to tuberculosis/HIV (TB/HIV) epidemics, we illustrate the critical role of incorporating uncertainty in formulating recommendations for interventions. Robustness is assessed as the magnitude of uncertainty that can be tolerated by a given intervention. We illustrate the methodology by exploring interventions that alter the rates of diagnosis, cure, relapse and HIV infection. Results We demonstrate several policy implications. Equivalence among alternative rates of diagnosis and relapse are identified. The impact of initial TB and HIV prevalence on the robustness to uncertainty is quantified. In some configurations, increased aggressiveness of intervention improves the predicted outcome but also reduces the robustness to uncertainty. Similarly, predicted outcomes may be better at larger target times, but may also be more vulnerable to model error. Conclusions The info-gap framework is useful for managing model uncertainty and is attractive when uncertainties on model parameters are extreme. When a public health model underlies guidelines, info-gap decision theory provides valuable insight into the confidence of achieving agreed-upon goals.