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The offset "V" bunionectomy with cortical screw and buried Kirschner wire fixation offers advantages over previously described distal metatarsal procedures for correction of hallux abducto valgus. The ability to correct an increased intermetatarsal angle (IMA) as well as a proximal articular set angle (PASA) deviation allows for the eradication of postoperative deforming forces, which often lead to recurrence of the deformity. Complete soft tissue release and repair allows for the repositioning of the sesamoidal apparatus, and also reduces the tendency for recurrence. The authors have performed approximately 500 of these procedures in the past 7 years and found it to provide extremely satisfying results. Gaining experience in the aforementioned techniques has lessened the need for base osteotomies and more unstable types of distal osteotomies. The criterion for the use of this osteotomy continues to broaden as the authors gain experience with its use. The offset "V" osteotomy is now utilized as either a primary or ancillary procedure in approximately 90% of the hallux valgus patients upon whom the authors operate.

Objective: To determine the prevalence of recent cocaine use and the reliability of patient self-reported cocaine use., Design: A survey with blinded comparison to a criterion standard., Setting: Walk-in clinic of a large public hospital in metropolitan Atlanta, Ga., Participants: Male patients, aged 18 to 39 years, presenting to the triage desk for immediate care during weekdays. Of the 415 eligible men who agreed to participate (acceptance rate, 82%), the average age was 29.5 years, 91.6% were black, and 89% were uninsured., Intervention: None., Main Outcome Measures: Comparison of self-reported illicit drug use with results from urinary immunoassays for benzoylecgonine, a major cocaine metabolite. Determination of which drug history questions produce the most accurate responses using anonymous urine testing as the criterion standard., Results: Thirty-nine percent of patients tested positive for the presence of benzoylecgonine and were statistically more likely to be older, black, and have a prior history of sexually transmitted disease (P less than .01). Seventy-two percent of men with positive urinary assays denied illicit drug use in the 3 days prior to sampling. When queried with several formats, subjects with positive urine assays were more likely to admit to "any illegal drug" use (87.5%) than to the more specific "any form of cocaine" use (60.6%) within the prior year (P less than .0001)., Conclusions: These results underscore the magnitude of cocaine abuse among black, inner-city men. Patient self-report of illicit drug use is highly inaccurate. Accuracy of self-report may be increased by asking less specific questions.

We conducted a random-sample survey of homeless children and their mothers residing in Philadelphia (Pa) shelters. One hundred forty-six families were included in the final sample, resulting in an 80% response rate. The aims of the survey were to characterize the child's current and past health status, to determine access to and use of medical services, and to determine the serum erythrocyte protoporphyrin levels and tuberculin skin test status of the children. In addition, psychological tests were administered to both child and parent to assess developmental level and psychological problems. Finally, detailed questions were asked concerning the reasons for the homeless condition. The important reasons for homelessness cited in the survey included physical abuse, substance abuse, disagreements with landlords, and poor living conditions. The children's health problems included a high incidence of reported accidents and injuries, burns, and lead toxicity; the parents suffered from depression, physical abuse, and substance abuse. School-aged children tended to have low scores on tests of expressive vocabulary and word decoding, and preschoolers seemed to be below age expectations in receptive vocabulary and visual motor skills. The findings of this study suggest that homeless children tend to score poorly on developmental and psychological tests and tend to sustain serious burns and accidents. Policy implications of the survey include suggestions for health screening, rehabilitation, and education.

These studies were performed to evaluate the reproductive and developmental toxicity of pyridostigmine bromide (PB) in rats. Separate male and female fertility/reproductive performance studies, a perinatal/postnatal study and a teratology study were conducted. Dose levels were sufficient to result in overt cholinergic tremors at the high dose in each study. PB did not affect male or female fertility/reproductive performance. Pups born to treated dams did show slight, transient decreases in body weight gain, apparently secondary to the nursing behavior of dams demonstrating overt tremors. PB did not result in an increase in visceral or skeletal malformations. A slight increase in delayed ossification and early resorption were seen at the highest dose tested and were considered secondary to maternal stress/toxicity.

Graduates of all U.S. combined internal medicine-pediatrics residency programs were surveyed in 1987 regarding a variety of demographic information about their residencies and current practices, the residency curricula they had followed for both specialties, and recommendations for modifications in training. The 71 responding graduates (from a total of 112) reported patient care as their major involvement (mean of 42.9 hours per week), with a majority (83%) seeing patients in both pediatric and adult age groups. Most were involved in primary care only (64%). The graduates reported that during both pediatrics and internal medicine training, they had had too many inpatient and intensive care rotations and too few elective and ambulatory rotations. The most important subspecialty rotations in internal medicine were considered to be cardiology, dermatology, and pulmonary medicine; and in pediatrics, infectious disease, cardiology, and adolescent medicine. The graduates recommended more outpatient subspecialty rotations, ambulatory rotations in medicine and pediatrics, and a combined medicine-pediatrics continuity clinic.

Data were gathered in 1987 from 180 pediatrics and 302 internal medicine residency training programs about (1) the length of vacation provided their residents, (2) time allowed them for absence from work for reasons other than vacation, (3) how many of them during the previous three years had been required to extend their training to make up absences from work, and (4) whether a system was in place to cover their unexpected absences from work. All these variables affect the duration--but not necessarily the quality--of training that residents actually experience. The data show that these variables demonstrated wide ranges that depended on the postgraduate year of training, the discipline, the program size, and the program type (university, university-affiliated, freestanding, or military). The Accreditation Council for Graduate Medical Education, training program directors, and the American Board of Pediatrics and the American Board of Internal Medicine each need to consider these variables in making their respective decisions about accrediting training programs, verifying the clinical competence of trainees, and certifying program graduates.

We evaluated 14 children with primary ureteropelvic junction obstruction, using preoperative excretory urography and renal imaging with the renal cortical labeling agent 99mtechnetium dimercaptosuccinic acid. All children with a reduction in function of 10 per cent or more in the obstructed kidney had severe calicectasis; others with severe calicectasis had minimal functional loss. Renal scanning with dimercaptosuccinic acid discourages surgery in the questionably obstructed kidney and encourages repair in the severely obstructed kidney. In 10 children who had followup renal imaging after repair relative function was not significantly different.

Early morphogenesis of the brain and its derivatives was studied in sixty-nine baboon and rhesus monkey embryos representing developmental stages 8--16, and compared with the staged human embryo. The baboon and rhesus monkey embryos develop in a similar temporal sequence when compared with human embryos with the following exceptions: 1) The respective developmental events for otic disc, adenohypophyseal pouch, and hippocampal internal sulcus formation in the baboon and rhesus monkey occur at stage 10, stages 11-12, and after stage 16, while the comparable stages in humans are 9, 10, and 16; 2) Alternatively, formation of the trigeminal primordium and the motor root of the trigeminal nerve and evagination of the neurohypophysis occur earlier in the baboon and rhesus monkey (i.e., stages 12-13, stage 14, and stage 15, respectively) than observed in the human embryo (stage 14, stage 15, and stage 16, respectively); and 3) Lens pore closure in baboon and human embryos takes place during stage 14, while in the rhesus monkey closure occurs during stage 15.

The diuretic renogram provides a previously unavailable noninvasive method for assessing and following urinary tract dilation of diverse cause, and defining true obstruction in children. Technetium-99m-DTPA (diethylenetriaminepentaacetic acid) is injected intravenously and a posteriorly placed gamma scintillation camera used to image the kidneys, ureters, and bladder. Furosemide is subsequently injected to stimulate a diuresis, and the washout pattern of isotope is monitored (time-activity histogram). Nonobstructive, obstructive, and poor renal function patterns were seen. Forty patients with varying degrees of hydroureteronephrosis were evaluated. Tracings were performed serially and compared with the clinical course in time, as well as with pressure flow studies and operative findings. All patients with a nonobstructed diuretic renogram did well, except for 1 boy in whom ureteropelvic obstruction developed later. Difficulty in evaluating the obstructive renogram pattern occurred only in some children with severe (grade V) hydronephrosis. Further standardization of the diuretic renogram with regard to time of diuretic injection, state of patient hydration, and regions of imaging may improve diagnostic accuracy.

A prototype instrument is described that permits efficient administration of test compounds to laboratory animals by intubation. The system integrates a balance, a computer and a volumetric dispenser. Complete animal identification, weight and dose records are kept and may be interfaced with mainframe computers. A range of doses may be delivered from a single stock solution. No carryover is evident between doses. The system is accurate, precise and rugged. The system is cost effective relative to current manual gavage techniques and offers added safety for investigators handling toxic materials.

Researchers have recently begun to compare male and female physicians' attitudes toward patients, medical knowledge, and practice styles. Although women start medical school with more "humanistic views," the conservative effect of medical socialization on both male and female students attenuates these differences. While some studies suggested that men are more scientifically knowledgeable, recent studies showed no significant differences in physicians' medical knowledge. Male and female physicians also had comparable diagnostic and therapeutic behavior. In the intimate world of physicians and patients, however, there were notable differences. Women physicians seemed better able to communicate sensitivity and caring to patients, which may account for the common perception that women are more caring and empathic physicians. Medical educators may wish to study more closely female physicians' communication styles to identify these behaviors and inculcate them into all physicians.

Personality traits, functional abilities, and demographic characteristics of 61 persons with severe musculoskeletal impairments were examined using a personality factors questionnaire, the Barthel Index, and a demographic questionnaire. Subjects were grouped by high or low scores on the personality factors scale (psychologic independence) and an independent living scale (social independence). Data were analyzed using correlations, chi-squares, analyses of variance, factor analyses, and discriminant analyses. Subjects with high psychologic independence tended to live in less restrictive settings, had fewer communication problems, and spent less time in comprehensive rehabilitation facilities. Those with high social independence tended to be married; have assertive, self-assured, and self-sufficient personalities; more education; and more earned income. Both groups of highly independent persons tended to have hired attendants, good health, and more transportation options. They were outgoing, predominantly female, and tended to perceive themselves as independent. Functional abilities were not significantly related to levels of psychologic and social independence.

Combined residency training in internal medicine and pediatrics has proliferated greatly in the last ten years. This survey of program directors (N = 55) of such residency programs reports their personal and professional demographic characteristics as well as their perceptions about aspects of combined training. The directors were more often affiliated with Internal medicine (33 directors [60%]), 47 (85%) were men, their mean age was 44 years, they had been out of medical school for a mean of 19 years, the mean time served as program director was 2.6 years, and 32 (58%) had completed a fellowship. The programs had existed for an average of 4.2 years, the mean entering class size was 2.8 persons, and the mean number of graduates per program was 4.2. We report directors' perceptions of why students choose combined training, why the programs have proliferated, and how these residents differ from family medicine residents. We comment on curriculum design and the goals of combined internal medicine-pediatrics residency training programs.

Auditory temporal ordering was investigated in 5 normal-hearing young adults. Ss made diotic 2IFC judgments for pure tones of 0.5, 1, 2, or 4 kc/s and critical-band noises centered at those frequencies, on duration (standard: 40 msec; variables: 10, 20, or 30 msec), level (standard: 70 db HL; variables: 40, 50 or 60 HL), and frequency (standard: 0.5 kc/s; variables: 1,2, or 4 kc/s). Interstimulus interval (ISI) was 5, 10, 20, 50, 100, or 200 msec. All stimuli were at 70 db HL except of course the variable stimuli in the level judgments. Performance improved with increasing ISI. Mean threshold ISIs (performance at 75%-correct) collapsed across pure tones and noise bands were 12.5, 6.25, and 6.25 msec for duration, level, and frequency, respectively. With ISI constant at 100 msec, ANOVAs revealed statistically significant differences among the variables for duration and for level but not for frequency (performance for frequency was nearly perfect at the shortest ISI). There were statistically significant differences between mean performance, and between mean threshold ISIs, for duration, level, and frequency, indicating that auditory temporal acuity is not independent of the kinds of sound, as has been suggested (Hirsh, J. Acoust. Soc. Am., 1959, 31, p. 759).

The social behavior of a group of institutionalized profoundly mentally retarded male adults was observed under conditions of increased space. The findings demonstrated that an increase in space of 29 percent significantly reduced the frequency of aggressive acts occurring within the group. Also observed was the effect of increased space on the residents' mobility and nonaggressive interactions. Results were discussed in relation to the residents' need for space.

Triamcinolone-induced alteration of the notochordal-basichondrocranial relationship in the rhesus monkey. Timed-mated pregnant rhesus monkeys received triamcinolone acetonide (10 mg/kg, IM) during early organogenesis. Treated and control embryos and fetuses were removed by hysterotomy on days 35, 42, 50, 60, and 70. All treated cases 42 days or older exhibited craniofacial and brain defects. Microscopic examination showed abnormal notochordal folding and a shortened cranial base in the 35-day embryos prior to any observed CNS involvement. Bends, deviations, focal proliferation, and persistence of the notochord and altered cranial base were observed in older cases. This study supports the hypothesis that encephalocele and related CNS disorders could be secondary to a primary paraxial mesodermal insufficiency.