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The prevention of insulin-dependent diabetes (IDD) in humans remains an elusive goal, despite the broad spectrum of therapeutic interventions that prevent the development of IDD in the non-obese diabetic (NOD) mouse. Can an animal model in which spontaneous autoimmune pathology is interrupted so easily serve as an archetype for the design of clinical trials aimed at the prevention of IDD in humans? In this article, Mark Bowman, Edward Leiter and Mark Atkinson review the intervention strategies that prevent IDD in the NOD mouse and indicate why these studies may well be relevant to the prevention of IDD in humans.

Background: Epidemiologic studies have implicated the ingestion of cow's milk in the pathogenesis of insulin-dependent diabetes mellitus (IDDM). Moreover, in a recent study, 100 percent of patients with new-onset IDDM had antibodies against bovine serum albumin (BSA), with a majority directed against a 17-amino-acid BSA peptide (ABBOS). Cellular immune mechanisms are thought to be the principal mediators of pancreatic beta-cell destruction in IDDM., Methods: We measured the responses of peripheral-blood mononuclear cells to BSA and ABBOS or serum IgG anti-BSA antibodies (by particle-concentration fluorescence immunoassay) in 71 patients with IDDM, 55 subjects at various degrees of risk for IDDM, 36 patients with other autoimmune disorders (chronic autoimmune thyroiditis, rheumatoid arthritis, and systemic lupus erythematosus), and 48 normal subjects., Results: The responses of peripheral-blood mononuclear cells to BSA or ABBOS were positive in 2 of 24 patients with new-onset IDDM, 1 of 25 first-degree relatives of patients with IDDM who were negative for islet-cell antibodies, 2 of 30 first-degree relatives of patients with IDDM who were positive for islet-cell antibodies, 1 of 28 patients with established IDDM, and 1 of 29 normal subjects. Similarly, anti-BSA antibodies were not detected significantly more often in patients with new-onset IDDM (3 of 31, 10 percent) than in normal subjects (1 of 37, 3 percent; P = 0.32). However, many patients with autoimmune disease and subjects at increased risk for IDDM had anti-BSA antibodies (frequency, 10 to 31 percent)., Conclusions: Anti-BSA antibodies may reflect a general defect in the process of immunologic tolerance associated with a predisposition to autoimmunity rather than immunity specific to beta cells. The absence of cellular immunity to BSA and ABBOS in IDDM does not support a role for this antigen in the pathogenesis of the disorder.

Background: Simulated patients are used with increased frequency for medical students and residents, but have not been used very often with practicing physicians. We hypothesized that educational materials could improve primary care physicians sexual practices history taking and counseling as assessed by a simulated patient in the physician's office., Methods: Simulated patient (SP) visits were made to 232 (75% of eligible) primary care physicians. The patient simulated was a sexually active young woman with vaginitis and sexually transmitted disease/human immunodeficiency virus risk behaviors. In advance of the visit, physicians were provided educational materials (monograph, pamphlet, and audiotape) developed for the study, including a risk assessment questionnaire that could be used with patients., Results: Most physicians randomly allocated to the intervention participated. Twenty-one percent of physicians refused to schedule an SP visit. Physicians who received an SP rated the experience highly. Physicians who prepared for the visit with the educational materials performed significantly better than those who did not. About two thirds of physicians reviewed the materials, many for the second time, after the SP visit. Physicians who used the study risk assessment questionnaire performed better. Many physicians (24.9% to 39.8%) did not meet each of the four goals for the visit, as assessed subjectively by the SP. Physician performance was better for measures of general patient interaction than for measures of sexual practices history taking and counseling techniques., Conclusion: The SP visit was acceptable to most physicians practicing in a community and was evaluated by them as an appealing and an effective educational experience. The SP, however, has limited feasibility because of cost. The SP led to review of materials by nearly all physicians either before or after the visit. Physicians who prepared before the visit performed better on every dimension, eliciting more information, displaying better patient interaction skills, and meeting more of the educational goals. Even with educational preparation, however, many physicians were not perceived as being effective counselors.

Medical malpractice claims are common and may be emotionally difficult for physicians. Most malpractice suits claim negligence. The most frequent types of claims include failure or delay in diagnosis, negligent treatment with drugs, failure to obtain consultation, failure to obtain informed consent, and negligent management of procedures. The most important risk-management strategy is the provision of good medical care. If a claim is filed, physicians should cooperate fully with the malpractice insurance carrier and refrain from discussing the case with colleagues.

This study assessed the validity, reliability and usability of the Patient-Doctor Interaction Scale (PDIS) in a university-based family practice center. Health maintenance visits and problem visits were included, and data were collected at the time of the visit and again 1 month later. Three different methods of administration (in-person, telephone, and mail) were used to assess usability. Of 91 patients approached, 1 refused to participate. A total of 64 (70%) patients completed the instrument adequately to permit analysis. PDIS scores correlated with overall assessment of patient satisfaction (P < 0.01), suggesting criterion-based validity. Internal consistency (reliability) of the PDIS was indicated by Cronbach's alpha which were consistently greater than 0.80. Scores and return rates varied by method of administration, with the telephone method performing best. The PDIS appears to fulfill the requirements for a valid, reliable and useful instrument to assess patient satisfaction in family practice settings.

Computerized literature searching was introduced into a family practice residency office site after a series of training sessions. BRS Colleague was the searching program used. Over 15 months, 147 searches were conducted, primarily by faculty. Because residents used the system infrequently, they preferred to find a faculty member to help with the search rather than complete the search by themselves. The mean number of searches per faculty user was 6.4 and the median number of documents found per search was 15. The users were moderately satisfied with the search process (2.4 on a scale of 1 as excellent to 5 as unusable). Search strategies tended to be unsophisticated, often using only one of several possible related search terms. Most searches took a limited amount of time (5 to 20 minutes). The program was sufficiently successful to warrant continuation. Computerized literature searching offers a method to meet the physicians' needs for ready access to information on patient-related questions.

The acquired immunodeficiency syndrome epidemic has drawn attention to screening for sexually transmitted diseases by primary care physicians. A telephone survey of primary care physicians in an area with a high incidence of STDs (Washington, DC) to ascertain the determinants and the extent of screening and counseling for STDs was completed in 1987. Ninety-nine physicians (33 internists, 38 obstetrician/gynecologists, and 28 family/general practitioners), representing 61% of those eligible, completed the interview. One third (39.4%) were screening for gonorrhea, more than one half (57.5%) for syphilis, and almost all (94%) had tested at least one individual for human immunodeficiency virus infection. Analysis suggested that concomitant screening for hepatitis B was significantly and positively associated with screening for gonorrhea and syphilis. Less than half (45.9%) of the physicians asked new patients about their sexual practices. Physicians should take histories of sexual practices and do more preventive counseling.

The quality of medical care delivered by physicians of different specialties has been the subject of debate for some time. Studies have suffered from a variety of flaws. This study used the MedisGroups comparative database to compare outcome measures in hospitalized patients aged 65 years and older treated either by the family physicians or internists as attending physicians. Using the 10 most common diagnostic related groups for internal medicine, 10,353 admissions to internists were compared with 5,473 admissions to family physicians. Patients admitted by family physicians had a significantly higher admission illness severity and were significantly older. There was no significant difference in morbidity and mortality. The lower average charges for patients admitted to family physicians were statistically significant.

Two instruments were used to assess patient improvement following visits to providers in a university based family practice center--the Modified Williamson Functional Assessment (MWFA) and the Mini-Duke-UNC Health Profile (Mini-DUHP). Of the 90 patients over the age of 18 seen for problem or health maintenance visits who were included in the study, 64 adequately completed the instruments at the time of the visit and one month later. Functional assessments by in-person, mail, and telephone methods of administration were similar. Patients' MWFA scores did not significantly improve by the time of the one-month follow-up. Mini-DUHP subscales for symptom and physical function also did not significantly improve. Mini-DUHP emotional, social, and composite scores indicated a decrease in function following the visits, particularly visits for health maintenance. MWFA and Mini-DUHP scores correlated only modestly, with the highest correlation occurring between Mini-DUHP Physical Score and the MWFA (0.414 or 0.509, P less than .001). Additional study is needed to identify or develop an instrument that can adequately assess broad changes in functioning for multiple diagnoses following specific physician interventions, and the reason for the decline in emotional and social function following visits needs further elucidation and evaluation.

This is a review of published reports comparing family physicians with internists. The results show that family physicians are more likely to stay in their field of training; to locate more frequently in rural and underserved areas; to see fewer referred patients; to have similar case severity; and to engage in more obstetrics and gynecology, surgery, trauma, acute illness, and pediatrics. Family physicians spend less time per patient, ask fewer history questions, obtain fewer physical examination items, order fewer diagnostic studies, make referrals less often, and hospitalize patients less often. The reasons for the practice style differences between family physicians and internists are likely to be multiple, but they probably include such factors as: training, decision-making expertise, patient demands, types of visits, office staff, economics, and attitude. The implications of the proposed reasons for the differences are discussed.

This study investigated analogical reasoning abilities of alcoholics who had been abstinent from alcohol for at least 1 year. Their performance was compared to that of nonalcoholic controls matched as a group for education, age, and gender. Solution times and error rates were modeled using a regression model. Results showed a nonsignificant trend for alcoholics to be faster, but more error prone, than controls. The same componential model applied to both groups, and fit them equally well. Although differences have been found in analogical reasoning ability between controls and alcoholics immediately following detoxification, we find no evidence of differences after extended periods of sobriety.

In the debate about which specialty should provide primary care for adults in the United States, part of the issue is the type of training given to the primary care provider and the overall quality of care provided by those who complete the training. This paper presents a literature review that summarizes the quality of care of family physicians by outcome and process measures. Studies in the literature are flawed by methodologic weaknesses, including the frequent lumping of all general and family physicians as a group and the general lack of description of the physicians involved. Some studies measuring the process of care indicate poorer process by family physicians or general practitioners, such as recording fewer medical process criteria used to measure quality of care. The quality of care by outcome measures, however, appears to be similar to that of other specialties. In general, the study of quality of care is in its infancy, and further work needs to be done to assess what training is needed to produce the highest quality primary care physicians.

Three hundred twenty-six participants of five 1-day continuing medical education courses on flexible sigmoidoscopy were surveyed to determine their use of lower intestinal endoscopes and to identify how well the education trained them to use the flexible sigmoidoscope. The number of participants using a flexible sigmoidoscope and/or colonoscope increased after the course. About one half of the respondents went from no use of the flexible sigmoidoscope to using it. About one fifth of the respondents were not using a flexible sigmoidoscope after the course for various reasons. Most respondents used more than one instrument after the course, with the combination of the 60-cm flexible sigmoidoscope and the rigid sigmoidoscope being most popular. The overwhelming majority found the flexible sigmoidoscope to be either very easy to use or reasonably easy to use. Only one complication was reported. Most of the respondents had attended only this 1-day course, but one third had taken either other courses or had been supervised for several procedures.

Participants in two one-day continuing medical education courses on flexible sigmoidoscopy were surveyed before, immediately after and ten months after the courses. 52 (29.5% of 176) participants completed all three survey forms. Before the course 32 (61.5%) expected to immediately use the flexible sigmoidoscope without further training. Ten months after the course 33 (63.4%) were using the flexible sigmoidoscope; four additional respondents were expecting to begin using the instrument. Twenty three of these (69.7%) had only attended the course without additional training. Those who found the instrument more difficult to use, or decided immediately after the course that more education was necessary, were less likely to use the instrument. Those not using the instrument also were older, more likely to be in solo practice and more likely to be surgeons. The course altered the educational plans of 23.1% of the respondents. This one-day format combining didactic and laboratory work with the instrument proved to be an efficient and effective means of education for using the instrument.

The Graduate Medical Education National Advisory Committee (GMENAC) adjusted needs-based model for determining physician requirements was applied to the specialties of anesthesiology, neurology, nuclear medicine, pathology, physical medicine and rehabilitation, and radiology, which had not been completed at the time of the original GMENAC final report. Physical medicine and rehabilitation continues to be projected as a shortage specialty; anesthesiology is in near balance. Neurology and pathology are no longer projected to be specialties of oversupply, but rather to be in near balance. Diagnostic radiology continues to be projected as a specialty of oversupply; therapeutic radiology is projected to be in near balance, as is nuclear medicine. The GMENAC aggregate-requirements estimates are thus revised upward from 466,000 to 473,000 full-time equivalent physicians for 1990, reducing the projected surplus from 15.0% to 13.3%.

Applying the adjusted needs-based model developed by the Graduate Medical Education National Advisory Committee (GMENAC), physician requirements in neurology were estimated for the year 1990. A Delphi panel of physician experts estimated appropriate patterns of treatment for 56 neurologic conditions. Their median estimates implied a need for 14,500 neurologists in 1990, suggesting a shortage relative to the projected supply. An advisory panel of former GMENAC members reviewed those estimates and recommended certain adjustments to ensure internal consistency and compatibility with those for other specialties. Adoption of these adjustments significantly reduces requirements, implying a total need for 8,400 neurologists--a figure in near balance with the projected supply of 8,650. The difference between the Delphi and Advisory Panel estimates reflects divergent views, apparent as well among the Delphi panelists, of the appropriate role of neurologists--consultants versus principal care providers.

The increasing numbers of women physicians will affect the practicing physician both directly and indirectly. Women physician practitioners have more female patients, spend more time with each patient, and perform more pap smears than their male counterparts. Although the data are sparse, few other differences have been found in the practices of male and female physicians. Because women physicians choose different specialties and are less productive in traditional terms than men, their increasing numbers will affect the perceived balances and imbalances in the specialties, thus shifting the competition among physicians. Women physicians are also more likely to choose organized practice settings where they are salaried. This paper explores the available data and speculates on the long-term implications of more women in the medical profession.

A survey of all family practice residency programs in the country was done to determine resident attrition reasons and rate by sex. Of 383 programs mailed surveys, four returns were from programs too new to have data, and 238 returns were usable, for an effective response rate of 62.7%. The overall attrition rate was 12.4% (699/5,656), and varied by the type of residency program. The most frequent reason for attrition as identified by the survey respondent was switching specialties (41.0%), followed by private practice 16.4% and involuntarily released 11.9%. The remainder left for a variety of other reasons. There was a slightly higher attrition rate for women (14.2%) than men (11.9%). The odds ratio for this was 1.22 (95% confidence interval 1.03 to 1.41). Women were more likely to leave for childbearing or rearing, or spouse relocation, although overall these numbers were small, and men also left for these same reasons.

Blind nasogastric intubation was attempted in a chronically debilitated patient. The nasogastric tube entered the trachea and was advanced through the left lower lobe bronchus into the left pleural cavity. During the subsequent two days of dietary supplement (Isocal) infusion, the patient developed fever, chills, decreased responsiveness, and left shoulder pain. This complication ultimately led to the patient's death. We have reviewed the known complications of nasogastric intubation and recommend that difficult intubations in weak or debilitated patients be followed by chest roentgenogram in order to confirm the correct placement of the tube.

In order to determine the impact of commercial company funding of continuing medical education (CME) courses, a survey was undertaken. Drug prescribing rates for drugs related to course content were determined by self-report survey of physician attendees (374 in number) for three different CME courses. The survey was performed immediately before and six months after the courses. A single, though different, drug company provided the majority of the funding for each course. Courses I and III were related to calcium channel blockers and Course II to beta blockers. The return rate before Course I was 73.0 percent; after, 54.0 percent (unmatched). The return rate for Course II was 49.4 percent before and 42.9 percent after (unmatched). There were 121 (61.4%) matched returns for Course III. While the rates for prescribing some of the related drugs increased after the courses, overall the sponsoring drug company's products were favored. Although physicians attending CME and accredited sponsors of CME need to be aware of this potential influence, the final burden of adequate evaluation of drugs remains with the physician prescriber. Further studies should be done to substantiate the findings and elucidate the mechanism(s) of the increase in sponsoring company's drug prescriptions.

The nation's supply of family physicians as estimated by the Graduate Medical Education National Advisory Committee appears fairly accurate. At the same time, the demands for family physicians appear to be strong, partially because case-management systems recognize the cost-effectiveness and appropriate training of family physicians for their needs. The largest factor inhibiting the supply of such physicians appears to be the relatively lower income of family practice compared to other specialty fields. This creates more difficulties in funding training positions and may limit the attractiveness of the field to medical school graduates.

The Graduate Medical Education National Advisory Committee Report is now almost half a decade old. Many of the recommendations have been implemented partially or completely, but many have not. This article recounts the major recommendations, what has happened with them, and the impact of the changes that have occurred. Graduate medical education, physician supply and requirements, specialty and geographical distribution, foreign medical graduates, and nonphysician providers are areas that need ongoing attention and should be the focus of further study and monitoring.

Twenty-one Holstein bull calves were randomly assigned at birth to 3 groups. Two groups (each of 7 calves) were raised as follows: fed a milk diet alone or fed milk with grain supplementation after 2 weeks of age; studies were done when calves reached 4 weeks of age. The 3rd group was fed on milk with grain supplementation until weaning after which the calves were maintained on grain and pasture. These calves (older calves) were studied at 12 weeks of age. Either propionate (0.28 mmol/kg) or glucose (0.56 mmol/kg) was injected IV in a random order. Samples of blood were obtained from the calves before and immediately after injections were done and at 2, 5, 10, 15, 30, 45, and 60 minutes after secretagogue injection. Plasma was examined for glucose by a glucose oxidase procedure and for immunoreactive insulin (IRI) and glucagon (IRG) by radioimmunoassay. The IRI response to the injection of glucose was greater in older calves (P less than 0.02). Patterns of IRI secretion, as determined by heterogeneity of regression, showed age differences for both secretagogues (P less than 0.05). Base-line IRG was greater in milk/grain-fed calves than in milk-fed calves (P less than 0.05). Mean IRG response to propionate injection was higher (P less than 0.05) in milk/grain-fed calves than in milk-fed calves. Plasma glucose concentration increased in older calves, but decreased in milk-fed calves after propionate injection. The data indicate that maturation in the ruminant is accompanied by altered regulation of insulin and glucagon secretion.(ABSTRACT TRUNCATED AT 250 WORDS)

Pseudotumor cerebri is characterized by increased intracranial pressure and papilledema, with an essentially normal neurologic examination. The major complication is visual loss. Many patients will have spontaneous remissions. The main method of following patients with pseudotumor cerebri is repeated visual field measurements. Several modes of treatment have been described, but their value is unclear.

A survey of family practice residency programme directors in the United States was undertaken to look at the impact of malpractice and malpractice insurance on residency education. Of 385 programmes 276 (71.7%) responded to the 20 question survey. The results indicated a mean rate of 0.043 claims per resident or faculty member in the previous year. One-fifth of the respondents did not report the type of malpractice insurance retained for residents and over half did not report the cost of insurance for residents. Current problems with liability were most often related to the region of the country, number of visits to the family practice centre, the number of residents, the number of faculty, the type of faculty employer and the type of resident employer. Programmes which anticipated future problems with liability were most likely to be those with current problems. The areas identified as most concerning to residents included: obstetrics, cost of malpractice insurance, difficulty obtaining coverage, and the general anxiety created by malpractice litigation.