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An instructional exercise in telephone management of medical problems using experimental and didactic techniques was designed for medical students taking a family medicine clerkship. The effectiveness of this curriculum was evaluated by comparing the students' proficiency against a standard established through the use of a Delphi group opinion technique. This study indicates that formal training experiences for medical students in managing telephone complaints in a family practice setting can improve the students' performance.

Beta 2-agonists are known to cause a range of unwanted biochemical and cardiovascular responses. The present study was designed to investigate the effect of chronic exposure to beta 2-stimulation on the magnitude of these responses produced by an acute challenge with a beta 2-agonist. In this single blind placebo controlled study in six healthy male volunteers, we have compared the effects of chronic dosing with either oral terbutaline (5 mg three times daily for two weeks) or placebo on a number of these responses produced by an intravenous infusion of terbutaline (6 micrograms per kilogram over 1 hour). The infusion was given twenty-four hours after the last dose of oral terbutaline or placebo. The rise in pulse rate, systolic blood pressure and plasma glucose and the fall in serum potassium during terbutaline infusion, although still demonstrable, were significantly reduced following treatment with oral terbutaline compared to placebo. This suggests downgrading of beta-receptor function after chronic beta 2-stimulation.

Summary Submucosal dissection of the oesophagus is a rare oesophageal disorder. We report a patient who had recurrent episodes of dissection and achalasia. Both recurrence and the association with achalasia are to our knowledge unique.

The reaction p+W→μ+μ−+X has been measured in a high‐statistics experiment using a 400 GeV/c proton beam, a magnetized beam dump, and a wide‐acceptance detector. Abbreviated results and a comparison with the Drell‐Yan Model are presented.

This paper describes the use of venous occlusion catheters inserted via the long saphenous vein or its tribularies for control of major retroperitoneal venous haemorrhage. The technique has been applied successfully in 10 cases of trauma and aortocaval fistula. Exposure and insertion are simple and quick and a measure of control is obtained before exposure of the injury which can then be completely repaired before deflation of the balloon and withdrawal of the catheter.

A two-channel digitized system for measuring small density and temperature fluctuations in turbulent air (e.g., in flow in a wind tunnel) is described. The method is based on the fact that ten rotational lines of the X(v" = 0) to B(v′ = 4) absorption manifold of O2 fall within the tuning range of the ArF excimer laser. Although fluorescence from the excited B states of O2 is weak due to predissociation, it is sufficient to provide a sensitive means of monitoring small changes in the ground state populations induced by temperature or density fluctuations. This can be done with a single-laser pulse, and the fluorescence is collected at 90° from the incident 193-nm laser beam; hence excellent temporal and spatial resolution is achieved.

Changes in plasma ammonia in response to exercise with and without pretreatment with propranolol have been studied. A standardised submaximal treadmill exercise test was used to assess the effects of placebo or propranolol 40 mg, 80 mg, or 160 mg twice daily given in random order for 3 days, the last dose being taken 90 min before exercise. After placebo the mean incremental rise in plasma ammonia in response to exercise was 16 mumol X 1(-1). The corresponding rise after propranolol 40 mg was 56 mumol X 1(-1) (p less than 0.01). All three doses of propranolol produced similar effects on plasma ammonia and exercise heart rates.

The aim of this study was to compare the conventional visual and tactile method of detecting carious dentine during cavity preparation using a mirror, probe and excavator with a visual method enhanced by a dye. The dye, 1% acid red in propylene glycol, was used on 100 cavities prepared by dental students and passed as clinically satisfactory by their teachers. Results showed dye stain at the enamel-dentine junction in 57 cavities (57%) which had been assessed as caries-free in this area using conventional visual and tactile means. Subsequent laboratory work on extracted carious teeth confirmed histologically that the dye stains demineralised dentine. If clinicians consider it important to render the enamel-dentine junction caries-free, it might be prudent to use the dye as an aid to diagnosis in this area.

In the aortofemoral segment Dacron has performed well for nearly 30 years. The choice of graft should be determined more by the handling characteristics than theoretical considerations. Whichever graft is selected the surgeon must be satisfied as to its durability and above all as to his technical ability to implant it accurately. In the femoropopliteal segment saphenous vein remains the graft of choice. It is not yet clear whether the technically more difficult in-situ operation has any advantage over reversed vein except in the use of smaller-calibre veins. In the absence of saphenous vein, all synthetics perform reasonably well to the level of the knee, particularly in the short term, but at present HUV appears preferably distally. Of the synthetics PTFE is easiest to use which makes it attractive to the less frequent user. However, we still await the arrival of an ideal arterial substitute.

Faced with poor student performance on the health care financing questions of a final examination in a community health clerkship, the faculty designed and utilized an innovative simulation game, Coverage, to assist students in learning the complexities of various health insurance plans. This article describes the development, design, and use of this game. Medical students have enjoyed playing the game and have improved their performance in the final examination.

We have evaluated the orally active anthracycline idarubicin at a dose of 40 mg/m2 in divided doses over 24 hours in 21 previously untreated patients with extensive-stage small cell carcinoma of the lung (SCCL). Subsequent iv therapy was cyclophosphamide (1000 mg/m2), vincristine (1 mg/m2), and etoposide (120 mg/m2 iv on Day 1 and 250 mg/m2 orally in divided doses on Day 2; CVE) in patients who failed to respond to idarubicin and in relapsed patients. Three (14%) of 21 patients treated with idarubicin responded, with two complete responses (CR). Patients failing to respond promptly and those who relapsed were treated with CVE. Seven patients did not receive CVE for the following reasons: early death, four patients; early CNS disease, two; and refusal, one. Fourteen patients received CVE. Of 12 patients failing to respond to idarubicin, eight progressed on CVE, three achieved partial response (PR), and one achieved CR. Two idarubicin responders who received CVE achieved PR and CR. The median survival of all 21 patients was 6 months. For those with World Health Organization performance scores of 0 or 1 the median survival was 6.2 months and for the rest it was 2.6 months. Although CVE chemotherapy was instituted promptly in patients not responding to idarubicin, these results seem inferior to those previously seen in our center with standard treatment from the start. We believe that patients with extensive SCCL often require a rapid and more guaranteed response to their first treatment.

Study of the telephone practice in four family practice settings reveals a complex interaction between patients, physicians, and receptionists. Patients present a limited number of complaints--80 percent of complaints represent 25 common chief complaints, and 95 percent represent 50 chief complaints. Little difference was observed between the symptoms reported by patients to the physicians as compared to those received by the receptionist staff. Physicians are more likely to use the telephone contact to treat the patient's complaint with home care advice or a prescription. Receptionists are more likely to use the telephone contact for scheduling an office visit.

An improved three-dimensional, nonrecursive model for atmospheric turbulence has been developed which provides for simulation of both instantaneous gusts and gust gradients along the flight path of the Space Shuttle. The one-dimensional gust and gust gradient spectral models, which form the basis for the simulation scheme, are developed from three-dimensional, von Karman spectra, integrated over finite limits based on the characteristic dimensions (length, width, and thickness) of the flight vehicle. By means of the simulation process nondimensional time series for both gusts and gust gradients have been generated and stored on a series of magnetic tapes for four altitude bands ranging from 0 to 10,000 meters. These Shuttle Simulated Turbulence Tapes (SSTT) have been validated by means of spectral and statistical analyses with satisfactory results. The dimensionless form of the time series coupled with the use of a von Karman spectral model (as opposed to a Dryden model) distinguish the SSTT from earlier turbulence simulation concepts.

The effects of alterations in serum calcium levels on the volume of distribution of a calcium tracer in bone and on bone blood flow were investigated in dogs by manipulation of parathyroid status. The volume of distribution increases with increasing serum calcium. This implies that there is a concentration-dependent binding mechanism in the extravascular space of bone, which is not saturated at the levels of serum calcium achieved in these experiments. The skeletal exchangeable calcium was increased in hypercalcemic dogs and decreased in hypocalcemic dogs. Cancellous bone contains proportionately more exchangeable calcium than cortical bone. Bone blood flow was decreased by 50% 15 min after injection of a bolus of parathyroid hormone (PTH) but returned to control values by 240 min. Fifty-two hours after the induction of hypercalcemia with repeated doses of PTH, there was no difference in blood flow over control animals.

The use of engineering signal and systems analysis techniques in physiological research and teaching is growing (for example, Rompelman et al., 1977; Kitney, 1979; Lal, 1979; Christakos and Lal, 1980) for they provide a powerful and precise body of methods for carrying out certain types of experimental and theoretical investigations. One factor which has hindered their introduction and use in physiology has been the lack of a small, fairly cheap, easy to use laboratory computing system equipped with a biomedically relevant range of facilities for stimulus generation, data capture, data analysis and process modelling.

Image localized 31P magnetic resonance spectroscopy of the spleen was performed in six normal volunteers, 13 patients with splenomegaly due to haematological malignancies, and two patients with benign causes of splenomegaly. The malignant disorders had elevated phosphomonoesters (PME) compared to controls, probably due to increased turnover of membrane phospholipids, with variable alterations in high energy phosphates. There appeared to be no relationship between grade of malignancy and relative PME peak area. An overlap in spectral characteristics between the benign and malignant cases of splenomegaly existed. Serial studies in a patient with high grade lymphoma receiving combination chemotherapy showed changes in phosphorus spectra, with an increase in the phosphodiester/beta adenosine triphosphate ratio.

We previously reported that 0.8 mg/kgof the F(ab’)2 fragment of antibody 7E3, directed at theplatelet GPIIb/IIIa receptor, can abolish periodic platelet thrombus formation on partially stenosed carotid arteries in monkeys (Mnks). The present study was designed to: 1) test another antibody to GPIIb/IIIa (10E5), 2)find the minimum effective dose, and 3) correlate this effect with changesin the template bleeding time (BT) and platelet aggregation (PA). Periodicplatelet thrombi were established in the carotid arteries of 7 anesthetized Mnks after mechanical stenosis (∽70%) and intimal damage. 4 Mnks were treated with 7E3. Mnks 1 and 2 were given 0.2 mg/kg, and this dose: abolished thrombus formation and prevented its return in response to epinephrine infusion and increased intimal damage; abolished PA in response to ADP (10 μM); and increased the BT from 8.5 to 16 min and from 5 to 11 min. Mnk 3 was given 0.1 mg/kg, and this dose abolished the thrombi, inhibited PA by ∽41% and increased the BT only to 10 minfrom 8 min. Mnk 4 was givenincremental doses of 7E3. After 0.1 mg/kg, thrombi were reduced but not abolished, PA was minimally inhibited and the BTwas unchanged (7.5 vs 8 min pre). Afteranother 0.1 mg/kg, thrombi were abolished but could be partially restoredwith extreme provocation, PA was abolished and BT remained 7.5min. Afteranother 0.2 mg/kg, thrombicould not berestored, PA was abolished and the BTincreased to 21 min. After a final0.2mg/kg, the BT increased to 33 min. 3 Mnks were treated with 10E5. Mnk1received 0.4 mg/kg: thrombi and PA werebothabolished, and the BT increased from 5.5 to 14.5 min.Mnk 2 received 0.2mg/kg: thrombi and PA were again abolished while the BT increased to8.5from4.5 min. Mnk 3 received 0.1 mg/kg, and this abolished thrombus formation,butinhibitedPA by only ∽50%and increasedthe BT minimally (7.5 to 8.5 min). Increasedoozing from the neckwounds wasonly observed in animals with significant BT prolongations.We conclude that ∽0.1-0.2 mg/kg of eitherantibody can abolish in vivo thrombusformation, and that it is not necessary to abolish PA or cause marked prolongation ofthe BT in order toabolishthrombus formation in this model.

The influence of the "preresidency syndrome" on students' selection of fourth-year courses was examined. The fourth-year courses selected by the classes of 1982 and 1986 in the Brown University Program in Medicine were compared. The author considered that members of the 1982 class were less likely than those in the 1986 class to have been influenced by perceptions of increased competition for residency positions. The students in the class of 1986 were found to have deferred third-year clerkships into the fourth year more often than the class of 1982. The class of 1986 selected more courses related to their intended specialty than did the class of 1982, particularly for those intending to pursue residencies in orthopedics. Also, the class of 1986 spent a greater proportion of their fourth year in electives at hospitals where they intended to apply for residencies. These data support the contention that medical students' perception that residency positions were more difficult to obtain led to changes in selecting courses in the fourth-year of medical school.

In 72 episodes of suspected or proven Hickman-catheter-associated infection occurring in 59 patients with various hematological disorders, patients were assigned to treatment with either vancomycin or teicoplanin in a randomized nonblinded prospective study. Of 60 episodes evaluable for response, 28 were treated with vancomycin and 32 were treated with teicoplanin. Sixteen infective episodes were microbiologically documented in the vancomycin group, and twenty-one were microbiologically documented in the teicoplanin group. Microbiologically and clinically documented infections treated with vancomycin had an 80% response rate, compared with a 69% response rate for those treated with teicoplanin (P = 0.316). Adverse events occurred in nine (25%) of the episodes in the vancomycin group, compared with three (8%) in the teicoplanin group (P = 0.044). Teicoplanin may provide an effective alternative to vancomycin in the treatment of Hickman-catheter-associated infection in patients with hematological malignancies.

In the study of brain ventricles for both teaching and research, it is often of considerable advantage to graphically display the reconstructed shape of the specimen. This paper describes the making of two-dimensional serial cross-sections and their storage for subsequent manipulation and display on a personal computer; the three-dimensional (3D) reconstructions may have hidden lines removed and various parts coloured for definition of areas of interest, for example the density and position of pyknotic (dead) nuclei. Current research involved the investigation of the effects of maternal hyperthermia on early embryonic brains. The 3D reconstructions were found ideal for understanding the temporal changes occurring in embryonic brains subjected to defined maternal heat stresses. The method involved 4 X 4 matrices using homogenous coordinate theory, being the most ideal and allowing a constant mechanism for all transformations. Total time from examination of sections to obtaining an accurate printed 3D reconstruction is approximately 1 h if 22 sections are used.

The production of carcinoembryonic antigen (CEA) by human breast cancer tissue has been studied in relation to the prognosis of patients with breast cancer. All of the patients were in a controlled trial of adjuvant chemotherapy for the treatment of operable breast cancer. CEA was studied in primary tumours and axillary node metastases from these patients using an immunoperoxidase (PAP) method. Sections of 290 primary carcinomas and 217 axillary metastases were examined for CEA. The CEA status of the primary tumours was of no value as a prognostic indicator nor in the selection of patients for chemotherapy. In contrast, patients could be divided into 3 groups on the basis of the CEA results in the axillary nodes. In one group, in which cases were strongly positive for CEA (24% of the total) the prognosis, as reflected by recurrence free survival, was relatively good and chemotherapy produced no further advantage. In another group in which cases were weakly positive for CEA (18% of the total) the prognosis was poor but chemotherapy produced significant improvement. In a third group, in which cases were negative for CEA (58% of the total) the prognosis was poor and was not improved by chemotherapy, at least in the short term. Thus, the CEA status of axillary metastases may be clinically useful.

The situational theory of leadership and the LEAD instruments for determining leadership style are explained, and the application of the situational leadership theory to the process of planning for and implementing organizational change is described. Early studies of leadership style identified two basic leadership styles: the task-oriented autocratic style and the relationship-oriented democratic style. Subsequent research found that most leaders exhibited one of four combinations of task and relationship behaviors. The situational leadership theory holds that the difference between the effectiveness and ineffectiveness of the four leadership styles is the appropriateness of the leader's behavior to the particular situation in which it is used. The task maturity of the individual or group being led must also be accounted for; follower readiness is defined in terms of the capacity to set high but attainable goals, willingness or ability to accept responsibility, and possession of the necessary education or experience for a specific task. A person's leadership style, range, and adaptability can be determined from the LEADSelf and LEADOther questionnaires. By applying the principles of the situational leadership theory and adapting their managerial styles to specific tasks and levels of follower maturity, the authors were successful in implementing 24-hour pharmacokinetic dosing services provided by staff pharmacists with little previous experience in clinical services. The situational leadership model enables a leader to identify a task, set goals, determine the task maturity of the individual or group, select an appropriate leadership style, and modify the style as change occurs. Pharmacy managers can use this model when implementing clinical pharmacy services.

Dipyridamole (Dip) is reputed to inhibit (I) platelet aggregation (PA) and acute thrombus formation (ATF) by two mechanisms including inhibiting 1.) platelet (Pt) phosphodiesterase, 2.) adenosine (A) reuptake by red cells, which should raise plasma A. Both effects should raise Pt cyclic AMP and thus be a potent platelet inhibitor (PI). Because aspirin (AS) inhibits Pt thromboxane A2 production, a synergistic (S) PI effect for ASA and Dip given together has been postulated and used in clinical trials but this S has never been shown to I ATP in any in vivo model, which reasonably mimics human arterial stenosis. We have shown that ATF followed by embolization, occurs periodically in mechanically stenosed (MS) monkey and rabbit carotid arteries, and dog (D) and pig coronary arteries (CA), causing cyclical reductions in coronary blood flow (CRF) (measured with EMF probes) and periodic acute ischemia, and that these CRF can be abolished with a variety of PI including 3.0 mg/kg of ASA. To determine if there is a S effect between ASA and Dip, in open chest D, Dip was given, 2.0 mg/kg IV to D with a MS circumflex CA and having 14±5 CRF’s per hour, due to periodic ATF; and simultaneously flow measured in an unstenosed normal LAD CA. The frequency and size of CRF’s were not changed by Dip, although ABP decreased 21±9 mm Hg and blood flow in the unstenosed LAD increased 259±47%. A low dose of ASA, 1.0 mg/kg, which by itself diminishes but does not abolish CRF’s in this model was given IV 10 min. after Dip and CRF’s continued unchanged. When a second dose of ASA 1.0 mg/kg was given IV to reach the minimum effective dose of ASA in this model, CRF were abolished in all D. Thus Dip was not effective alone or in combination with low dose ASA to I CRF in this model which simulates the patient with stenosed CA. The majority of clinical trials that show inhibition of ATF, used ASA and Dip together without 3 separate patient groups on Dip alone, ASA alone and ASA plus Dip. The widespread use of Dip with ASA to prevent ATF in man needs to be reevaluated.

Epidemiological studies have shown that early first pregnancy reduces the risk of developing breast cancer, which indicates that initiation of the disease occurs at an early age. Thus the subclinical lesion of breast cancer might already be present in the breast before childbearing begins and the growth of any such focus might be modified by the endocrine changes of pregnancy. To test this hypothesis the relation between parity and age at presentation was studied in 341 unselected patients with breast cancer presenting to a single clinic. The mean age at presentation was 5.2 years lower in parous than nulliparous women (p0.001) and fell with increasing parity. It is concluded that reproductive history influences not only the risk of breast cancer but also the latent interval of a proportion of breast carcinomas.Epidemiological studies have shown that early 1st pregnancy reduces risk of developing breast cancer, thus suggesting that initiation of the disease occurs at an early age. Therefore, the subclinical lesion of breast cancer might already be present in the breast before childbearing begins and the growth of any such focus might be modified by the endocrine changes of pregnancy. To test this hypothesis the relation between parity and age at presentation was studied in 341 unselected patients with breast cancer presenting at a single clinic. The mean age at presentation was 5.2 years lower in parous than nulliparous women (P 0.001) and fell with increasing parity. The conclusion is drawn that reproductive history influences not only the risk of breast cancer but also the latent interval of a proportion of breast carcinomas.

A clinical clerkship in family medicine at Brown University has been developed utilizing many innovative educational modalities. These include games, simulations, group problem solving, research projects, videotaping, case presentations, field trips, sensitivity sessions, computer assisted instruction, patient management problems, slide-tape shows, and direct clinical experiences. These modalities are described together with a new approach to evaluation. Students' evaluations of the clerkship have been excellent, providing evidence that this clerkship offers a model of learning that is both effective and enjoyable.

A quality assurance program for a clinical pharmacokinetics service that meets current Joint Commission on Accreditation of Hospitals (JCAH) requirements for quality assurance is described. The clinical pharmacokinetics service is provided by pharmacists who have been certified through a staff development program. The clinical pharmacokinetics quality assurance program is part of the department's overall quality assurance program. Information from records maintained by pharmacists who are involved in the pharmacokinetics service is reviewed monthly and compared with 14 criteria that were approved by the pharmacy and therapeutics committee. Results of the monthly audits are summarized in a trend report; these results are communicated to the pharmacists involved, and any necessary corrective actions are taken. The program has led to more appropriate selection of target peak and trough serum drug concentrations, improved documentation of patient data, and better monitoring of each patient's renal function. Physician use of the service has increased as the quality of the service has improved. The quality assurance program has provided mechanisms for monitoring the quality of patient-care services and satisfying current JCAH requirements.

The pharmacokinetics of prenalterol in healthy young volunteers after i.v. and oral dosing has been studied. There is evidence of non-linearity following the i.v. dosing. Evidence of dose-dependent pharmacokinetics following i.v. dosing has been obtained. The sustained-release formulation is very effective: almost 12 h were needed to achieve 50 per cent of the total AUC.

Although viruses have recently been implicated in the pathogenesis of Paget's disease and Perthes' disease, little information is available regarding bone and marrow response to the presence of a noncarcinogenic virus. Vaccinia virus was introduced into the medullary cavity of the femoral shaft of 30 New Zealand White rabbits, and an appropriate control inoculation was performed. Virus was recovered from the inoculation site in 50% of the animals at intervals to one month after inoculation. Histologic abnormalities were observed in 69% of the test femora; similar abnormalities were not observed in the control femora. These abnormalities consisted of bone and marrow necrosis, lymphocyte and plasma cell infiltration, and new bone formation. Some of the newly formed bone was also necrotic. The latter observation suggests an alternative mechanism for the death of new bone, which, in Perthes' disease, has customarily been attributed to repeated ischemic insults.

On embryonic day 21, pregnant guinea pigs were exposed to a 44 degrees C environment for 1 hour. As a result, all brain ventricular zone cells in M phase of the mitotic cycle when heat-shock occurred became immediately pyknotic and all cell division was stopped for 4-8 hr. The pyknotic cells were removed at a definable rate until mitosis resumed, after which removal occurred in an apparently random manner. Long delays in the return to mitosis were related to increased destruction of S-phase cells deep within the ventricular zone and largely confined to the alar lamina. Upon recovery, a rostrocaudal delay in mitosis was apparent, and the number of mitotic figures was increased compared with control numbers for 1 hr, after which they returned to control numbers. It was evident that up to 40% of the cells within the ventricular zone were destroyed following brief maternal heat stress.