The effect of a primary-care pathway on internal medicine residents' career plans

There has been no evidence that primary-care pathways, a recent innovation in internal medicine residency programs, have affected the career choices of their trainees. We report the experience of the first four cohorts of primary-care trainees in internal medicine compared with traditional-pathway trainees at Boston City Hospital. Primary-care residents remained committed to their plans for a career in general internal medicine throughout training. In contrast, two thirds of the traditionally trained residents who were planning a career in general internal medicine at the beginning of their training changed their plans to subspecialty medicine. Thus, the primary-care pathway reinforced the career plans of trainees in general internal medicine, whereas traditional training influenced potential generalists toward subspecialty medicine.

A review of the use, evaluations, and criticisms of the preliminary criteria for the classification of systemic lupus erythematosus

The use of the Preliminary Criteria for the Classification of Systemic Lupus Erythematosus (SLE) has been reviewed. Most authors describing 10 or more patients have used the criteria. Although originally designed for classification of patients, the criteria have often been used for the diagnosis of SLE. The sensitivity of the criteria was evaluated and found to be similar to the 90% reported in the original ARA trial. Studies on specificity yielded conflicting results. Various suggestions to improve the criteria have been made, including a more detailed description of some of the organ involvements and the adoption of laboratory tests that have been improved since or were unavailable at the time of original publication of the criteria.

Serum amyloid A protein in amyloidosis, rheumatic, and enoplastic diseases

Serum levels of amyloid protein A (SAA) have been shown to be elevated in different types of amyloidosis and in rheumatic diseases by radioimmunoassay using 125 iodine labeled AA and anti-AA. SAA levels were elevated in both primary and secondary amyloidosis, but there were highly significant differences between these levels. In heredofamilial amyloid, SAA levels were within normal limits. While the mean SAA level was elevated in persons over 70 years, the fact that some persons in this age group had normal levels suggested that marked elevation after age 70 may be due to occult inflammatory or neoplastic disease. High SAA levels in patients with rheumatoid arthritis correlated, in most cases, with physician evaluation of disease activity and Westergren ESR. SAA levels in patients with systemic lupus erythematosus were lower than those in patients with rheumatoid arthritis, and most patients with degenerative joint disease had normal levels. Very high levels of SAA were found in patients with neoplastic diseases. Patients with carcinoma of the lung and bowel had much higher levels than patients with carcinoma of the breast. Determination of SAA levels may be of value in evaluating different forms of systemic amyloidosis, assessing the activity of rheumatic disease, and screening for occult inflammatory or neoplastic disease.

Patterns of pulmonary involvement in systemic amyloidosis

The clinical and histopathologic features of pulmonary amyloidosis were reviewed in 22 patients with systemic amyloidosis who came to autopsy. Eleven of 12 patients (92 percent) with primary amyloidosis had prominent interalveolar amyloid deposits. Symptoms attributable to these deposits were found in four cases (33 percent), while severe lung involvement was the apparent cause of death in one. Extensive deposition was noted in all three cases of amyloidosis associated with multiple myeloma or Waldenstrom's macroglobulinemia. Five of seven patients (71 percent) with secondary amyloidosis showed histologic lung involvement, which was perivascular or tracheobronchial in location, but not associated with symptoms. Histologic lung involvement is frequent in all forms of amyloidosis and lung tissue obtained from any patient with unexplained interstitial or reticular-alveolar pulmonary disease should be stained with Congo-red and viewed for green birefringence under polarizing microscopy for the presence of amyloid.

The rheumatologic manifestations of diabetes mellitus

The rheumatologic disorders associated with diabetes mellitus have been reviewed. From the evidence presented, it can be concluded that neuroarthropathy and osteolysis are definitely assoicated with diabetes. Ankylosing hyperostosis and periarthritis probably represent valid associations, and possible, but still unproven associations exist for gout, pseudogout, the carpal tunnel syndrome, osteoarthritis, Dupuytren's contracture and joint contractures. Despite the lack of a proven pathophysiologic basis these interrelationships may be clinically relevant. The discovery of one of these disorders may provide a clue to underlying glucose intolerance, and idabetics should be followed with the knowledge that they are at risk for the development of certain musculoskeletal problems.

Skin involvement in generalized amyloidosis. A study of clinically involved and uninvolved skin in 50 patients with primary and secondary amyloidosis

A punch or excisional biopsy of the skin was done in 50 patients with generalized amyloidosis: In 46, clinically normal skin, usually the forearm, was biopsied and in four, only cutaneous lesions. Amyloid was seen in the skin of 21 of 38 patients with primary and multiple myeloma-associated amyloidosis. Sixteen of 34 biopsies from clinically uninvolved skin were positive. Five of 12 patients with secondary amyloidosis had amyloid deposits in clinically normal skin. Overall, amyloidosis was definitively diagnosed on skin biopsy examination in 26 patients. A punch biopsy of clinically involved or uninvolved skin is an innocuous, simple procedure with a high diagnostic yield and can be done in an office setting.

The identification of amyloid P-component (protein AP) in normal cultured human fibroblasts

The amyloid protein, AP, has not previously been detected in normal or nonamyloidotic tissues. In this study, human fibroblasts were examined for the presence of AP by immunofluorescence technique. Normal human skin fibroblasts were cultured in Eagle's minimum essential medium for varying periods of time. Antiserum was prepared in rabbits using AP isolated from amyloid-rich tissues. Using indirect immunofluorescence and anti-AP, fluorescent material was found to be distributed in a punctate pattern throughout the cytoplasm with sparing of the nucleus. The fluorescent reaction was speicifically inhibited by absorption of anti-AP with AP-positive serum but not by addition of AP-negative human cord serum. Thus, AP may have a fibroblast origin and a relationship to normal connective tissue.

Synovial membrane histopathology in the differential diagnosis of rheumatoid arthritis, gout, pseudogout, systemic lupus erythematosus, infectious arthritis and degenerative joint disease

The synovial membrane histologic sections from patients with six common rheumatic diseases were reviewed without knowledge of the clinical diagnosis. After histopathologic evaluation, the synovial membrane characteristics were grouped according to the patient's clinical diagnosis, and included 29 patients with rheumatoid arthritis, 13 with systemic lupus erythematosus, 17 with degenerative joint disease, 10 with acute bacterial arthritis, 8 with gout, and 13 with pseudogout. The only specific characteristics identified were bacteria (infectious arthritis), crystals (gout, pseudogout), and lymphoid follicles (rheumatoid arthritis). Nevertheless, other characteristic features of differential diagnostic utility were recognized, including the intensity and nature of synovial lining cell hyperplasia and of leukocyte infiltration. Light microscopic histopathologic changes in the common rheumatic diseases are not specific, but are of diagnostic utility. Complete and exhaustive review of each pathologic synovial membrane characteristic provides more justification for the routine use of synovial membrane biopsy as an adjunct to arthrocentesis in the evaluation of common rheumatic diseases.

Amyloid deposition in a renal transplant in familial Mediterranean fever

A patient with familial Mediterranean fever and amyloidosis who received a cadaver renal transplant 6 1/2 years ago was studied to determine the relation of the serum precursor of secondary amyloid (SAA) to the clinical course and to the deposition of amyloid in the transplant. Amyloid fibrils extracted from the patient's kidneys contained protein AA as a major constituent, which identified the amyloid as secondary. Protein AA antiserum was used in an indirect immunofluorescent technique to stain amyloid deposits in sections of the original kidney. A renal biopsy at 2 years showed no amyloid, but a renal biopsy at 4 years showed amyloid. Serum levels of SAA from 3 years before transplant to 6 years after transplant were elevated throughout most of the course.

Components of asymmetrical visual encoding of geometrically transformed scripts

Austrian and Israeli subjects were presented tachistoscopically with geometrically transformed numbers, nonsense syllables in Latin letters and Hebrew words (only the Israeli). Opposite reading and writing habits and different hand dominance were used as experimental variables. Criteria for evaluating the data were scanning pattern (voluntary preferred reading direction) and reading performance. A difference in reading pattern was found between Austrian right- and left-handed subjects but no difference in their reading performance. Also between Austrian and Israeli right-handed subjects a difference in the reading pattern appeared as well as in reading performance. Furthermore, the scanning pattern used by Austrian right-handed subjects in reading geometrically transformed numbers was different from their pattern in reading syllables. Distinguished were two sources of asymmetries, an intrinsic in visual mechanisms and a structural one in the stimulus itself.

Movements while driving cars around curves

The eye fixations of 5 experienced and 4 inexperienced car drivers were analyzed while driving curves to the left and to the right. For experienced drivers in a curve to the left the mean duration of eye fixations was longer and the amplitude of the eye movements greater than in a curve to the right. No such difference was observed in inexperienced drivers who manifested neither uniformity within the same curves nor differentiation between the two types of curves. Mean duration of eye fixations of experienced subjects was shorter while driving in a curve to right, but their amplitude of eye movement was greater in a curve to left than those of inexperienced drivers. In Esp. 2, it was pointed out that there is already a change in the pattern of eye movements prior to entering a curve. Upon approaching the curve the mean duration of eye fixation decreased, and the fixations were mainly shifted toward the future driving path. Results are interpreted in terms of the adequacy of the eye fixations (supposedly influenced by prior long-term learning) for information at near distance for vehicle control and at longer distances for setting proprioceptive forward programs for possible future sensomotoric activity.

Murine amyloid protein AA in casein-induced experimental amyloidosis

Amyloidosis was induced in mice by 25 subcutaneous injections of casein. The splenic amyloid fibrils were identified by electron microscopy to be closely associated with reticular cells. After isolation of the fibrils by simple physical techniques, their ultrastructure revealed single filaments of 80 to 100 A width, which were rigid, nonbranching, and of indeterminate length. This is comparable to previous studies on human preparations. The amyloid fibrils were dissociated by solution in guanidine and chromatography. The resultant amyloid fibril protein was characterized as to its molecular weight, amino acid analysis, and amino-terminal sequence. It was thus definitely identified as protein AA, the major component of secondary amyloidosis. An antibody to this protein, murine AA, identified a cross-reacting mouse serum protein SAA and indicated a species specificity when tested against human preparations. A comparison is made with the AA protein in another murine model as well as AA proteins from human, guinea pig, monkey, and mink amyloidosis.

Generalized amyloid in a family of Swedish origin. A study of 426 family members in seven generations of a new kinship with neuropathy, nephropathy, and central nervous system involvement

We report a new kinship with systemic amyloid presenting as peripheral neuropathy in the fourth and fifth decades of life. A progressive sensory and motor loss starting in the lower extremities occurs from this disease, and there is subsequent renal, cardiac, gastrointestinal, ocular, and cutaneous involvement. Histologic studies show that amyloid deposition is mainly in connective tissue structures; there is an unusual infiltration of the meninges and central nervous system. Review of records of 426 family members in seven generations showed that this disease is inherited as an autosomal dominant. The absence of immunoglobulin disorders in two affected family members studied in depth suggests that this is not the primary type of amyloid in which the deposits are composed of fragments of immunoglobulin light chains. Similarly the absence of elevated levels of protein SAA (the serum precursor of secondary amyloid) suggests that this is not a secondary form of amyloid.

Fractionation of primary amyloid fibrils. Characterization and chemical interaction of the subunits

Amyloid fibrils of kappa origin from a patient with primary amyloidosis are dissociated in various denaturants and fractionated into their subunit components on Sepharose 6B. Solubilization of the fibrils in 4 M guanidine-HCl followed by reduction and alkylation produced 22 000 and 17 000 dalton fractions. Without prior reduction and alkylation, these fractions exist as a high molecular weight protein which can be separated on Sepharose 6B. A high molecular weight protein can be directly dissociated from the amyloid fibril with 1% sodium dodecyl sulfate or 1 M NaCl. Reduction and alkylation of this material produces the two lower molecular weight fractions, i.e., 22 000 and 17 000. These have in the first 20 residues identical N-terminal amino acid sequences; they share immunologic identity and have similar tryptic peptide map profiles. Amino acid analysis of the 22 000 dalton fraction is identical with the intact immunoglobulin light chain isolated from the patient's serum. These data suggest that the insoluble amyloid fibril is the result of aggregation by disulfide linkages between the 22 000 and 17 000 dalton fractions.

Tuberculous arthritis: A report of two cases with review of biopsy and synovial fluid findings

Two cases of tuberculous arthritis with synovial fluid findings are presented, and the major series with culture results and synovial fluid analyses are reviewed. Synovial fluid cultures are positive for tuberculosis in almost 80 per cent of proved cases. Specimens obtained by open synovial biopsy are positive by histology or culture in over 90 per cent of proved cases. Little experience with closed needle biopsy has been published. About one-fifth of the patients with tuberculous arthritis will have a positive synovial fluid acid-fast smear for tubercle bacilli. The tuberculous synovial effusion invariably has an elevated protein level, fair to poor mucin clot formation and usually a low joint fluid sugar level. The synovial fluid white cell count is usually in the range of 10,000 to 20,000 cells/mm3, but it varies widely. Most fluids exhibited a predominance of polymorphonuclear leukocytes. The importance of bacteriologic or histologic study of the synovial fluid and membrane in establishing the diagnosis is emphasized. In general, this disease is different from tuberculous involvement of serous membranes both in the frequency of positive cultures and in the difference in cellular response.

Identity of a peritoneal fluid immunoglobulin light chain and the amyloid fibril in primary amyloidosis

A monoclonal immunoglobulin has been isolated from the peritoneal fluid of a patient with primary amyloidosis. The immunoglobulin was reduced and alkylated and the light and heavy chains were compared to the major protein constituent of that patient's hepatic amyloid fibrils. N-terminal amino acid sequences of the light chain and amyloid fibril were identical when carried to 20 residues and were typical of a kappa I light chain. Molecular weight studies suggested that the fibril protein was composed of an intact light chain with a molecular weight of 23,000. The hypothesis that amyloid fibril protein in primary amyloid is derived from circulating monoclonal immunoglobulin is discussed.