Anabolic steroids: what should the emergency physician know?

Anabolic steroids have not currently made their way into the daily practice of emergency physicians. The patients that use and abuse them have. In addition, those patients that are suffering from the consequences of illnesses that have excess levels of androgens are commonly evaluated in the emergency department. Clinicians should familiarize themselves with the practices of anabolic steroid users, so they can provide more beneficial council to their patients. As research continues, the emergency physician may find uses for androgens within the emergency department.

Modulation of hippocampal excitability by 5-HT4 receptor agonists persists in a transgenic model of Alzheimer's disease

5-HT(4) receptors are widely distributed in both peripheral and central nervous systems where they couple, via a G-protein, to the activation of adenylate cyclase. In the brain, the highest 5-HT(4) receptor densities are found in the limbic system, including the hippocampus and frontal cortex. It has been suggested that activation of these receptors may be of therapeutic benefit in diseases that produce cognitive deficits such as Alzheimer's disease (AD). Previous electrophysiological studies have shown that the 5-HT(4) agonist, Zacopride, can increase population spike amplitude recorded in region CA1 of rat hippocampal slices in a cyclic AMP (cAMP)/cAMP-dependent protein kinase A-dependent manner. We report here that the 5-HT(4) agonist, Prucalopride, and the 5-HT(4) partial agonist, SL65.0155, produce a similar effect in rat hippocampal slices and that the specific 5-HT(4) antagonist, GR113808, blocks these effects. To investigate the potential use of 5-HT(4) agonists in the treatment of AD, Prucalopride was applied to hippocampal slices from a transgenic mouse line that overexpresses the Abeta peptide. Despite the deficit in synaptic transmission present in these mice, the percentage increase of the CA1 population spike induced by Prucalopride was the same as that observed in wild-type mice. These data support 5-HT(4) receptors as a target for cognitive enhancement and suggest that a partial agonist would be sufficient to produce benefits, while reducing potential peripheral side effects. In addition, we show that 5-HT(4) receptors remain functional in the presence of excess Abeta peptide and may therefore be a useful target in AD.

LPA1 receptor-deficient mice have phenotypic changes observed in psychiatric disease

Several psychiatric diseases, including schizophrenia, are thought to have a developmental aetiology, but to date no clear link has been made between psychiatric disease and a specific developmental process. LPA(1) is a G(i)-coupled seven transmembrane receptor with high affinity for lysophosphatidic acid. Although LPA(1) is expressed in several peripheral tissues, in the nervous system it shows relatively restricted temporal expression to neuroepithelia during CNS development and to myelinating glia in the adult. We report the detailed neurological and behavioural analysis of mice homozygous for a targeted deletion at the lpa(1) locus. Our observations reveal a marked deficit in prepulse inhibition, widespread changes in the levels and turnover of the neurotransmitter 5-HT, a brain region-specific alteration in levels of amino acids, and a craniofacial dysmorphism in these mice. We suggest that the loss of LPA(1) receptor generates defects resembling those found in psychiatric disease.

Gabapentin is not a GABAB receptor agonist

Recent experiments have demonstrated that formation of functional type B gamma-aminobutyric acid (GABA(B)) receptors requires co-expression of two receptor subunits, GABA(B1) and GABA(B2). Despite the identification of these subunits and a number of associated splice variants, there has been little convincing evidence of pharmacological diversity between GABA(B) receptors comprising different subunit combinations. However, Ng et al. [Mol. Pharmacol., 59 (2000) 144] have recently suggested a novel and important pharmacological difference between GABA(B) receptor heterodimers expressing the GABA(B1a) and GABA(B1b) receptor subunits. This study suggested that the antiepileptic GABA analogue gabapentin (Neurontin) is an agonist at GABA(B) receptors expressing the GABA(B1a) but not the GABA(B1b) receptor subunit. The importance of this finding with respect to identifying novel GABA(B) receptor subunit specific agonists prompted us to repeat these experiments in our own [35S]-GTPgammaS binding and second messenger assay systems. Here we report that gabapentin was completely inactive at recombinant GABA(B) heterodimers expressing either GABA(B1a) or GABA(B1b) receptor subunits in combination with GABA(B2) receptor subunits. In addition, in both CA1 and CA3 pyramidal neurones from rodent hippocampal slices we were unable to demonstrate any agonist-like effects of gabapentin at either pre- or post-synaptic GABA(B) receptors. In contrast, gabapentin activated a GABA(A) receptor mediated chloride conductance. Our data suggest that gabapentin is not a GABA(B)-receptor agonist let alone a GABA(B) receptor subunit selective agonist.

A cis-acting element known to block 3' mRNA degradation enhances expression of polyA-minus mRNA in wild-type yeast cells and phenocopies a ski mutant

mRNA lacking a 3' polyA tail is not translated efficiently in wild-type eukaryotic cells, but is translated efficiently in yeast ski mutants. This enhanced expression could be due to altered translational specificity. However, as the SKI genes are required for 3' mRNA degradation, it could be a consequence of inhibition of 3' mRNA decay. Therefore, we asked if inhibition of 3' decay of a polyA-minus mRNA in cis would allow its efficient expression in wild-type cells. Capped in vitro reporter transcripts were prepared with or without a 3' cis-acting element known to inhibit 3' degradation (oligoG) and electroporated into yeast cells. The addition of oligoG to a polyA-minus mRNA enhanced expression 30-fold in wild-type cells. This level of expression was the same as that for an oligoG-minus, polyA-minus transcript in a ski mutant. The addition of oligoG did not significantly enhance the expression of polyA-minus mRNA in a ski mutant. The oligoG-dependent increase in expression was due to an increase in initial rate of translation and an increase in the functional half-life of the mRNA, similar to the effects observed in a ski mutant. The enhanced expression of the oligoG-containing RNA did not require Pab1p. We conclude that the enhanced translation of polyA-minus RNA in a ski mutant is due to inhibition of 3' mRNA degradation. Furthermore, a polyA-minus mRNA is expressed in wild-type cells when terminated in an element known to inhibit 3' decay in cis.

Inhibition of mRNA turnover in yeast by an xrn1 mutation enhances the requirement for eIF4E binding to eIF4G and for proper capping of transcripts by Ceg1p

Null mutants of XRN1, encoding the major cytoplasmic exoribonuclease in yeast, are viable but accumulate decapped, deadenylated transcripts. A screen for mutations synthetic lethal with xrn1Delta identified a mutation in CDC33, encoding eIF4E. This mutation (glutamate to glycine at position 72) affected a highly conserved residue involved in interaction with eIF4G. Synthetic lethality between xrn1 and cdc33 was not relieved by high-copy expression of eIF4G or by disruption of the yeast eIF4E binding protein Caf20p. High-copy expression of a mutant eIF4G defective for eIF4E binding resulted in a dominant negative phenotype in an xrn1 mutant, indicating the importance of this interaction in an xrn1 mutant. Another allele of CDC33, cdc33-1, along with mutations in CEG1, encoding the nuclear guanylyltransferase, were also synthetic lethal with xrn1Delta, whereas mutations in PRT1, encoding a subunit of eIF3, were not. Mutations in CDC33, CEG1, PRT1, PAB1, and TIF4631, encoding eIF4G1, have been shown to lead to destabilization of mRNAs. Although such destabilization in cdc33, ceg1, and pab1 mutants can be partially suppressed by an xrn1 mutation, we observed synthetic lethality between xrn1 and either cdc33 or ceg1 and no suppression of the inviability of a pab1 null mutation by xrn1Delta. Thus, the inhibition of mRNA turnover by blocking Xrn1p function does not suppress the lethality of defects upstream in the turnover pathway but it does enhance the requirement for (7)mG caps and for proper formation of the eIF4E/eIF4G cap recognition complex.

The yeast antiviral proteins Ski2p, Ski3p, and Ski8p exist as a complex in vivo

The yeast superkiller (SKI) genes were originally identified from mutations allowing increased production of killer toxin encoded by M "killer" virus, a satellite of the dsRNA virus L-A. XRN1 (SKI1) encodes a cytoplasmic 5'-exoribonuclease responsible for the majority of cytoplasmic RNA turnover, whereas SKI2, SKI3, and SKI8 are required for normal 3'-degradation of mRNA and for repression of translation of poly(A) minus RNA. Ski2p is a putative RNA helicase, Ski3p is a tetratricopeptide repeat (TPR) protein, and Ski8p contains five WD-40 (beta-transducin) repeats. An xrn1 mutation in combination with a ski2, ski3, or ski8 mutation is lethal, suggesting redundancy of function. Using functional epitope-tagged Ski2, Ski3, and Ski8 proteins, we show that Ski2p, Ski3p, and Ski8p can be coimmunoprecipitated as an apparent heterotrimeric complex. With epitope-tagged Ski2p, there was a 1:1:1 stoichiometry of the proteins in the complex. Ski2p did not associate with Ski3p in the absence of Ski8p, nor did Ski2p associate with Ski8p in the absence of Ski3p. However, the Ski3p/Ski8p interaction did not require Ski2p. In addition, ski6-2 or ski4-1 mutations or deletion of SKI7 did not affect complex formation. The identification of a complex composed of Ski2p, Ski3p, and Ski8p explains previous results showing phenotypic similarity between mutations in SKI2, SKI3, and SKI8. Indirect immunofluorescence of Ski3p and subcellular fractionation of Ski2p and Ski3p suggest that Ski2p and Ski3p are cytoplasmic. These data support the idea that Ski2p, Ski3p, and Ski8p function in the cytoplasm in a 3'-mRNA degradation pathway.

High resolution transmission soft X-ray microscopy of deterioration products developed in large concrete dams

In concrete structures, the reaction of certain siliceous aggregates with the highly alkaline concrete pore solution produces an alkali-silicate gel that can absorb water and expand. This reaction can lead to expansion, cracking, increased permeability, and decreased strength of the concrete. Massive concrete structures, such as dams, are particularly susceptible to the damage caused by the alkali-silica reaction because of the availability of water and because massive gravity dams usually do not contain steel reinforcement to restrain the expansion. Both the cement hydration products and alkali-silica reaction products are extremely sensitive to humidity. Consequently, characterization techniques that require high vacuum or drying, as many existing techniques do, are not particularly appropriate for the study of the alkali-silica reaction because artefacts are introduced. Environmental scanning electron micrographs and scanning electron micrographs with energy dispersive X-ray analysis results demonstrate the effect of drying on the morphology and chemical composition of the alkali-silicate reaction gel. Thus, the impetus for this research was the need to observe and characterize the alkali-silica reaction and its gel product on a microscopic level in a wet environment (i.e. without introducing artefacts due to drying). Only soft X-ray transmission microscopy provides the required high spatial resolution needed to observe the reaction process in situ. The alkali-silica reaction can be observed over time, in a wet condition, and at normal pressures, features unavailable with most other high resolution techniques. Soft X-rays also reveal information on the internal structure of the sample. The purpose of this paper is to present research, obtained using transmission soft X-ray microscopy, on the effect of concrete pore solution cations, namely sodium and calcium, on the product formed as a result of alkali attack. Alkali-silicate reaction (ASR) gel was obtained from the FURNAS Dam in Minas Gerais, Brazil. Images of the ASR gel in sodium hydroxide indicated dissolution and repolymerization of the silicate into a less dense form, demonstrating the expansive nature of the gel when exposed to alkalis. In the calcium hydroxide solution, ASR gel, silica fume, and chemical grade silica gel each reacted with the calcium ions in solution to produce a calcium silicate hydrate precursor with a lathlike, branching morphology. The distinctive spherulitic microstructure formed during this reaction was identified as the 'sheaf of wheat' morphology, previously described in the literature. In addition, the development of the sheaf of wheat morphology was documented over time. These results suggest that of the cations studied in this investigation, it is the alkalis in concrete pore solution that produce the expansive ASR gel, while reaction with calcium ions does not result in expansion or damage to the concrete structure. More broadly, these results demonstrate the advantage of transmission soft X-ray microscopy for the study of the alkali-silica reaction, indicating the value of this technique for further studies in concrete technology.

Imaging of humic substance macromolecular structures in water and soils

Humic substances (HSs) are the natural organic polyelectrolytes formed from the biochemical weathering of plant and animal remains. Their macromolecular structure and chemistry determine their role in biogeochemical processes. In situ spectromicroscopic evidence showed that the HS macromolecular structures (size and shape) vary as a function of HS origin (soil versus fluvial), solution chemistry, and the associated mineralogy. The HSs do not simply form coils in acidic or strong electrolyte solutions and elongated structures in dilute alkaline solutions. The macromolecular structural changes of HSs are likely to modify contaminant solubility, biotransformation, and the carbon cycle in soils and sediments.

X-ray microscopic visualization of specific labeling of adhesive molecule CD36 and cytoadherence by Plasmodium falciparum infected erythrocytes

We investigated the cytoadherence of Plasmodium falciparum infected erythrocytes to target cells that express CD36 by soft x-ray microscopy. Using immunogold beads enhanced with silver, we localized CD36 on the surface of intact melanoma cells and throughout Triton extracted melanoma cells. We examined the orientation of parasites within erythrocytes that bound to target cells, and the interactions between the red cell membrane and the target cell, and we confirmed that fibrillar structures on the surface of melanoma and endothelial cells can be involved in the association between infected erythrocytes and melanoma cells or endothelial cells.

Intracellular structures of normal and aberrant Plasmodium falciparum malaria parasites imaged by soft x-ray microscopy

Soft x-ray microscopy is a novel approach for investigation of intracellular organisms and subcellular structures with high spatial resolution. We used x-ray microscopy to investigate structural development of Plasmodium falciparum malaria parasites in normal and genetically abnormal erythrocytes and in infected erythrocytes treated with cysteine protease inhibitors. Investigations in normal red blood cells enabled us to recognize anomalies in parasite structures resulting from growth under unfavorable conditions. X-ray microscopy facilitated detection of newly elaborated structures in the cytosol of fixed, unstained, intact erythrocytes, redistribution of mass (carbon) in infected erythrocytes, and aberrant parasite morphology. In cysteine protease inhibitor-treated, infected erythrocytes, high concentrations of material were detected in abnormal digestive vacuoles and aggregated at the parasite plasma membrane. We have demonstrated that an abnormal host erythrocyte skeleton affects structural development of parasites and that this aberrant development can be detected in the following generation when parasites from protein 4.1-deficient red blood cells infect normal erythrocytes. This work extends our current understanding of the relationship between the host erythrocyte membrane and the intraerythrocytic malaria parasite by demonstrating for the first time that constituents of the erythrocyte membrane play a role in normal parasite structural development.

Characterization of the tumor invasion area in the rat intracerebral glioma

Tumor cell invasion surrounding intracerebrally implanted tumors in rats was studied by comparing the results of cerebral microangiography, fluorescence imaging of blood-brain barrier (BBB) disruption and histopathology. Each comparison was on subsequent sections taken from an initial 1 mm coronal slice of brain taken through the cell injection site containing tumor using the RT-2 glioma model. Tumor extension was assessed at 3, 5, 7 and 9 days after tumor implantation. Analysis of the brain adjacent to tumor shows that the actual tumor cell invasion area is greater than the area of BBB disruption at later stages of tumor growth and the extent of tumor vascularization lies well within the area defined by the extent of tumor cell invasion. Furthermore, this study found that the size of the area of tumor cell invasion remains relatively stable in proportion to the solid tumor mass at various stages of growth such that the area of tumor invaded brain was approximately 2.5 times greater than the area outlined by solid tumor mass. We conclude that measurement of the solid tumor mass, tumor vascular area and region of blood-brain barrier disruption due to tumor, grossly underestimate the total tumor volume. Therapies aimed at controlling glial tumor growth must, therefore, include normal appearing regions of brain peripheral to the abnormal region defined as tumor and tumor invaded brain as defined by radiographic and imaging studies.

Peroneal tenosynovitis following acute gonococcal infection

A 17-year-old adolescent girl presented with tenosynovitis of the peroneal tendons following diagnosis and treatment of an endocervical gonococcal infection. The need for careful history in any sexually active adolescent is emphasized. Acute peroneal tenosynovitis, although not previously cited in the literature, can occur and should be suspected.

Toxicity of photodynamic therapy with photofrin in the normal rat brain

The widespread acceptance of photodynamic therapy (PDT), a potential adjuvant brain tumor therapy under clinical evaluation since 1980, has been partially restrained by its potential toxicity toward normal brain tissue. This study examined PDT-produced injury of normal rat brain as a function of photosensitizer dose. Brain injury was characterized by correlating measurements of the area of cerebral edema using T2-weighted magnetic resonance images, measurement of brain water content at the lesion site, microscopic examination of histological sections through the PDT lesion, and by evaluation of the area of blood brain barrier (BBB) disruption using computerized morphometric analysis of the region of Evans blue (EB) dye-labelled albumin extravasation. Monochromatic red light (630 nm) was delivered intracerebrally using a 5-mm-long cylindrical, diffusion-tip optical fiber at a constant energy dose of 15 joules. A Photofrin dose of 2 mg/kg of body weight produced a transient breakdown in the blood brain barrier around the site of the implanted optical fiber demonstrated by magnetic resonance imaging (MRI), extravasation of EB dye and pallor on hematoxylin and eosin-stained microscopic tissue sections. A much larger area of BBB disruption was seen at a dose of 4 mg/kg of Photofrin, and this drug dose resulted in significant permanent brain injury. In this model, a Photofrin dose of 4 mg/kg body weight is not tolerated by the normal brain.

Physician-related barriers to breast cancer screening in older women

Despite evidence that annual mammographic screening in women 50 years and older reduces mortality, surveys of physicians and patients have repeatedly demonstrated that annual screening mammography is not performed. The fundamental question addressed in this chapter is: If the assumption is made that the scientific evidence supports the use of mammography, what, then, are physician-related barriers to mammographic screening of elderly women? Using a model that classifies barriers to implementing prevention protocols into three categories (predisposing, enabling, and reinforcing factors), literature is reviewed to help identify reasons for low mammographic screening rates, especially in elderly women. This article concludes with a discussion of strategies that may help overcome barriers to mammographic screening in elderly women.

The unit of analysis error in studies about physicians' patient care behavior

OBJECTIVE

To estimate the frequency with which patients are incorrectly used as the unit of analysis among statistical calculations in published studies of physicians' patient care behavior.

DESIGN

Retrospective review of studies published during 1980-1990. ARTICLES: 54 articles retrieved by a computerized search using medical subject headings for physicians and study characteristics. Article selection criteria included the requirement that the physician should have been the correct unit of analysis.

INTERVENTION

Presence of the error was determined by consensus using published criteria.

MAIN RESULTS

The error was present in 38 articles (70%). The number of study physicians was reported in 35 articles (65%). The error was found in 57% of articles that reported the number of study physicians and in 95% of those that did not. The error rate was not lower among articles published more recently nor among those published in journals with higher rates of article citations in the medical literature.

CONCLUSION

The unit of analysis error occurs frequently and can generate artificially low p values. Failure to report the number of study physicians can be a clue that this type of error has been made.

Improved survival from intracavitary photodynamic therapy of rat glioma

The effectiveness of intratumoral photoradiation in photodynamic therapy (PDT) using a polyporphyrin photosensitizer was studied in the RT-2 rat glioma model. One week after intracerebral implantation of RT-2 cells, experimental rats received a single i.p. injection of 2 mg/kg of Photofrin. After administration of the photosensitizer (48 h), the tumors were partially resected and the exposed cavity was irradiated with 15 J of laser light at a wavelength of 630 nm. Further treatment with a large craniectomy significantly enhanced rat survival. Control rats which received no photosensitizer but were treated with surgery, alone or in combination with laser irradiation, succumbed from early tumor recurrence. Photodynamic therapy without decompressive surgery resulted in hemorrhagic infarction of residual tumor and adjacent brain with focal cerebral edema which resulted in cerebral herniation and early death. Our results indicate that photodynamic therapy is effective in treating residual brain tumor but at the expense of brain tissue surrounding the tumor. Unless relieved, intracranial pressure from photodynamic therapy-associated cerebral edema in this animal model resulted in shortened survival.

Relation between polyporphyrin distribution and blood brain barrier changes in the rat glioma model

Photofrin (a polyporphyrin mixture) distribution in a rat glioma model was studied in relation to changes in the blood brain barrier (BBB). At selected intervals after intraperitoneal injection of Photofrin, the concentration of polyporphyrins (PP) and Evans Blue Dye, an indicator of BBB permeability, were determined for tumor, brain adjacent to tumor (BAT), and normal brain tissue. Contrary to earlier reports of maximal accumulation at 4-24 hours, tumor levels of PP increased throughout the 96 hour measurement period. During the early stages of tumor development, PP uptake by tumor appeared to be less correlated to BBB disruption. We conclude that passive diffusion through an incompetent BBB does not completely explain PP accumulation in tumor tissue.

Traumatic spondylolisthesis of the lower cervical spine: case report

A case of traumatic spondylolisthesis of C6 and C7 is presented. The mechanism of injury and the therapeutic implications are discussed.

Interstitial photoradiation injury of normal brain

The effect on normal brain of continuous interstitial laser irradiation at 630 nm through an implanted cylindrical-shape, diffusion-tipped optical fiber was studied in the rat. Brain water content in the laser irradiation area (LIA) and Evans blue (EB) dye content in selected areas of the brain were measured for different laser power outputs from 0 to 250 mW after 5 minutes of photoradiation. The degree and nature of tissue damage was examined histologically and correlated with the laser power level. There is significant brain damage, blood brain barrier (BBB) disruption, and brain edema in LIA for laser power outputs in excess of 100 mW from the diffusion tip (p less than 0.001). Brain edema in the LIA is strongly correlated with BBB disruption indicated by the presence of EB. Histologically, the cortical surface was more susceptible than deeper white matter regions to interstitial laser irradiation. Possible indirect mechanisms of brain injury from interstitial laser irradiation are discussed.

The Duke Minority Medical Student Summer Fellowship: one program's attempt to attract minority residents

Despite numerous Federal and private funding programs aimed at increasing the numbers of underrepresented minorities in medicine, the participation of minority groups in the medical profession remains low and shows little sign of improvement. With the goal of improving minority representation in our primary care residency program, the Minority Medical Student Summer Fellowship started in July 1990. The program's purpose is to give minority medical students positive exposure to primary care and attract them back for residency training. In this four-week elective, students participate in seminars with our primary care residents, see patients in a variety of clinics, and complete a project. Key implementation issues include support of the medicine chairman and dean, funding, and malpractice coverage for the students. Program evaluation from the first two students rated the clinic experiences higher than the seminar sessions and the independent project. Both students stated our fellowship made them more likely to train at this medical center should they enter a primary care program. Implications for other programs are listed.

Can physician education lower the cost of prescription drugs? A prospective, controlled trial

OBJECTIVE

To determine whether an educational program featuring a drug cost manual can assist physicians in reducing their patients' out-of-pocket prescription drug expenses.

DESIGN

Prospective controlled trial.

SETTING

A general internal medicine-teaching clinic in a university hospital.

PARTICIPANTS

Fifty-one medical interns.

INTERVENTION

Thirty-one interns received a manual of comparative drug prices annotated with prescribing advice, two feedback reports, and weekly cost-oriented prescribing reminders. A control group concurrently participated in a manual-based educational program on cholesterol management.

MEASUREMENTS

Copies of 3012 prescriptions written over 8 months were analyzed.

MAIN RESULTS

Intervention group physicians prescribed less expensive drugs within classes of drugs. The change in drug price score per prescription was -0.15 (95% Cl, -0.27 to -0.04; P = 0.01). A score of 3 was assigned to the most expensive, 2 was assigned to intermediate-priced, and 1 was assigned to the least expensive drug or drugs in the class. An increase of 0.74 months' (Cl, 0.49 to 0.98; P less than 0.001) supply of medication was dispensed per prescription, reducing dispensing fees. The program was well accepted by the physicians.

CONCLUSION

This relatively simple educational intervention can help physicians to reduce their patients' drug expenses and may serve as a model for incorporating cost information into the routine practice of medicine.

Quantitative analysis of the outpatient oral case presentation: piloting a method

OBJECTIVE

To measure the content of oral outpatient case presentations and to assess the correlation of objective assessments of this content with subjective ratings provided by the clinic attending physician.

DESIGN

Blinded assessment via audiotape of 36 oral case presentations of new patient evaluations by 23 medical residents.

SETTING

Outpatient general medical clinic.

PARTICIPANTS

Duke University Medical Center medical residents during their outpatient rotation.

MEASUREMENTS AND MAIN RESULTS

Important deficiencies were found in oral case presentation content. Specifically, psychosocial data were often missing (employment history) was mentioned in 28% of presentations; illicit drug use, in 17%; household social structure, in 11%; sexual history, in 6%). An assessment and a plan were mentioned only 56% and 69% of the time, respectively. No correlation was seen between an objective "content score" and the attending physician's subjective rating of the quality of the presentation (r = 0.09).

CONCLUSIONS

1) The outpatient care presentation can be quantitatively assessed in a simple, straightforward manner; 2) outpatient case presentations have important deficiencies in content; and 3) preceptors' evaluations of case presentations may be based upon factors other than content of the presentation.