For doctors' eyes only: medical records in two Israeli hospitals

"Scientific" and "craft" representations of medical diagnosis can be regarded as complementary discursive systems used by physicians in order to legitimate and monopolize their professional power. This paper examines the medical record as a context for the interplay of these two discourses. During interviews conducted with 78 Israeli physicians, 94% have refused to give patients access to their medical records. This refusal is discussed vis-à-vis a reading of the actual contents of medical records, which are shown to contain many errors, inconsistencies and ambiguities. The paper concludes by offering an alternative, anthropological model for medical records as fieldnotes.

On the validity of the dispersion model of hepatic drug elimination when intravascular transit time densities are long-tailed

The dispersion model with mixed boundary conditions uses a single parameter, the dispersion number, to describe the hepatic elimination of xenobiotics and endogenous substances. An implicit a priori assumption of the model is that the transit time density of intravascular indicators is approximately by an inverse Gaussian distribution. This approximation is limited in that the model poorly describes the tail part of the hepatic outflow curves of vascular indicators. A sum of two inverse Gaussian functions is proposed as an alternative, more flexible empirical model for transit time densities of vascular references. This model suggests that a more accurate description of the tail portion of vascular reference curves yields an elimination rate constant (or intrinsic clearance) which is 40% less than predicted by the dispersion model with mixed boundary conditions. The results emphasize the need to accurately describe outflow curves in using them as a basis for determining pharmacokinetic parameters using hepatic elimination models.

Electrophysiological evidence for agonist properties of flumazenil, a benzodiazepine receptor antagonist, in rat hippocampus slices

The purpose of this study was to determine the ability of the putative benzodiazepine antagonist flumazenil to modulate the excitatory synaptic responses recorded from rat hippocampus slices. The benzodiazepine agonist clonazepam was demonstrated to depress the CA1 population spike. This effect was attributed to an enhancement of GABA efficacy after its electrically-elicited release from local inhibitory circuitry. As an unexpected effect, flumazenil failed to antagonize this depressing effect. Moreover, flumazemil was observed to significantly depress, on its own, the magnitude of the evoked response to the activation of the excitatory afferents. This intrinsic depressant activity of flumazenil suggests that flumazenil acts 'in vitro' as an agonist at the benzodiazepine receptors, and is consistent with some previously reported atypical effects of flumazenil 'in vivo'.

Vaccine tolerance in steroid substituted patients with congenital adrenal hyperplasia

The tolerance and side effects of vaccinations were determined in patients with congenital adrenal hyperplasia (CAH) who receive physiological corticosteroid substitution. In a retrospective approach, questionnaires about the frequencies of vaccinations and observed side effects were sent to CAH patients, and medical records were reviewed. We received 82 questionnaires from 63 patients with CAH and salt-losing and 19 patients without salt-losing. Patients age ranged from 2-40 years. No statistical differences were found for vaccination frequencies between patients with or without salt-losing. CAH patients had received complete vaccinations against diphtheria, tetanus and poliomyelitis in 79%, 85% and 78%, respectively, whereas pertussis vaccination was complete in only 23%. Live vaccination against measles, mumps and rubella was performed in 63%, 50% and 38%. Side effects of vaccination were indicated in 5 out of 82 questionnaires who all belonged to CAH patients with salt-losing. Transient side effects were an anaphylactic reaction, probably to tetanus immunoglobulin, in 1 case, and fever and convulsions after diphtheria, pertussis and tetanus (DPT) vaccine in 2 cases. In 2 further patients putative complications were noted. Encephalitis with permanent disabilities was observed after the third DPT vaccination, but a causative relation could not be established. In another boy, encephalopathy noticed after measles vaccination was induced by previous toxicosis. Although encephalopathy was described in 2 patients after vaccinations, no vaccination damage could be proven in our retrospective study. As expected, an increased vaccination risk in CAH patients was not demonstrated.

[In vitro murine spermatogenesis: cytologic study of the meiosis stage]

Spermatogenesis is a complex process of cellular multiplication and differentiation, the regulation of which is only partially understood. This may be due; 1) to the redundancy of the mechanisms of local regulation; 2) to the ubiquitous character of those growth factors and cytokines present in the testis; 3) to the lack of long term culture systems allowing male germ cell development. We describe herein two culture systems associating Sertoli cells and germ cell in which part of the meiotic step can occur in vitro. In the first system, pachytene spermatocytes prepared by centrifugal elutriation are cultured on a layer of Sertoli cells. In the second system small fragments of seminiferous tubules are seeded in bicameral chambers. The cytological and immunocytochemical studies presented show that pachytene spermatocytes of stages IV-VI differentiate into spermatids of steps 1 to 5.

An evaluation of postoperative follow-up tests in colon cancer patients treated for cure

BACKGROUND

Currently patients with colon cancer who are potentially cured by surgery are followed periodically with physical examinations, blood tests and imaging studies to detect tumor recurrence early, on the presumption that intervention can effect outcome. There is little information to indicate whether frequent visits to the doctor's office or frequent testing improves survival or quality of life.

METHODS

Ninety-eight patients with resected stage B2, B3 or C (modified Astler-Coller) colon cancer who developed recurrent disease while enrolled in prospective adjuvant trials at Mayo Clinic sponsored by the North Central Cancer Treatment Group were studied to evaluate the utility of follow-up tests to detect the first recurrence of colon cancer and the outcome following various interventions for these recurrences. These patients had a history, physical examination, complete blood count, chemistry panel and chest x-ray approximately every 3-4 months in the 1st year and then every 6-12 months thereafter for a total of 5 years. Bowel evaluation was done at 6 months, 12 months and annually thereafter. In addition, a minority of patients had carcinoembryonic antigen (CEA) testing, and radioisotope liver scans at various intervals.

RESULTS

Symptoms signaled the diagnosis of recurrent disease in 55 patients, physical examination in 4 patients, and abnormalities in chest x-ray in 18 patients. An elevated CEA was the initial abnormal test in 5 patients, abnormal liver scans in 5 patients, elevated liver function tests in 6 patients and laparotomy for other reasons in 2 patients. Hemoglobin, barium enema, and fecal blood testing were useful in 1 patient each. Thirty-one percent of recurrences were diagnosed between scheduled visits. In our series, histories, physical examinations, and chest x-rays led to the detection of 79% of the recurrences while liver function tests, liver scans and CEAs led to the detection of 16% of recurrences. Sixteen patients underwent resection for cure for their first recurrence; the diagnosis of recurrence was signaled by symptoms in 6 patients, chest x-ray in 6 patients and abnormal liver function tests, CEA, hemoglobin, and laparotomy for colostomy closure in 1 patient each.

CONCLUSIONS

The majority of tumor recurrences were detected by symptoms, physical examinations and chest x-rays. Testing for asymptomatic tumor recurrences during the 1st follow-up year is likely to be much less fruitful for detecting resectable recurrences than testing patients in the 2nd through 4th follow-up years. Patients who had a disease recurrence in the 1st postoperative year were less likely to be candidates for curative intent surgery. Lower tumor grade at initial diagnosis correlated both with likelihood of undergoing secondary surgical resection and the chance of doing well following this. These data may be helpful for defining more appropriate follow-up test for detection of tumor recurrence in patients with resected colon cancer.

Pre- and postmeiotic expression of male germ cell-specific genes throughout 2-week cocultures of rat germinal and Sertoli cells

The present study was aimed at examining, by reverse transcription polymerase chain reaction, the expression of germ cell-specific genes in cocultures of Sertoli cells with either pachytene spermatocytes (PS) or round spermatids (RS). In situ hybridization studies showed that the mRNAs encoding phosphoprotein p19 and the testis-specific histone TH2B were specifically expressed in PS whereas those encoding the transition proteins TP1 and TP2 were specific to RS. This resulted in p19:TP1 and TH2B:TP2 ratios that were much higher in PS fractions than in RS fractions prepared by elutriation. When PS or RS were seeded on Sertoli cell monolayers in bicameral chambers, both the number and the viability of the cells decreased during the coculture. However, both parameters were equal to, or higher than, 60% after 2 wk. In PS-Sertoli cell cocultures, the ratios of p19:TP1 and TH2B:TP2 decreased dramatically during the second week of culture; this was due not only to a decrease in the levels of p19 and TH2B mRNAs but also to an enhancement in the relative amounts of TP1 and TP2 as compared to the amounts present on the first day of the coculture. Conversely, both ratios remained low in RS-Sertoli cell cocultures; this was due to a decrease in the levels of the four mRNAs studied during the coculture period. DNA flow cytometry studies showed the occurrence of a haploid cell population (1C) in PS-Sertoli cell cocultures from Day 2 onward, together with a decrease in the tetraploid cell population (4C). No such changes were observed in Sertoli cell-only cultures. By contrast, the haploid population decreased 3-fold during the first week in RS-Sertoli cell cocultures. Immunocytochemical studies demonstrated further that 5-bromo-2'-deoxyuridine-labeled PS of stages V-VIII were able to differentiate into RS under the present coculture conditions. Hence, although clearly imperfect, the present coculture system should help to clarify the local regulations governing spermatogenesis and should allow easier study of spermatogenic cell gene expression.

On the degree of solute mixing in liver models of drug elimination

One of the fundamental differences between various liver models regards the underlying assumptions on the intrahepatic mixing process. A model-independent method for the evaluation of the departure from the perfectly mixed system is proposed which is based on an application of the relative entropy concept to hepatic transit time distributions of intravascular markers. This approach provides a measure of the distance between two probability distributions. Available data measured in isolated perfused livers indicate that sinusoidal solute mixing is nearly optimal. The suggestion of maximum mixedness in the liver may explain the discrepancy between the apparent validity of the venous equilibrium model and the physiological irrelevance of the underlying well-stirred assumption. In terms of the dispersion model the results are in accordance with the model equation obtained for mixed boundary conditions.

Preferential expression of novel MUC1 tumor antigen isoforms in human epithelial tumors and their tumor-potentiating function

The human MUC1 gene expresses at least 2 type 1 membrane proteins: MUC1/REP, a polymorphic high m.w. MUC1 glycoprotein often highly expressed in breast cancer tissues and containing a variable number of tandem 20 amino acid repeat units, and the MUC1/Y protein, which lacks this repeat array and, therefore, is not polymorphic. Despite their documented importance in signal transduction processes, the relative expression of the 2 isoforms in epithelial tumors is unknown. Using antibody reagents which recognize different MUC1 domains, the expression of these isoforms in malignant epithelial cells has been evaluated. A comparison of the amounts of the 2 isoforms revealed preferential expression of the novel MUC1/Y protein in breast cancer tissue samples. Furthermore, although the MUC1/REP protein is almost undetectable in HeLa cervical adenocarcinoma epithelial cells, the MUC1/Y isoform is extensively expressed in these cells. The presence of the MUC1/Y sequence as well as that of an additional tandem-repeat-array-lacking isoform, designated MUC1/X, were demonstrated by reverse transcriptase PCR amplification of RNA extracted from HeLa and ovarian carcinoma cells. It has been shown previously that the MUC1 cytoplasmic domain interacts with the SH2 domain containing GRB2 protein, which transduces signals to ras, a protein which in its activated form can lead to cell transformation. We present here data demonstrating that MUC1/Y isoform expression increases the tumorigenic potential of DA3 mouse mammary epithelial cells; in contrast, potentiation of tumorigenicity is not observed with MUC1/REP expression. Our studies thus demonstrate that expression of the MUC1 gene in epithelial tumors can give rise to substantial levels of MUC1 proteins devoid of the tandem repeat array, which are generated by alternative splicing mechanisms.

The role of the alliance in the pharmacologic treatment of depression

BACKGROUND

The purpose of this study was to determine the influence of the therapeutic alliance on the efficacy of pharmacotherapy for depression.

METHOD

The sample consisted of 31 depressed outpatients treated with antidepressants. The alliance was measured by the patient and therapist versions of the California Pharmacotherapy Alliance Scale. Treatment outcome was measured by the Hamilton Rating Scale for Depression and the Beck Depression Inventory, and the Symptom, Sign, Side-Effect Checklist was also completed.

RESULTS

The alliance measures accounted for between 21% and 56% of the variance in the three outcome measures. By averaging across outcome measures, therapist perceptions of the alliance predicted 41% of the variance in improvement in depressive symptoms, where patient perceptions predicted 25%. Scores on both alliance measures were lower than those reported in studies of psychotherapy. Patient attitude toward medication was correlated with somatic complaints, but not with depression scores. Therapist perception of patient hostility correlated with patient depression. Patients differed in the way their alliance and outcome interacted, so that the association might be positive or negative.

CONCLUSION

Alliance is correlated with outcome in pharmacotherapy management of depression, although there may be interindividual variability across patients. In the pharmacotherapy of depression, therapist perception of alliance is a better predictor of symptom outcome than patient perception, while the reverse is usually found in psychotherapy.

Vasoactive drugs inhibit oxygen radical production of neutrophils

A concentration response study was performed to clarify whether vasoactive drugs, routinely used in intensive care patients, inhibit oxygen radical production of neutrophils. Moreover, in a cell-free system, it was investigated whether these drugs exert free radical scavenging properties. Vasoactive agents were incubated with neutrophils from healthy human volunteers, which were stimulated by N-formyl-methionyl-leucyl-phenylalanine (FMLP) and by opsonized zymosan to produce oxygen radicals, detected by chemiluminescence measurements. Sympathomimetics (epinephrine greater than norepinephrine, dopamine and dobutamine) as well as phosphodiesterase-inhibitors (amrinone and enoximone) inhibited FMLP-induced and zymosan-induced oxygen radical production of neutrophils in a concentration-dependent and drug-specific fashion. With the exception of amrinone, FMLP-induced chemiluminescence of neutrophils was impaired nearly 10-fold more markedly than zymosan-induced chemiluminescence. Glyceryl trinitrate, nifedipine and prostacyclin had no effect on oxygen radical production of neutrophils. In the cell-free system, epinephrine, norepinephrine, dopamine, amrinone and enoximone demonstrated oxygen free radical scavenging properties. This study shows that vasoactive drugs, frequently used in the clinical setting, may suppress oxidative burst after FMLP-receptor stimulation. As demonstrated in the cell-free system, this suppression was, at least in part, due to oxygen radical scavenging.

Tissue-Specific and Development-Dependent Accumulation of Phenylpropanoids in Larch Mycorrhizas

The tissue-specific and development-dependent accumulation of secondary products in roots and mycorrhizas of larch (Larix decidua Mill.; Pinaceae) was studied using high-performance liquid chromatography and histochemical methods. The compounds identified were soluble catechin, epicatechin, quercetin 3-O-[alpha]-rhamnoside, cyanidin- and peonidin 3-O-[beta]-glucoside, 4-O-[beta]-hydroxybenzoyl-O-[beta]-glucose, 4-hydroxybenzoate 4-O-[beta]-glucoside, maltol 3-O-[beta]-glucoside, and the wall-bound 4-hydroxybenzaldehyde, vanillin, and ferulate. In addition, we partially identified a tetrahydroxystilbene monoglycoside, a quercetin glycoside, and eight oligomeric proanthocyanidins. Comparison between the compounds accumulating in the apical tissue of fine roots, long roots, and in vitro grown mycorrhizas (L. decidua-Suillus tridentinus) showed elevated levels of the major compounds catechin and epicatechin as well as the minor compound 4-hydroxybenzoate 4-O-[beta]-glucoside specifically in the root apex of young mycorrhizas. The amounts of wall-bound 4-hydroxybenzaldehyde and vanillin were increased in all of the mycorrhizal sections examined. During the early stages of mycorrhization the concentrations of these compounds increased rapidly, perhaps induced by the mycorrhizal fungus. In addition, studies of L. decidua-Boletinus cavipes mycorrhizas from a natural stand showed that the central part of the subapical cortex tissue and the endodermis both accumulate massive concentrations of catechin, epicatechin, and wall-bound ferulate compared with the outer part of the cortex, where the Hartig net is being formed.

Cholesterol 7 alpha-hydroxylase activity in hypothyroidism and hyperthyroidism in humans

Alterations of serum cholesterol levels are well recognized findings in hypothyroidism and hyperthyroidism. It remains unclear, whether thyroid hormones may affect serum concentrations of cholesterol through changes in the activity of cholesterol 7 alpha-hydroxylase, the rate-limiting enzyme in the catabolic conversion of cholesterol to bile acids. We determined serum concentrations of the bile acid precursor 7 alpha-hydroxy-4-cholesten-3-one, which reflects cholesterol 7 alpha-hydroxylase activity in the liver, in 19 patients with hypothyroidism and in 10 patients with hyperthyroidism before and after treatment, respectively. In patients with hypothyroidism, serum concentrations of cholesterol and LDL-cholesterol decreased by 33% (p < 0.0005) and 39% (p < 0.0005), respectively, after replacement therapy with thyroid hormones. In contrast, serum concentrations of 7 alpha-hydroxy-4-cholesten-3-one (21.7 +/- 15.8 ng/ml vs 24.5 +/- 18.1 ng/ml before treatment, n.s.) as well as serum HDL-cholesterol were unchanged during substitution therapy. In patients with hyperthyroidism, serum concentrations of cholesterol and LDL-cholesterol increased by 27% (p < 0.01) and 39% (p < 0.01) after antithyroid treatment, respectively. Again, serum concentrations of 7 alpha-hydroxy-4-cholesten-3-one did not change significantly during treatment (15.8 +/- 12.6 ng/ml vs 14.7 +/- 8.1 ng/ml before treatment, n.s.). These findings indicate that in humans, thyroid hormones influence serum lipid concentrations by other mechanisms than by affecting the activity of cholesterol 7 alpha-hydroxylase.

The quality evolution in managed care organizations: shifting the focus to community health

Community demand for high-quality, cost-effective health care is forcing many new changes for managed care organizations (MCOs). Competition among MCOs often prevents cooperative and comprehensive approaches to the enhancement of the health status of the community. MCOs are beginning to measure quality based on the health of enrolled populations, and communities are seeking communitywide quality of care indicators. To cope with the demands of capitated health care, MCOs need to shift their focus to managing the health status of specific community populations. Strategies for managing the health status of populations include community assessments, collaboration among competing players, and a focus on consumer health information.

MR imaging of enhancing intraosseous disk herniation (Schmorl's nodes)

OBJECTIVE

This study was conducted to show vascularization of Schmorl's nodes with enhanced MR imaging and to correlate this finding with clinical complaints.

MATERIALS AND METHODS

Retrospectively, 412 gadopentetate dimeglumine-enhanced MR imaging examinations of the lumbar and thoracic spine of 372 patients were reviewed for Schmorl's nodes, vascularization of Schmorl's nodes, and associated bone marrow edema. Sagittal T2-weighted spin-echo and unenhanced and enhanced T1-weighted spin-echo images with and without fat suppression were evaluated in symptomatic and asymptomatic patients.

RESULTS

Of the 372 patients, 142 (38%) had 341 Schmorl's nodes. Gadopentetate dimeglumine-enhanced MR imaging revealed vascularized tissue in 30 Schmorl's nodes of 23 patients (mean age of patients, 53 years old). Associated bone marrow edema was found in nine of 30 vascularized Schmorl's nodes. The mean diameter (8.2 mm) of the nine vascularized Schmorl's nodes that were surrounded by bone marrow edema was significantly (p < .05) greater than the mean diameter (6.4 mm) of the 21 vascularized Schmorl's nodes that had no bone marrow edema. The vascularized Schmorl's nodes were significantly (p < .05) smaller in the seven asymptomatic patients (mean, 5.2 mm) than in the 23 patients with back pain (mean, 7.9 mm). We saw bone marrow edema adjacent to Schmorl's nodes less frequently in asymptomatic patients (one of seven) than in symptomatic patients (10 of 23).

CONCLUSION

Vascularized Schmorl's nodes were larger and more frequently associated with bone marrow edema in patients with back pain than in asymptomatic patients. Enhanced MR images of Schmorl's nodes revealed vascularity, which was not shown on unenhanced MR images.

Errors in clearance estimation after bolus injection and arterial sampling: nonexistence of a central compartment

In conventional pharmacokinetics monotonic decreasing drug disposition curves are usually assumed after bolus injection. For arterial sampling starting about 1 min after dosing the resulting neglect of the initial concentration peak leads to a relative overestimation of clearance which may be approximated by the percentage of systemic drug extraction. This error can be avoided by administering the drug as a short-term infusion.

Thoracoscopic surgery of the oesophagus in rats: a training concept for the treatment of tracheo-oesophageal malformations in preterm infants

In extremely preterm babies with type Vogt III b oesophageal atresia, the primary operative management can be restricted to a gastrostomy and ligation of the fistula. Some of these patients, however, may not even tolerate a thoracotomy or placement on the operating table. We developed a minimally invasive procedure to prepare and ligate the oesophagus thoracoscopically and perform laparoscopic gastrostomy in a rat model. In 15 operations we observed only one complication. This study implies that after adequate practice, thoracoscopic dissection of the oesophagus with ligation of a tracheo-oesophageal fistula could be performed even in every small infants.

Higher prevalence and greater severity of coronary disease in short versus tall men referred for coronary arteriography

The incidence of myocardial infarction is higher in short individuals than in tall ones. To test whether the prevalence and severity of coronary disease is greater in short than in tall individuals, we compared a group of short men (height < [mean height - one SD]) to a group of tall men (height > [mean height + one SD]) drawn from a sample of 1046 consecutive men referred for coronary arteriography. Short men had a higher frequency of > or = 50% diameter stenosis; more diseased vessels (1.61 +/- 1.09 vs 1.15 +/- 1.11, p = 0.0004); a higher frequency of three-vessel disease (26.8% vs 16.1%, p = 0.04); and more total occlusions (40.1% vs 27.3%, p = 0.03). By multivariate analysis, height independently predicted > or = 50% lesions in the right coronary artery (p = 0.01) and left anterior descending artery (p = 0.06); three-vessel disease (p = 0.04); total occlusion (p = 0.04); and the number of diseased vessels (p = 0.005). This higher prevalence and greater severity of coronary disease may explain the higher incidence of and deaths caused by myocardial infarction previously reported in short men.

Health and functional status of long-term survivors of bone marrow transplantation. EBMT Working Party on Late Effects and EULEP Study Group on Late Effects. European Group for Blood and Marrow Transplantation

BACKGROUND

Although many patients now survive the short-term complications of bone marrow transplantation for life-threatening hematologic disease, information on the health and activity of long-term survivors is sparse.

OBJECTIVE

To evaluate the morbidity and mortality of patients surviving more than 5 years after allogeneic bone marrow transplantation.

DESIGN

Retrospective, multicenter study.

PATIENTS

798 recipients of bone marrow transplants (477 adults, 321 children) from 43 European centers. Patients had received transplants before December 1985 and had survived at least 5 years. Patients had received allogeneic or syngeneic bone marrow for leukemia, lymphoma, inborn diseases of the hematopoietic and immune systems, and severe aplastic anemia.

MEASUREMENTS

Survival, clinical performance according to Karnofsky score (in increments of 10%), and social reintegration were assessed as outcomes. Patient age and sex, primary disease and status at transplantation, histocompatibility of the donor, conditioning regimen, type of prophylaxis of graft-versus-host disease, and acute and chronic graft-versus-host disease were evaluated as variables.

RESULTS

For the 55 5-year survivors, actuarial mortality was 8% at 10 years and 14% at 15 years. The leading causes of death were disease recurrence (21 patients), chronic graft-versus-host disease with complicating infections and lung disease (11 patients), secondary cancer (8 patients), and the acquired immunodeficiency syndrome (AIDS) (5 patients). When patients with recurrent disease were excluded, late death was associated with chronic graft-versus-host disease (P < 0.001), occurrence of secondary cancer (P < 0.001), male sex of the patient (P = 0.05), and female sex of the donor (P = 0.002). Clinical performance was normal (Karnofsky score, 100%) or minimally reduced (Karnofsky score, 90%) in 93% of patients; 89% of patients resumed full-time work or school. Reduced performance status and incomplete resumption of social activity were associated with chronic graft-versus-host disease, recurrent leukemia, AIDS, secondary cancer, organ dysfunction, and neurologic or psychological problems. Other risk factors for incomplete resumption of social activity were female sex (P = 0.002) and older age at transplantation (P = 0.001).

CONCLUSIONS

More than 5 years after bone marrow transplantation, most patients were in good health (93%) and had returned to full-time work or school (89%). Recurrence of the primary disease, secondary cancer, and chronic graft-versus-host disease and its sequelae remain problems for some patients.