[A national qualifying internal medicine examination for Israeli medical students]

In 1991 the deans of the 4 medical schools in Israel decided to institute a national qualifying examination in internal medicine. This marked the beginning of the process of unifying the qualifying examinations in all major medical fields. We describe the development of the examination, experience with its administration to 720 students in 1992-1994, and the outcome of this initial effort. The examinations were prepared by a committee of senior faculty from the 4 schools, representing all the relevant clinical areas. Professional consultation was provided by the Unit for Medical Education of Tel Aviv University. Each examination consisted of 180 multiple choice items, reflecting an agreed representation of the various medical specialties, and was designed to test both comprehension and problem-solving ability. A syllabus was published by the committee and distributed to students and faculty in preparation for the examination. In composing the examination, the committee took into consideration differences in general policy and varying emphases in the curricula of the 4 schools. Analysis of the results of the 3 annual examinations showed both a high level of reliability and high quality of the majority of the individual test items. There was a trend with time to slightly lower average scores, and fewer passed the exam last year. There was improvement in the results after the first 2 years in the area of problem-solving related to interpretation of imaging, blood smears and clinical photographs, but this trend did not continue into 1994. The introduction of a high level examination based on a common syllabus provided important feedback, improving both student motivation and clinical teaching. For all schools, the outcome of the examination served as an important external indicator of teaching standards. Following this positive experience, uniform examinations in surgical subjects and pediatrics were introduced for the first time in 1993. The committee recommends that Israeli medical schools gradually introduce a comprehensive qualifying examination based on a mutually agreed list of objectives and syllabus.

Refractive variation during autorefraction: multivariate distribution of refractive status

The refractive variation of a sample of 106 university students (63 females and 43 males) studying optometry was examined by means of autorefraction. Stereo-pair scatter plots in Euclidean three-dimensional h-space are used to illustrate the nature of the spread or distribution of data measurements found in particular subjects. A wide variety of different distributions were observed ranging from tightly to loosely clustered arrangements of measurements. Some aspects of departure from multivariate normality, including outliers (atypical measurements in a sample) and polymodal or multimodal distributions, are demonstrated. Outliers appear to be possible anywhere in the space of the scatter plots, although outliers may be more common in the region of h-space corresponding to transitory increases in accommodation. Multimodal distributions may be indicative of changes in ocular fixation during autorefraction or may reflect accommodative or other anomalies. Other departures from multivariate normality such as kurtosis and skewness are also of importance when attempting to form an understanding of variation of refractive state. Measurements made on an artificial or test eye showed very tight clusters in h-space. This suggests that the autorefractor itself contributes little to the variation observed during autorefraction of an eye.

Outcome of patients with nonsustained ventricular tachycardia and severely impaired ventricular function who have negative electrophysiologic studies

Twenty-nine consecutive patients with a prior myocardial infarction, severely reduced left ventricular ejection fraction (26% +/- 8%), and asymptomatic nonsustained ventricular tachycardia were enrolled in a prospective trial. After a negative programmed electric stimulation study (3 extrastimuli at 2 sites with 2 drive trains), the 26 men and 3 women (mean age 71) were monitored for a mean of 13 months without antiarrhythmic drug therapy. Five patients died suddenly or had sustained ventricular tachycardia; three others had a cardiac, nonarrhythmic death. Events occurred in the first 13 months of the surveillance period. Clinical factors associated with a poor outcome included congestive heart failure and lack of beta-blocker therapy. In addition, patients with events tended to have lower ejection fractions than those without (21% vs 28%, p not significant). Thus a negative programmed electric stimulation study does not necessarily imply a benign outcome in patients with a prior infarction and nonsustained ventricular tachycardia if they also have severe left ventricular dysfunction and a history of heart failure. These data have important implications for the design and conduct of contemporary clinical trials.

Cervical screening

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Drinking outcomes of alcohol abusers diagnosed as antisocial personality disorder

Clinical research and wisdom suggest that alcoholics with antisocial personality (ASPs) disorders have poorer drinking outcomes after treatment than alcoholics without this disorder. The present study challenges this wisdom, suggesting that poor prognosis and response to treatment have been confounded by not covarying on pretreatment drinking measures. Thirty-one ASPs are compared with 118 non-ASPs randomly assigned to extended cognitive behavioral and relationship enhancement treatments. Thirteen to 18 months after treatment initiation, ASPs average more abstinent days than do non-ASPs. Drinking intensity is a function of a patient-treatment matching effect: ASPs treated with cognitive behavioral treatment (CB) drink less/drinking day than do either non-ASPs treated in CB or ASPs treated in relationship enhancement. This finding is supportive of a comparable matching effect for CB and ASP found by Kadden et al. (1989). Examination of the process indicates that, irrespective of drinking index, ASPs respond poorly when they experience high posttreatment support for abstinence, whereas non-ASPs respond better with support. We conclude that early pessimism for successful treatment of ASP alcoholic drinking outcome may be unwarranted.

[Cervical necrotizing fasciitis]

Necrotizing fasciitis of the head and neck is a rare infection caused by a mixed bacterial flora with anaerobic predominance. Mortality is due to misdiagnosis which results in late and inadequate treatment. The natural course of this serious infection involves spreading necrosis of the soft tissues of the neck with erosion of major blood vessels. A 33-year-old man and a 66-year-old woman are presented to demonstrate the usual etiological factors of cervical necrotizing fasciitis, mainly dental and pharyngeal infections. Diagnosis is by bacteriological culture and CT-scan; a high degree of clinical suspicion is necessary. Treatment included aggressive surgery, appropriate antibiotic coverage and hyperbaric oxygen, and resulted in successful outcomes in our 2 cases.

How well is hypertension controlled in CAPD patients?

To determine how well hypertension is controlled in continuous ambulatory peritoneal dialysis (CAPD) patients, we monitored the blood pressure of 31 hypertensive adult CAPD patients treated with antihypertensive agents. Blood pressure (BP) monitoring, using a noninvasive, ambulatory BP monitor, began in the morning and continued every 30-60 min for 24 h (mean 42 readings per patient). The mean BP of all patients over 24 h was 145.6/91.3 mm Hg. In these, 40.5% of systolic BP readings exceeded 150 mm Hg and 50.2% of diastolic readings exceeded 90 mm Hg, suggesting that hypertension was inadequately controlled for a considerable period of time. Diabetic patients had even worse control of BP. Mean BP, heart rates, and BP loads were not different, between daytime or nighttime. These findings suggest that CAPD patients do not preserve the normal circadian rhythm of BP and that their hypertension is not controlled any better during the night than during the day. We repeated BP monitoring after adjustment of antihypertensive medications in 8 patients who had poorly controlled hypertension. Systolic and diastolic BP loads in subsequent studies improved significantly from the first study.

IN CONCLUSION

hypertension is suboptimally controlled in most CAPD patients; diabetic patients fare even worse in the control of hypertension; most patients do not preserve the circadian rhythm of BP and there is no difference in the adequacy of hypertension control during the day or at night; assessment of hypertension with ambulatory BP monitoring helps guide therapy and control of hypertension.

Ovulation and follicular development associated with three low-dose oral contraceptives: a randomized controlled trial

OBJECTIVE

To address the hypothesis that multiphasic oral contraceptives (OCs) increase rather than decrease the risk of functional ovarian cysts.

METHODS

In this single-center, randomized controlled study, women were assigned to a multiphasic pill, a lower-dose monophasic pill, a higher-dose monophasic pill, or nonsteroidal contraception. Forty volunteers were randomized (ten each) to three different pill regimens or to nonsteroidal contraception. During 6 months of treatment, follicular development was measured by vaginal ultrasonography and ovulation was indicated by serum progesterone levels.

RESULTS

The relative risk (RR) of developing a follicular structure greater than 30 mm in diameter during a cycle with the higher-dose monophasic pill was 0.5 (95% confidence interval [CI] 0.1-1.9; P = .49) compared with the multiphasic pill. The risk with the lower-dose monophasic pill was comparable to that with the multiphasic pill (RR 1.3, 95% CI 0.5-3.6; P = .56). With the multiphasic pill, the maximum ovulation rate over 60 cycles was 1.7 per 100 cycles (95% CI 0.0-8.9).

CONCLUSION

This multiphasic pill more closely resembled the lower-dose monophasic pill than the higher-dose monophasic pill in its suppression of follicular development.

Calcium homeostasis of an elderly population upon admission to a nursing home

OBJECTIVE

To evaluate the skeletal health, calcium, and vitamin D homeostasis of patients upon their entry to a long-term-care facility. Factors that could contribute to the risk of future osteoporotic fractures were also evaluated.

DESIGN

Cross-sectional study.

PATIENTS

Two hundred eighty-seven consecutive admissions were invited to participate; 109 patients were recruited into the study.

MEASUREMENTS

A high prevalence of low to low-normal circulating levels of 25(OH)D was found in nursing home residents upon their admission to the nursing home, with 86% of the patients having circulating 25(OH)D levels of less than 50 nmol/L and 41% having levels below 25 nmol/L. Frankly elevated parathyroid hormone levels were found in 16% of the patients. Additionally, alkaline phosphatase and osteocalcin levels were elevated in 23% and 13% of the patients, respectively. Bone mineral measurements were in the osteoporotic range for 85% of the nursing home residents. Bone density results for females with a history of any classic osteoporotic fracture were significantly lower than for those with no fracture history (68.5 arbitrary units (AU) for those with no fracture history, 58.8 AU in those with history of hip fracture; P < 0.05). The bone mineral measurements were higher in women with adequate 25(OH)D compared with women with deficient or borderline 25(OH)D with and without fracture history. Levels of 25(OH)D were positively correlated with urine calcium/creatinine (r = .24; P = 0.03) and 1,25(OH)2D (r = .28; P = 0.01) and were negatively correlated with 1-84 PTH (r = -.24; P = 0.02).

CONCLUSION

Hypovitaminosis D is prevalent among elderly patients entering a nursing home with secondary hyperparathyroidism and apparently increased bone turnover present in patients with circulating 25(OH)D levels below 50 nmol/L. Bone density measurements showed that a majority of the individuals entering a nursing home are osteoporotic. There is a positive association between 25(OH)D levels and bone mass and a negative association between 25(OH)D levels and a history of fracture.

Disposition of zatosetron, a serotonin (5-HT3) receptor antagonist, in humans

Zatosetron is being tested clinically as an antianxiety agent; it is a highly selective antagonist of the serotonin 5-HT3 receptor, with minimal agonist activity. The disposition of [14C]zatosetron was studied in five healthy men after a single oral dose (46.2 mg). Serum levels of radioactivity and parent drug peaked in 3-8 hr. About 15% more radioactivity was measured in red blood cells than in plasma. In serum, the parent compound represented about 85% of the radioactivity, zatosetron-N-oxide represented 10%, and N-desmethyl-zatosetron and 3-hydroxy-zatosetron each represented 2-3%. The t1/2 of zatosetron was 25-37 hr. About 75% of zatosetron added to human plasma became reversibly bound to protein. Concentrations of zatosetron in saliva were generally 10-50% higher than those in serum. About 80% of the administered radioactivity was eliminated in urine and 20% in feces; radioactivity was measurable in the excreta for 10-12 days after drug administration. The major route of metabolism of zatosetron was a stereoselective N-oxidation to form 8-alpha-methyl, 8-beta-oxo zatosetron (zatosetron N-oxide). In urine, approximately 45% of the radioactivity was unchanged zatosetron, 35% was zatosetron N-oxide, 10% was N-desmethyl-zatosetron, and 5% was 3-hydroxy-zatosetron. In feces, 30% of the radioactivity was unchanged zatosetron, and 70% was N-desmethyl-zatosetron. Overall, approximately 60% of the administered zatosetron was metabolized in humans. In a separate multiple-dose study, the disposition of zatosetron was found to be similar to that in the single-dose study.

The effects of illness on sleep behaviour in infants

For the purpose of evaluating the association between health problems and sleep disturbances as part of a community survey of sleep patterns in childhood, a questionnaire was administered to 752 mothers of children between the ages of 4 months and 4 years, and to the nurses at their regular baby clinics. The questionnaire covered the areas of past and present sleep and settling behaviour, as well as health history and demographic data. The study group consisted of 66 (8.9%) children who had either chronic medical problems, or history of an illness requiring hospitalisation. Regular night waking was reported in 35% and 34% of the group with and without history of illness, respectively. The mean number of interrupted nights per week was similar in both groups and so were the sleep problems perceived by the mothers. We conclude that in this age group the results do not support an association between health problems and prolonged sleep disturbances.

[Intestinal tuberculosis presenting as Crohn's disease]

A 24-year-old woman who had immigrated from India 3 years before was referred because of diarrhea, abdominal pain and weight loss. Crohn's disease was suspected, but investigation revealed active pulmonary tuberculosis and tuberculosis of the small and large intestine. She was treated with rifampicin, 600 mg/day, INH 300 mg/day, and ethambutol, 400 mg/day, and recovered fully within 6 months.

Affective correlates of alcohol and cocaine use

The affective correlates of alcohol and cocaine use were investigated in two studies. In the first, alcoholics (n = 50) and cocaine addicts (n = 40) were administered factor scales from the Inventory of Drinking Situations as well as the General Temperament Survey. Substance use in negative affect states was reported more often by alcoholics than by cocaine addicts, even when age and race differences were statistically controlled. Alcoholics also reported higher levels of negative temperament, and substance use in negative affect states was correlated with negative temperament across groups. In a study using subjects dependent on both drugs (n = 21), alcohol was more likely to be used in negative affect situations than was cocaine. Thus, the affective correlates of substance use are associated with both individual differences and drug-specific effects. Possible reasons for the differential association of alcohol with negative affect are proposed.

Ranitidine for erosive oesophagitis: a double-blind, placebo-controlled study. Glaxo Erosive Esophagitis Study Group

A multicentre, randomized, double-blind, placebo-controlled study was conducted to evaluate the efficacy and safety of ranitidine 150 mg and 300 mg in 342 patients with erosive oesophagitis. Treatment was given four times daily, and continued for 12 weeks or until healing (that is, normal or only erythematous mucosa). Erosive oesophagitis healing rates, as determined by endoscopy, were significantly greater in ranitidine-treated patients by 4 weeks compared with those of placebo-treated patients. By 12 weeks, erosive oesophagitis healing rates were 83 and 81% for ranitidine-treated patients (150 and 300 mg, respectively) and 58% for placebo-treated patients (P less than or equal to 0.001, ranitidine vs. placebo). Symptomatic relief was achieved within 24 hours after starting either dosage of ranitidine. Heartburn frequency (P less than 0.001) and severity (P less than 0.001), as well as antacid consumed per week (P less than 0.001), were reduced in both ranitidine groups in comparison with placebo. Healing rates and symptom relief were similar in the two ranitidine groups. Both dosages of ranitidine were well tolerated. Ranitidine (150 mg) given four times daily appears to be as effective as 300 mg ranitidine given four times daily in patients with moderate to severe oesophageal erosions.

Familial tufted angioma

Tufted angioma is a rare slowly progressive vascular lesion found typically in children and young adults. Cases appear sporadically and clinically have been confused with low grade angiosarcoma, Kaposi's sarcoma, and multiple glomus tumours. We report a case of a patient with tufted angioma in whom a strong family history of similar lesions is apparent, transmitted in an autosomal-dominant mode of inheritance.

Design of an expert system and its application to dermatopathology

Expert systems are computer programs which use inference and knowledge to solve problems which usually require the expertise of a human specialist. This paper examines the application of expert systems to histopathology and explains their construction by describing the design of an expert system 'dermdx', intended to aid in the interpretation and diagnosis of biopsies of inflammatory diseases of the skin. The system consists of an expert shell, which performs the inference, and a rule-base, which contains the knowledge with which the system operates. The system can be easily updated or adapted to other tasks.

Ellipsoidal confidence regions for mean refractive status

Confidence regions for mean dioptric power can be represented by ellipsoids in a three-dimensional space called h-space. A convenient graphical representation is provided by stereo-pair drawings that, at a glance, show the estimated accuracy with which the mean power is known. As an example, a sample of autorefractor measurements made on one eye were used to construct a 95% confidence ellipsoid for the mean objective refractive status of that eye. Key dimensions of the ellipsoid are compared with those of another eye. The analysis is of fundamental importance for scientific studies of variation and change of refractive status. Its potential clinical importance is also discussed.

The distribution of dioptric power: ellipsoids of constant probability density

A sample from a population of dioptric powers may be used to estimate the distribution of dioptric powers in the population itself. This paper describes the method and shows further how one can obtain a graphical representation of the distribution. The graphical representation takes the form of ellipsoids of constant probability density. The centroid of each ellipsoid estimates the mean of the population while the size, shape and orientation show the extent and nature of the spread of the population. For illustrative purposes the theory is applied to measurements of refractive status before and after radial keratotomy. The ellipsoids are presented as stereo-pairs. They are useful for comparative and predictive purposes. Thus the ellipsoid that contains 95% of the population after surgery defines the set of refractive errors within which the refractive error of a particular eye can be expected to fall with a probability of 95%.

Disposition in humans of racemic picenadol, an opioid analgesic

Racemic picenadol is being tested clinically as an analgesic. The (+)-enantiomer of picenadol is an opioid agonist and the (-)-enantiomer is a weak agonist/antagonist. The disposition of racemic [14C] picenadol was studied in healthy men after a single dose was administered im (N = 3) and orally (N = 5). After the dose, virtually none of the radioactivity that appeared in blood was associated with the red cells. In plasma, approximately 4% of the radioactivity was attributable to the parent drug, the remainder being picenadol glucuronide (approximately 35%) and other metabolites. The t1/2 for total radioactivity was 6 hr, that for the unchanged drug was 3.5 hr. Picenadol was present in plasma almost exclusively as the (+)-enantiomer. However, after incubation with glucuronidase and sulfatase, plasma contained 2 to 4 times more (-)- than (+)-picenadol, indicating that more conjugated (-)-picenadol than conjugated (+)-picenadol was in the plasma. After im and oral administration of [14C]picenadol, plasma levels of radioactivity were generally 10 and 70 times higher than those in saliva, respectively. More than 90% of the administered radioactivity was excreted in the urine, mostly as picendol glucuronide, and lesser amounts of picenadol sulfate and N-desmethylpicenadol sulfate. Only about 1% of the administered dose of picenadol appeared unchanged in urine. The disposition of racemic picenadol in humans was stereoselective, the (-)-picenadol apparently being metabolized preferentially over the (+)-enantiomer. This finding was of particular interest in view of the dissimilar pharmacologic activities of the enantiomers.(ABSTRACT TRUNCATED AT 250 WORDS)

Multicystic structures appearing in mature cystic teratomas of the ovary: an immunohistochemical and ultrastructural study

Multicystic or sieve-like areas are frequently present in the walls of mature cystic ovarian teratomas. This histological, immunohistochemical and ultrastructural study supports the contention that such cysts arise from oleous material which has been extravasated through the cyst wall and become lodged within fibrous tissue and small blood vessels. Some cysts may also arise from degenerate sebaceous glands.