Internal medicine training in ambulatory gynecology

OBJECTIVE

To assess internists' perceptions of their training in the management of common problems in ambulatory gynecology and to compare these perceptions with their clinical practice experiences.

METHODS

We surveyed 325 internists in the Portland, Oregon, metropolitan area about their residency training and practice experiences in the diagnosis and management of 25 clinical problems in ambulatory gynecology and five nongynecologic problems.

RESULTS

Responses were received from 159 internists (48.5%). Overall, the internists reported relatively little residency training in the management of many common gynecologic disorders. Women internists managed gynecologic problems more than did their male counterparts, independent of the number of women patients in their practices.

CONCLUSIONS

Internal medicine residency programs need to expand training in ambulatory gynecology to better prepare graduates for clinical practice.

Acyclovir treatment of varicella in otherwise healthy adolescents. The Collaborative Acyclovir Varicella Study Group

STUDY OBJECTIVE

To determine whether orally administered acyclovir is of therapeutic benefit for varicella in otherwise healthy adolescents, and to compare the severity of the disease in adolescents with that in younger children.

DESIGN

Multicenter, randomized, placebo-controlled, double-blind trial.

SETTING

Patients' homes and university hospital clinics.

PATIENTS

Sixty-eight adolescents between 13 and 18 years of age with varicella entered the study. Of the 62 adolescents with laboratory-confirmed varicella who were included in the final analysis, 31 received acyclovir and 31 received placebo.

INTERVENTIONS

Placebo or an 800 mg acyclovir tablet was given orally four times daily for 5 days, beginning within 24 hours of onset of rash.

MEASUREMENTS AND MAIN RESULTS

Acyclovir recipients had significant reductions in times to cessation of new lesion formation (p less than 0.001), maximum number of lesions (p = 0.019), and defervescence (p = 0.045). Mean constitutional illness score was significantly reduced on day 4 (0.5 vs 1.5, p = 0.05), as was the mean number of residual hypopigmented lesions present on 28-day follow-up examination (22.7 vs 92.7, p = 0.018). Two complications, both bacterial superinfections, occurred in placebo recipients. Adverse experiences and varicella-zoster virus antibody titers measured 28 days after enrollment were similar in both treatment groups. Comparison of placebo recipients with children 2 to 12 years of age participating in a companion study indicated that varicella is more severe in adolescents: mean maximum total lesions (421 vs 347, p = 0.003), mean maximum constitutional illness score (3.1 vs 2.2, p = 0.032), and mean number of residual lesions (92.7 vs 33.2, p = 0.01) were all greater in the adolescent population.

CONCLUSIONS

Oral acyclovir therapy is safe and effective for treatment of varicella in otherwise healthy adolescents; this may be an appropriate subgroup for treatment with antiviral drugs because the disease is more severe in them than in younger children.

Parental values, reinforcement, and young children's prosocial behavior: a longitudinal study

In this study, the authors assessed the relation of parental reinforcement and parental values to young children's prosocial behaviors. Parents' dyadic interactions with their 1- to 2-year-old children were videotaped in the home on two occasions approximately 6 months apart. The children also were videotaped playing with a peer at 3 1/2 to 4 1/2 years of age. Parental reinforcement of the children's prosocial behaviors was coded, as were the children's prosocial behaviors with the peer. The frequency of girls' spontaneous prosocial behaviors decreased in the early years; modest consistency was observed for boys (but not girls) across the two parental sessions. No relation existed between the frequency of children's prosocial behaviors with their parents and their behaviors with peers. Both maternal and paternal valuing of compliance were negatively related to the mothers' use of reinforcement for children's spontaneous prosocial behaviors. Parental reinforcement of compliant prosocial behaviors was negatively related to children's compliance with a peer's request for prosocial behavior and positively related to defensive behavior with the peer. Fathers' valuing of prosocial behavior was associated with children's compliance with the peer's requests for prosocial action. Parents who valued compliance had children who exhibited low levels of compliant prosocial behaviors with the peer, possibly because of the depressed level of peer interaction.

DSM-III-R as a taxonomy. A cluster analysis of diagnoses and symptoms

While there have been many applications of cluster analysis in psychiatric classification research, there are no studies in which cluster analysis is used to discover the taxonomic structure implicit in the DSM-III itself. In order to do so, the symptom index in the DSM-III-R manual was summarized in a two-way matrix of disorders by symptoms and then analyzed using a hierarchical classes model and companion algorithm (HICLAS) that permits overlap among classes. A novel feature of this model is that superordinate-subordinate relationships among diagnostic and symptom classes are explicitly represented. The HICLAS analysis revealed that there are several discrete symptom classes in DSM-III-R and that many psychiatric disorders can be modeled as combinations of one or more of these classes. The disorders associated with these symptom classes tend to fit the hierarchical classes model relatively well, particularly the mood disorders and the psychotic disorders. However, disorders such as adjustment, personality, and sexual disorder fit the model poorly or not at all. The results are in line with the conjecture that the taxonomic model implicit in DSM-III-R is a hybrid of discrete symptom classes and some other structure, perhaps a dimensional one.

Management of suspected iron deficiency: a cost-effectiveness model

Iron deficiency is frequent among physically active women. Several diagnostic and therapeutic strategies have been advocated. We determined how women's preferences for care varied with their risk of iron deficiency and/or anemia. The women's strength of feelings (utilities) and management costs were used to assess: 1) no evaluation or therapy; treatment based on a 2) complete blood count (CBC) or 3) ferritin level; and 4) empiric iron therapy. The analysis was applied to groups with differing iron deficiency prevalence. Women (N = 22) were adverse to the risk of both anemia and iron deficiency without anemia, and their preferences did not correlate with age, running mileage, years of running, or vitamin supplement use. Because of women's desire to avoid undiagnosed deficiency, the benefits of no evaluation, complete blood count assessment, and, to a less extent, serum ferritin decreased as the prevalence of iron deficiency increased. Ferritin level was more effective per cost than a CBC. However, empiric therapy had the highest effectiveness per cost. These results suggest a strategy that combines both patient concerns and the clinical suspicion of disease in choosing management for physically active women at risk for iron deficiency.

Gaucher disease: heterologous expression of two alleles associated with neuronopathic phenotypes

To investigate the molecular basis for the distinct neuronopathic phenotypes of Gaucher disease, acid beta-glucosidases expressed from mutant DNAs in Gaucher disease type 2 (acute) and type 3 (subacute) patients were characterized in fibroblasts and with the baculovirus expression system in insect cells. Expression of the mutant DNA encoding a proline-for-leucine substitution at amino acid 444 (L444P) resulted in a catalytically defective, unstable acid beta-glucosidase in either fibroblasts from L444P/L444P homozygotes or in insect cells. This mutation was found to be homoallelic in subacute neuronopathic (type 3) Gaucher disease. In comparison, expression of the mutant cDNA encoding an arginine-for-proline substitution at amino acid 415 (P415R) resulted in an inactive and unstable protein in insect cells. This allele was found only in a type 2 patient with the L444P/P415R genotype. The substantial variation in the type 3 phenotype (L444P homozygotes) suggests the complex nature of the molecular basis of phenotypic variation in Gaucher disease. Yet, the association of neuronopathic phenotypes with alleles producing severely compromised (L444P) or functionally null (P415R) enzymes indicates that the effective level of residual activity at the lysosome is likely to be a major determinant of the severity of Gaucher disease.

Hematuria in a young recreational runner

A 27-year-old recreational jogger developed gross hematuria following a 2-mile run. Evaluation revealed a transitional cell carcinoma of the bladder. Etiologies for pigmenturia and the pathogenesis of exertional hematuria are reviewed. The need to exclude other causes of hematuria before attributing the finding to exercise is emphasized.

Collagenase synthesis by cloned rabbit pulp cells--molecular and immunological identity of pulp cell and fibroblast enzyme

Cultures of cloned rabbit pulp (RP) cells without stimulation produced collagenase of a concentration as high as reference rabbit skin fibroblast cultures which were stimulated with phorbol myristate acetate (PMA, 100 ng/ml). The RP cell collagenase was compared with reference fibroblast collagenase in Western blot analysis using monoclonal antibodies prepared against RP cell collagenase and a polyclonal antibody prepared against rabbit fibroblast collagenase. Both enzyme preparations revealed, with either antibody, identical bands of approximate molecular masses 57,000, 52,500, and 45,000. These antibody preparations variously inhibited RP cell collagenase activity. Intracellular collagenase in RP cells in culture was demonstrated by the indirect immunofluorescence antibody technique using polyclonal anti-fibroblast collagenase antibody. RNA samples from RP cells hybridized with rabbit fibroblast collagenase cDNA (clone H9) and showed a distinct band at 2.7 kb. Both control and PMA-stimulated RP cells and PMA-stimulated reference skin fibroblasts demonstrated strong cytoplasmic hybridization between H9 and collagenase mRNA. The results indicate that RP cell collagenase is identical to rabbit fibroblast collagenase, and that the RP cell line provides a useful in vitro reference system for the study of collagenolysis in the rabbit model.

Exercise training reduces intraocular pressure among subjects suspected of having glaucoma

The effect of exercise conditioning on elevated intraocular pressure has not been previously described among sedentary individuals. We prospectively observed intraocular pressure for nine sedentary subjects suspected of having glaucoma before and after 3 months of aerobic exercise training. Mean (+/- SEM) aerobic capacity, as assessed by maximal oxygen uptake, increased 6.3 +/- 1.6 mL.kg-1.min-1 (30%) (P less than .02). Mean intraocular pressure decreased 4.6 +/- 0.4 mmHg (20%) (P less than .001) at the end of the conditioning period. With cessation of exercise and subsequent detraining, intraocular pressure returned to elevated preconditioning levels by 3 weeks. Regular aerobic exercise is associated with a reduction in elevated intraocular pressure and may represent an effective nonpharmacologic intervention for patients suspected of having glaucoma.

A myogenic factor from sea urchin embryos capable of programming muscle differentiation in mammalian cells

Using the basic helix-loop-helix domain of the myogenic factor myogenin as a probe, we identified a clone from a sea urchin cDNA library with considerable sequence similarity to the vertebrate myogenic factors. This cDNA, sea urchin myogenic factor 1 (SUM-1), transactivated a muscle creatine kinase-chloramphenicol acetyltransferase reporter gene in 10T1/2 fibroblasts to a level comparable to that of the vertebrate myogenic factors. In addition, bacterially expressed beta-galactosidase-SUM-1 fusion protein interacted directly with the kappa E-2 site in the muscle creatine kinase enhancer core as assayed by electrophoretic mobility shift assays. Stably transfected SUM-1 activated the muscle differentiation program and converted 10T1/2 cells from fibroblasts to myotubes. In sea urchin embryos, SUM-1 RNA was not detected before gastrulation. It accumulated to its highest levels during the prism stage when myoblasts were first detected by myosin immunostaining and then diminished as myocytes differentiated. SUM-1 protein was localized in secondary mesenchyme cells when they could first be identified as muscle cells by myosin immunostaining. These results implicate SUM-1 as a regulatory factor involved in the early decision of a pluripotent secondary mesenchyme cell to convert to a myogenic fate. SUM-1 is an example of an invertebrate myogenic factor that is capable of functioning in mammalian cells.

Psychophysics of muscle tension in psychiatric inpatients

Twelve psychiatric inpatients and 16 control subjects each took part in a psychophysics experiment in which the method of production was used to study the perception of tension in the frontalis and forearm extensor muscles. Subjects tensed each muscle between 0% and 50% maximum effort, with 25% effort repeated every third trial, and used as a reference stimulus. Patients showed significantly lower correlations between frontalis EMG and percent effort than the control subjects, but no between-groups differences were found for forearm. Correlations were higher for differences between successive trials than for absolute values because of apparent baseline shifts in perception and/or production of muscle tension. The performance among the patients was not correlated with severity of psychiatric symptoms, antipsychotic medication, abnormal movements, or parkinsonian symptoms, although the n was small. Analysis of the regression of EMG on percent effort revealed approximately equal descriptive strength for three functions: a linear relationship, Stevens' power function, and Fechner's law. The implications of these findings for self-regulation therapies are discussed.