Teaching women's health skills: confidence, attitudes and practice patterns of academic generalist physician

OBJECTIVE

This study assesses the readiness of academic general internists to perform and precept a commonly utilized women's health examination, and procedural and management skills.

DESIGN

Full-time faculty from divisions of general internal medicine and departments of family practice in 9 states reported their encounter frequency with, comfort precepting, and the importance they ascribe to several examination, procedural, and management skills relevant to women's health care; and their attitudes toward performing the pelvic exam and obtaining a Pap smear.

MEASUREMENTS AND MAIN RESULTS

A total of 331 general internal medicine physicians (GIMs) and 271 family medicine physicians (FPs) completed questionnaires, with response rates of 57% and 64%, respectively. More than 90% of GIMs and FPs indicated they were confident precepting the breast and Pap/pelvic examinations. A relatively small percentage of GIMs expressed confidence precepting the management of dysfunctional uterine bleeding (22%), initiating Depo-Provera (21%), and initiating oral contraceptives (45%), while a substantially larger percentage indicated that these skills were important to primary care practice (43%, 44%, and 85%, respectively). Although GIMs indicated they were confident precepting the Pap/pelvic exam, they were less likely than FPs to agree with the following statements: "Performing routine Pap smears is a good use of my time" (GIMs 65%, FPs 84%); "It is a waste of health care dollars for primary care physicians to refer patients to gynecologists for routine Pap/pelvic exams" (GIMs 69%, FPs 90%); "I feel very well trained to do a routine bimanual exam" (GIMs 71%, FPs 98%), and "The clinic where I practice is well equipped to do a Pap smear" (GIMs 78%, FPs 94%).

CONCLUSIONS

Although most academic GIMs are confident precepting the breast and pelvic examination, only a minority are confident precepting the management of dysfunctional uterine bleeding, initiating Depo-Provera, and initiating oral contraceptives. These findings suggest that a number of academic GIMs may not be prepared or willing to perform or precept important women's health skills.

A comparison of multiple urine markers for interstitial cystitis

PURPOSE

We measured several urine markers in 24-hour specimens from patients with interstitial cystitis and healthy controls. For each marker we determined whether the urine level was significantly different in interstitial cystitis and control cases, and whether the marker level correlated with the symptom score.

MATERIALS AND METHODS

Study participants included 36 female patients with interstitial cystitis and 36 age matched female volunteers. Multiple urine aliquots were obtained to measure the various markers.

RESULTS

Certain markers were significantly increased in interstitial cystitis, including anti-proliferative factor, epidermal growth factor, insulin-like growth factor (IGF) binding protein-3 and interleukin (IL)-6. Markers significantly decreased in interstitial cystitis were heparin-binding epidermal growth factor-like growth factor, cyclic guanosine monophosphate and methylhistamine. Other markers were not significantly different in the interstitial cystitis and control groups, including total glycosaminoglycans, epitectin, hyaluronic acid, IL-8, IL-1 and nitrates plus nitrites. IGF-1 was undetectable in 24-hour urine samples but spot voided samples from the same interstitial cystitis population had IGF-1 levels similar to previously reported levels. The only significant association of marker with symptom score was a positive correlation of IL-6 with nocturia. For all markers the conclusions were the same whether the marker was normalized to creatinine or to 24 hours.

CONCLUSIONS

This study confirmed several previously reported urine alterations in interstitial cystitis, including increased anti-proliferative factor, epidermal growth factor, IGF binding protein-3 and IL-6, and decreased heparin-binding epidermal growth factor-like growth factor and cyclic guanosine monophosphate. Of all markers studied anti-proliferative factor had the least overlap in the interstitial cystitis and control groups, and so it is the most likely candidate to become a diagnostic test.

Correlation of problem-based learning facilitators' scores with student performance on written exams

Problem-based learning (PBL) is widely used in medical education. In some cases, facilitators assign a grade to reflect a student's performance in small-group sessions. In our PBL track, facilitators were asked to assess student knowledge base independent of their group participatory skills. To determine if facilitators' grades were correlated with student performance in written exams, a retrospective study of data from our PBL track was undertaken. Data from 156 students and 107 facilitators in six years of a PBL track at Penn State College of Medicine was analyzed by the Pearson correlation after pairing facilitator grades with written exam grades for each of the eight blocks of the curriculum. Exam reliability and validity were assessed by Cronbach's alpha and correlation with USMLE I board scores. The mean alpha was 0.549 +/- 0.221. The mean correlation with USMLE scores was 0.558 +/- 0.151. Facilitators' scores for knowledge were positively associated with students' exam grades. The corresponding significant Pearson correlation coefficients were between 0.342-0.622. However, the coefficients of determination showed that the correlation was not significant. Coefficients of determination showed that the knowledge scores explained only 12 to 39% of the variance in exam scores. Overestimation by facilitators was significantly (p < 0.0001) greater for students in the bottom 25% of the class by exam score than for students in the top 25% of the class. On the basis of this study, we concluded that facilitator assessment of student knowledge base is not useful.

High yield synthesis of nitriles by a new enzyme, phenylacetaldoxime dehydratase, from Bacillus sp. strain OxB-1

3-Phenylpropionitrile was synthesized from Z-3-phenylpropionaldoxime (0.75 M) in a quantitative yield (98 g/l) by the use of cells of Escherichia coli JM 109/pOxD-90F, a transformant harboring a gene for a new enzyme, phenylacetaldoxime dehydratase, from Bacillus sp. strain OxB-1. Other arylalkyl- and alkyl-nitriles were also synthesized in high yields from the corresponding aldoximes. Moreover, 3-phenylpropionitrile was successfully synthesized by the recombinant cells in 70 and 100% yields from 0.1 M unpurified E/Z-3-phenylpropionaldoxime, which is spontaneously formed from 3-phenylpropionaldehyde and hydroxylamine in a butyl acetate/water biphasic system and aqueous phase, respectively.

[Studies on the chemical constituents from Tribulus terrestris]

AIM

To investigate the chemical constituents of the fruit of Tribulus terrestris J..

METHODS

Various chromatographic techniques were used to separate the chemical constituents. ESIMS, IR, 1HNMR, 13CNMR and HMBC were used to determine the structures of the isolated constituents.

RESULTS

Two new compounds were isolated from the fruits of Tribulus terrestris J. and were identified as neohecogenin-3-O-beta-D-glucopyranosyl (1-->2)-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (I); neohecogenin-3-O-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (II).

CONCLUSION

Compounds I and II are new steroidal saponins.

Nonbladder related symptoms in patients with interstitial cystitis

PURPOSE

Clinical experience and epidemiological studies suggest that patients with interstitial cystitis have multiple nonbladder related symptoms. However, to our knowledge this finding has not been tested with a validated questionnaire and matched controls. With the University of Wisconsin scale, we compare the scores for patients with interstitial cystitis to those for control subjects. This validated questionnaire includes 7 bladder and 18 reference symptoms not related to the bladder.

MATERIALS AND METHODS

A total of 35 female patients with interstitial cystitis and 35 age matched female controls completed the University of Wisconsin questionnaire.

RESULTS

For the 7 bladder symptoms the difference between interstitial cystitis and control groups was extremely significant (p = 0.0001). Patients with interstitial cystitis had higher scores than controls for 2 reference symptoms, including other pelvic discomfort, backache, dizziness, chest pain, aches in joints, abdominal cramps, nausea, heart pounding and headache (p <0.01). However, they did not have higher scores for blind spots and/or blurred vision, numbness and/or tingling in fingers or toes, swollen ankles, feeling of suffocation, sore throat, cough, flu, nasal congestion and ringing in ears. The majority of patients with interstitial cystitis had a 0 score for all but 2 of the reference symptoms.

CONCLUSIONS

Patients with interstitial cystitis had increased scores for 9 reference symptoms but did not indiscriminately report high scores for generalized complaints. This result suggests that in some cases of interstitial cystitis the pathophysiology may affect other organ systems besides the bladder. Alternatively, some of these symptoms may result from changes in sleep pattern or other factors associated with interstitial cystitis.

Purification, characterization, and gene cloning of purine nucleosidase from Ochrobactrum anthropi

A bacterium, Ochrobactrum anthropi, produced a large amount of a nucleosidase when cultivated with purine nucleosides. The nucleosidase was purified to homogeneity. The enzyme has a molecular weight of about 170,000 and consists of four identical subunits. It specifically catalyzes the irreversible N-riboside hydrolysis of purine nucleosides, the K(m) values being 11.8 to 56.3 microM. The optimal activity temperature and pH were 50 degrees C and pH 4.5 to 6.5, respectively. Pyrimidine nucleosides, purine and pyrimidine nucleotides, NAD, NADP, and nicotinamide mononucleotide are not hydrolyzed by the enzyme. The purine nucleoside hydrolyzing activity of the enzyme was inhibited (mixed inhibition) by pyrimidine nucleosides, with K(i) and K(i)' values of 0.455 to 11.2 microM. Metal ion chelators inhibited activity, and the addition of Zn(2+) or Co(2+) restored activity. A 1.5-kb DNA fragment, which contains the open reading frame encoding the nucleosidase, was cloned, sequenced, and expressed in Escherichia coli. The deduced 363-amino-acid sequence including a 22-residue leader peptide is in agreement with the enzyme molecular mass and the amino acid sequences of NH(2)-terminal and internal peptides, and the enzyme is homologous to known nucleosidases from protozoan parasites. The amino acid residues forming the catalytic site and involved in binding with metal ions are well conserved in these nucleosidases.

Confidence of graduating internal medicine residents to perform ambulatory procedures

OBJECTIVE

To evaluate the training of graduating internal medicine residents to perform 13 common ambulatory procedures, 3 inpatient procedures, and 3 screening examinations.

DESIGN

Self-administered descriptive survey.

SETTING

Internal medicine training programs associated with 9 medical schools in the eastern United States.

PARTICIPANTS

Graduating residents (N = 128); response rate, 60%.

MEASUREMENTS AND MAIN RESULTS

The total number of procedures performed during residency, importance for primary care physicians to perform these procedures, confidence to perform these procedures, and helpfulness of rotations for learning procedures were assessed. The majority of residents performed only 2 of 13 outpatient procedures 10 or more times during residency: simple spirometry and minor wound suturing. For all other procedures, the median number performed was 5 or fewer. The percentage of residents attributing high importance to a procedure was significantly greater than the percentage reporting high confidence for 8 of 13 ambulatory procedures; for all inpatient procedures, residents reported significantly higher confidence than importance. Continuity clinic and block ambulatory rotations were not considered helpful for learning ambulatory procedures.

CONCLUSIONS

Though residents in this sample considered most ambulatory procedures important for primary care physicians, they performed them infrequently, if at all, during residency and did not consider their continuity clinic experience helpful for learning these skills. Training programs need to address this deficiency by modifying the curriculum to ensure that these skills are taught to residents who anticipate a career in primary care medicine.

Confidence of academic general internists and family physicians to teach ambulatory procedures

OBJECTIVE

To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures.

DESIGN

Mailed survey.

SETTING

Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states.

PARTICIPANTS

Convenience sample of full-time teaching faculty.

MEASUREMENTS AND MAIN RESULTS

A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians' confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year.

CONCLUSIONS

Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

NAD(+)-dependent (S)-specific secondary alcohol dehydrogenase involved in stereoinversion of 3-pentyn-2-ol catalyzed by Nocardia fusca AKU 2123

An NAD(+)-dependent alcohol dehydrogenase was purified to homogeneity from Nocardia fusca AKU 2123. The enzyme catalyzed (S)-specific oxidation of 3-pentyn-2-ol (PYOH), i.e., part of the stereoinversion reaction for the production of (R)-PYOH, which is a valuable chiral building block for pharmaceuticals, from the racemate. The enzyme used a broad variety of secondary alcohols including alkyl alcohols, alkenyl alcohols, acetylenic alcohols, and aromatic alcohols as substrates. The oxidation was (S)-isomer specific in every case. The K(m) and Vmax for (S)-PYOH and (S)-2-hexanol oxidation were 1.6 mM and 53 mumol/min/mg, and 0.33 mM and 130 mumol/min/mg, respectively. The enzyme also catalyzed stereoselective reduction of carbonyl compounds. (S)-2-Hexanol and ethyl (R)-4-chloro-3-hydroxybutanoate in high optical purity were produced from 2-hexanone and ethyl 4-chloro-3-oxobutanoate by the purified enzyme, respectively. The K(m) and Vmax for 2-hexanone reduction were 2.5 mM and 260 mumol/min/mg. The enzyme has a relative molecular mass of 150,000 and consists of four identical subunits. The NH2-terminal amino acid sequence of the enzyme shows similarity with those of the carbonyl reductase from Rhodococcus erythropolis and phenylacetaldehyde reductase from Corynebacterium sp.

Production of (R)-3-pentyn-2-ol through stereoinversion of racemic 3-pentyn-2-ol by Nocardia fusca AKU 2123

Wet cells of Nocardia fusca AKU 2123 are good catalysts for the production of (R)-3-pentyn-2-ol (PYOH) from (RS)-PYOH through a stereoinversion reaction. Under optimal conditions (350 mM potassium phosphate buffer, pH 8.0, 30% (w/v) wet cells, 0.12% NADPH, 10% glucose, and 30 U/ml glucose dehydrogenase) (R)-PYOH of high optical purity (98.7% e.e.) was produced from 2% (v/v) (RS)-PYOH with a yield of 70.4% by 140 h incubation.

A novel energy dependent mechanism reducing daunorubicin accumulation in acute myeloid leukemia

Using cyclosporin A (CsA) to inhibit P-glycoprotein (P-gp) function we showed previously that there was a discordance between the ability of acute myeloid leukemic (AML) blast cells to accumulate daunorubicin and P-gp antigen expression (Xie et al, Leukemia 1995; 9:1882-1887). This discordance suggests that a CsA-sensitive drug efflux mechanism distinct from P-gp is expressed in many clinical samples. In the present study using the ATP depleting agents cyanide, azide, or dinitrophenol to inhibit energy dependent transport processes, we observed even larger increases in daunorubicin accumulation than were seen with CsA. Similar patterns were seen in a wide range of P-gp negative human cancer cell lines. Also the observed cyanide effect did not correlate with the expression of mRNA for multidrug resistance-associated protein (MRP), the only other member of the ABC family of membrane transporters that is known to be capable of effluxing daunorubicin. Thse results suggest that daunorubicin accumulation in many cases of AML is modulated by one or more novel energy-dependent processes that are distinct from P-gp or MRP. We speculate that this novel drug transport mechanism(s) may influence the response of AML patients to daunorubicin and other therapeutic agents.

[Prevention of sinomenine on isolated rat myocardial reperfusion injury]

Acute myocardial ischemia and reperfusion injury of rats were produced by ligating the left coronary artery for 15 min and reopening. The myocardial calcium contents were increased from 3.53 +/- 0.58 mumol/g dry wt in sham operation group to 6.02 +/- 1.19 mumol/g dry wt with reducing SOD/MDA ratio and showing ventricular extrasystole (VE), ventricular tachycardia (VT), and ventricular fibrillation (VF). Sinomenine (Sin) and verapamil (Ver) infusion 15 min before ischemia attenuated the elevated calcium contents to the level of the sham operation group, increased SOD/MDA ratio, and produced antagonistic effects on VE, VT, VF. These improvements indicated that Sin, similar to Ver, prevented myocardial injury by lowering intracellular Ca2+ accumulation.

Delayed radiation encephalopathy after radiotherapy for nasopharyngeal cancer: a CT study of 45 cases

The CT features of 45 cases of delayed radiation encephalopathy (including radiation necrosis) following radiotherapy for nasopharyngeal carcinoma are reported. The brain lesions were uni- or bilateral and involved mainly the white matter and subsequently the gray matter of the lower portion of the brain included within the portals of irradiation and its vicinity. The lesions were edematous and hypodense on CT and showed postcontrast enhancement in 50% of the cases. Within the period of follow-up (1-5 years), the lesions showed remissions and exacerbations and in some cases stabilized. In addition, there was progressive cerebral atrophy, manifesting itself mainly as dilatation of the temporal horns, the neighboring cisterns, and sylvian fissures. In some cases that were followed for a long time, the cerebral lesions showed either foci of calcification or encephalomalacia and/or porencephaly.