Morphine concentrations in fatalities after palliative treatment of acute burn injury

The evaluation of a morphine concentration in postmortem blood is routine for a forensic toxicologist. We here report three fatal cases where we found high morphine concentrations with 7.96, 4.30, and 5.82 mg/l in femoral blood that have to be estimated as unusually high. All these individuals died due to severe burn injuries and obtained morphine in the context of their palliative care in the last hours of their lives. According to the autopsy results, the cause of death in case 1 was burn disease with burns of about 90% of the body surface area (BSA), case 2 burn trauma, and case 3 burn shock. Besides morphine, propofol, fentanyl, sufentanil, midazolam, diazepam, lorazepam, cefazolin, and rocuronium were detected in femoral blood. The findings fitted well with the detailed clinical documentation. Further evidence of therapeutic concentrations of quetiapine, duloxetine, and melperone could be matched to preexisting medication of the individuals. Physiologically based pharmacokinetic modelling (PBPK) was applied, developed for the intravenous administration of morphine, to find an explanation for the high morphine concentrations in femoral blood. Quantification of morphine in body fluids and tissue was performed to calculate morphine tissue concentration ratios to the morphine concentration in femoral blood. The presented cases show that pharmacokinetic simulations can reflect decreased renal clearance and decreased hepatic metabolism in general. However, this prediction is not sufficient to explain the high morphine concentrations in femoral blood measured here. It can be assumed that burn shock in particular leads to altered pharmacokinetics, namely decreased distribution of morphine.

Chiral analysis of amphetamine, methamphetamine, MDMA and MDA enantiomers in human hair samples

A novel analytical method was developed for the simultaneous quantification of the R/S-enantiomers of amphetamine, methamphetamine, MDA and MDMA in hair samples using liquid chromatography-tandem mass spectrometry (LC-MS-MS). This method involved a straightforward derivatization step with dansyl chloride and the use of a chiral column, enabling the separation and quantification of all eight enantiomers in a single analysis. The method exhibited excellent linearity across a concentration range of 0.03-3.00 ng/mg for each enantiomer. Precision and accuracy were within acceptable limits, with bias and relative standard deviation (RSD) values consistently below 6% and 9%, respectively. Selectivity and specificity assessments confirmed the absence of any interference from contaminants or co-extracted drugs. The method demonstrated high sensitivity, with limits of detection (LOD) below 8 pg/mg and limits of quantification (LOQ) below 19 pg/mg for all analytes. Extraction recovery exceeded 79%, and matrix effects were minimal for all analytes. Processed sample stability evaluations revealed consistent results with deviations below 11% for all analytes. Application of the method to 32 authentic human hair samples provided valuable insights into amphetamine use patterns, allowing differentiation between medical amphetamine consumption and illicit use based on enantiomeric composition. Additionally, the method detected co-use of methamphetamine, MDA or MDMA in some samples, highlighting its applicability in drug monitoring and real-life case scenarios within a forensic institute. This innovative analytical approach offers a sensitive and selective method for enantiomeric differentiation of amphetamine, methamphetamine, MDA and MDMA in human hair samples, providing a valuable tool for forensic and clinical investigations.

Why aren't there more women leaders in academic medicine? the views of clinical department chairs

PURPOSE

A scarcity of women in leadership positions in academic medicine has persisted despite their increasing numbers in medical training. To understand the barriers confronting women and potential remedies, clinical department chairs with extensive leadership experience were interviewed.

METHOD

In 1998-99, open-ended interviews averaging 80 minutes in length were conducted with 34 chairs and two division chiefs in five specialties. Individuals were selected to achieve a balance for gender, geographic locale, longevity in their positions, and sponsorship and research intensity of their institutions. The interviews were audiotaped and fully transcribed, and the themes reported emerged from inductive analysis of the responses using standard qualitative techniques.

RESULTS

The chairs' responses centered on the constraints of traditional gender roles, manifestations of sexism in the medical environment, and lack of effective mentors. Their strategies for addressing these barriers ranged from individual or one-on-one interventions (e.g., counseling, confronting instances of bias, and arranging for appropriate mentors) to institutional changes (e.g., extending tenure probationary periods, instituting mechanisms for responding to unprofessional behavior, establishing mentoring networks across the university).

CONCLUSION

The chairs universally acknowledged the existence of barriers to the advancement of women and proposed a spectrum of approaches to address them. Individual interventions, while adapting faculty to requirements, also tend to preserve existing institutional arrangements, including those that may have adverse effects on all faculty. Departmental or school-level changes address these shortcomings and have a greater likelihood of achieving enduring impact.

Gender equity in undergraduate medical education: a status report

This status report summarizes recent data on and studies of women's experiences as medical students. Women medical students in the United States now number over 29,000--44% of enrollees. Despite large increases in the numbers of women students, harassment and gender stereotyping continue to detract from their education and opportunities. Moreover, specialty choices have remained remarkably stable, with comparatively few women entering surgery and most subspecialties. Because equal opportunity has not yet been achieved, medical schools need to monitor the experiences of their trainees and to target interventions where problems still exist in order to ensure that progress toward gender equity continues.

Women in academic medicine

Women now constitute 43% of US medical students, 37% of residents, and 27% of full-time medical school faculty. Less than 11% of women faculty are full professors, however, compared to 31% of men, and these proportions haven't changed in more than 15 years. Since the proportion of women reaching the top ranks remains relatively low, the pool of women available for leadership positions in academic medicine is still small. This review article first summarizes recent data on women's representation in academic medicine and then discusses why they are not succeeding at the same pace as men. Reasons include a complex combination of women's choices, sexism, cultural stereotypes, constraints in combining family responsibilities with professional opportunities, and lack of effective mentoring. Multiple approaches are required to overcome these "cumulative disadvantages," among them improving the gender climate at academic medical centers; the mentoring of women faculty, residents, and students; and skill-building opportunities for women.

[Electron microscopy study of HES cryopreserved erythrocytes]

Using electron microscopy (EM), it was examined whether cryopreservation with HES causes shape changes of erythrocytes. Each of 11 erythrocyte suspensions (Hct = 40; HES 200,00/0.5/12.5%; 60 mM NaCl) was separated into 40-ml samples, cooled down to -196 degrees C and finally stored. In addition, 11 samples were stored at -80 degrees C for 3 months. The preparation for EM was done immediately after thawing or in case of native cells shortly after donation. On EM micrographs, there was no visible difference between native and cryopreserved erythrocytes. In every case the preparations showed normocytes, either as single cells or having attracted other ones, forming rouleau. Packed cells were attached tightly to each other without any gap in between. The tangent count method neither revealed an excess of convexity nor of concavity. The erythrocyte membrane looked normal, and the cytoplasmatic space was filled with electron-dense material (hemoglobin) homogeneously; Heinz bodies were not seen. Scanning microscopy portrayed native as well as cryopreserved cells as discocytes with the characteristic bioconcave resting shape of human erythrocytes. It is concluded that cryopreservation of erythrocytes with HES does not cause shape changes. Therefore, a sequestration into the reticulo-endothelial system (RES) by means of identification of morphological abnormalities may not be expected.

Context in medical education: the informal ethics curriculum

As some formal bioethics instruction has become the norm in American medical schools, a trend has emerged toward increased attention to context in both bioethics education and bioethical decision-making. A focus on classical dilemmas and a textbook knowledge of principles is yielding its previous dominance to permit a more detailed examination of ethical behaviour in actual practice in medicine. After documenting and analysing this emerging trend in bioethics education and its parallel in bioethics theory and research, we turn to the context of medical education itself to look beyond formal bioethics instruction to the 'informal curriculum' that is so central to the moral development of medical students and residents. A qualitative research strategy is being used to study the informal curriculum through analysing tape-recorded informal conversations students and residents have with their friends and colleagues at work about issues bearing on their professional development. Data presented are documenting 'the unwritten code' for medical students on a surgical clerkship and the senior residents' informal ways of producing a 'practical ethics of conduct' that shapes understanding of what is good, skilful, and right on that surgical service. How conceptions of appropriate conduct are conveyed, rewarded and sanctioned also reveals how professional demeanour is taught, permitting discussion about what should be retained and what changed. The context in which ethical issues arise enhances understanding of ethical practice in medicine.

Medical school policies for part-time faculty committed to full professional effort

The need for information about medical schools' efforts to allow faculty who wish to remain fully academic but work less than full time has been growing steadily. Building on the AAMC's 1993-94 survey of faculty appointment and tenure policies, in 1994 the authors surveyed 102 U.S. and Canadian medical schools that had answered yes to the question, "Does the medical school provide for faculty who choose to work less than full-time but whose full professional effort is directed towards the institution?" Seventy-one U.S. and Canadian medical schools reported provisions for "full professional effort" (FPE) faculty, and 32 of these had developed specific procedures for such faculty. Other nomenclatures in use for FPE faculty include "limited full-time," "full status/partial load," and "reduced period of responsibility." Almost half of the 71 survey respondents reported that FPE faculty could be appointed to, or remain on, a tenure track; more than half of these schools said that they lengthened the probationary period on a prorated basis. Women, much more frequently than men, had chosen the FPE option, especially women clinical faculty. While FPE faculty face more challenges than full-time faculty in accomplishing the tasks necessary for promotion in academic medicine, well-structured FPE options can benefit not only individual faculty members and their families but also the institution, which retains the commitment of valued faculty members seeking flexibility.

Maternity and parental leave policies at COTH hospitals: an update. Council of Teaching Hospitals

Because residents' demands for parental leave are increasing, updated information about maternity and paternity leave policies was solicited from hospitals that are members of the Council of Teaching Hospitals (COTH) of the AAMC. A 20-item questionnaire, combining forced-choice categories and open-ended questions, was faxed to 405 COTH hospitals in October 1994; 45% responded. A total of 77% of the respondents reported having written policies for maternity and/or parental leave; in 1989, only 52% of COTH hospitals had reported having such policies. Forty-one percent of the 1994 responding hospitals offered dedicated paid maternity leave, with a mean of 42 days allowed. Twenty-five percent of the respondents offered paternity leave, and 15% offered adoption leave. It is encouraging that the majority of the teaching hospitals that responded to the survey had adopted written policies, but the 23% without written policies remain a source of concern. Well-defined policies for maternity, paternity, and adoption leave can reduce stress and foster equity both for trainees requiring leave and for their colleagues.

Gender-associated differences in matriculating and graduating medical students

Data from the 1993 Matriculating Student Questionnaire (MSQ) and the 1994 Medical School Graduation Questionnaire (GQ) of the Association of American Medical Colleges were investigated for differences in responses between men and women. Notable differences were discovered, particularly with regard to career plans and experiences during medical school. Findings from the GQ include that a higher proportion of women rated curricular coverage of numerous subjects inadequate and that women students more frequently reported mistreatment during medical school. Women were also more likely than men to work in clinics serving the indigent and to complete a primary care clerkship. Over 30% of the 1994 women seniors, compared with 18% of the men, planned to pursue generalist careers. The authors discuss the gender-associated differences, with reference to previous studies, and conclude that medical educators should ensure that women have access to the same skill-development opportunities that men do and to a humane learning environment. Moreover, educators should examine what adaptations can encourage students of both genders to develop an ethic of "social responsibility."

Part-time faculty in academic medicine: present status and future challenges

OBJECTIVE

To determine the number, personal and professional characteristics, and attitudes of part-time medicine faculty.

PARTICIPANTS

Part-time faculty in departments of medicine were identified by the chairs of medicine and faculty roster representatives of the Association of American Medical Colleges for each U.S. medical school and by a survey of faculty.

MEASUREMENTS

A 79-item questionnaire including questions about working conditions, attitudes toward professional and personal issues, and institutional policies.

RESULTS

A total of 245 eligible questionnaires were returned (69% of the estimated number of eligible part-time faculty). Sixty-three percent were men and 27% were women. Women faculty worked an average of 35 h/wk, combining their careers with childbearing, whereas men worked 51 h/wk, divided between their faculty position and private practice. Respondents' work time was devoted to teaching and patient care, with no time dedicated for research. Most faculty (86%) were in nontenured track positions; approximately one half (47%) developed the position themselves. Only 8% reported that existing institutional policies allowed part-time faculty more time to reach promotion and tenure standards. A high degree of career satisfaction existed (mean score, 8.6 on a 10-point scale) even though faculty believe that part-time status makes promotion more difficult and negatively influences colleagues' perceptions of them.

CONCLUSION

We estimate that more than 400 faculty work part time in departments of medicine in U.S. medical schools. The majority are men who combine academic careers with private practice. Most part-time faculty work as clinician/teachers in nontenure track positions and are satisfied with their careers.

Parental leave policies for faculty in U.S. medical schools

OBJECTIVE

To assess medical school policies for maternity and other parental leaves as well as related opportunities for part-time employment, flexibility in tenure systems, and the availability of child care centers.

DESIGN

Cross-sectional survey of all 127 U.S. medical schools based on telephone interviews and review of faculty handbooks.

MEASUREMENTS AND MAIN RESULTS

Ninety-three percent of medical schools responded. Twenty-two percent of medical schools have no written guidelines for maternity leave, 45% categorize maternity leave as a form of sick or disability leave, and only 34% have developed specific policies. Most schools (61%) require that maternity leave be taken from allotted sick days or from vacation days (or from both) for women to obtain salary support. The time available from sick and vacation leave averages 6.8 weeks. Although 72% of schools make allowances in the tenure probationary period for extended leaves of absence, few have developed specific provisions for childbearing or childrearing. Finally, 18% of medical schools have child care facilities.

CONCLUSIONS

Considerable work is needed to develop adequate support for faculty members who are parents. Recommendations include developing specific parental leave policies and flexible tenure systems and providing adequate child care facilities.

Ifosfamide/etoposide and mesna uroprotection in advanced breast cancer

The object of the study was to evaluate the effectiveness of ifosfamide/etoposide and mesna therapy in advanced breast cancer. A total of 44 patients with breast cancer were included in the trial. Eligibility criteria included measurable, refractory disease; prior anthracycline therapy (or its contraindication); a life expectancy of at least 3 months; and adequate hepatic, renal, CNS and bone marrow function. All patients were less than or equal to 70 years of age and had a Karnofsky performance status of greater than or equal to 50%. There were 36 evaluable cases. Sites of metastatic disease included bone (19), skin (18), liver (9), lung (14), lymph node (19), and miscellaneous (7). Treatment consisted of 1,500 mg/m2 ifosfamide given i.v. on days 1-5, 120 mg/m2 etoposide given i.v. on days 1-3, and 400 mg i.v. mesna given with and at 4 and 8 h after ifosfamide. Cycles were repeated every 28 days. Initial doses were reduced by 25% or 50% in patients who had previously undergone both chemotherapy and radiotherapy. A median of 4 cycles (range, 2-8) were given. The myelotoxicity was marked: WHO grades 3/4 leukopenia (n = 37), grades 3/4 thrombocytopenia (n = 12), and grades 2/3 anemia (n = 13). Due to myelotoxicity, dose reduction or prolongation of treatment-free intervals was necessary in 28 cases. Alopecia was seen in 35 patients and CNS toxicity, in 8. Partial remission (PR) was obtained in five cases and complete remission (CR), in three. Sites of response included the lung (5), skin (4), lymph node (5), and peritoneum (1). The duration of response was 4 (n = 2) and 8 (n = 1) months for CR and 2 (n = 2), 6 (n = 2), and 10 (n = 1) months for PR. We conclude that the ifosfamide/etoposide and mesna regimen is effective, but its myelotoxicity is treatment-limiting.

Maternity leave policies for residents: an overview of issues and problems

This article examines evidence of the need for maternity leave policies in residency programs and reviews studies of such policies. The author concludes that communication to residents of an established maternity leave policy facilitates equitable treatment of residents and minimizes disruptions for their colleagues and patients. The development of maternity leave policies is discussed in the context of existing and proposed federal legislation and the current pressures on program director and hospital administrators to improve other aspects residency training. Strategies for building flexibility in residency programs are presented.

Women in medical education. A status report

Women now make up 37 percent of medical school applicants, 34 percent of medical students, 28 percent of residents, and 19 percent of full-time medical school faculty members. These proportions have grown from 26, 25, 19, and 15 percent, respectively, 10 years ago. A comparison of the academic performance of male and female medical students reveals few differences, particularly on standardized measures. However, women trainees experience more stress than men. Traditional differences in the choice of specialty by men and women are not diminishing. Women's accession to senior faculty positions has not kept pace with their increasing representation on the faculty--a cause of continuing concern. The percentage of female faculty members who are professors has changed from 8 to 9 percent in 10 years (as compared with 32 percent of male faculty members in 1988). I conclude that the numbers of women are increasing rapidly at the lower levels of medical education, but not at the upper levels.

AI/LEARN: an interactive videodisk system for teaching medical concepts and reasoning

This paper describes AI/LEARN, an educational videodisk system designed to teach clinical observational skills and reasoning in medicine. The AI/LEARN system uses a learning conditions approach to teaching. To teach visual concepts, we use the principle of exemplar/nonexemplar pairs and immediate feedback. To teach If-Then problem solving we use the format of minicases with delayed feedback. The software to operate the system has been custom developed and is domain independent. The result is a prototype of a new authoring package for videodisk teaching which operates on IBM compatible microcomputers. The medical domain selected for this prototype system was rheumatic diseases; the knowledge used to teach reasoning skills is derived from the knowledge base of an expert system: AI/RHEUM.

Pathologic features of muscle in systemic lupus erythematosus: a biopsy series with comparative clinical and immunopathologic observations

Clinical evidence of skeletal muscle involvement is frequent in systemic lupus erythematosus (SLE). In order to characterize the manifestations of SLE in skeletal muscle, a biopsy series on 19 patients with SLE was studied in terms of the histologic, histochemical, and direct immunofluorescent features of skeletal muscle. The results were correlated with clinical and laboratory data. The histologic spectrum included inflammatory myopathy, vasculitis, perifascicular atrophy, and neurogenic atrophy. Histochemical examination revealed type I fiber predominance in 44 per cent of patients and selective type II fiber atrophy in 33 per cent. Direct immunofluorescent examination of skeletal muscle biopsy specimens revealed immunoglobulin and complement deposition in vessel walls, in sarcolemmal basement-membrane areas, and within non-necrotic muscle fibers. The histologic, histochemical, and immunochemical findings are correlated with the findings in other organ systems.

Research opportunities for medical students: an approach to the physician-investigator shortage

The recently documented decline in numbers of physician-scientists has broad implications not only for the quality of the clinical research which will be conducted in the next decade but also for the quality of the clinical education that future medical students will receive. The authors' recommendations about what can be accomplished at the medical school level to help reverse this decline are based upon a survey of research opportunities presently offered by schools and on an examination of research components in medical school curricula with special emphasis on the federally supported Medical Scientist Training Program. Three ways in which medical students may become involved in research are described, and each is examined for the purpose of increasing its effective utilization. A heightened understanding of the supply problem and greater interaction among deans, faculty, and students is indicated.