The large-scale capture of eastern grey kangaroos (Macropus giganteus) and red kangaroos (Osphranter rufus) and its application to a population management project

OBJECTIVE

A large-scale capture method was developed to enable sterilisation of a macropod population in western Sydney from 2005 to 2018.

METHODS

Until March 2007, free ranging eastern grey kangaroos and red kangaroos were herded into purpose-built 15 m diameter capture yards (CYs) for darting with a projectile syringe. From March 2007 onwards, animals were free-range darted in large areas without herding. Kangaroos were darted with 1.33-5.10 mg/kg tiletamine/zolazepam and 0.01-0.02 mg/kg medetomidine, ± 0.03 mg/kg acepromazine. Deaths were monitored. Population counts were performed annually.

RESULTS

There were 5825 capture events involving 3963 kangaroos. Over 85% of all captures occurred from 2005 to 2008. Of all reported deaths (n = 523), 135 were attributed to ill health. Musculoskeletal injuries incurred during capture were the main project-related cause of death (n = 116). Post capture myopathy was uncommonly diagnosed following capture (n = 19).

CONCLUSION

The herding and capture method enabled a large number of kangaroos to be mobilised and captured with low mortality rates, and the use of CYs resulted in fewer capture-related injuries and deaths than free-range capture. The drug doses and combinations used for darting were safe and effective, and the capture technique was successfully applied to a population management project.

Laparoscopic ovariectomy in eastern grey kangaroos (Macropus giganteus) and red kangaroos (Macropus rufus)

OBJECTIVE

To develop a technique for permanent sterilisation of female eastern grey kangaroos (Macropus giganteus) and red kangaroos (M. rufus) as part of a large-scale macropod management program on an enclosed 1545-ha site in western Sydney.

METHODS

Free-ranging female kangaroos (n = 1409: 1285 eastern grey kangaroos, 124 red kangaroos) were anaesthetised via remote anaesthetic drug delivery of tiletamine/zolazepam, medetomidine and acepromazine prior to inhalational anaesthesia using isoflurane-oxygen. A laparoscopic ovariectomy technique was developed using standard laparoscopic equipment to effect permanent sterilisation of the kangaroos. The technique described was also adapted for use on immature animals weighing as little as 1 kg. No direct post-surgical care was provided once the animals had recovered from the anaesthetic.

RESULTS

The procedure was simple to perform and had a very high success rate, with an overall project mortality rate of 2.13% (n = 30). Seven kangaroos (0.05% of all operated kangaroos) were euthanased as a direct result of the surgical procedure. Surgical complications were rare but included inadvertent gastrointestinal tract puncture with the trocar, intraoperative haemorrhage and subcutaneous emphysema leading to pouch eversion following surgery.

CONCLUSION

The procedure described is a rapid and effective method of permanent fertility control in macropods and carries a low mortality rate.

HIV Tat protein affects circadian rhythmicity by interfering with the circadian system

OBJECTIVES

Sleep disorders are common in patients with HIV/AIDS, and can lead to poor quality of life. Although many studies have investigated the aetiology of these disorders, it is still unclear whether impaired sleep quality is associated with HIV itself, social problems, or side effects of antiretroviral therapy (ART). Moreover, despite its known neurological associations, little is known about the role of the trans-activator of transcription (Tat) protein in sleep disorders in patients with HIV/AIDS. The purpose of this study was to test the hypothesis that the sleep quality of patients with HIV/AIDS affected by an altered circadian rhythm correlates with cerebrospinal HIV Tat protein concentration.

METHODS

Ninety-six patients with HIV/AIDS between 20 and 69 years old completed the Pittsburgh Sleep Quality Index. Their circadian rhythm parameters of blood pressure, Tat concentration in cerebrospinal fluid, melatonin concentration, CD4 cell count and HIV RNA viral load in serum were measured.

RESULTS

The circadian amplitude of systolic blood pressure and the score for sleep quality (Pittsburgh Sleep Quality Index) were negatively correlated with HIV Tat protein concentration, while the melatonin value was positively correlated with Tat protein concentration.

CONCLUSIONS

The HIV Tat protein affects circadian rhythmicity by interfering with the circadian system in patients with HIV/AIDS and further increases the melatonin excretion value. A Tat protein-related high melatonin value may counteract HIV-related poor sleep quality during the progression of HIV infection. This study provides the first clinical evidence offering an explanation for why sleep quality did not show an association with progression of HIV infection in previous studies.

Who filled first-year family medicine residency positions from 1991 to 2004?

Graduates of U.S. allopathic schools have filled less than one half of the family medicine positions offered in the National Resident Matching Program (NRMP) Match since 2001. Overall fill rates in July have been relatively stable at approximately 94 percent. Family medicine has become reliant on international medical graduates (IMGs), who in 2004 made up 38 percent of first-year residents.

Rhetoric, reality and revolution in family practice and primary care

It is distressing to an observer from south of Canada to read the paper from the Ontario College of Family Physicians (Rosser and Kasperski). It indicates disruption and confusion within an admirable healthcare system - a system with a reputation of getting things right when it comes to family practice and primary care. Apparently, all is not well.

Chiropractors are not a usual source of primary health care

Chiropractors are the largest source of office-based care in the United States that does not involve a physician, but people do not view chiropractors as primary providers of health care or advice. Unlike the care given by primary care providers, the majority of care provided by chiropractors is limited to musculoskeletal problems.

Learning from malpractice claims about negligent, adverse events in primary care in the United States

BACKGROUND

The epidemiology, risks, and outcomes of errors in primary care are poorly understood. Malpractice claims brought for negligent adverse events offer a useful insight into errors in primary care.

METHODS

Physician Insurers Association of America malpractice claims data (1985-2000) were analyzed for proportions of negligent claims by primary care specialty, setting, severity, health condition, and attributed cause. We also calculated risks of a claim for condition-specific negligent events relative to the prevalence of those conditions in primary care.

RESULTS

Of 49345 primary care claims, 26126 (53%) were peer reviewed and 5921 (23%) were assessed as negligent; 68% of claims were for negligent events in outpatient settings. No single condition accounted for more than 5% of all negligent claims, but the underlying causes were more clustered with "diagnosis error" making up one third of claims. The ratios of condition-specific negligent event claims relative to the frequency of those conditions in primary care revealed a significantly disproportionate risk for a number of conditions (for example, appendicitis was 25 times more likely to generate a claim for negligence than breast cancer).

CONCLUSIONS

Claims data identify conditions and processes where primary health care in the United States is prone to go awry. The burden of severe outcomes and death from malpractice claims made against primary care physicians was greater in primary care outpatient settings than in hospitals. Although these data enhance information about error related negligent events in primary care, particularly when combined with other primary care data, there are many operating limitations.

What people want from their family physician

The public wants and is satisfied by care provided within a patient-physician relationship based on understanding, honesty, and trust. If the U.S. health care system is ever to become patient-centered, it must be designed to support these values and sustain, rather than fracture, the relationships people have with their primary physician.

Few people in the United States can identify primary care physicians

Almost one decade after the Institute of Medicine (IOM) defined primary care, only one third of the American public is able to identify any of the medical specialties that provide it, and only 17 percent were able to accurately distinguish primary care physicians from medical or surgical specialists and non-physicians. This lack of discrimination compromises the goal of achieving primary care for all and merits immediate attention.

Indirect monitoring of endogenous gene expression by positron emission tomography (PET) imaging of reporter gene expression in transgenic mice

PURPOSE

Repetitive imaging with microPET of endogenous albumin gene expression by using transgenic mice in which the Herpes Simplex Virus Type 1 thymidine kinase (HSV1-tk) reporter gene is driven by the albumin promoter (AL-HSV1-tk).

METHODS

Transgenic mice were imaged repeatedly on a microPET scanner with approximately 200 microCi of 9-[4-[18F]fluoro-3-(hydroxymethyl)butyl]guanine (FHBG) (a substrate for HSV1-TK enzyme). Four transgenic mice were monitored for body weight, serum albumin, and imaged at the end of each of three dietary phases (17%, 0%, and 25% protein diet). Each phase last 14-21 days. The 0% protein diet has been reported previously to reduce albumin gene expression in rats. Twenty non-transgenic mice of the same strain followed a similar feeding schedule and were monitored for serum albumin, body weight, and sacrificed at various time points for determination of their GAPDH normalized albumin mRNA levels.

RESULTS

Transgenic mice showed a relatively high FHBG signal from the liver region as expected. Variation of the mean FHBG signal in two mice with a fixed 17% protein diet over a four-month period was <19% s.d. The mean +/- s.e. FHBG liver standardized uptake value (SUV) in four transgenics went from 4.49 +/- 0.32 to 2.17 +/- 0.52 to 6.21 +/- 0.72 as the mice went through the three diets of 17%, 0%, and 25% sequentially. Non-transgenic mice showed GAPDH normalized albumin mRNA that went from 37.68 +/- 6.04 to 26.41 +/- 4.29 to 52.42 +/- 4.09. The FHBG SUV from transgenics was well correlated with GAPDH normalized albumin mRNA from non-transgenics (r(2) = 0.97) supporting that endogenous gene expression of albumin can be indirectly imaged with FHBG.

CONCLUSION

Measuring correlated changes in albumin expression in wild type mice and HSV1-TK expression by microPET in transgenic mice in which the reporter gene is driven by the albumin promoter demonstrates that the HSV1-tk gene can be used to monitor, in living animals, modulated expression of transgenes.

The U.S. primary care physician workforce: undervalued service

Primary care physicians work hard, but their compensation is not correlated to their work effort when compared with physicians in other specialties. This disparity contributes to student disinterest in primary care specialties.

The U.S. primary care physician workforce: persistently declining interest in primary care medical specialties

A persistent, six-year trend in the choice of specialty training by U.S. medical students threatens the adequacy of the physician workforce of the United States. This pattern should be reversed and requires the attention of policy makers and medical educators.

The U.S. primary care physician workforce: minimal growth 1980-1999

Growth in the primary care physician workforce (physicians per capita) in the United States has trailed the growth of the specialist physician population in recent years. This has occurred despite calls during the same period for increased production of primary care physicians and educational reforms focusing on primary care.

Family physicians are an important source of newborn care: the case of the state of Maine

Family physicians (FPs) provided 30 percent of inpatient newborn care in Maine in the year 2000. FPs cared for a large proportion of newborns, especially those insured by Medicaid and in smaller, rural hospitals where FPs also delivered babies. Family medicine's commitment to serve vulnerable populations of newborns requires continued federal, state, and institutional support for training and development of future FPs.

Family physicians make a substantial contribution to maternity care: the case of the state of Maine

Family physicians provided nearly 20 percent of labor and delivery care in Maine in the year 2000. A substantial proportion of this care was provided to women insured by Medicaid and those delivering in smaller, rural hospitals and residency-affiliated hospitals. As family medicine explores its future scope, research identifying regional variations in the maternity care workforce may clarify the need for maternity care training in residency and labor and delivery services in practice.

Family physicians are an important source of mental health care

While comprising about 15 percent of the physician workforce, family physicians provided approximately 20 percent of physician office-based mental health visits in the United States between 1980 and 1999. This proportion has remained stable over the past two decades despite a decline in many other types of office visits to family physicians. Family physicians remain an important source of mental health care for Americans.

Family physicians' solutions to common medical errors

In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from "do not make errors" (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

Consequences of medical errors observed by family physicians

In two studies about medical errors, family physicians reported health, time, and financial consequences in nearly 85 percent of their error reports. Health consequences occurred when the error caused pain, extended or created illness, or placed patients, their families, and others at greater risk of harm. Care consequences included delayed diagnosis and treatment (sometimes of serious health conditions such as cancer), and disruptions to care that sometimes even resulted in patients needing care in a hospital. Other important consequences were financial and time costs to patients, health care providers, and the health system generally. However, sometimes no consequence was apparent.

Types of medical errors commonly reported by family physicians

In a group of studies about medical errors in family medicine, the five error types most often observed and reported by U.S. family physicians were: (1) errors in prescribing medications; (2) errors in getting the right laboratory test done for the right patient at the right time; (3) filing system errors; (4) errors in dispensing medications; and (5) errors in responding to abnormal laboratory test results. "Errors in prescribing medications" was the only one of these five error types that was also commonly reported by family physicians in other countries.

Family physicians increase provision of well-infant care despite decline in prenatal services

Over the past 20 years, family physicians and general practitioners (FP/GPs) and pediatricians have upheld their commitment to preventive care for infants. Non-Metropolitan Statistical Areas (non-MSAs) depend on family physicians for almost one half of their well-infant care. FP/GPs have increased their overall provision of well-infant care despite a decline in delivery of prenatal services. This commitment to child health care demands continued excellence of family physician training in pediatric medicine, preventive care, and child advocacy.

A preliminary taxonomy of medical errors in family practice

OBJECTIVE

To develop a preliminary taxonomy of primary care medical errors.

DESIGN

Qualitative analysis to identify categories of error reported during a randomized controlled trial of computer and paper reporting methods.

SETTING

The National Network for Family Practice and Primary Care Research.

PARTICIPANTS

Family physicians.

MAIN OUTCOME MEASURES

Medical error category, context, and consequence.

RESULTS

Forty two physicians made 344 reports: 284 (82.6%) arose from healthcare systems dysfunction; 46 (13.4%) were errors due to gaps in knowledge or skills; and 14 (4.1%) were reports of adverse events, not errors. The main subcategories were: administrative failure (102; 30.9% of errors), investigation failures (82; 24.8%), treatment delivery lapses (76; 23.0%), miscommunication (19; 5.8%), payment systems problems (4; 1.2%), error in the execution of a clinical task (19; 5.8%), wrong treatment decision (14; 4.2%), and wrong diagnosis (13; 3.9%). Most reports were of errors that were recognized and occurred in reporters' practices. Affected patients ranged in age from 8 months to 100 years, were of both sexes, and represented all major US ethnic groups. Almost half the reports were of events which had adverse consequences. Ten errors resulted in patients being admitted to hospital and one patient died.

CONCLUSIONS

This medical error taxonomy, developed from self-reports of errors observed by family physicians during their routine clinical practice, emphasizes problems in healthcare processes and acknowledges medical errors arising from shortfalls in clinical knowledge and skills. Patient safety strategies with most effect in primary care settings need to be broader than the current focus on medication errors.

Title VII funding is associated with more family physicians and more physicians serving the underserved

Title VII funding of departments of family medicine at U.S. medical schools is significantly associated with expansion of the primary care physician workforce and increased accessibility to physicians for the residents of rural and underserved areas. Title VII has been successful in achieving its stated goals and has had an important role in addressing U.S. physician workforce policy issues.

What physicians need to know about seniors and limited prescription benefits, and why

More and more often, seniors are faced with outpatient prescription benefits that have annual spending limits, and they may be forced to cut back on use of medications when they run out of benefits before the end of the year. Family physicians can play a valuable role by helping seniors choose the best value medications for their budgets and by checking whether or not seniors can afford their prescriptions.

A cross-national study of acute otitis media: risk factors, severity, and treatment at initial visit. Report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN)

BACKGROUND

Treatment of acute otitis media (AOM) differs worldwide. The Dutch avoid antimicrobials unless fever and pain persist; the British use them for 5 to 7 days, and Americans use them for 10 days. If effects of therapies are to be compared, it is necessary to evaluate rates of risk factors, severity of attacks, and their influence on treatment decisions. We wanted to compare the prevalence of risk factors for AOM and evaluate their association with severity of attacks and of severity with antimicrobial treatment.

METHODS

We undertook a prospective cohort study of 2,165 patients with AOM enrolled by primary care physicians; 895 were enrolled from North America, 571 were enrolled from the United Kingdom, and 699 were enrolled from The Netherlands. The literature was searched using the key words "acute otitis media," "severity," and "international comparisons."

RESULTS

The prevalence of several AOM risk factors differs significantly among patients from the three country networks; these factors include race, parent smoking habits, previous episodes, previous episodes without a physician visit, tonsillectomy or adenoidectomy, frequency of upper respiratory tract infections, day care, and recumbent bottle-feeding. Dutch children have the most severe attacks as defined by fever, ear discharge, decreased hearing during the previous week, and moderate or severe ear pain. In country-adjusted univariate analyses, increasing age, exposure to tobacco smoke, day care, previous attacks of AOM, previous attacks without physician care, past prophylactic antimicrobials, ear tubes, adenoidectomy, and tonsillectomy all contribute to severity. Only country network, age, history of AOM, previous episode without physician care, and history of adenoidectomy and tympanostomy tubes are independently related to increased severity, while current breast-feeding is protective. Severity of attacks influences treatment decisions. Dutch children are least likely to receive antimicrobials, and even for severe attacks the British and Dutch physicians usually use amoxicillin or trimethoprim-sulfa; North American children with severe attacks are more likely to receive a broad-spectrum second-line antimicrobial.

CONCLUSION

Dutch children have the highest ratings in all severity measures, possibly reflecting parental decisions about care seeking for earaches. When comparing groups of patients with AOM, it is necessary to adjust for baseline characteristics. Severity of episode affects physician treatment decisions. Adoption of Dutch guidelines restricting use of antimicrobials for AOM in the United States could result in annual savings of about $185 million.

Uncoordinated growth of the primary care work force

Family physicians, nurse practitioners and physician assistants are distinctly different in their clinical training, yet they function interdependently. Together, they represent a significant portion of the primary care work force. Training capacity for these professions has increased rapidly over the physician assistant decade, but almost no collaborative work force planning has occurred.

Role conflicts of physicians and their family members: rules but no rulebook

OBJECTIVES

To elucidate the difficulties physicians have when a family member becomes ill and to elicit their underlying causes.

DESIGN

Using a key informant technique, we solicited chairs of family medicine departments for their experiences with the health care provided to seriously ill family members. We then conducted in-depth, semistructured telephone interviews that were then transcribed, coded, and labeled for themes.

SUBJECTS

8 senior family physicians whose parents had experienced a serious illness within the past 5 years. All of the subjects reflected on experiences stemming from their fathers' illness.

RESULTS

These physicians faced competing expectations: at an internal level, those of their ideal role in their family and their ideal professional identity; and at an external level, those originating from other family members and from other physicians. Reconciling these conflicting expectations was made more difficult by what they deemed to be suboptimal circumstances of the modern health care system.

CONCLUSIONS

Conflicting rules of appropriate conduct, compounded by the inadequacies of modern health care, make the role of physician-family member especially challenging. The medical profession needs a clearer, more trenchant understanding of this role.

Family physicians' personal experiences of their fathers' health care

OBJECTIVES

The American health care system is complicated and can be difficult to navigate. The physician who observes the care of a family member has a uniquely informed perspective on this system. We hoped to gain insight into some of the shortcomings of the health care system from the personal experiences of physician family members.

STUDY DESIGN

Using a key informant technique, we invited by E-mail any of the chairpersons of US academic departments of family medicine to describe their recent personal experiences with the health care system when their parent was seriously ill. In-depth semi-structured telephone interviews were conducted with each of the study participants. The interviews were transcribed, coded, and labeled for themes.

POPULATION

Eight family physicians responded to the E-mail, and each was interviewed. These physicians had been in practice for an average of 19 years, were nationally distributed, and included both men and women. Each discussed their father's experience.

RESULTS

All participants spoke of the importance of an advocate for their fathers who would coordinate medical care. These physicians witnessed various obstacles in their fathers's care, such as poor communication and fragmented care. As a result, many of them felt compelled to intervene in their fathers' care. The physicians expressed concern about the care their fathers received, believing that the system does not operate the way it should.

CONCLUSIONS

Even patients with a knowledgeable physician family member face challenges in receiving optimal medical care. Patients might receive better care if health care systems reinforced the role of an accountable attending physician, encouraged continuity of care, and emphasized the value of knowing the patient as a person.

Hispanic versus white, non-Hispanic physician medical practices in Colorado

The purpose of the study was to extend the scope of earlier research on minority physicians attending to the needs of the poor and their own ethnicity by contrasting practice characteristics of Hispanic doctors in Colorado with those of their white, non-Hispanic counterparts. It was found that Hispanic physicians spent more hours per week in direct patient care, were more likely to have a primary care specialty, and were less often specialty board certified than white, non-Hispanic doctors. Hispanic generalists established practices in areas in which the percentages of the population that were (1) below poverty level, (2) Hispanic, (3) Hispanic and below poverty level, and (4) white, non-Hispanic, and below poverty level were greater than in areas in which white, non-Hispanic primary care physicians practiced. These findings argue for special provision to admit ethnic minorities to undergraduate and graduate medical education programs.

NHBPEP report on high blood pressure in pregnancy: a summary for family physicians

The National High Blood Pressure Education Program's Working Group on High Blood Pressure in Pregnancy recently issued a report implicating hypertension as a complication in 6 to 8 percent of pregnancies. Hypertension in pregnancy is related to one of four conditions: (1) chronic hypertension that predates pregnancy; (2) preeclampsia-eclampsia, a serious, systemic syndrome of elevated blood pressure, proteinuria and other findings; (3) chronic hypertension with superimposed preeclampsia; and (4) gestational hypertension, or nonproteinuric hypertension of pregnancy. Edema is no longer a criterion for preeclampsia, and the definition of blood pressure elevation is 140/90 mm Hg or higher. Patients with gestational hypertension have previously unrecognized chronic hypertension, emerging preeclampsia or transient hypertension of pregnancy, an obstetrically benign condition. Because distinguishing among these conditions can be done only in retrospect, clinical management of gestational hypertension consists of repeated evaluations to look for signs of emerging preeclampsia. Women with chronic hypertension should be followed for evidence of fetal growth restriction or superimposed preeclampsia. Management options for chronic hypertension in most women include discontinuing antihypertensive medications during pregnancy, switching to methyldopa or continuing previous antihypertensive therapy.

Direct graduate medical education payments to teaching hospitals by Medicare: unexplained variation and public policy contradictions

PURPOSE

To comprehensively examine both inter- and intrastate variations in Medicare's cost-rate structure for teaching hospitals and to assess the Medicare payment system for graduate medical education (GME), as presently configured, as an instrument to promote physician workforce reform, specifically sufficient public access to primary care physician services.

METHOD

Using Public Use Files of hospital cost reports from the Health Care Financing Administration for fiscal year 1997, 648 hospitals that met inclusion criteria for moderate GME volume were identified. The average and range of direct costs of resident training were computed for these teaching hospitals to illustrate differences within and between the 45 states that had at least two teaching hospitals that qualified for comparison. The cost rate upon which direct medical education (DME) payments are based was then correlated with the percentage of a state's counties that were wholly designated primary care health personnel shortage areas (PCHPSAs) in 1997 and with its primary care physician-to-population ratio, as determined from the Area Resource FILE:

RESULTS

Variations in inter- and intrastate DME costs exist. In some states, the range in DME rates substantially exceeded the mean cost. DME funding policies are more generous toward teaching hospitals in states with greater primary care physician-to-population ratios and smaller proportions of counties wholly designated PCHPSAS:

CONCLUSION

Inherent inequities in DME funding seriously undermine the current Medicare GME payment system's capacity to contribute to U.S. physician workforce reform and to improve access to care. There is actually a financial incentive to train residents in areas in which there is relatively less need for their services.

Tympanometry interpretation by primary care physicians. A report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN)

BACKGROUND

The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts.

METHODS

Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis.

RESULTS

The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis.

CONCLUSIONS

Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.

Strategies for changing clinicians' practice patterns. A new perspective

How can we persuade clinicians to adopt proven practices? Education, incentives, feedback, social marketing, and various other change strategies have inconsistent and unpredictable effects. We propose a theoretical framework that can provide a reliable basis for selecting effective change strategies. We divide clinicians into 4 categories on the basis of their responses to new information about the effectiveness of clinical strategies. We similarly divide the universe of practice change strategies into knowledge-oriented and behavior-oriented methods. We then show why specific combinations of these strategies are likely to be consistently effective for each of the 4 categories of clinicians.

Seeing is believing: non-invasive, quantitative and repetitive imaging of reporter gene expression in living animals, using positron emission tomography

The ability to monitor reporter gene expression in living animals and in patients will permit longitudinal examinations both of somatically transferred DNA in experimental animals and patients and of transgenic constructs expressed in experimental animals. If investigators can non-invasively monitor the organ and tissue specificity, the magnitude and the duration of gene expression from somatically transferred DNA and from transgenes, conceptually new experimental paradigms will be possible. If clinicians can non-invasively monitor the location, extent and duration of somatically transferred genes, they will be better able to determine the correlations between expression of therapeutic genes and clinical outcomes. We have developed two reporter gene systems for in vivo reporter gene imaging in which the protein products of the reporter genes sequester positron-emitting reporter probes. The "PET reporter gene" dependent sequestration of the "PET reporter probes" is subsequently measured in living animals by Positron Emission Tomography (PET). We describe here the principles of PET reporter gene/PET reporter probe in vivo imaging, the development of two imaging systems, and the validation of their ability to non-invasively, quantitatively and repetitively image reporter gene expression in murine viral gene transfer and transgenic models.

The development and goals of the AAFP center for policy studies in family practice and primary care. American Academy of Family Physicians

In this article we describe the creation and role of the Center for Policy Studies in Family Practice and Primary Care established by the American Academy of Family Physicians in Washington, DC, this year. We recount the events leading to the decision to implement the Center, list its guiding assumptions, and explain its initial structure and function. We also identify the 3 themes that will guide the early work of the Center: sustaining the functional domain of family practice and primary care; investing in key infrastructures; and securing universal health coverage.