Dimensional versus conceptual incommensurability in the social and behavioral sciences

This commentary analyzes the extent to which the incommensurability problem can be resolved through the proposed alternative method of integrative experiment design. We suggest that, although one aspect of incommensurability is successfully addressed (dimensional incommensurability), the proposed design space method does not yet alleviate another major source of discontinuity, which we call conceptual incommensurability.

A funding mosaic for loss and damage

In the context of climate policy, "loss and damage" refers to unavoided climate change impacts, including those from extreme weather events and slow-onset events such as sea-level rise, increasing temperatures, and loss of biodiversity. Some argue that focusing on loss and damage distracts industrialized countries from attempts to avoid losses and damages in the first place through decarbonization and adaptation. Others argue that insufficient mitigation by industrialized countries has unleashed an unfair burden on developing countries, so developed countries alone must address loss and damage financially. The impasse was broken at the 27th Conference of the Parties (COP27)-the international climate negotiations-in November 2022, through a decision on new funding arrangements for loss and damage, including a new fund. Reflecting on the funding needs, Maldives' Environment Minister Aminath Shauna argued at COP27 that the world requires a "mosaic of solutions." As a transitional committee begins to assemble recommendations to operationalize this mosaic of funding arrangements, several critical questions require insights from the scientific community.

A comparative study of the acceptance and understanding of evolution between China and the US

Prior work has found that Americans' views on evolution are significantly and positively related to their understanding of this theory. However, whether this relationship is cross-culturally robust is unknown. This article extends earlier work by measuring and comparing the acceptance and understanding of evolution among highly educated individuals in China and the United States. We find a significantly higher evolution acceptance level in the Chinese sample than in the US sample, but no significant difference in their average levels of evolution knowledge. Our analysis also shows that accepting evolutionary theory is related to understanding in both the US and the Chinese samples. These results provide evidence for the robustness of the relationship between understanding and acceptance of evolution across different cultural contexts. To our knowledge, this is the first attempt to comprehensively test understanding of evolutionary theory within a Chinese sample and to compare these results with the US sample.

Knowledge about the nature of science increases public acceptance of science regardless of identity factors

While people's views about science are related to identity factors (e.g. political orientation) and to knowledge of scientific theories, knowledge about how science works in general also plays an important role. To test this claim, we administered two detailed assessments about the practices of science to a demographically representative sample of the US public (N = 1500), along with questions about the acceptance of evolution, climate change, and vaccines. Participants' political and religious views predicted their acceptance of scientific claims, as in prior work. But a greater knowledge of the nature of science and a more mature view of how to mitigate scientific disagreements each related positively to acceptance. Importantly, the positive effect of scientific thinking on acceptance held regardless of participants' political ideology or religiosity. Increased attention to developing people's knowledge of how science works could thus help to combat resistance to scientific claims across the political and religious spectrum.

A Case of Sustained Internal Contradiction: Unresolved Ambivalence between Evolution and Creationism

Many people feel the pull of both creationism and evolution as explanations for the origin of species, despite the direct contradiction. Some respond by endorsing theistic evolution, integrating the scientific and religious explanations by positing that God initiated or guided the process of evolution. Others, however, simultaneously endorse both evolution and creationism despite the contradiction. Here, we illustrate this puzzling phenomenon with interviews with a diverse sample. This qualitative data reveals several approaches to coping with simultaneous inconsistent explanations. For example, some people seem to manage this contradiction by separating out ideological claims, which prioritize identity expression, from fact claims, which prioritize truth. Fitting with this interpretation, ambivalent individuals tended to call explanations “beliefs” (not knowledge), avoid mention of truth or falsity, and ground one or both beliefs in identity and personal history. We conclude with a brief discussion of the affordances of this distinction.

Why does the Chinese public accept evolution?

A substantial proportion of Chinese nationals seem to accept evolution, and the country is sometimes held up to show that the sorry state of evolution acceptance in the United States is not inevitable. Attempts to improve evolution acceptance generally focus on improving communication, curricular reform, and even identifying cognitive mechanisms that bias people against evolution. What is it that the Chinese scientific community did so well, and can it be generalized? This paper argues that evolution acceptance in China has a very specific history, one that other countries are very unlikely to emulate. We show that the interactions among science, education, mass media, social and political movements, and ideological arguments about evolution greatly influenced the Chinese public's understanding and acceptance of evolution. We find that it was not just formal education, but many more ideologically motivated methods of evolution exposure that contributed to the high rate of acceptance. But since the purpose of evolution dissemination has moved beyond merely teaching biology, the Chinese public persists with substantial misunderstandings of the theory. Thus, bottom line percentage of acceptance figures can be misleading; the details and the history really matter.

Non-Scientific Criteria for Belief Sustain Counter-Scientific Beliefs

Why is evolutionary theory controversial among members of the American public? We propose a novel explanation: allegiance to different criteria for belief. In one interview study, two online surveys, and one nationally representative phone poll, we found that evolutionists and creationists take different justifications for belief as legitimate. Those who accept evolution emphasize empirical evidence and scientific consensus. Creationists emphasize not only the Bible and religious authority, but also knowledge of the heart. These criteria for belief remain predictive of views about evolution even when taking into account other related factors like religion, political affiliation, and education. Each view is supported by its own internally specified criteria for what constitutes a justified belief. Changing minds may thus require changing epistemic norms.

Morton, Gould, and Bias: A Comment on "The Mismeasure of Science"

A closer look at Stephen Jay Gould’s criticisms of Samuel Morton vindicates Gould’s accusations of racial bias in Morton’s cranial measurements.

Opiate refractory pain from an intestinal obstruction responsive to an intravenous lidocaine infusion

A 24-year-old female patient presented to our community emergency department (ED) for abdominal pain that had progressively worsened over the last 28 hours. Of note, 1 month prior to her presentation, the patient had a colostomy due to a rectal abscess and required stoma revision 5 days prior to her visit to our ED. The patient's pain was refractory to opiate analgesia in our ED, but experienced significant relief after an intravenous lidocaine infusion. Computer tomography of the abdomen and pelvis ultimately revealed a large bowel obstruction just proximal to the colostomy site. Historically, options for ED management of severe pain have been limited beyond narcotic analgesia. For patients whom are refractory to opiates in the ED, or for whom opiates are contraindicated, lidocaine infusions have shown promise for a variety of both acute and chronic painful conditions.

Remeasuring man

Samuel George Morton (1799-1851) was the most highly regarded American scientist of the early and middle 19th century. Thanks largely to Stephen Jay Gould's book The Mismeasure of Man, Morton's cranial capacity measurements of different races is now held up as a prime example of and cautionary tale against scientific racism. A team of anthropologists recently reevaluated Morton's work and argued that it was Gould, not Morton, who was biased in his analysis. This article is a reexamination of the Morton and Gould controversy. It argues that most of Gould's arguments against Morton are sound. Although Gould made some errors and overstated his case in a number of places, he provided prima facia evidence, as yet unrefuted, that Morton did indeed mismeasure his skulls in ways that conformed to 19th century racial biases. Gould's critique of Morton ought to remain as an illustration of implicit bias in science.

Do simple models lead to generality in ecology?

Modellers of biological, ecological, and environmental systems cannot take for granted the maxim 'simple means general means good'. We argue here that viewing simple models as the main way to achieve generality may be an obstacle to the progress of ecological research. We show how complex models can be both desirable and general, and how simple and complex models can be linked together to produce broad-scale and predictive understanding of biological systems.

Surface ablation techniques

The ongoing quest for a safe, simple, effective, minimally invasive, and stable refractive surgical procedure to correct refractive errors has stimulated the development of surface ablation techniques and laser in situ keratomileusis. In this review, we describe the history, patient assessment, techniques, outcomes, and complications of surface ablation (photorefractive keratectomy, laser-assisted sub-epithelial keratectomy, epithelial laser-assisted in situ keratomileusis) and compare the results of various surface techniques. Surface ablation procedures will continue to evolve, with potential improvements in outcomes accompanying future sophisticated ablation profiles and laser technology.

Incidence and effects of genetic factors on canine impaction in an isolated Jewish population

INTRODUCTION

The etiology of palatal canine impaction is multifactorial and includes a genetic contribution. The aim of this study was to find the incidence and effects of genetic factors on palatally impacted canines in a genetically isolated community of ultraorthodox Hassidic Jews of Ashkenazi decent.

METHODS

For this study, we retrospectively evaluated 1000 charts of Hassidic Jewish patients. Their distribution was 58% female and 42% male, with a mean age of 14 years.

RESULTS

From those patients, 49 (4.9%) were determined to have canine impaction. Of these 49, 69.4% had unilateral palatal impaction, 26.5% had bilateral palatal impaction, and 4.1% had unilateral labial impaction. The z-test of proportion showed that female patients have a greater percentage than males for unilateral palatal impaction (P <0.01) with left-side dominance (P <0.01).

CONCLUSIONS

Our results imply that genetics plays a significant role in maxillary canine palatal impaction. A genetically isolated Hassidic Jewish community can be a useful group to study the effects of genetic factors on various dental anomalies, including palatally displaced canines.

Richard Rufus's theory of mixture: a medieval explanation of chemical combination

Richard Rufus of Cornwall offered a novel solution to the problem of mixture raised by Aristotle. The puzzle is that mixts or mixed bodies (blood, flesh, wood, etc.) seem to be unexplainable through logic, even though the world is full of them. Rufus's contribution to this long-standing theoretical debate is the development of a modal interpretation of certain Averroistic doctrines. Rufus's account, which posits that the elemental forms in a mixt are in accidental potential, avoids many of the problems that plagued non-atomistic medieval theories of mixture. This paper is an initial examination of Rufus' account.

Gas and air embolization during hysteroscopic electrosurgical vaporization: comparison of gas generation using bipolar and monopolar electrodes in an experimental model

STUDY OBJECTIVE

To compare the composition of gases generated by bipolar hysteroscopic vaporizing electrodes using electrolyte-rich medium (normal saline) with those of monopolar vaporizing electrodes using nonelectrolytic medium (1.5% glycine).

DESIGN

In vitro study (Canadian Task Force classification II-1).

SETTING

Laboratory.

INTERVENTION

Fresh morbid bovine cardiac muscle was fully immersed in normal saline for the bipolar vaporizing electrode and 1.5% glycine for the monopolar vaporizing electrode. Standard hysteroscopic electrodes were activated at usual and maximum power outputs from radiofrequency electrosurgical generators appropriate for each system. The gases generated were captured and analyzed by gas chromatography and fast Fourier transform.

MEASUREMENTS AND MAIN RESULTS

Gaseous by-products of electrosurgical vaporization of test tissues largely consisted of hydrogen, carbon monoxide, and carbon dioxide. The composition of gases generated by hysteroscopic monopolar and bipolar electrodes in this laboratory model appear to be similar.

CONCLUSION

These gases are all highly soluble in serum. This observation suggests that emboli of gaseous by-products of electrosurgery are unlikely to have an adverse impact on patients. On the other hand, air emboli, largely composed of relatively insoluble nitrogen, are more likely to result in clinically significant cardiopulmonary events.

Hysteroscopic endometrial ablation using free heated saline for the treatment of menorrhagia

STUDY OBJECTIVE

To assess the safety and efficacy of hysteroscopic endometrial ablation using controlled intrauterine instillation and circulation of heated (90 degrees C) saline.

DESIGN

Phase II clinical study (Canadian Task Force classification II-2).

SETTING

Preliminary study performed in an outpatient ambulatory surgery center of a university hospital.

PATIENTS

Twenty women with menorrhagia of benign causes.

INTERVENTION

Hysteroscopic endometrial ablation.

MEASUREMENTS AND MAIN RESULTS

There were no complications. At no time did fluid leak from the fallopian tubes or cervix during treatment. Six patients had concurrent laparoscopy to measure serosal temperatures and to observe fimbriae directly during the 10-minute treatment. Serosal and endocervical temperatures were not elevated. Eighteen women kept evaluable menstrual diaries for 2 months before and 12 months after surgery. Ten women (55.6%) became amenorrheic, four (22.1%) hypomenorrheic, and three (16.7%) returned to normal periods after 12 months of follow-up. One woman (5.6%) reported a 75% decrease in menstrual flow but continued to be menorrhagic by definition. One patient subsequently underwent hysterectomy for simple endometrial hyperplasia.

CONCLUSION

This procedure appears to be a safe method of globally ablating the endometrium, resulting in effective treatment of menorrhagia.

Advantages of concurrent biochemotherapy modified by decrescendo interleukin-2, granulocyte colony-stimulating factor, and tamoxifen for patients with metastatic melanoma

PURPOSE

Concurrent biochemotherapy results in high response rates but also significant toxicity in patients with metastatic melanoma. We attempted to improve its efficacy and decrease its toxicity by using decrescendo dosing of interleukin-2 (IL-2), posttreatment granulocyte colony-stimulating factor (G-CSF), and low-dose tamoxifen.

PATIENTS AND METHODS

Forty-five patients with poor prognosis metastatic melanoma were treated at a community hospital inpatient oncology unit affiliated with the John Wayne Cancer Institute (Santa Monica, CA) between July 1995 and September 1997. A 5-day modified concurrent biochemotherapy regimen of dacarbazine, vinblastine, cisplatin, decrescendo IL-2, interferon alfa-2b, and tamoxifen was repeated at 21-day intervals. G-CSF was administered beginning on day 6 for 7 to 10 days.

RESULTS

The overall response rate was 57% (95% confidence interval, 42% to 72%), the complete response rate was 23%, and the partial response rate was 34%. Complete remissions were achieved in an additional 11% of patients by surgical resection of residual disease after biochemotherapy. The median time to progression was 6.3 months and the median duration of survival was 11.4 months. At a maximum follow-up of 36 months (range, 10 to 36 months), 32% of patients are alive and 14% remain free of disease. Decrescendo IL-2 dosing and administration of G-CSF seemed to reduce toxicity, length of hospital stay, and readmission rates. No patient required intensive care unit monitoring, and there were no treatment-related deaths.

CONCLUSION

The data from this study indicate that the modified concurrent biochemotherapy regimen reduces the toxicity of concurrent biochemotherapy with no apparent decrease in response rate in patients with poor prognosis metastatic melanoma.

Outcomes in patients with myocardial infarction who are initially admitted to stepdown units: data from the Multicenter Chest Pain Study

PURPOSE

To assess whether the admission of patients with chest pain to a stepdown unit would jeopardize the outcome of those patients who ultimately "ruled in" for a myocardial infarction.

PATIENTS AND METHODS

We compared the risk of an adverse outcome in initially uncomplicated, "rule-out myocardial infarction" patients who were admitted directly to a stepdown unit (n = 58) or to a coronary care unit (n = 409) at 6 hospitals and who then ultimately "ruled in" for a myocardial infarction.

RESULTS

An adverse outcome (death, serious complication, or invasive intervention) occurred in 16 (28%) stepdown unit patients compared with 159 (39%) coronary care unit patients. Among patients eligible for initial care in either location, the risk of an adverse outcome after controlling for clinical characteristics was similar in the two groups using each of two different multivariate approaches.

CONCLUSION

Although our study was not of sufficient size to exclude the possibility of a small benefit from initial triage to a coronary care unit, our data suggest that (1) admission of initially uncomplicated chest pain patients with a relatively low probability of acute myocardial infarction to a stepdown unit does not seriously jeopardize those who eventually "rule in" for myocardial infarction; and (2) larger observational or randomized studies, which could reduce the residual possibility of somewhat higher risk in the stepdown unit, would be ethical to perform.

Terconazole--a new antifungal agent for vulvovaginal candidiasis

Terconazole is a new broad-spectrum antifungal agent for the treatment of vulvovaginal candidiasis. Instead of an imidazole structure, terconazole contains a triazole ring, a structure developed specifically to improve antifungal activity. Clinical studies of this antifungal agent have involved 5,500 women worldwide and a number of terconazole formulations, including 80-mg vaginal suppositories and 0.4% vaginal cream. The highlights of several large, major studies are discussed in this review article. In European studies, mycologic cure rates for terconazole regimens approached or exceeded 90%. Speed of action was rapid, and relapse rates were low. In double-blind, multicenter studies conducted in the United States, clinical cure rates for 0.4% terconazole cream ranged from 86% to 96% and microbiologic cure rates from 77% to 91% at 8 to 10 days after therapy. Most patients remained free of positive signs and symptoms and microbiologic evidence of infection at 30 to 35 days posttherapy. Symptomatic relief tended to be more rapid for patients treated with 0.4% terconazole cream than for those treated with 2.0% miconazole nitrate cream. In US studies of 80-mg terconazole suppositories, clinical cure rates 8 to 10 days after therapy were between 89% and 92%, and microbiologic cure rates were between 80% and 85%. Relapse rates were also low with this form of therapy. No statistically significant differences were found between three days of treatment with 80-mg terconazole suppositories and seven days of treatment with 100-mg miconazole nitrate suppositories. This research demonstrates that terconazole is a fast-acting, highly effective, well-tolerated therapy for vulvovaginal candidiasis.

Data assessing the usefulness of screening obstetrical ultrasonography for detecting fetal and placental abnormalities in uncomplicated pregnancy: effects of screening a low-risk population

To investigate the usefulness of screening in low-risk populations, the authors evaluated the yield of ultrasonography for detecting abnormalities in 678 clinically uncomplicated pregnancies. The yield of ultrasonography in high-risk women who were referred for amniocentesis was remarkably similar to the yield in other women. All four diagnoses of twins were correct, but overall only six of 12 initial ultrasound diagnoses of fetal demise or fetal anomalies were confirmed at delivery. Of the eight major fetal anomalies present at delivery, including two cases of Down's syndrome, three had been detected by ultrasonography; none of the nine minor anomalies had been detected, usually because they were too small or might be detectable only at a later gestational age. Although ultrasonography may have a nearly perfect predictive value for certain anomalies, on average, in this study, positive ultrasonography increased the probability of an adverse outcome of pregnancy from 5.3% to 36%, while a normal ultrasound examination decreased the probability to 4.4%. These data, which emphasize the implications of screening a low-risk population, suggest that recommendations regarding routine screening obstetrical ultrasonography should await sufficiently large controlled trials demonstrating consistent clinical benefit, in terms of reassurance or of providing a baseline for future comparison or in terms of improved outcome at a reasonable cost.

Identification and preliminary validation of predictors of major bleeding in hospitalized patients starting anticoagulant therapy

Among 617 hospitalized patients who started long-term anticoagulant therapy, major bleeding developed before discharge in 28 (5 percent) and minor bleeding in another 38 (6 percent), with daily incidence rates of 0.4 and 0.5 percent, respectively. The most common site of bleeding was gastrointestinal, and one patient died from bleeding. Four independent risk factors for major in-hospital bleeding were identified and weighted using multivariate discriminant analysis in a randomly chosen group of 411 patients: co-morbid conditions other than the indication for anticoagulant therapy (specific signs of heart, liver, or kidney dysfunction, cancer, and severe anemia); the use of heparin to begin therapy in patients age 60 years or older; the intensity of therapy (measured by the maximal prothrombin time or partial thromboplastin time); and liver dysfunction that worsened during treatment. These findings were validated in an independent testing group of 206 patients; the risk factors identified 151 patients at low (1 percent) risk of major bleeding, 33 at moderate (6 percent) risk, and 22 at high (23 percent) risk. The accuracy and clinical impact of this prediction rule should be evaluated further in other hospitals.

Correlates of cardiac and sudden death after ambulatory monitoring in a community hospital. Importance of clinical characteristics, congestive heart failure and tachyarrhythmias

To analyze the prognostic importance of arrhythmias on routine 24-hour ambulatory monitoring, we prospectively followed 755 consecutive patients undergoing monitoring at a community hospital in the context of usual medical care. Of the 755 patients, 114 (15%) had ventricular tachycardia on monitoring. At a mean follow-up of 38 months, multivariate survival analysis indicated that congestive heart failure was the strongest correlate of death from all causes (relative risk (RR) = 2.6), cardiac death (RR = 3.5), and the sudden cardiac death (RR = 5.6); ventricular tachycardia was significantly correlated with death from all causes and with cardiac death, but had only a borderline association with sudden cardiac death (RR = 1.9, p = 0.08). While ventricular tachycardia on ambulatory monitoring is of prognostic importance, congestive heart failure, as determined by routine clinical examination, was a more powerful prognostic correlate of deaths from all causes, death from cardiac causes, and sudden cardiac death.

The characteristics and hospital course of patients admitted for presumed acute pyelonephritis

To study the characteristics and hospital courses of patients hospitalized for presumed acute pyelonephritis, the authors analyzed 185 cases. Judged by explicit clinical and laboratory criteria, 54% of the patients definitely had pyelonephritis, 22% probably had pyelonephritis, 9% possibly had pyelonephritis, and 16% did not have pyelonephritis. In pretreatment urine cultures, 79% of patients had a single pathogen and 77% had colony counts of 100,000 or more organisms per ml. Non-Escherichia coli infections and positive blood cultures were the only two independent predictors of the concomitant renal stones or genitourinary tract abnormalities that were found in 29% of patients with pyelonephritis. About 15% of all patients continued to have temperatures greater than or equal to 101 degrees F 48 hours after the initiation of antibiotic therapy, but persistent fever did not correlate with a history of prior urinary tract infection, the presence of resistant pathogens, renal stones, or genitourinary tract abnormalities. The authors conclude that many of these patients did not have pyelonephritis, and that certain characteristics correlate with the presence of underlying anatomic abnormalities.

Exposure to magnetic resonance imaging does not produce taste aversion in rats

A taste aversion test was used to evaluate possible toxic effects of magnetic resonance imaging (MRI). Thirty male Sprague-Dawley rats were randomly assigned to four groups: Group One (n = 10) received 30 minutes exposure inside the MRI scanner; Group Two (n = 10) received a sham exposure to the MRI scanner; Group Three (n = 5) was injected with 0.15 M lithium chloride; and Group Four (n = 5) was injected with vehicle. All groups were given 10 minutes access to a 0.1% saccharin solution immediately prior to their respective treatment. The rats treated with lithium chloride displayed a taste aversion to the saccharin solution upon subsequent testing over an eight day period. The two control groups (Two and Four) and the rats exposed to MRI did not display any aversion to the saccharin solution. These results are compared to other studies that have shown that magnetic fields can influence biological systems.

Screening procedures in the asymptomatic adult. Comparison of physicians' recommendations, patients' desires, published guidelines, and actual practice

To assess attitudes and practices regarding screening tests and preventive procedures, we surveyed 83 physicians in a hospital-based ambulatory care practice and compared their recommendations with the recommendations in published guidelines, the desires of 188 of their own patients, and the physicians' actual practice patterns on the surveyed patients. The surveyed physicians recommended screening procedures more frequently than the published guidelines in 48 situations and less frequently in 18 situations. Physicians at earlier levels of training tended to recommend more procedures than those who had completed training. Patients desired far more frequent screening than recommended either by their physicians or by the published guidelines. Physicians did not live up to their own recommendations for four of 14 procedures or to published guidelines for five of 14 procedures, with such failure occurring principally in situations where the test or procedure would normally be done personally by the physician.

Evaluation of two rapid methods for the detection of herpes simplex virus antigen in patient specimens

An indirect immunofluorescent antibody procedure (IFA) for the detection and typing of herpes simplex virus (HSV) and an enzyme-linked immunosorbent assay (ELISA) procedure were compared with conventional viral culture. Specimens for culture and ELISA were inoculated into serum free viral transport medium (VTM) and, for IFA, onto slides provided in the kit. Tissue cultures (MRC-5 and primary rabbit kidney) were inoculated and examined daily for cytopathogenic effect (CPE). The remaining VTM was frozen at -70 degrees C until tested by the ELISA system. Slides for IFA were stained with HSV common and HSV-2 specific monoclonal antibodies. Of 155 specimens, 47 (30 percent) were unsatisfactory for the IFA test owing to an inadequate number of epithelial cells on the slides. Of 108 adequate specimens, 45 were culture positive; 39 were positive by the IFA test with a sensitivity of 87 percent and a specificity of 90 percent. Of the 39 positives, 29 (75 percent) were correctly classified as type 1 or type 2, six (15 percent) were typed incorrectly, and four (10 percent) were inadequate for typing by the IFA test. All 155 specimens were suitable for testing by the ELISA procedure. Of 55 specimens positive by culture, only 25 (sensitivity 45 percent) were positive by ELISA. However, the specificity was 100 percent. After incubation of two, three, and six days, the tissue cultures detected 71 percent, 89 percent, and 100 percent of the positives, respectively.

Acute chest pain in the emergency room. Identification and examination of low-risk patients

Clinical and laboratory data from 596 patients who came to an emergency room complaining of chest pain indicated that no single variable could identify low-risk patients as well as a normal ECG. A combination of three variables--sharp or stabbing pain, no history of angina or myocardial infarction, and pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall--defined a very-low-risk group in which ECGs did not add accuracy to the evaluation and were potentially misleading; however, only 48 patients (8%) fell into this category. Standard cardiac enzyme levels were of almost no use as an emergency room indicator of myocardial infarction. These findings emphasize the difficulty of identifying patients at low risk for myocardial infarction or unstable angina in the emergency room without consideration of many factors from the history, the physical examination, and the ECG.

Do endocrines play an etiological role in diabetic and nondiabetic sexual dysfunctions?

Sexually dysfunctional diabetic and nondiabetic males were compared with a group of normal controls using different endocrinological, psychophysiological, and psychological parameters. One hundred male subjects participated in this study: 47 diabetics with sexual dysfunction (DD), 31 nondiabetics with sexual dysfunction (NDD), and 22 normal controls (C). They were evaluated by an internist (physical examination and medical history), a psychologist (psychological and sexual functioning tests), a psychiatrist (psychiatric history and mental status examination), a urologist (genitourinary physical examination), and an endocrine biochemist (evaluation of endocrine factors). Additionally, subjects were evaluated for nocturnal penile tumescence (NPT) during three nights in the sleep laboratory to obtain a differential diagnosis of impotence, that is, psychogenic vs. organic. Both sexually dysfunctional groups showed significant differences on several measures in the psychological and psychophysiological evaluations. There were also significant differences between these two groups and the control group. Plasma levels of total testosterone and serum levels of prolactin, luteinizing hormone (LH) and follicle-stimulating hormone (FSH) showed no significant differences among the three groups, but there were some significant correlations between the endocrine and psychological measures. No significant correlations were found between the endocrine and psychophysiological measures.

The value of the autopsy in three medical eras

To determine whether advances in diagnostic procedures have reduced the value of autopsies, we analyzed 100 randomly selected autopsies from each of the academic years 1960, 1970, and 1980 at one university teaching hospital. In all three eras about 10 per cent of the autopsies revealed a major diagnosis that, if known before death, might have led to a change in therapy and prolonged survival; another 12 per cent showed a clinically missed major diagnosis for which treatment would not have been changed. Among 1980 autopsies, renal disease and pulmonary embolus were less common causes of death than before, but systemic bacterial, viral, and fungal infections increased significantly and were missed clinically 24 per cent of the time. The introduction of radionuclide scans, ultrasound, and computerized tomography as diagnostic procedures did not reduce the use of conventional tests in patients who subsequently died and were studied by autopsy. Over-reliance on these new procedures occasionally contributed directly to missed major diagnoses. We conclude that advances in diagnostic technology have not reduced the value of the autopsy, and that a goal-directed autopsy remains a vital component in the assurance of good medical care.

The Grafenberg spot and female ejaculation: a review of initial hypotheses

A controversial set of hypotheses have been proposed as an explanation for nonvulval (i.e., nonclitoral) orgasms in women. First, women have a small sensitive area in the anterior wall of the vagina (the Grafenberg spot) which seems to trigger these "deeper" orgasms. Second, stimulation of this area may be associated with ejaculatory response during orgasm. Investigation of these hypotheses was conducted under laboratory conditions in an effort to assess their validity. Eleven women, six of whom claimed to be "ejaculators," were examined by two gynecologists. Gynecologists found an area similar to other descriptions of the Grafenberg Spot in four of the 11 women. It was not found more in ejaculators than nonejaculators. Examination of the ejaculate of six women failed to detect elevated levels of prostatic acid phosphatase and the substance appeared similar in biochemical properties to urine. A number of alternative explanations for the failure to confirm the hypotheses are offered.

A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain

To determine whether data available to physicians in the emergency room can accurately identify which patients with acute chest pain are having myocardial infarctions, we analyzed 482 patients at one hospital. Using recursive partitioning analysis, we constructed a decision protocol in the format of a simple flow chart to identify infarction on the basis of nine clinical factors. In prospective testing on 468 other patients at a second hospital, the protocol performed as well as the physicians. Moreover, an integration of the protocol with the physicians' judgments resulted in a classification system that preserved sensitivity for detecting infarctions, significantly improved the specificity (from 67 per cent to 77 per cent, P less than 0.01) and positive predictive value (from 34 per cent to 42 per cent, P = 0.016) of admission to an intensive-care area. The protocol identified a subgroup of 107 patients among whom only 5 per cent had infarctions and for whom admission to non-intensive-care areas might be appropriate. This decision protocol warrants further wide-scale prospective testing but is not ready for routine clinical use.

Strategies contributing to effectiveness of health science faculty training

Strategies contributing to effectiveness of design, development, and operation of national training programs for health science faculty are presented. Focus is on programs similar to those conducted by the National Medical Audiovisual Center (NMAC)-programs that involve improvement of teaching skills and cooperative efforts (non-funded) between a development agency and geographically dispersed, independent training organizations. Although strategies presented here emanated from experience at NMAC, they may be generalized to encompass training conducted by other networks of cooperating organizations operating in similar contexts. Further, the strategies are consonant with literature on instructional design, adult learning, and innovation.

Description of a universal data entry and retrieval program for vascular surgeons

Until recently, vascular surgeons have had to make judgments based on an impression of their experiences rather than upon the actual facts. Presently, with the simplified and less costly use of computers, the establishment of a computerized data base is feasible. Our goal had been to develop a system suitable for micro- or minicomputers which can be programmed in ordinary English and, once in place, requires essentially no knowledge of computers or computer programming for its successful use. Such a data base could put to an end the comparison of series that are truly incomparable because of differences in data classification and presentation. For example, in the case of a femoropopliteal bypass, which eventuates in a successful thrombectomy, some call it a success, some call it a failure, and some list it as both a success and failure. Many ignore the thrombectomy entirely and choose to place the final result in the plus category of "limb salvage." One seemingly insurmountable problem has been that because practice patterns differ, it has been necessary to design individual computer programs. A programmer has been required to write each of these programs, with consequent great expense and delay. While there are programs available for establishing a data base, they largely have required the use of large computers. Using such a computer implies a time sharing system with frustrations in regard to both availability and ease of use.