Physicians For Years Research Articles

THE TUNNEL-VISION EFFECT OF COVID-19: AN INCIDENTAL DISCOVERY OF SEVERE BICUSPID AORTIC VALVE STENOSIS

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Bicuspid aortic valve is the most common congenital valvular abnormality, and has an autosomal dominant pattern with incomplete penetrance. Early recognition in the outpatient setting is imperative to prevent the development of aortic stenosis, particularly before it becomes severe. Once the disease progresses to end stage, patients may begin to experience dyspnea on exertion, syncope, and orthopnea. CASE PRESENTATION: We present a case of a 52-year-old male with complaints of shortness of breath, retrosternal chest pain, and nonproductive cough. His dyspnea began 3 months ago, but have progressed to where he felt dyspneic at rest 6 hours prior to admission. He had a positive SARS-CoV-2 PCR two weeks prior at an ancillary testing site. He worked as an iron welder for 37 years, and stated that he hasn't seen a physician in years. Despite a negative SARS-CoV-2 PCR in the ED, he was placed in negative pressure isolation. His initial vitals were BP 114/84, HR 124, RR 36, SpO2 91% on room air, and temperature 102.2 F. There was a loud systolic murmur over the precordium (clearly audible over the ventilation equipment), bibasilar rhonchi on auscultation, minimally elevated JVD, and no bipedal edema. Labs revealed a troponin of 0.152 ng/dL and proBNP 2020 pg/mL, and CXR AP view showed an enlarged cardiac silhouette and minimal bibasilar infiltrate. EKG revealed sinus tachycardia of 120 bpm and LBBB. He was given IVF and IV antibiotics for suspected sepsis due to superimposed bacterial pneumonia. Transthoracic echocardiogram revealed severe bicuspid aortic valve stenosis (velocity 4.01 m/sec, mean PG 42.8 mm Hg, and AVA di 0.75 cm2) and LVEF 30-35%. The following morning, the patient went into flash pulmonary edema requiring urgent intubation and mechanical ventilation. Surprisingly, his repeat SARS-CoV-2 PCR was positive, however his clinical picture was more suggestive of decompensated heart failure rather than active COVID-19. He was aggressively diuresed and extubated 3 days later, and was successfully discharged home with close follow up for possible surgical intervention. DISCUSSION: Bicuspid aortic valve is one of the most significant risk factors leading to severe aortic stenosis (1). Symptoms may remain clinically silent for years, and usually occur only when there is an increase in LVEDP (1). In our case, the patient's recent diagnosis of COVID-19 two weeks prior was a smoke screen of his more insidious underlying valvulopathy. Luckily, he did not succumb to COVID-19, as an international registry of 74 patients with untreated severe aortic stenosis who developed COVID-19 had a mortality of 59.5% and 23.5% for those older and less than 80 years, respectively (2). CONCLUSIONS: It is imperative that we as clinicians remain vigilant and avoid becoming fixated on COVID-19 and its complications, as this may obscure an underlying disease with harmful repercussions if left untreated. REFERENCE #1: Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O'Gara PT, Ruiz CE, Skubas NJ, Sorajja P, Sundt TM 3rd, Thomas JD;American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jun 10;63(22):e57-185. doi: 10.1016/j.jacc.2014.02.536. Epub 2014 Mar 3. Erratum in: J Am Coll Cardiol. 2014 Jun 10;63(22):2489. PMID: 24603191. REFERENCE #2: Danny Dvir, Matheus Simonato, Ignacio Amat-Santos, Azeem Latib, Faraj Kargoli, Luis Nombela-Franco, Marco Agrifoglio, Francesco Giannini, Damiano Regazzoli, Bernhard Reimers, Emmanuel Villa, Victor M. Becerra-Munoz, Marco Mennuni, Andrea Rognoni, Thomas Modine, Lionel Leroux, Rodrigo Estevez-Loureiro, Roberto Nerla, Fausto Castriota, Alfredo Cerillo, Lars Sondergaard, Alessandro Iadanza, Alison Duncan, Flavien Vincent, Massimo Mancone, Lucia Bi tolo, Viviana Maestrini, Luca Testa, Wojtek Wojakowski, Stefano Salizzoni, Vinicius Esteves, Fernanda Mangione, Cleverson Zukowski, Nicolas Amabile, Mony Shuvy & Gregg W. Stone (2021) Severe Valvular Heart Disease and COVID-19: Results from the Multicenter International Valve Disease Registry, Structural Heart, DOI: 10.1080/24748706.2021.1908646 DISCLOSURES: No relevant relationships by Maie Abdullah, source=Web Response No relevant relationships by Nabil Braiteh, source=Web Response No relevant relationships by Kareem Ebeid, source=Web Response No relevant relationships by Altif Muneeb, source=Web Response No relevant relationships by Fnu Shailesh, source=Web Response

Impact of nontreatment oncology research trials on physician engagement in clinical research in an oncology community practice setting.

44 Background: The rapid development of new oncology drugs has created a significant increase in the number of clinical research studies. This underscores the need for greater participation in research by physicians as well as patients. Many physicians hesitate to participate in oncology clinical trials that provide treatment options for their patients given the complexity of the protocols. Non-treatment clinical trials may serve as a bridge for engaging physicians in clinical research and enhance the culture of research in community oncology practices. Methods: A large non-treatment oncology clinical trial was opened in a network of community oncology practices with approximately 1,000 physicians. We evaluated the number of physicians who did not enroll a patient onto a clinical trial in Year 1 but did enroll patients onto the non-treatment study. We further examined the number of physicians who enrolled a patient onto the non-treatment study that also enrolled patients onto a treatment clinical trial. Overall physician engagement in clinical research was measured by comparing practices where non-treatment study was offered to locations that did not participate in the non-treatment study. Negative impact on treatment accruals was also evaluated. Results: There were 105 physicians that practice at a site with the non-treatment study who had 0 accruals in Year 1 but enrolled a patient to any clinical trial in Year 2. Ninety-two of those physicians were responsible for enrolling over 900 patients to the non-treatment study in Year 2. Additionally, 46 of the 0 accruing physicians in Year 1, enrolled a patient to the non-treatment study also enrolled a patient to a treatment clinical trial. We also found that 24 physicians who did not did not enroll a patient in Year 1 and did not enroll a patient to the non-treatment study did enroll patients to a treatment clinical trial in Year 2. Conclusions: Participation in oncology treatment clinical trials can be difficult in the community oncology setting. Participation in a non-treatment study may serve as a bridge to engage more physicians in clinical research and enhance the culture of research within a community oncology practice.

Abstract P5-13-06: Factors associated with follow up medical care among women with early stage breast cancer

Abstract Introduction: In patients with early stage breast cancer treated with curative intent, optimal follow-up guidelines vary widely among national organizations. NCCN guidelines suggest patients should be followed by a medical oncologist (MO) every 3-6 months and by a radiation oncologist (RO) every 6-12 months for the first 5 years. These recommendations are not evidence based and have an unknown effect on cancer outcomes. We sought to evaluate the patterns of follow-up care and predictors of discontinuation of follow-up care. Methods: Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked dataset, we evaluated patients diagnosed with stage I and II breast cancer who underwent surgery from 2002-2007 with follow-up to 2012. Patients who died in the 5-year period following diagnosis were excluded. We evaluated patterns of follow-up visits for the 5 years after diagnosis among surgeon, MO and RO. We defined discontinuation of follow-up care as >12 months without a visit claim from any of the three providers. We performed a Cox-proportional hazards multivariate analysis to determine factors associated with discontinuation of follow-up care. Patients were censored if a new cancer was diagnosed. Results: A total of 35,484 stage I and II breast cancer patients were included in the analysis. In addition to the surgeon, 77.5% saw a MO, and 57.8% saw RO in the first year. The mean number of total physician appointments for years 1-5 were 9.4, 3.3, 2.4, 2.0 and 1.7, respectively. During the 5 years, 13,908 (39.6%) patients discontinued follow-up visits. The discontinuation rate averaged about 12% per year for years 2-5. Discontinuing physician visits increased with increasing age. Patients who saw all 3 physicians in year 1 were less likely to discontinue follow-up visits (OR = 0.54, 0.51-0.57). Patients were more likely to discontinue physician visits if they were hormone receptor negative (HR = 1.41, 1.33-1.49), were black (HR = 1.14, 1.06-1.22) or Hispanic (HR = 1.36, 1.17-1.58) compared to white, lived in a rural as opposed to urban setting (HR 1.12, 1.05-1.18), were unmarried (HR = 1.16, 1.12-1.20), had a higher comorbidity score (HR = 1.15, 1.10-1.21), or were in a lower SES quintile (HR = 1.08, 1.02-1.15). Women who had a mastectomy (vs lumpectomy) (HR =0.83, 0.80-0.87) and those who were receiving chemotherapy (HR = 0.55, 0.52-0.59) or radiation therapy (OR = 0.60, 0.57-0.62) were less likely to discontinue physician visits. Conclusions: Clinical practice guidelines for surveillance of breast cancer after primary treatment are based on expert opinion and have an unclear effect on long-term outcomes. Coordination of follow-up care may reduce discontinuation. More research is needed to determine the optimal follow-up for maintaining adherence to therapy, reducing over-testing and encouraging secondary cancer screening guidelines. Citation Format: Hershman DL, Quyyumi F, Accordino MK, Buono DL, Neugut AI, Hillyer GC, Wright JD. Factors associated with follow up medical care among women with early stage breast cancer [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P5-13-06.

The attitudes of pharmacists and physicians in Bosnia and Herzegovina towards adverse drug reaction reporting

Introduction: Adverse drug reactions (ADRs) are threat to the patient’s safety and the quality of life, and they increase the cost of health care. Spontaneous ADR reporting system mainly relies on physicians, but also pharmacists, nurses, and even patients. The aim of this study was to explore attitudes, barriers, and possible improvements to ADR reporting practices in Bosnia and Herzegovina.Methods: A self-reported questionnaire was developed to collect data on the perception of pharmacovigilance practice and ADR reporting. The survey was conducted in the period between September, 2014 and October, 2014.Results: The response rate was 73% (44 of 60) and 93% (148 of 160) among the pharmacist and family medicine physician groups, respectively. Regarding the attitudes to pharmacovigilance practice and reporting, both the pharmacists and physicians found the practices important. The majority of pharmacists and physicians in year 2014 did not report any ADR, while 18% of the pharmacists and 12% of the physicians, who participated in this study, reported one ADR. Reporting procedure, uncertainty, and their exposure were the main barriers to reporting ADRs for the pharmacists. The physicians claimed lack of knowledge to whom to report an ADR as the main barrier. A significant number of the respondents thought that additional education in ADR reporting would have a positive impact, and would increase the ADR reporting rate.Conclusions: Despite the overall positive attitude towards ADR reporting, the reporting rate in Bosnia and Herzegovina is still low. Different barriers to the ADR reporting have been identified, and there is also the need for improvements in the traditional education in this field.

What Does This Retina Examination Show?

A 50-year-old man was evaluated for a 5-month history of blurry vision. He had been diagnosed with the metabolic syndrome many years previously but has not seen his physician in years. He reported no current use of medications. On examination, he had a body mass index of 30.6 and a blood pressure of 160/102 mmHg. A dilated examination of the retina is shown in the Figure. Quiz at jama.com Figure. Left, Fundus photograph of the right eye. Right, Fundus photograph of the left eye.

Multiple physicians are not independently associated with inappropriate prescribing: a cross-sectional study of geriatric patients

Many frail elderly individuals use several medications, which can lead to unnecessary adverse drug events, resulting in medication-associated hospitalizations of which up to half are potentially preventable [1]. Several methods are available to improve the appropriateness of medications used by the elderly. For example, the Prescribing Optimization Method (POM) [2] evaluates medication adherence and classifies potentially inappropriate prescriptions into different categories. As most clinical specialists do not have a complete overview of all the medicines prescribed or used by patients and often do not have sufficient time or knowledge to optimize polypharmacy, it can be expected that the number of physicians visited contributes to inappropriate prescribing. Previous studies have shown that inappropriate prescribing is associated with multiple prescribers [3–5]. The objective of our cross-sectional study was to investigate the relationship between the number of physicians visited and inappropriate prescribing in geriatric patients in the Netherlands. One of the authors (RV) quantified the original POM questions into the domains to form an index (sumPOM) (see Table 1) to evaluate whether the medications used by elderly patients on admission to an acute geriatric ward of a teaching hospital in Tilburg, the Netherlands had been prescribed inappropriately. Under-prescription (scored 1 point) was assessed in each patient and each drug was evaluated in terms of the remaining seven domains. If a drug was prescribed without its indication being clearly stated, then it was not evaluated for lack of effect. Prophylactic medications were considered effective. Per drug, each domain was scored 0 points if it was appropriate and 1 point if it was inappropriate. The causality of adverse effects was determined with the Naranjo scale. Table 1 Scoring system of the Prescribing Optimization Method Two hundred patients [mean age 82.8 (± 6.4 = SD) years] had a mean of 8.6 (± 4.2) prescriptions and had visited a mean of 3.3 (± 1.7) different physicians in the year before admission. The sumPOM score ranged from 0 to 20. In each patient there were 5 (± 3.8) instances of inappropriate prescribing, involving all classes of drugs. The number of physicians visited was clearly associated with inappropriate prescribing on univariate regression analysis [regression coefficient (β) 0.54, 95% CI 0.24, 0.84] (Table 2), but not after adjustment for the number of prescriptions (β −0.02, 95% CI −0.28, 0.24). The number of physicians visited was also related to the number of prescriptions (β 0.82, 95% CI 0.48, 1.15) (data not shown). The number of prescriptions remained the most important independent predictor of inappropriate prescribing in the full model multivariate regression analysis (β 0.52, 95% CI 0.40, 0.64). In this model, living in warden-assisted or sheltered accommodation was associated with a higher rate of inappropriate prescribing than living independently (β 1.91, 95% CI 0.31, 3.51). In contrast, previous contact with a geriatrician was a significant predictor of fewer inappropriate medications (β −1.32, 95% CI −2.29, 0.35), probably because geriatricians are more aware of potential medication-related problems in elderly patients. Table 2 Results of linear regression analysis using inappropriate prescribing (expressed as sum POM) as an outcome variable and the ‘number of visited physicians in the previous year’ as main predictor of interest In a further analysis (data not shown), individual POM domains were not independently associated with the number of physicians visited. The sumPOM collects information about implicit inappropriate prescribing (whether a drug was indicated), but also about explicit inappropriate prescribing (potential drug–drug and drug–disease interactions). Both may adversely affect the benefit : harm ratio of treatment. We did not investigate the clinical consequences of inappropriate prescribing, but it is known that they are associated with preventable harm [1]. In conclusion, many elderly patients admitted to an acute geriatric ward had been prescribed inappropriate medications. However, a visit to a geriatrician in the previous year was found to be associated with fewer inappropriate prescriptions. Physicians' prescribing skills, especially regarding polypharmacy, can be improved by using a systematic medication review method, such as the POM. Like others [3–5], we found the number of physicians visited to be associated with inappropriate prescribing on univariate analysis, but not after adjustment for the number of prescriptions. This makes it important to adjust for the number of drugs used in future studies of risk factors for inappropriate prescribing.

Career choices and career progression in emergency medicine in the UK: national surveys

BackgroundThe number of consultants in emergency medicine (EM) in the UK needs to be increased substantially. However, the UK College of Emergency Medicine reports that there are shortages of specialist trainees in EM. We analysed data about career choices for EM made by doctors in our multipurpose cohort studies of UK-trained junior doctors' career intentions. We previously reported that doctors who make early career choices for EM are less likely than doctors who choose other specialties to pursue their original specialty choice. Here, we update our findings. MethodsQuestionnaire surveys were undertaken of all doctors who graduated from all medical schools in the UK in the year-of-qualification cohorts of 1993, 1996, 1999, and 2000. Doctors were invited to complete either a postal or a web-based questionnaire in the first postgraduate year and at years 3, 5, 7, and 10 after graduation. For each survey, non-responders were sent up to five reminders. Subsequent surveys excluded only doctors who previously had indicated that they did not wish to participate, were deceased, or were untraceable after exhaustive searching. Response rates to the first-year surveys ranged from 55·5% to 78·9%. 7391 (66·7%) of 11 078 people who replied in year 1 and 7452 (71·5%) of 10 423 people who replied in year 5 also replied in year 10. We compared career choices in the earlier years with career destinations in year 10. Data were analysed by univariate cross-tabulation and χ2 tests; and we show percentages with 95% CIs. FindingsOf the doctors who told us in year 1 that EM was their first choice of long-term career, only 24·6% (95% CI 19·6–30·4) were working in EM 10 years after graduation. As comparisons, 75·8% (95% CI 73·9–77·6) of those who chose general practice, 58·4% (55·9–61·0) of those who chose surgical specialties, 50·8% (46·9–54·7) of those who chose anaesthetics, and 45·0% (42·8–47·3) of those who chose hospital physician specialties in the first postgraduate year were working in their first-year choice of specialty 10 years after graduation. Of those who specified EM as their first choice of career in year 5, 66·7% (95% CI 60·7–72·1) were working in EM 10 years after graduation. The corresponding figures for general practice, surgical specialties, anaesthetics, and the hospital physician specialties were 91·5% (95% CI 90·4–92·6), 86·9% (84·7–88·9), 86·1% (83·2–88·6), and 81·5% (79·2–83·6), respectively. Of the doctors who were working in EM 10 years after graduation, 26·3% (95% CI 21·0–32·4) had specified EM as their career choice in the first postgraduate year. By contrast, 92·4% (90·0–94·2) of practising surgeons and 74·9% (71·7–77·7) of hospital physicians in year 10 had told us in year 1 that that they wanted to be surgeons or hospital physicians, respectively. The most common initial career choices of doctors in EM 10 years after graduating, other than EM itself, were surgical specialties, general practice, hospital physician specialties, and anaesthetics. InterpretationCompared with many other specialties, doctors who pursue EM tend to choose it quite late. Therefore, EM workforce expansion could be partly achieved by opening up late routes into EM, so that trainees in other related specialties could transfer their training to EM with credit for the relevant competencies they already had, rather than having to start their core EM training from year 1. Training in EM might be most usefully linked to training in surgical specialties, hospital physician specialties, and anaesthetics. FundingThis is an independent study commissioned and funded by the Policy Research Programme (project 016/0116) in the Department of Health. The views expressed are not necessarily those of the funding body.

The Case Files

A 49-year-old woman presented to the emergency department with a complaint of color change to her left leg while walking. She was watching a parade when she developed paresthesias to her left thigh and leg, and noticed her entire left thigh and leg were discolored and blue. She denies prior occurrence or any injury or trauma to the leg. She had no headache, weakness, change in vision, chest pain, shortness of breath, palpitations, abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms. She had no history of prior thromboembolism or arterial pathology. She is not a smoker, and has not seen a physician for years. She also denied recent travel, oral contraceptives, recent surgery, any medical conditions, or surgical history. She stated that her leg appears slightly better than before, and the paresthesias have resolved. She is morbidly obese, and appears slightly anxious, with an elevated heart rate of 115 bpm. Her vital signs are otherwise within normal limits. Her entire leg from her inguinal ligament to her foot is mottled and slightly cyanotic with marked swelling. She has normal range of motion. Her leg is warm and not tender. Sensation is intact, and distal pulses are palpable. The rest of her physical exam is unremarkable. Her EKG is sinus tachycardia without ST/T wave changes. A heparin drip is empirically ordered before the negative Doppler of the left lower extremity study for DVT. Vascular surgery is consulted, and a CT angiogram of the aorta with runoff is obtained. (Fig. 1–3.)Figure 1: Transverse view of right iliac artery compressing left iliac vein against lumbar spine just distal to venous bifurcationFigure 2: Transverse view of venous congestion in left lower extremity contributing to markedly swollen leg found on examImageThe patient was admitted when the CT suggested a pelvic DVT. Later review of the CTA lead to the diagnosis of a left iliac vein DVT due to May-Thurner syndrome. May-Thurner syndrome is also known as iliac compression syndrome, and is a rare congenital anatomic variant that causes narrowing of the left common iliac vein by compression from the chronic pulsation of the right common iliac artery against the lumbar spine. This compression leads to swelling, pain, varicosities, and venous ulcers, and predisposes the patient to thrombus formation. Establishing the diagnosis is critical because severe complications such as phlegmasia cerulea dolens or pulmonary embolus leading to sudden death can occur. This syndrome was first described by James Playfair McMurrich in 1908, but was named after May and Thurner in 1957 who described it after examining 430 cadavers. (Angiology 1957;8[5]:419.) They documented occurrence where the right iliac artery crossed over the left iliac vein, and hypothesized that this chronic compression impeded flow and thrombosis because of the intimal hyperplasia that ensued. It has been suggested from cadaver examinations and retrospective CT reviews that approximately 22–24 percent of the population has this variant and is asymptomatic. (J Vasc Surg 2004;39[5]:937.) May-Thurner most commonly affects women 20–40 years old. Thrombosis occurs more commonly on the left side, and should be considered a risk factor for patients presenting with a left-sided iliofemoral DVT. (Diagn Interv Radiol 2007;13[3]:152.) Risk factors are similar to those with a lower extremity DVT such as oral contraception, obesity, pregnancy, immobilization, cancer, recent surgery, and genetic hypercoagulable states. Venography is the study of choice. Ultrasound Doppler of the extremity is usually negative. Similar to other DVTs, patients are anticoagulated to prevent clot progression. Unfortunately, anticoagulation alone is not sufficient in these patients because reoccurrence most likely occurs from anatomical chronic compression. Localized thrombolytic therapy or catheter-directed administration of an antifibrinolytic is effective in eliminating the clot. Angioplasty with an endovascular stent can be placed after successful thrombectomy. Failure of stent placement increases the risk for rethrombosis or venous insufficiency. (J Vasc Surg 2004;39[5]:937; Diagn Interv Radiol 2007;13[3]:152.) Complications with stent placement include in-stent thrombosis, stent migration, and retroperitoneal hemorrhage. (J Vasc Surg 2007;46[4]:743.) Retrospective and prospective studies suggest that endovascular stent placement is the front-line treatment. (J Vasc Surg 2007;46[4]:743; J Cardiovasc Surg 2001;42[1]:83; AJR Am J Roentgenol 2004;183[5]:1523.)

Underestimating Medical Therapy for Coronary Disease . . . Again

The question of how best to treat patients with multivessel coronary artery disease and left ventricular dysfunction has challenged physicians for years. Although most clinicians are comfortable recommending revascularization when there is angina, extensive coronary disease, and a left ventricular ejection fraction of more than 35%,1–3 the benefits of such a strategy are less clear when the ejection fraction is substantially impaired. The evidence base for the benefits of revascularization is even weaker when angina is not present in patients with ischemic cardiomyopathy. In such a situation, myocardial viability and hibernation (i.e., chronically hypoperfused myocardium resulting in a hypocontractile . . .

Isolated Splenic Vein Thrombosis in a Patient with Polycythemia Vera

Purpose: Polycythemia vera (PCV) is a known cause of hypercoagulable states, however, isolated splenic vein thrombosis associated with PCV is only rarely reported. We report a case of the insidious onset of a splenic vein thrombosis presenting as an upper gastrointestinal bleed in a patient with PCV. Case: A 46 year old white female presented to the emergency room with complaints of melena for four days. She denied vomiting and abdominal pain associated with the melena. Her history was significant for polycythemia vera for which she had not seen a physician in years. She reported intermittent phlebotomy in the past. She denied non-steroidal anti-inflammatory use. Hemodynamics were significant for orthostasis, and presenting labs revealed a hemoglobin of 6.9 gm/dL. Abdominal examination was normal. After volume resuscitation, an esophagogastroduodenoscopy was performed. This revealed a normal esophagus and duodenum but multiple large, gastric varices with red marking signs in the gastric fundus. The finding of isolated gastric varices prompted an evaluation for a splenic vein thrombosis. An ultrasound Doppler exam revealed patent portal veins and a patent splenic vein at the level of the splenic hilum. As this did not exclude the possibility of a more central splenic vein occlusion, a CT venogram was ordered for confirmation. This revealed non-visualization of the splenic vein, suggesting a chronic splenic vein thrombosis. Extensive collateral formation was noted around the stomach and spleen. The patient underwent splenectomy with gastric devascularization and ligation of gastric and retroperitoneal varices as definitive treatment. The patient had a full recovery. This case highlights the importance of maintaining a high level of suspicion for the consequences of thrombosis in unusual locations in patients with hypercoagulable states. This case also demonstrates the relative lack of sensitivity of extracorporeal ultrasound for the diagnosis of splenic vein thrombosis.

Wie adhärent wird Clinical Management in randomisierten, kontrollierten Studien durchgeführt?

CM is increasingly used as a control condition in depression research. In the present study, the adherence of standardized CM sessions and their influence on outcome in depressed inpatients was investigated for the first time. In a randomized controlled trial, 43 inpatients with a diagnosis of Major Depression received medication treatment plus three-weekly CM sessions for 5 weeks. The 17-item version of the Hamilton Depression Rating Scale was the outcome measure. A total of 167 randomly selected audiotapes of CM sessions were evaluated using an adherence scale. The CM sessions delivered by psychiatric residents showed overall a high quality and included extensive support by the physician. The length of sessions was extended. The purity of sessions was associated with higher response rates. A diagnosis of Axis II-disorders or -traits and the clinical experience of the physician in years were predictors for less adherend treatments. However, both of them did not function as moderator variables.

CISAPRIDE FOR THE TREATMENT OF INFANTILE COLIC 518

Symptoms of crying and discomfort from infantile colic have plagued both parents and physicians for years. Few therapeutic options exist. The etiology is most likely multifactorial, but some evidence favors motility dysfunction. We initiated a randomized, double-blind, placebo -controlled, crossover study to test the hypothesis that cisapride (0.2 mg/kg QID) would reduce the symptom of crying associated with colic. Healthy, normally growing infants, without symptoms of constipation or GER, and not concurrently treated for colic(medications or elemental formulas) and who fit the classic definition of colic, were enrolled. During the study period, the parents kept crying time logs which have previously been shown to have good correlation to actual crying times (r=0.85-0.9). After a 3 day observation period, the patients received 6 days of either placebo or cisapride which was then crossed over after a 2 day washout period. The parents subjectively rated each week for efficacy of the medication/placebo. At this time, twenty-six patients have completed this ongoing study. Some patients have appeared to show a dramatic response to treatment of colic with cisapride. Results of initial statistical analysis failed to show significant differences in crying times between cisapride (0.87±1.49,mean±SD) and placebo (0.36±1.33) or parental subjective rating. A trend to decreased hours of crying on cisapride over placebo is present, but large standard deviations in crying times between infants exist. A larger sample size may allow demonstration of statistically significant differences in crying times.

Limitations of AIDS Reporting Under Favorable Circumstances

To assess completeness of acquired immunodeficiency syndrome (AIDS) reporting by a consortium of Philadelphia physicians, we compared the consortium's patient data base to AIDS case reports received by the Philadelphia Department of Public Health (PDPH). Several circumstances favored better than ordinary reporting. Consortium physicians were highly motivated, specialized in the care of patients with human immunodeficiency virus disease, had worked with PDPH physicians for years, and knew beforehand about the plan to compare data bases. Of 295 patients in the consortium data base diagnosed with AIDS at least nine months prior to this study, 267 (90.5%) had been reported to the PDPH and 28 (9.5%) had not. Only two of the missed reports were deliberately withheld, each in response to the patient's request. Reporting completeness increased with the time elapsed since diagnosis, varied by practice from 70% to 100%, and was unrelated to patient demographic, insurance status, or occupational characteristics. AIDS reporting for patients in health care occupations (11/13 = 85% reported) was not significantly different from reporting for patients in other occupations (256/282 = 91% reported). We conclude that, under conditions favorable to reporting, approximately 10% of AIDS patients are not reported; the only patient characteristic that predicts reporting is the time elapsed since diagnosis; and nearly all reporting failures are inadvertent.

The Impact of a Physician??s Warning on Recovery After Alcoholism Treatment

Objective. —To study whether alcoholic workers had seen physicians during the year they were identified by their company, whether they recalled physicians' warnings about drinking, and whether such warnings affected outcomes 2 years later. Design. —Workers were interviewed at intake and 2 years later: subgroups who did and did not see physicians and who did and did not recall warnings were compared. Setting. —A company-union employee assistance program. Participants. —Two hundred problem drinkers, newly identified on the job, predominantly male, blue-collar workers. Outcomes. —Drinking, drunkenness, average daily alcohol consumption, and impairment score. Results. —Among the 200 participants, 74% saw physicians in the index year; only 22% recalled warnings. Recall of a warning was associated with liver disease, continued drinking while ill, supervisors' job warnings, older age, and marijuana use. Two years later, those warned were more likely to be abstaining, and sober, and were less impaired. Conclusions. —Recalling a physician's warning at intake into alcoholism treatment was associated with better prognosis 2 years later. However, among this group of employees whose drinking was serious enough to be identified on the job, fewer than a quarter recalled physicians' warnings, even though more than three quarters had seen physicians in the year preceding intake. ( JAMA . 1992;267:663-667)

The Impact of a Physician's Warning on Recovery After Alcoholism Treatment

To study whether alcoholic workers had seen physicians during the year they were identified by their company, whether they recalled physicians' warnings about drinking, and whether such warnings affected outcomes 2 years later. Workers were interviewed at intake and 2 years later: subgroups who did and did not see physicians and who did and did not recall warnings were compared. A company-union employee assistance program. Two hundred problem drinkers, newly identified on the job, predominantly male, blue-collar workers. Drinking, drunkenness, average daily alcohol consumption, and impairment score. Among the 200 participants, 74% saw physicians in the index year; only 22% recalled warnings. Recall of a warning was associated with liver disease, continued drinking while ill, supervisors' job warnings, older age, and marijuana use. Two years later, those warned were more likely to be abstaining, and sober, and were less impaired. Recalling a physician's warning at intake into alcoholism treatment was associated with better prognosis 2 years later. However, among this group of employees whose drinking was serious enough to be identified on the job, fewer than a quarter recalled physicians' warnings, even though more than three quarters had seen physicians in the year preceding intake.

Practice Guidelines and Standards: An Overview

Organized medicine, insurance companies, regulators, and the peer review organizations are all interested in practice guidelines. Recently, the U.S. Congress established the Agency for Health Care Policy and Research, which is charged with overseeing the development of practice guidelines. If properly developed, disseminated, and used, practice guidelines should reduce the incidence of inappropriate care and help control costs. Although guidelines have been used by physicians for years, guidelines now being developed should be more comprehensive, specific, exhaustive, and--on the basis of the best scientific evidence of effectiveness and expert opinion--more effectively discriminate between useful and useless care. Practice guidelines can improve the quality of care when used voluntarily by physicians in practice, when used as standards for quality monitoring and assurance programs, and when used as the basis for reimbursement for services. All interested parties should share responsibilities for the research, development, and production of appropriateness criteria, their translation into guidelines and standards, and the dissemination and maintenance of the guidelines, including evaluation, revision, and updating.

Treatment of Infective Endocarditis

Endocarditis possesses a mystique few other diseases in clinical medicine have. I recall a time—not very many years ago—during my residency training when a practicing internist told me of a patient with bacterial endocarditis for whom he was caring in his community hospital. I thought patients with such fascinating conditions were shunted to gargantuan medical centers in the metropolis! Of course, my naivete disappeared when I entered the real world of medical practice and learned how commonly questions about endocarditis arise. Although the disease has fascinated physicians for years, its changing nature requires periodic reassessment. There has been a profound alteration in the type of patient in whom the infection develops, from the young person with rheumatic valvular disease to the elderly with degenerative or calcific valvular changes, patients with mitral valve prolapse, intravenous drug users, persons with prosthetic valves—groups presenting problems not even envisioned in the days of Osier.

Single-Dose Treatment of Cystitis

Based on the rationale that (1) cystitis is a superficial mucosal infection pathologically, (2) successful treatment of bladder infections depends on antibiotic levels achieved in urine, and (3) many antibiotics achieve very high urinary concentrations, the concept of treating acute cystitis with a single-dose antibiotic regimen has been attractive to physicians for years. The observation that a single irrigation of the bladder with neomycin sulfate cures many patients with bladder bacteriuria further suggested that brief drug therapy might well be effective. Unfortunately, early attempts to use single-dose sulfonamides, streptomycin sulfate, and cephaloridine were not uniformly successful. Inclusion of patients with chronic infections, unrecognized upper-tract involvement (localization studies were not usually done), and drug-resistant organisms may have contributed to single-dose treatment failures. However, in 1967 Gruneberg and Brumfitt 1 cured 88% of infections judged clinically to be cystitis with a single, 2-g dose of sulfadoxine (sulphormethoxine). Subsequently, Ronald et al, 2

The Foreskin Saga

A recent article, Whither Foreskin 1 again questions the value of circumcision, a problem bandied by physicians for years. It also calls to attention that this subject lends itself to some fanciful titles for medical articles, eg, Penile Plunder, 2 The Fate of Foreskin, 3 and The Rape of the Phallus, 4 a group I feel justified in joining. In June 1965, Morgan 4 attacked circumcision as barbarous (Iagree), of no health value (I am shocked), and resulting in decreased sexual pleasure in the male (I am depressed). I am certain that I was not alone among the circumcised readers of that article in becoming quite concerned. My father was a young physician at the time of my circumcision and presumably had it done with best intentions. Nonetheless, although I am not a psychiatrist, a number of questions came to my mind. Did this represent an unconscious attack

THE CHEMICAL PATHOLOGY OF PYLORIC OCCLUSION IN RELATION TO TETANY

Gastric tetany, that form of nerve hyperirritability associated with vomiting, dilatation of the stomach and pyloric occlusion, has interested and puzzled physicians for years. The condition is included in the realm of surgery, since it is usually the result of a gross lesion near the pylorus, and, consequently, its cure depends on operative measures. The clinical literature on the subject has established no definite etiology and the various theories proposed to explain the relationship between the disturbance of gastric physiology and tetany have been unconvincing. In this paper are recorded the clinical histories and blood analyses of seven cases of obstruction at or near the pylorus, with a summary of the results of some experimental work on dogs. The facts to be presented support the theory that directs attention to the loss of hydrochloric acid from the stomach as the cause of critical changes in the composition and physiochemical properties