Practitioner's Office Research Articles

Microelectronic and nanoelectronic interfacing techniques for biological systems

A variety of electronic and opto-electronic interfacing techniques for the transduction of biological signals is available which utilise technology normally accessed for microelectronic and nanoelectronic semiconductor device fabrication. Correct interfacing of electronics to biological systems leads to the possibility of creating a range of devices which are capable of being used as biosensors or as monitoring units for individual biological cells. This can be thought of as 'bioelectronic interfacing'. Fabrication of these devices at the microelectronic scale leads to the creation of multi-analyte sensors or electrode arrays 'on chip'. There are many application areas for these devices, ranging from disposable multi-analyte sensors for use in the general practitioner's office to novel research tools allowing the monitoring of networks of neural cells in vitro. The Bioelectronics Research Group at the University of Glasgow has fabricated and tested multi-microelectrode devices for monitoring biological cells in culture. Electrical signals have been recorded extracellularly from individual neural and cardiac cells in vitro; the adhesion and movement of individual cells have been monitored on microelectrodes via electrical impedance techniques. The devices can be adapted as multi-analyte biosensors by immobilising a range of biological molecules on the electrode array. It is possible to further utilise micro- and nano-fabrication techniques to provide patterned molecular arrays for sensors, cell guidance or molecular electronic applications on planar surfaces. One important future application of this might be in nerve repair where guidance cues could be provided for nerve regrowth on surfaces and some examples of this will be shown. At the smallest scale, we are now trying to image and interact with biological molecules on these surfaces using scanning tunnelling microscopy. Possible benefits of this might be better fabrication and immobilisation of molecules for biosensors and the optimisation of surface biocompatibility treatment.

Determining the Value of a Periodontal Diagnostic Test

The purpose of this analysis is to present a method to determine the value of diagnostic tests for evidence of bacterial activity related to periodontal disease. Five population studies are discussed: 1) screening the general population; 2) screening the patients of a general practice; 3) diagnosing initial patients referred to a periodontist; 4) monitoring periodontal maintenance patients; and 5) monitoring postsurgical refractory patients. A decision tree is constructed in which the primary decision branches are test and no test. Chance branches after the test branch were test positive and test negative. The treatment alternatives in the treatment branches were prophylaxis and oral hygiene, scaling and root planing, and advanced periodontal therapy (including surgical intervention and/or antibiotics or chemotherapies). Probabilities for the prevalence of disease in each population were obtained from epidemiological surveys. Disease activity and outcome states were estimated from clinical studies of periodontal treatment. For initial periodontal patients, using a sensitivity of .87 and a specificity of .84 the value of the test branch is .851 versus .566 for the no test branch. Assumptions on the diagnostic test's sensitivity and specificity and the utility of outcomes were tested with the decision analysis techniques of sensitivity and 2-way threshold analyses. These analyses show that using a test had a greater value than no test for older patients in the general practitioner's office, and for the 3 types of periodontal treatment patients. In contrast, using the test had a lower value than not using the test in younger dental patients in the general practitioner's office and for screening the general population. The diagnostic and treatment schemes proposed here are amendable to rigorous testing to evaluate their reliability and usefulness.

Prevalence and Incidence of Diabetes in a Swedish Community 1972–1987

The prevalence and incidence of diabetes mellitus were studied from 1972 to 1987 in Laxå, a rural community with 8500 inhabitants located in mid-Sweden. Data were collected from clinical records at the primary health care centre in Laxå, from departments of internal medicine and paediatrics and from a general practitioner's office in the area. In addition, a case finding procedure involving 85% of the residents aged 35-79 years was performed in 1983-1987. The age-standardized prevalence of diabetes rose significantly (p less than 0.001) from 26 per 1000 in 1972 to 43 per 1000 in 1987. The largest rise in prevalence for males occurred in the age group 45-54 years and for females in the age group 65-74 years. The age-standardized mean annual incidence of diabetes was 3.46 per 1000 population. A small (non-significant) increase in incidence of Type 2 diabetes over time was seen in men which may in part be an effect of the case finding strategy. The overall incidence rates thus appeared to be rather stable while the prevalences tended to increase, probably mainly due to earlier detection of diabetic individuals in recent years, leaving a larger number of patients with a longer duration of diabetes to be cared for in the future.

Nursing Homes and Fax Machines-Reply

In Reply.— We are happy to respond to Dr Patrick's question on confidentiality. This concern was also a major factor in our initial inquiries. Our fax machine is located in the geriatric nurse practitioner's office, which is the hub of nursing home activities. Each nursing home telephone number is programmed into the machine and given its own autodial button and label. Each nursing home name is also keyboard entered at the time of programming. When a nursing home is called using the autodial feature, a visual display confirms where the call is being sent. The only numbers entered into our machine are those of the local nursing homes. We have on occasion pressed the wrong button and sent an order to the wrong nursing home, but given the configuration of our system, we have never called for a pizza or an attorney. Because of the manner in which medication

Topical Anesthetic Abuse

Topical ocular anesthetic abuse is a serious disorder causing keratitis and persistent epithelial defects. It may be the result of either prescription by the patient's eye care practitioner, theft from the practitioner's office, or occult additives in therapeutic medications. The authors report observations of six individuals suffering from this disorder which suggest that persistent epithelial defects, corneal stromal ring infiltrates, disproportionate pain, and prescription or nonprescription substance abuse may be factors involved. Penetrating keratoplasty was required to treat corneal perforation in two patients, and permanent corneal structural damage was noted in two eyes. Two eyes had a relentless downhill course culminating in enucleation. Because five of the six patients were diagnosed and treated as having presumed Acanthamoeba keratitis during the course of their disease, topical ocular anesthetic use should be included in the differential diagnosis of chronic keratitis and may masquerade as Acanthamoeba keratitis. The authors believe that practitioners should not prescribe or dispense topical anesthetics and should avoid clinical settings which provide an opportunity for the theft of topical ocular anesthetics.

Is Your Office Safe? No

The practitioner's office can be an unsafe environment for fitting contact lens (CLs), owing to numerous reservoirs of microbial contamination. These include sinks, trial lenses, solutions, lens cases, multidose dropper bottles, and storage trays. Microbes may also be introduced to the eyes via the practitioner's fingers, the patient's lashes or lids, or cosmetic residues on the ocular adnexa. Because sterility is difficult to achieve in an office, CL fitters must accept the more realistic goal of disinfection. Periodic cultures are necessary to monitor the effectiveness of office hygiene and disinfection. Cultures are especially important, considering that the panel of organisms routinely used to test lens care solutions may not reflect those in office settings, which may become resistant to preservatives. It has been shown, for example, that 50% of chlorhexidine-preserved solutions used in offices can become contaminated with Serratia marcescens within 7 days of bottle opening. At present, it appears that contamination is best avoided by using solutions containing 15 ppm of polyaminopropylbiguanide (PAPB). Frequent replacement of solutions, trial lenses, and lens cases may also help to reduce the likelihood of microbial contamination in the office.

Disc haemorrhages and glaucoma in a general ophthalmic practice.

The composition of the clientele from an ophthalmological practitioner's office is described with special reference to the occurrence of glaucoma and disc haemorrhages (h in singular; hh in plural). This study could not be planned as an epidemiological survey and gives no clue to sensitivity or specificity of hh in glaucoma. During a period of about 10 years ending with 1986 there were 731 patients with h and/or glaucoma. When detected, 185 patients had h but no glaucoma, 33 had both h and glaucoma and 513 had glaucoma but no h. During the follow-up period hh were detected in 83 cases of glaucoma, and glaucoma developed in 27 cases with hh. The detection rate of hh among glaucoma was low but steady, indicating that hh may occur at any stage of the glaucoma process. This study shows no predilection for hh in cases with general hypertension or diabetes, nor is the frequency of hh among pseudoexfoliation cases significantly lower than among cases without this stigma.

Preferential Looking and Acuity Card Testing in the Private Practitioner's Office

Clinical experience with the use of a forced choice preferential looking device and with an acuity card testing procedure in a private pediatric ophthalmology practice is described. An attempt was ...

Utility of Rheumatoid Factor in the Diagnosis of Juvenile Rheumatoid Arthritis

Rheumatoid factor is commonly used by clinicians to assess children with possible juvenile rheumatoid arthritis. To assess its usefulness, we reviewed the case histories of patients in whom latex agglutinating rheumatoid factor was determined during 1981 to 1982 at our institution. A total of 437 charts were available for review. There were 11 patients with positive tests for rheumatoid factor, of whom five had juvenile rheumatoid arthritis, all polyarticular. A total of 426 children had negative results, of whom 100 had juvenile rheumatoid arthritis. This yields a sensitivity of 4.8% and a specificity of 98%. We then estimated the prevalence of juvenile rheumatoid arthritis in three clinical settings: a primary practitioner's office, a tertiary children's hospital walk-in clinic, and a pediatric rheumatology center. The predictive values and marginal benefits for rheumatoid factor were then calculated in those settings using Bayes' theorem. In the two general outpatient settings, the primary practitioner's office and tertiary walk-in clinic, the positive predictive values were 0.7% and 0.5%, respectively; marginal benefits were 0.4% and 0.3%, respectively. Rheumatoid factor testing appeared to be of some benefit in the pediatric rheumatology center with a positive predictive value of 72.5% and marginal benefit of 22.5%. In no case was rheumatoid factor testing helpful in establishing a diagnosis of juvenile rheumatoid arthritis or in ruling it out. Testing for rheumatoid factor is a poor screening procedure for juvenile rheumatoid arthritis in the general situations in which it is more likely to be requested and of supportive diagnostic value only in the highly restricted population of older children with polyarticular arthritis.

DIFFERENCES IN PEDIATRIC SUBSPECIALITY TRAINING REQUIREMENTS

The special requirements of the Accreditation Council for Graduate Medical Education state that the subspecialty rotations in pediatric training programs should not consume more than 11 months. No guidelines are offered concerning which subspecialties should be required or offered as electives. To examine current residency training practices we polled all pediatric residencies with at least 20 residents. Of 109 programs, 37 (34%) responded. Responses showed that the number of required subspecialty months ranged from 0 (22%) to 10 (3%) with a mean of 2.9 months. Subspecialty rotations most frequently required by pediatric training programs are: development 15 (41%), cardiology 13 (35%), hematology/oncology 13 (35%) and neurology 11 (30%). Pediatric surgery is required by 7 programs (19%), while only 6 (16%) require infectious disease and only 4 programs (11%) require experience in a practitioner's office. In addition to required rotations, elective time available for subspecialty training ranged from 4 to 10 months. Required subspecialty experiences vary widely among graduates of United States training programs. Potential explanations include differences in the perception of what knowledge and expertise are required for entry into practice as well as factors other than educational considerations, such as patient service commitment and faculty influence. Whether these differences in required subspecialty training are beneficial or detrimental requires further investigation.

Screening for visual field abnormalities with automated perimetry

Recent studies indicate that automated perimetry can serve as an effective method of screening for visual field abnormalities associated with ophthalmologic and neurologic disorders. The techniques have been successfully applied to the private practitioner's office for screening of patients and to mass visual field screening of the general population. This paper describes the principles underlying automated perimetric screening, evaluates the capabilities and limitations of such techniques, and provides some general guidelines for using automated perimetric screening procedures.

Benevolent Gambling.

It has been said that medicine is the only profession which seeks to "put itself out of business"--that is, which has as its highest goal the prevention of those conditions for which the treatment is its stock in trade. There can be no serious argument with this preventive ideal: the conditions on which health practitioners focus their professional attention are, with the sole exceptions of pregnancy and childbirth, theoretically unnecessary and--apart from the issue of "secondary gain"--distinctly disadvantageous to those who develop them. This statement is as true of conditions which bring people to the offices of mental health practitioners as it is of conditions which bring them to physicians. It is my purpose in this paper to examine the concept of prevention as it applies to mental and emotional disorders and to assess the current state of allegedly preventive professional activities.

Active immunizations for adults.

Lack of effective antiviral drugs has led to dependence on vaccines for control of many viral diseases. These diseases are primarily diseases, so immunization activities have largely been directed toward children. Notable exceptions to this emphasis on children are influenza immunizations. Even with effective viral vaccines, significant efforts to im­ munize children, and generous financial support to purchase vaccines, it is becoming evident that a portion of the adult population remains susceptible to one or more of these common diseases. These adults are victims of one or more of the following circumstances: (a) the widespread use of vaccines creates a herd immunity that reduces the usual exposure to these viruses; (b) not all persons are immunized in childhood; or (c) some persons receive ineffective or mishandled vaccines (vaccine failure). The bottom line is that an increasing proportion of adults could greatly benefit from childhood vaccinations. The situation is somewhat complicated by the relative lack of knowledge of these vaccines among nonpediatricians, as well as indications that these vaccines are less antigenic (1) and at times more reactive (2) in adults. Adults are the primary target for influenza and rabies vaccines, although children frequently receive the latter. Influenza immunization creates con­ fusion, frustration, and/or fright because of the many influenza strains that have been isolated, the phenomena of antigen drift and shift, the unpredicta­ bility of influenza outbreaks, the varying manufacturing processes, the cre­ ation of priority categories to receive the vaccines, frequent reactions, and the unexplained relation between Swine influenza vaccine and the Guil­ lain-Barre syndrome. Decisions on administration of rabies vaccination may be delayed and the vaccine may cause serious side effects. Several viral vaccines are required only by the traveler, and at times are unavailable at the family practitioner's or internist's office. Finally, in the

Behavior Modification and Haloperidol in Chronic Facial Pain

Neuralgiform pain and migrainous pain, both of which are amenable to drug therapy, comprise a relatively small percentage of the group of patients with facial pain who come to the practitioner's office. The largest group of facial pain patients are those with myofascial connective tissue disorders. A second group includes patients with neuropathic pain due to trauma such as oral surgery. A third group is made up of those without any identifiable focus of pain in the extracranial tissue. In these three nonneuralgiform and nonmigrainous groups, it is thought that personality factors affecting psychophysiologic mechanisms are of great importance. These patients are generally difficult to treat. A variety of modalities of therapy, such as behavior modification, hypnosis, and biofeedback, has been reported as helpful in some of these patients. In this report we focus on 12 subjects who failed with all these forms of therapy. We found that they responded to relaxation therapy (after Jacobson) along with haloperidol. We describe further characteristics of these patients and details of our method of treatment.

Principles of Quantitative Perimetry: Testing and Interpreting the Visual Field

Most ophthalmologists agree that accurate perimetry is indispensable in the diagnosis and management of ocular disorders, especially glaucoma and neuro-ophthalmologic diseases. Sloppy examination of the visual field may suggest a wrong diagnosis or provide the ophthalmologist with a false sense of well-being while his patient's vision deteriorates. Unfortunately, skillful perimetry is all too uncommon in many office practices. Visual field testing is often relegated to unskilled technicians who lack interest, use uncalibrated or inaccurate equipment, or conduct hasty and undirected examinations. Ophthalmologists often lack sufficient knowledge of theoretical and practical aspects of perimetry. The major goal of this new perimetric technique textbook is to upgrade the quality of visual field testing in the practitioner's office. The first part of the book, which is clearly directed at the ophthalmologist, considers in some detail the theoretical basis of perimetry. A long chapter, which constitutes nearly one fourth of the book, deals with

Medical care in a Free Community Clinic

IN THE 1960s a number of "free clinics" were developed in various North American cities.¹These clinics had the common objective of providing medical care and counseling in an atmosphere different from the practitioner's office, hospital clinic, or university dispensary. Usually organized by young physicians and health care activists, they were free in the sense of charging little or nothing for their services; using the word in another sense, they were free of the usual structure of health care provision. An attempt was made in these clinics to keep the patient and the patient's needs paramount, to minimize paper work and bureaucracy, and to make the physician a member rather than director of the health team. Particular emphasis was placed on avoiding judgmental attitudes about venereal disease, pregnancy, birth control, or drug use, and on providing patient education in all these areas. The free clinics were in large part

Medical Care in a Free Community Clinic

IN THE 1960s a number of "free clinics" were developed in various North American cities.¹These clinics had the common objective of providing medical care and counseling in an atmosphere different from the practitioner's office, hospital clinic, or university dispensary. Usually organized by young physicians and health care activists, they were free in the sense of charging little or nothing for their services; using the word in another sense, they were free of the usual structure of health care provision. An attempt was made in these clinics to keep the patient and the patient's needs paramount, to minimize paper work and bureaucracy, and to make the physician a member rather than director of the health team. Particular emphasis was placed on avoiding judgmental attitudes about venereal disease, pregnancy, birth control, or drug use, and on providing patient education in all these areas. The free clinics were in large part

Peer review for quality care in private solo dental practice

A proposal by which peer review of private dental practices can be carried out is made. The history of and demand for peer review of medical care and the existence of peer review of dental care in group practice and in tax-supported clinics is described. This type of evaluation is needed in the offices of private solo practitioners who are paid on a fee-for-service basis. A procedure for conducting this review is presented. A proposal by which peer review of private dental practices can be carried out is made. The history of and demand for peer review of medical care and the existence of peer review of dental care in group practice and in tax-supported clinics is described. This type of evaluation is needed in the offices of private solo practitioners who are paid on a fee-for-service basis. A procedure for conducting this review is presented.

The Eye in General Practice

This book is written by an ophthalmologist for general practitioners. Now in its sixth edition, it clearly fills a need that is felt in English-speaking countries. The present revision holds the line with respect to limited content and detail. The new color illustrations are well chosen and of good quality. If it is fair to criticize a work beset by the problem of what to exclude and what to admit, this reviewer would like to have seen a fuller treatment of angle-closure glaucoma with respect to anatomical predisposition and pathophysiological mechanism. Perhaps the next edition can expand on the method of estimating narrowness of the angle (by flashlight shadow) and recognition of an attack precipitated by dilatation of the pupil in the practitioner's office. A well-drawn diagram and a well taken photograph would help immeasurably here. The patient should be instructed to reportimmediatelyany blurring, nausea, or headache that

PEDIATRIC PERCEPTIONS: THE PUBLIC HEALTH NURSE—A NEGLECTED RESOURCE

I Write to emphasize the very great assistance, particularly the kind of assistance, that I find dedicated nurses especially trained in pediatrics and Public Health can give to pediatricians. My emphasis is not on the number of patients who can be seen but the quality of service that can be given. For many years my academic environment and concentration on teaching and consultation protected me from the pressures present in a busy practitioner's office. During these years, I was often impressed by the great gratitude from parents of patients because, as they would say, "You have answered a lot of our questions." Often they would also say: "We like our own pediatrician very much, but his office is so crowded and he is so busy that we feel guilty in asking him all the questions we have about our children. What we really like about this visit is the way you have so generously given us of your time to answer all those questions that bother us."So, when I recently saw the new offices of a pair of pediatricians starting into practice, I was frankly upset to notice that in the many small examining rooms it was evident that chairs were kept at a minimum. Still more upsetting was the explanation that this arrangement made it easier for the physician to walk out of the room because he would be standing. Not only would there be less awkwardness in interrupting a conversation but the mothers would be less likely to sit down and ask questions if there were not enough chairs for everyone to be seated.