Significant Clinical Experience Research Articles

Changing approaches to the diagnosis of tuberculosis.

Since this subject was last reviewed in the American Journal of Respiratory and Critical Care Medicine (1), new diagnostic tests for tuberculosis have been approved for use in the United States, Europe, and other industrialized regions, and there has been significant clinical experience with their use. In addition, several other new diagnostic assays have been studied and may be nearing approval by the Food and Drug Administration (or similar agencies in other countries) for routine clinical use. This commentary will review the need for new diagnostic tests for tuberculosis, examine the status of currently available tests and of several promising tests in development, and discuss potential scenarios in which such diagnostic tests might be used.

Continuing medical education examination—facial aesthetic surgery

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic plastic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts. Learning Objectives: After studying this article, the reader should be able to: Determine the aesthetic objectives of an osseous genio-plasty. Describe the important surgical anatomy for genio-plasty. Physicians may earn 1 hour of Category 1 CME credit by successfully completing the examination based on material covered in this article. The examination begins on page 517.

Forehead plasty for facial rejuvenation

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic plastic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

A personal technique for facial rejuvenation

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic plastic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts. # Commentary {#article-title-10}

The alar sliding graft for correcting alar collapse and expanding the nasal tip

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic plastic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Simultaneous breast augmentation and mastopexy

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Avoiding complications of transblepharoplasty lower-lid and midface rejuvenation

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Finesse in Breast Augmentation Through Use of the “No-touch” Technique

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Tarsal Suspension Canthoplasty

“Operative Strategies” is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts. # Commentary {#article-title-2}

Circumferential Body Lift

Operative Strategies is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Face and neck lift:The subcutaneous approach

Operative Strategies is a fully illustrated guide to the favorite techniques of aesthetic surgeons based on their significant clinical experience. Authors are Aesthetic Society members or other recognized experts.

Evaluation of the mechanical environment during distraction osteogenesis.

Physical forces have been hypothesized to direct the process of bone regeneration during distraction osteogenesis. However, despite significant clinical experience, relatively little is known about how the mechanics of distraction influence bone formation. This study investigated net fixator forces and strains in the distraction callus during bilateral lengthening of tibiae in New Zealand White rabbits. Distractions yielded a classic viscoelastic response with a sharp increase in fixator force, followed immediately by significant relaxation. Tension acting on mesenchymal gap tissue caused by distraction was estimated to reach more than 30 N by the time full lengthening was achieved. Average maximum cyclic strains within the distraction zone during ambulation were estimated to be 14% to 15% and supported by the results of fluoroscopic imaging. Paradigms for fracture healing have hypothesized that such strains are incompatible with new bone formation. The documented clinical success of distraction osteogenesis at stimulating large volumes of new bone suggests that other mechanisms that warrant additional investigation may be at work during distraction.

Osler and ophthalmology

Sir William Osier (1849–1919) has been called the father of American medicine (Fig. 1). This Canadian from Dundas, Ontario is remembered as a great clinician, scientist and teacher*. His name survives as a burden for medical students and forgetful clinicians who must distinguish between the Osler-Weber-Rendu disease, the Osler-Vasquez disease, the Osler phenomenon, the Osler sign, Osler’s triad, and of course Osler’s nodes. Nevertheless, his most enduring contributions probably lie in the structures he imposed on medical education and medical practice. He was an active, but gentle reformer with an abiding affection for medical students and for the common physician engaged in general practice. He was instrumental in organizing a system where American medical students would first obtain a general education before going to medical school. He also changed the nature of the medical curriculum to include significant clinical experience — allowing students to actually examine and care for patients on the wards. To his credit, the institutions which he established in medical education have survived largely unchanged to the present day. In addition, he wrote The Principles and Practice of Medicine (1892) a seminal textbook that served as the standard reference for generations of physicians. Nevertheless, before he had done any of these things, the young Willie Osler had different plans.

Response and critique

This paper is being published when there is concerned discussion about the relationship of psychiatry to the community mental health movement. The number of psychiatrists in CMHCs has dropped considerably. Some would say that the CMHCs are pushing psychiatrists out while others would point the finger in the opposite direction, suggesting that psychiatrists are abandoning the CMHCs. In any case, the matter is important enough for the American Psychiatric Association and the National Council of Community Mental Health Centers to be planning a national meeting on the topic. If psychiatrists continue to diminish in numbers in CMHCs or if they are only to be part-time prescription signers, there is little point in trying to train more of them for such careers. If they are to have more significant involvement, it is essential to explore the relationships between academic programs and CMHCs. The concerns on each side reflect more than suspicion by the CMHCs that the academic programs will rip them off and by the academic chairmen that the resident will be used for service instead of being educated. The problems reflect the current criticisms of the CMHCs, namely that they have changed from the original health services model to a social activist model, that they have adopted anti-medical attitudes relegating psychiatrists to signing prescriptions or insurance forms, and that they have given undue emphasis to unproven prevention programs while neglecting the seriously mentally ill. Such criticisms are of intense concern to those of us who early identified the CMHC as the basic delivery system for the public sector and who have advocated a model of community mental health as developed in the mid 1960's. To have a successful relationship between an academic program and a CMHC there must be an underlying assumption that the CMHC movement will continue (hopefully more like the original than the present model) and that it will involve psychiatrists in appropriate numbers and professionally meaningful roles. If so, all psychiatrists ought to get a significant clinical experience in such a center. The issue is not one of "control"--academic departments have long been placing students in clinical settings which they don't control. A basic issue in the relationship is that the CMHC must recognize that the reason for a student being assigned to any clinical setting is to learn--not just to give service. Whether the

Revascularization of the celiac and superior mesenteric arteries.

Numerically significant clinical experience relative to the surgical treatment of arterial occlusive disease of the gastrointestinal tract has not been published. Attempted revascularization of the celiac and mesenteric arteries has been documented only by isolated case reports, and in these most of the operative procedures were performed under emergency situations for acute mesenteric thrombosis. 6,11-15 Even rough appraisal as to incidence of celiac and superior mesenteric arterial occlusive disease is difficult because until recently 2 essential factors for this have been lacking—namely, general awareness of the problem and application of techniques for confirming the diagnosis. Although the abdominal angina syndrome will probably never rival the clinical importance of such occlusive arterial lesions as those affecting the brain, heart, and legs, it most certainly will prove to be far more significant than presently considered. One reason ischemic problems of digestive organs may remain less than common is that in most instances