Development of a practice-oriented curriculum. 9. Arthrology

The background problem this article addresses is the need to reduce the quantity of medical information to a standard core of knowledge relative to the overwhelming amount of scientific information to be learned in the limited amount of time students have available. The article is part of a study the aim of which is to define a core students, independent of their further medical specialization. The design of this study is a survey of a representative sample of Swiss general practitioners who were asked to identify in the list of Nomina Anatomica the most prevalent anatomical entities (terms) occurring in their practice. To assure the representativeness of the sample the identified terms were compared to prevalent diagnoses of all Swiss general practitioners and to the incidence of cases in German hospitals. From the list of International Anatomical Nomenclature (IANC) 280 anatomical terms could be identified with respect to arthrology. Of these, 250 were judged uniformly by the physicians: 52 terms were considered relevant, while it was not though necessary for 198 terms to be relevant, while it is was not thought necessary for 198 terms to be learned, i.e. general practitioners agreed on 89.3% of the terms. Only 29.7% of the terms in the IANC list belong to anatomical core knowledge in arthrology. There is evidence for the representativeness of these findings when compared to the prevalence of diagnoses made by general practitioners and to the incidence of cases in German hospitals. The method of using criteria of prevalence in a survey to identify a core of knowledge in medicine is suited for the definition of learning content necessary for professional purposes.     

Short-term preoperative radiotherapy results in down-staging of rectal cancer: a study of 1316 patients

OBJECTIVE: The incidence of back pain in children in our country is unknown. Several causes can produce this symptom, but it is necessary to rule out pathologies that require specific treatments. The goal of this work was to study the incidence and the etiology of back pain in children in our country. PATIENTS AND METHODS: We present a prospective study done in our Orthopedic Department during a period of 7 months. Twenty-two patients were referred with back pain of at least two months duration. The incidence was 2.9% compared to the total number of patients. The average age ranged from 7 to 17 years. RESULTS: A careful history and a radiological examination diagnosed 50% (11 cases) of the causes of backache in the present study. An idiopathic etiology was the most frequent cause and represented 9 patients (41%). In the remaining 12 cases (59%) pathological causes that required special treatment were identified including 2 cases of Scheuermann disease, 4 cases of painful scoliosis, 3 spondylolysis with spondylolisthesis, 2 cases of discitis, 1 benign neoplasm and 1 psychogenic cause. CONCLUSIONS: We recommend conservative management with the use of medication for relief of pain and physical therapy in the idiopathic cases. In the remaining cases, the specific treatment of the disease can improve the back pain.     

Race, asthma, and persistent wheeze in Philadelphia schoolchildren

OBJECTIVES: Many studies show asthma to be more common in Black than in White children. This study assessed how much of this difference remains after adjustment for other potentially race-associated predictors of asthma. METHODS: We assessed the predictors of active diagnosed asthma and persistent wheeze in 1416 Black and White Philadelphia children aged 9 to 11 years, as reported by parents. RESULTS: Black race remained a significant predictor of active diagnosed asthma (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 1.3, 4.1) but not of persistent wheeze (OR = 1.0; 95% CI = 0.6, 1.8). The excess risk of asthma in Black children was not appreciably altered by adjustment for other demographic and environmental factors. CONCLUSIONS: Black race is an important risk factor for active diagnosed asthma in these urban children, a relationship not explained by social factors. This finding and the lack of an association of race with persistent wheeze after adjustment for social factors suggest that race may be more important to the acquisition of an asthma diagnosis than to the prevalence of the symptoms.     

Current status of general hospital use for patients with tuberculosis in the United States: eight-year update

Questionnaires were sent to the tuberculosis control officers in 50 states to determine the current use of general hospitals and sanatoriums for patients with tuberculosis. Replies were received from 46 states; 4 states supplied information by telephone. Fifteen states reported using both general hospitals and specialized hospitals for treatment of tuberculosis in 1980. The most common reason for the continued use of a state-operated facility for patients with tuberculosis was the lack of funds to pay for care in general hospitals. Average length of stay in general hospitals was 21 days or less; in specialized facilities, it was 60 to 90 days. The specialized hospitals usually combined care for patients with mental illness, mental retardation, other chest or chronic diseases, and tuberculosis. With one exception, there were no plans to close any of the remaining specialized facilities. No significant problems with respect to care of patients with known tuberculosis in general hospitals were documented.     

Traumatic subdural pneumocephalus causing rise in intracranial pressure in the early phase of head trauma: report of two cases

The mortality rate is high and prognosis is worse among new-borns with prenatal diagnosis of heart malformation, mainly due to factors such as its association with other malformations, and a range of more severe diseases probably resulting from the predominance of the obstetric use of the four chamber view. In this study we retrospectively assessed the range of cardiopathies diagnosed by foetal echocardiography and their evolution, compared with previous years. From January 1994 to December 1995, 1173 foetal echocardiograms were performed at a gestation age of 24 weeks. Sixty-one foetuses (5.2%) had cardiac anomalies, structural in 56 and arrhythmia in 5. The risks and indications were maternal in 37%, foetal in 31%, familial in 17% and environmental in 15%. Three were false negatives (VSD:2; truncus arteriosus: 1). Five died in utero, and 18 were assessed after birth with a mean gestational age of 37 weeks and birth weight of 3 Kg, a caesarean section was performed in 9. All but one were born in central hospitals. Six children were operated on. Two children died, one after surgery. Compared with the four previous years of activity, indication due to foetal risk rose from 6 to 31%, the number of cases diagnosed with heart disease increased from 14 to 30 per year, and the mortality decreased from 59 to 11%. Despite this, we still observe that the vast majority of new-borns who are hospitalised due to a severe heart disease had no prenatal diagnosis, indicating the need to continue our educational policy in this field.     

Epidemiological aspects of inflammatory bowel disease in a north Italian population: a 4-year prospective study

OBJECTIVE: To determine the incidence and clinical characteristics at presentation of inflammatory bowel disease (IBD) in a defined area of north Italy. DESIGN: A 4-year prospective population-based epidemiological study. SETTING: An area in Lombardia defined by the National Health Service scheme with about 294,000 inhabitants, two referral hospitals and 259 general practitioners (GPs). PATIENTS: Subjects presenting to a GP with symptoms compatible with IBD underwent a diagnostic work-up at one of the referral hospitals. Those with ulcerative colitis (UC), Crohn's disease (CD) or indeterminate colitis diagnosed according to a defined protocol were included, as were residents of the area with IBD diagnosed elsewhere. Rigid case ascertainment methods were used. Patients were followed for one year; 125 patients were identified. RESULTS: The patient ascertainment rate was constant over the 4 years; UC was diagnosed in 82 patients, CD in 40, and indeterminate colitis in three. The mean annual incidence of IBD for the whole period was 10.6/10(5) inhabitants (95% confidence limits, 7.2-15.1), 7.0/10(5) for UC (4.3-10.7) and 3.4/10(5) (1.6-6.3) for CD. The mean interval between onset of symptoms and diagnosis was under 6 months. The clinical characteristics of our patients were similar to those of north European and American series. CONCLUSION: The incidence of IBD was higher than previously observed in Italy but was still lower than in some north European countries and in the USA. Our data could be used as a basis for future longitudinal studies and in international comparative investigations.     

Effect of physician-recommended treatment on mental health practitioners' attributions for chronic fatigue syndrome.

Objective: To evaluate whether differing treatment recommendations for chronic fatigue syndrome (CFS) by physicians influence attributions about CFS among mental health practitioners. Participants and Study Design: 93 mental health practitioners were randomly assigned to 1 of 3 conditions. All groups read the same case study of a person diagnosed with CFS, with the only difference between groups being the type of treatment recommended by a physician. The treatment conditions included a drug trial (Ampligen) or 1 of 2 differing psychotherapy approaches, cognitive–behavior therapy with graded activity or cognitive coping skills therapy. Results: Ss in the 3 groups did not differ with respect to their prior familiarity with CFS. Ss who read the case study proposing treatment with Ampligen were more likely to report that the patient was correctly diagnosed and more likely to perceive the patient as disabled than those whose case study described cognitive–behavioral therapy with graded activity as the treatment. Conclusion: Results of this investigation support the hypothesis that physician recommendations for CFS treatment can influence subsequent attributions about a patient's illness among mental health practitioners. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychological factors in psychosomatic diseases: an outline of research results

This article presents an outline of 13 research studies which were carried out in the 1980s at the Clinical Psychology Division of the Psychology Department at the Faculty of Arts in Ljubljana. The studies concentrated on various psychosomatic diseases and dysfunctions by applying 26 psychodiagnostic instruments. The problems, the usefulness of the instruments, and basic characteristics of diseases were analyzed, and a model for further research into psychological factors in psychosomatic diseases was proposed. We are of the opinion that the fundamental dimensions of personality--aggressiveness and ways of coping with stress within a specific life style and supported by information from life history--deserve special attention. Therefore, we suggest that a set of basic psychodiagnostic instruments be compiled. We also suggest that particularly general practitioners be acquainted with these factors involved in psychosomatic dysfunctions, because they most often confront problems of this kind. We believe that somatic therapy is doubtless necessary, but insufficient, because a patient is not treated as a whole, which is imperative in psychosomatics. This is a sphere where medicine and psychology will meet more regularly in the future.     

The role of state policies and programs in buffering the effects of poverty on children's immunization receipt

OBJECTIVES: This study assessed the influence of public policies on the immunization status of 2-year old children in the United States. METHODS: Up-to-dateness for the primary immunization series was assessed in a national sample of 8100 children from the 1988 National Maternal and Infant Health Survey and its 1991 Longitudinal Follow-Up. RESULTS: Documented immunization rates of this sample were 33% for poor children and 44% for others. More widespread Medicated coverage was associated with greater likelihood of up-to-dateness among poor children. Up-to-dateness was more likely for poor children with public rather than private sources of routine pediatric care, but all children living in states where most immunizations were delivered in the public sector were less likely to be up to date. Poor children in state with partial vaccine replacement programs were less likely to be up to date than those in free-market purchase states. CONCLUSIONS: While state policies can enhance immunization delivery for poor children, heavy reliance on public sector immunization does not ensure timely receipt of vaccines. Public- and private-sector collaboration is necessary to protect children from vaccine-preventable diseases.     

Rage attacks in children and adolescents with Tourette''s disorder: a pilot study

BACKGROUND: Sudden, explosive episodes of rage occur in a significant number of clinically referred children with Tourette's disorder and cause considerable psychosocial morbidity. The etiology of these symptoms is unknown. We conducted a pilot study of 12 consecutive children with Tourette's disorder and rage attacks to determine whether comorbidity of Tourette's-associated disorders is related to these symptoms. METHOD: Twelve consecutive children with Tourette's disorder who presented with rage attacks were evaluated, including 2 females and 10 males. Tourette's disorder diagnosis, presence of comorbid disorders, and tic severity were assessed using DSM-IV diagnostic criteria and standardized rating scales. RESULTS: All 12 children met diagnostic criteria for Tourette's disorder, obsessive-compulsive disorder (OCD), and attention-deficit/hyperactivity disorder (ADHD). Two children were also diagnosed with comorbid oppositional defiant disorder, and 4 children were diagnosed with comorbid conduct disorder. None of the subjects met diagnostic criteria for a mood disorder. All subjects had only mild tic severity. CONCLUSION: The clinical phenomenon of rage attacks in children with Tourette's disorder resembles intermittent explosive disorder and may reflect specific underlying neurologic disturbances. This pilot study suggests that rage attacks in Tourette's disorder may be related to the presence of comorbid disorders.     

Echocardiographic diagnosis of thrombus originating from the ductus arteriosus

OBJECTIVES: This study examined the impact of French routine programs urging the combined measles-mumps-rubella immunization of 15-month-old children. METHODS: We applied a cohort analysis to surveillance data collected by general practitioners to estimate the cumulative incidence rate per 1000 unvaccinated children and the proportion of susceptible children, by age and for each birth cohort between 1985 and 1995. RESULTS: More than 70% of unvaccinated children born in 1985 and 1986 had measles by the age of 10. This incidence rate dramatically decreased after implementation of the routine measles-mumps-rubella immunization program in 1989, but the proportion of 5-year-olds susceptible to measles has not decreased appreciably. In 1996, more than 15% of the children born between 1990 and 1995 were susceptible. CONCLUSIONS: The measles vaccine coverage achieved by the French routine immunization program remains insufficient as regards reducing the number of susceptible children.     

Surgical management of patients with radiation enteritis

A systematic study of celiac disease in a defined population of Arab children has not been previously reported. We therefore performed a prospective study to determine the incidence and clinical presentation of celiac disease in Jordanian children. A total of 34 (12 boys and 22 girls) cases were diagnosed over a period of 36 months. Nine cases were clustered in three families. The incidence was calculated to be 1:2,800 live births. The mean age at presentation was 4.6 years (range 0.3-13), but it was 8.4 years at the time of diagnosis. Diarrhea was the main initial symptom in 15 (44%) patients. Other signs and symptoms included recurrent abdominal pain in five patients (14%), short stature in four (12%), abdominal distension in three (9%), constipation in three (9%), pallor and recurrent mouth ulcers in two patients each. At the time of diagnosis, 24 (71%) had hypochromic microcytic anemia, and nine (26%) had rickets. The relatively high incidence of celiac disease may be related to the large wheat consumption in this population (135 kg/head/year), and the late onset could be related to the widespread prevalence of prolonged breast-feeding in Jordan (12 months) and late introduction of cereals (6.2 months) in children with late presentation. The delay in diagnosis might be due to the presence of other diseases clinically resembling celiac disease in our community.     

Intestinal invagination in children in the county of Hordaland 1983-92]

The incidence of intussusception was examined with respect to whether children lived in the city of Bergen, where pediatricians were the primary contacts in 45% of the cases, or in the remaining municipalities where pediatricians were the primary contacts in 18%. Diagnosis and course of illness were compared for children admitted by pediatricians and general practitioners. Information was retrieved from hospital medical records. During 1983-92, 142 children 0 to 14 years were given the diagnosis on basis of barium enema (139 children) or surgery (three children). The incidence was 1.8 per 1,000 children per year for Bergen vs. 1.4 in the rest of the county (p = 0.3). Children admitted by pediatricians more often had the correct referral diagnosis (70% vs. 42%, p = 0.003), but they did not differ with respect to median age (8 months for both), median duration of symptoms (12 vs. 24 hours), percent in need of surgery (58% vs. 59%) or in symptoms. The lack of difference in incidence between Bergen and the more distant municipalities suggests that spontanous resolution of intussusception is uncommon. Although pediatricians more often admitted the children with the correct diagnosis, duration of symptoms and outcome did not differ from those admitted by general practitioners. This suggests that the general practitioners also appreciated the urgency of the symptoms.     

Skin diseases in Bamako (Mali)

BACKGROUND: Skin diseases have only recently been considered as a possible public health problem in developing countries. Data supporting this matter are scarce. The aim of this study is to report the experience of a specialized dermatologic center in Bamako (Mali) in order to complete two previous studies conducted in the Bamako area: a prevalence study in the general population and a study in nonspecialized health centers of Bamako. It is our intention to provide a comprehensive picture of the problem of skin diseases in an African developing country. METHODS: We retrospectively collected all cases of skin diseases diagnosed during consultations provided at the Institut Marchoux in Bamako, the only center specializing in dermatology in Mali, during the year 1993. RESULTS: A total of 10,575 new outpatients were seen with 10,889 skin diseases. The main skin diseases registered were as follows: infectious dermatoses (41% of all diagnoses, including scabies (16.6%), superficial mycoses (13.6%), and primary pyoderma (5.6%)), dermatitis (20.4%), papular urticaria (4.4%), acne (4.2%), pityriasis alba (3.6%), keratoderma (3.6%), and urticaria (3%). Typical tropical infectious diseases accounted for only 1% of all diagnoses. CONCLUSIONS: It appears that certain skin diseases (mainly scabies and pyoderma) are an important health problem for the population of the Bamako area. Public health policies should be implemented in order to manage this problem rationally.     

The prevalence of HBsAg in hospitalized children as a marker of hepatitis B virus infection]

The aim of this study was to determine the prevalence of hepatitis B surface antigen (HBsAg) in hospitalised children, as specific marker for hepatitis B virus (HBV) infection. Our study group consists of 517 children, 68 of them diagnosed with chronic hepatitis. For HBsAg determination we used an ELISA test (Labsystems); for some children we also tested by ELISA the following markers: the antibodies and anti-hepatitis C virus (HCV) antibodies. From 517 children 24.28% were HBSAg positive and 75% of children with chronic hepatitis were positive for the same marker. Almost 100% of chronic active hepatitis (CAH) patients was positive for HBSAg. CONCLUSIONS: 1. The prevalence of HBsAg was much higher as compared with the healthy population prevalence; it is a clear prove that HBV infection has an important role in chronic hepatitis appearance. 2. For all HBsAg positive patients, it is necessary to determine other markers like HBeAg-anti-HBe antibodies system as well as markers for other viral hepatitis (HDV, HCV). 3. The anti-HBV infection vaccine will reduce significantly the prevalence of HBV and HDV infections; 4. Biological molecular technique, like PCR will be necessary in our country, in the future, even the price is so high, to monitoring the IFN treatment for chronic infection as unique solution for these patients.     

Identification of acute-phase proteins (APP) in circulating immune complexes (CIC) in esophageal cancer patients'' sera

OBJECTIVES: We describe the attitude and views of general practitioners towards the menopause and hormone replacement therapy (HRT) in metropolitan Brisbane, Australia. METHODS: A total of 216 general practitioners were nominated by a random sample of urband-welling women aged 45-54 years who formed the Brisbane Women's health study. A 20-30 minute face-to-face questionnaire with the general practitioners was administered and analysed by demographic characteristics. RESULTS: There was a 93% response rate. Management of the menopause and HRT was routinely undertaken by general practitioners for their own patients. After deciding to initiate HRT, > 60% of general practitioners ordered five investigations or more. They may have confused the risk of thrombo-embolism from oestrogens used in the post-menopause with that for contraception. There were differences between male and female practitioners in some areas. Male general practitioners, in particular, reported more difficulty with tailoring and adjusting regimes. CONCLUSIONS: Specific areas for further education are explored to meet the educational needs of general practitioners.