Doctors who perform operations. A study on in-hospital surgery in four diverse geographic areas (second of two parts)

To facilitate manpower planning in the surgical field, a study was c onducted into the work loads of surgeons in various specialities in 4 different geographical areas. Surgeons in group practice and surgeons who were Board-certified specialists carried a statistically significant larger work load of surgery. The certified surgeons performed more and more complex operations. The mean operative work load increased steeply with age, reaching a maximum at 40-44 years, and fell linearly after that age. Approximately 18 years following medical school graduation were needed for a surgeon to achieve his maximum work load. The geographic factor had no appreciable effect on work loads. Tables which broke down frequencies for each major type of operation for each type of surgical specialist indicated that even commonplace operations were not frequent events on the average for any individual surgeon. It is concluded from the study that work loads are relatively low due to excessive supply of surgeons. This is of concern because there is some doubt about maintenance of surgical skills by those doctors who perform infrequent operations. The widest variation in practice was evident between ophthalmologists and thoracic surgeons, indicating that manpower planning in this field would have to be done on a specialty-by-specialty basis. 3 plans for redistributing the operative work load and reducing the number of specialist surgeons are considered.     

Differential diagnosis of a mass in the upper lateral neck

The differential diagnosis and the duration of symptoms are presented for a group of 288 patients encountered over a ten-year period with a mass in the region of the neck behind and below the angle of the mandible. While infections constituted the largest aetiological group (48.3 per cent), 109 cases (37.9 per cent) had some form of neoplasia, with malignancy being found in 48 (16.6 per cent). The duration of symptoms varied widely, only the acute infections having an acceptably short delay prior to hospital admission. The mean symptom duration for all the neoplastic cases was in excess of five months.     

Gene expression of pituitary adenylate cyclase activating polypeptide (PACAP) in the rat hypothalamus

Pituitary adenylate cyclase activating polypeptide (PACAP) isolated from ovine hypothalamus is considered to be a member of the vasoactive intestinal peptide/glucagon/secretin/growth hormone-releasing hormone family of peptides. Two forms of PACAP, PACAP38 and PACAP27, have been demonstrated in the rat hypothalamus. The PACAP precursor contains another peptide called PACAP-related peptide (PRP), but so far no information on this peptide in tissue exists. We have developed three radioimmunoassays specific for PACAP38, PACAP27 and PRP and demonstrate that all three preproPACAP peptides are expressed in the rat hypothalamus, the PACAP38/PACAP27 ratio being around 60 and the PACAP38/PRP ratio being around 10. HPLC analysis of hypothalamic extract showed that PACAP38 and PACAP27 are found in only one form corresponding to the respective synthetic peptides, whereas PRP eluted in two peaks, the predominant form corresponding to synthetic PRP1-29. The cellular distribution of PACAP38, PACAP27, and PRP and corresponding mRNA in the hypothalamus was determined with immunohistochemistry and in situ hybridization histochemistry. PACAP- and PRP-immunoreactive neuronal perikarya were observed in the medial parvocellular part of the paraventricular nucleus (PVN) in colchicine pretreated rats. Some cell bodies of magnocellular variety were found in the PVN. PACAP mRNA containing cells were observed in moderate numbers in the same parts of the paraventricular nucleus. PACAP- and PRP immunoreactive fibres and varicosities were distributed in the PVN and in the periventricular nucleus. These data show that PACAP38, PACAP27 and PRP are expressed in the parvocellular part of the PVN, implying roles as hypothalamic regulatory peptides.     

Small intestinal bleeding

Bleeding from the small intestine may be difficult to diagnose, because of the organ's length and free intraperitoneal location. Although there is a variety of causes of intestinal bleeding, angiodysplasia is the most common. Several different tests can be used to identify the bleeding site preoperatively or intraoperatively, including enteroscopy.     

Identification and characterization of differentiating soluble antigens of sheep and goat poxviruses

Soluble antigens of sheep and goat poxviruses (SPV, GPV) were isolated and purified from scab suspensions prepared from lesions of experimentally infected homologous hosts. The soluble antigens were then subjected to sequential ammonium sulphate precipitation. All the obtained fractions reacted in counter immunoelectrophoresis (CIE) with both the antisera against SPV and GPV except the fraction obtained at 30% saturation level (30% SSPV), which did not react with antiserum against GPV. This differentiating soluble SPV antigen was found to consist of 210 K proteins in exclusion chromatography. The 210 K proteins contained 3 polypeptides of 100, 35 and 17 K in polyacrylamide gel electrophoresis in the presence of sodium dodecyl sulphate (SDS-PAGE). The study thus gave an evidence that the SPV-specific proteins are of a higher molecular mass nature.     

Psychological factors in the prediction of Lyme disease course

We developed methodology for prospective randomized effectiveness studies using a demonstration project at a multispecialty practice, health maintenance organization, and hospital in academic medical center. An operational unit called the effectiveness registry was developed to design and support comparisons of potential practice improvements with standard care. The studies differ from observational effectiveness studies in that they provide long-term follow-up of randomized comparison groups. Physician involvement in data collection is limited. No tests or observations are made other than those required for clinical care. Follow-up and data collection are modeled after tumor registry procedures. Patients who refuse randomization enter the study in whichever treatment arm they choose. The protocol for each study is approved by the institutional review board (IRB) before recruitment begins, and all patients, randomized and nonrandomized, sign an informed consent document. Between its beginning on October 7, 1993 and April 7, 1997, the IRB approved 14 trials. Four were terminated after entering at most a few patients. Recruitment is complete in four trials and continues in six. Randomization was accepted by 74% (596/804) of the patients. Over 800 patients in 10 studies are being followed at least annually. Major peer-reviewed journals have accepted reports of initial findings for two studies. Prospective randomized effectiveness studies are feasible in the multipractice setting and have potential to provide useful and reliable assessment of treatment outcomes. Collaborative arrangements between several institutions are needed to provide larger sample sizes.     

Giant congenital nevocellular nevus overlying an encephalocele

OBJECTIVE: To compare patients with knee osteoarthritis (OA) who have and do not have back pain, and evaluate the prevalence, characteristics, and consequences of back pain among knee OA patients. METHODS: During a 3-year period, consecutive patients attending an outpatient rheumatology clinic were evaluated for the presence of back pain, and 368 were found to have OA of the knee. Clinical status was evaluated by the Clinical Health Assessment Questionnaire, radiographs, and joint examinations. RESULTS: Back pain was present in 54.6% of patients with OA of the knee. Almost every clinical status measure was worse among those reporting back pain, including Health Assessment Questionnaire (HAQ) disability, pain, global severity, fatigue, and psychological status. Back pain was more common in women and the obese, but was not associated with age, marital status, formal education, smoking history, or knee radiographic scores. In multivariate analyses the strongest correlates of back pain in knee OA patients were anxiety, night pain, HAQ disability, and global severity. CONCLUSION: Back pain is prevalent among OA clinic patients, more common than in rheumatoid arthritis or population studies, is linked to body mass index, and is associated with clinically significant increases in pain and other measures of clinical distress.     

Lyme disease in outdoor workers on Assateague Island: high tick-exposure but low disease risk

Endothelin-1 (ET-1)-converting enzyme (ECE) activity in the human serum lipoprotein fraction was studied using a sensitive enzyme immunoassay and reverse-phase high performance liquid chromatography. The ECE activity of cleaving synthetic human big ET-1 into ET-1 by the serum lipoprotein fraction was about 14-times greater than that by whole serum, and the activity was closely associated with lipoprotein itself. The lipoprotein ECE activity, which was optimal at pH 7.0, was inhibited by EDTA, o-phenanthroline, phosphoramidon, thiorphan, phenylmethanesulfonyl fluoride and chymostatin, but not by cysteine or aspartic proteinase inhibitors, suggesting metalloproteinase- and chymotrypsin-like properties. These results suggest that the serum lipoprotein ECE may be involved in the processing of big ET-1 to ET-1 in the circulatory system.     

Temperature effect on the action of corticotropin-releasing hormone (CRH) on secretion of immunoreactive beta-endorphin (IR beta EP) in TM3 and AtT-20 cell lines

Testicular function is sensitive to chemical and thermal stresses. To investigate the effects of small temperature changes on CRH-stimulated beta EP release, we employed TM3 cells, a mouse prepubertal Leydig cell line that secretes ir beta EP. To monitor beta EP secretion from these cells we used the reverse hemolytic plaque assay. After 3.5 hr incubation of cells with hormone, the EC50 of the CRH dose-response curve at 34 degrees C and 37 degrees C were 0.1 nM and 1 nM, respectively. For comparison, we also investigated the effect of temperature on CRH-stimulated beta EP release from a non-testicular cell line, AtT-20, a mouse anterior pituitary cell line. Using radioimmunoassay to measure ir beta EP levels in the media of AtT-20 cells, the EC50s for the CRH dose-response curve at 34 degrees C and 37 degrees C were 0.2 nM and 2 nM, respectively, at 1 h. After 3.5 h this temperature dependent difference in EC50 was still observed. These results suggest that CRH receptors or post-receptor actions in Leydig cells and anterior pituitary corticotropes are sensitive to small temperature changes.