Albert J. Finestone

Long-term results of femoroinfrapopliteal bypass in diabetic patients with severe ischemia of the lower extremity☆

In patients with severe lower extremity ischemia (ischemic necrosis or pain at rest associated with physical findings of peripheral arterial insufficiency), diabetes mellitus should not deter thorough arteriography and consideration of arterial reconstruction. Infrapopliteal bypass can produce prolonged limb salvage in diabetic patients in lieu of primary amputation.

Drug delivery systems improve pharmaceutical profile and facilitate medication adherence.

Innovations in dosage forms and dose delivery systems across a wide range of medications offer substantial clinical advantages, including reduced dosing frequency and improved patient adherence; minimized fluctuation of drug concentrations and maintenance of blood levels within a desired range; localized drug delivery; and the potential for reduced adverse effects and increased safety. The advent of new large-molecule drugs for previously untreatable or only partially treatable diseases is stimulating the development of suitable delivery systems for these agents. Although advanced formulations may be more expensive than conventional dosage forms, they often have a more favorable pharmacologic profile and can be cost-effective. Inclusion of these dosage forms on drug formulary lists may help patients remain on therapy and reduce the economic and social burden of care.

Inhibition of Hyaluronidase in vivo by Adrenal Cortical Activation

Summary The inhibition of hyaluronidase injected into the skin of patients with normal pituitary-adrenal responses to epinephrine has been observed. The diffusing effect of hyaluronidase was gauged by the disappearance of fluorescein dye injected with it intracutaneously. The failure of antagonism to the action of hyaluronidase to occur in patients with hypoadrenocorticism was noted. The possibility of utilizing the method described as a test for pituitary-adrenal response to epinephrine is discussed.

What Is Professionalism

1. Cummins S, Petticrew M, Sparks L, Findlay A. Large scale food retail interventions and diet. BMJ. 2005;330(7493):683-684. 2. Tarnapol Whitacre P, Tsai P, Mulligan J. The Public Health Effects of Food Deserts: Workshop Summary. Washington, DC: Institute of Medicine and National Research Council; 2009. 3. Borradaile KE, Sherman S, Vander Veur SS, et al. Snacking in children: the role of urban corner stores. Pediatrics. 2009;124(5):1293-1298. 4. Lucan SC, Karpyn A, Sherman S. Storing empty calories and chronic disease risk: snack-food products, nutritive content, and manufacturers in Philadelphia corner stores. J Urban Health. 2010;87(3):394-409. 5. The White House, Office of the First Lady. First Lady Michelle Obama announces nationwide commitments to provide millions of people access to healthy, affordable food in underserved communities. http://www.whitehouse .gov/the-press-office/2011/07/20/first-lady-michelle-obama-announces -nationwide-commitments-provide-milli. Accessed October 12, 2011.

The psychophysiology of stress

Abstract When emotions affect the body, reactive physiologic changes occur. Thus, during the course of everyday events we all respond psychophysiologically with neural and hormonal discharges. The physician has available to him a very large body of literature on this subject, as well as much anecdotal material from clinical practice that varies in depth depending on the insight and interest of the reporting physician. This paper describes and defines the evidence now available that reinforces the concept that the mind influences the body.

An unusual case of portal systemic encephalopathy

SummaryA middle-aged woman with severe obesity, but without any evidence of chronic liver disease, developed episodes of portal systemic encephalopathy following a jejunoileal bypass. High arterial blood ammonia in the face of apparently normal liver morphology indicated the presence of spontaneous portal systemic shunting of blood. This was further supported by an abnormal oral ammonia tolerance test. Selective abdominal angiography revealed occlusion of the portal vein and its tributaries, with development of extensive collateral circulation. It is suggested this unusual complication had developed as a result of previous abdominal surgery.

Linking needs assessment in continuing medical education to health care outcomes

&NA; There is currently a need in the health care industry to develop and implement strategies to improve both the quality and cost effectiveness of health care delivery. Continuing medical education (CME), like other components of the health care system, is being pressured for more accountability in physician education programs. Specifically, CME professionals are being asked to address quality assurance issues (either physician performance or health care outcomes) as measures of the impact of educational programs and activities. Major research studies reported in the CME literature have pointed to the importance of determination of practice or real learning needs as a prerequisite for effective education. Furthermore, it has been suggested that research in CME should focus on evaluating the effects of CME interventions on major causes of morbidity and mortality. The funded, on‐going project described in this paper is a continuing medical education efsort designed to address and correct dejiciencies in clinical quality and cost effectiveness documented by a mandatory statewide hospital data collection system. The database measures quality and effectiveness of care using two specific data elements: severity of illness upon admission and patient outcome upon discharge, in terms of morbidity and mortality for selected Diagnostic Related Groups. Key clinical findings are the focus. This article provides a conceptual framework and descriptive analysis of (1) the rationale for using large administrative databases in designing, implementing, and evaluating continuing medical education programs, and (2) the replicable problem‐solving process that can be used in identifying the real learning needs of physicians from large administrative databases.

An office-based primary care trial of pindolol (‘Visken’) in essential hypertension

A large, open, multi-centre study was performed by physicians in general practice to evaluate the efficacy and tolerance of pindolol (10 to 20 mg per day) in the treatment of patients with essential hypertension. The records of 7324 patients who completed the 6-week protocol with pindolol alone or in combination with a diuretic were analyzed by computer. Substantial reductions in both systolic and diastolic blood pressure were obtained in the majority of patients regardless of age, sex or race. No difference in blood pressure response was found between patients taking diuretics concurrently and those on pindolol alone. Side-effects were generally not troublesome and a trend toward a reducing incidence of side-effects was noted in all patients as the duration of therapy increased. Black patients tended to complain of fewer side-effects than did white patients.

Mandatory Continuing Education

To the Editor.— The communication by MAJ Glidden Neil Libby is well written and has an attention-getting title, but in my opinion it is only a pastiche. Practically all students, mature or otherwise, realize the inherent weakness of many lecture type programs. However, this is not to say that all lectures are useless; my point is not to defend the lecture. I am certain that Major Libby must know that increasing numbers of programs are built about information obtained from registrants, practice profiles, and problems uncovered by medical audits. Self-assessment and repeat medical audits are increasingly used to evaluate the effectiveness of these programs. Mandatory continuing education is another issue really unrelated to questions of effectiveness of these programs. If ineffective programs are presented and approved, a simple solution would be to establish different guidelines for approval for continuing education credits. I do not believe that communications such as this