William T. Shockcor

Primary biliary cirrhosis: survival of a large cohort of symptomatic and asymptomatic patients followed for 24 years.

We extended by 10 years, a follow-up study of 279 patients with primary biliary cirrhosis initially evaluated at the Yale Liver Study Unit between 1955 and 1979. Thirty-six patients (13%) were asymptomatic at the time of diagnosis. Accurate follow-up survival data were available for 247 patients (89%), ranging up to 24 years after the original diagnosis. Median predicted survival of patients in this study from the time of diagnosis is twice as long for patients who present without symptoms compared to symptomatic patients (16 vs 7.5 years, p < 0.0001). However, overall survival of those asymptomatic patients is shorter than that predicted for an age- and gender-matched control population (p < 0.0001), a difference that became apparent only after 11 years of follow up. With a median follow up of 12.1 years, 33% of the asymptomatic patients remained free of symptoms of liver disease, However, once symptoms develop, their survival is similar to those presenting with symptoms. Independent predictors of diminished survival include: elevated bilirubin, increasing age, ascites, advanced fibrosis and the degree of portal bile stasis on liver biopsy. It was not possible to predict which asymptomatic patients would remain symptom free.

Human immunodeficiency virus infection in intravenous drug users: A model for primary care

PURPOSE Intravenous drug users (IVDUs) often encounter barriers to primary care. To improve access, we developed a primary care clinic--Central Medical Unit (CMU)--for substance abusers in drug treatment. We report outcomes for services offered to IVDUs with human immunodeficiency virus (HIV) infection. PATIENTS AND METHODS During 1990, 24% (120 of 509) of IVDUs eligible for CMU were HIV positive. Diagnostic therapeutic and preventive goals for IVDUs with HIV infection were evaluated for acceptance and compliance by chart review for these 120 patients. RESULTS On admission, 65% (78 of 120) of patients reported having no source of primary care, 64% (77 of 120) were male, and 77% (92 of 120) were in methadone maintenance. All were screened for tuberculosis, syphilis, and hepatitis; 94% (15 of 16) of eligible patients accepted tuberculosis prophylaxis and 83% (5 of 6) accepted syphilis treatment, but only 36% (5 of 14) accepted hepatitis B vaccine. Of those who accepted therapy, 87% (13 of 15) were compliant with tuberculosis prophylaxis, and 100% (5 of 5) were compliant with syphilis treatment. Influenza vaccine was accepted by 49% (59 of 120) and pneumococcal vaccine by 81% (97 of 120). Ninety-eight percent (118 of 120) accepted T-cell testing: 61% had T-helper counts less than 500/mm3 and 25% were less than 200/mm3. Of those eligible, 89% (70 of 79) accepted antiretroviral therapy, and 100% (35 of 35) accepted Pneumocystis carinii pneumonia prophylaxis. Six-month compliance rates for these therapies were 84% (59 of 70) and 77% (27 of 35), respectively. CONCLUSION By offering primary care services with drug treatment, the CMU model may be an effective way of providing access to primary care for HIV-infected IVDUs and for facilitating compliance.

Multidisciplinary evidence-based medicine journal clubs: curriculum design and participants' reactions.

BACKGROUND Evidence-based medicine (EBM) is becoming an accepted educational paradigm in medical education at a variety of levels. It focuses on identifying the best evidence for medical decision making and applying that evidence to patient care. METHODS Three EBM journal clubs were developed at the West Virginia University School of Medicine. One was for senior medical students, another for residents, and the third for primary care faculty members. In each, the sessions stressed answering clinical questions arising from actual patient-care issues. The curricular structure and development of the journal clubs are described. Participants anonymously evaluated aspects of the journal clubs regarding their educational value with Likert scale questions. RESULTS Faculty members and residents generally gave high evaluations to all aspects of the EBM journal clubs. Student evaluations were more mixed. For each of the evaluation questions, the student means were lower than those of faculty and residents. However the differences reached statistical significance only in the responses to the usefulness of the sessions in understanding the medical literature (P < 0.01). Residents and faculty rated the EBM sessions more favorably than grand rounds or the resident lecture series. CONCLUSIONS The establishment of evidence-based medicine journal clubs is feasible, and learners seem to value the sessions. More developed learners may gain more from the experience than those earlier in their medical education.

Evaluating the complaint of fatigue in primary care: Diagnoses and outcomes

PURPOSE This case series describes associated diagnoses and prognoses of persistent fatigue in a community-based, primary care population. PATIENTS AND METHODS All patients presenting to a private practice internist with a chief complaint of fatigue of more than 1 months duration were prospectively evaluated with clinically directed examination and diagnostic testing. Patients were excluded if they had a previously diagnosed illness associated with fatigue. Fatigue was attributed to newly established diagnoses or medication use based on explicit criteria. Change in the state of each patients fatigue was measured 6 months after entry. RESULTS Fifty-two consecutive patients entered the study. The diagnoses associated with fatigue were a medical disorder in 25 patients, depression in 10 patients, and no definitive diagnosis in 18 patients. The mean cost of diagnostic testing was

Creating an Objective Structured Clinical Examination for the Internal Medicine Clerkship: Pitfalls and Benefits

131. At 6 months, 37 of 52 patients (72%) reported improvement in or resolution of their fatigue. CONCLUSION In a primary care setting, many patients presenting with persistent fatigue have an associated, treatable disease that can be determined using a cost-effective, clinically directed approach. Most will experience an improvement in their fatigue.

Patient-Perceived Barriers to Preventive Health Care Among Indigent, Rural Appalachian Patients

The objective-structured clinical examination (OSCE) is a useful tool in evaluating clinical competence. Traditional clinical-evaluation measures have been criticized as arbitrary and lacking reliability, whereas written exams test primarily cognitive aspects. The OSCE focuses on learner actions rather than abstract knowledge and evaluates in a uniform fashion. A 15-station OSCE was created for an internal medicine junior clerkship, based on predetermined skill and content goals. The exams then were scored by a single, blinded reviewer, again in a predetermined fashion. The OSCE has been studied in terms of reliability, content validity, and construct validity. The exam has become accepted by the department and has guided the continuing curricular development. The OSCE is not designed to measure all the domains of a learners educational process. However, when used in conjunction with other evaluating mechanisms, it provides an objective outcome measure of the medical education process.