Scurvy is still present in developed countries.

Introduction: Scurvy, while uncommon, still occurs in developed countries despite the widespread availability of vitamins and fortified foods. A vitamin C deficiency prevalence of 10 to 14% in adults was reported in the National Health and Nutrition Examination Survey (NHANES) in 1994.

Objective: We report the case of a 57-year-old male who presented with a combined vitamin C deficiency (scurvy) and a Zinc deficiency.

Seek first to understand.

A recent study suggests that doctors often diminish effective time with patients by talking about themselves in a manner that does not improve the patient visit and is sometimes disruptive to it. Good care requires hearing what the patient has to say, as the doctor cannot set proper goals for a visit without knowing the patient's agenda. Listening to the patient is the key both to good patient care and to caring for the patient.

Burden of comorbid medical conditions and quality of diabetes care.

Objective: With performance-based reimbursement pressures, it is concerning that most performance measurements treat each condition in isolation, ignoring the complexities of patients with multiple comorbidities. We sought to examine the relationship between comorbidity and commonly assessed services for diabetic patients in a managed care organization.

Research Design And Methods: In 6,032 diabetic patients, we determined the association between the independent variable medical comorbidity, measured by the Charlson Comorbidity Index (CCI), and the dependent variables A1C testing, lipid testing, dilated eye exam, and urinary microalbumin testing.

Severe acute pharyngitis caused by group C streptococcus.

Introduction: Adult group C beta-hemolytic streptococcal pharyngitis has a prevalence of approximately 5%. It can present with a broad spectrum of severity.

Case Report: We report a 30-year-old woman who presented with severe Group C streptococcal pharyngitis.

Pharyngitis management: defining the controversy.

Despite numerous controlled trials, clinical practice guidelines and cost-effective analyses, controversy persists regarding the appropriate management strategy for adult pharyngitis. In this perspective, we explore this controversy by comparing two competing clinical guidelines. Although the guidelines appear to make widely diverging recommendations, we show that the controversy centers on only a small proportion of patients: those presenting with severe pharyngitis.

Does residency training improve performance of physical examination skills?

Background: Few studies use objective structured clinical examinations (OSCEs) to measure physical examination skills of internal medicine residents. Little is known about performance by year of residency training.

Purpose: To determine differences between postgraduate year (PGY)-1 and PGY-3 residents on performance and comfort of physical examination skills.

Principles to consider in defining new directions in internal medicine training and certification.

SGIM endorses seven principles related to current thinking about internal medicine training: 1) internal medicine requires a full three years of residency training before subspecialization; 2) internal medicine residency programs must dramatically increase support for training in the ambulatory setting and offer equivalent opportunities for training in both inpatient and outpatient medicine; 3) in settings where adequate support and time are devoted to ambulatory training, the third year of residency could offer an opportunity to develop further expertise or mastery in a specific type or setting of care; 4) further certification in specific specialties within internal medicine requires the completion of an approved fellowship program; 5) areas of mastery in internal medicine can be demonstrated through modified board certification and recertification examinations; 6) certification processes throughout internal medicine should focus increasingly on demonstration of clinical competence through adherence to validated standards of care within and across practice settings; and 7) regardless of the setting in which General Internists practice, we should unite to promote the critical role that this specialty serves in patient care.

Optimal management of adults with pharyngitis--a multi-criteria decision analysis.

Background: Current practice guidelines offer different management recommendations for adults presenting with a sore throat. The key issue is the extent to which the clinical likelihood of a Group A streptococcal infection should affect patient management decisions. To help resolve this issue, we conducted a multi-criteria decision analysis using the Analytic Hierarchy Process.

Delay in time to receipt of thrombolytic medication among Medicare patients with kidney disease.

Background: Patients with kidney disease and acute myocardial infarction (AMI) receive standard therapy, including thrombolytic medication, less frequently than patients with normal kidney function. Our goal is to identify potential differences in thrombolytic medication delays and thrombolytic-associated bleeding events by severity of kidney disease.

Methods: This is a retrospective cohort analysis of Cooperative Cardiovascular Project data for all Medicare patients with AMI from 4,601 hospitals.

A propensity score analysis of the impact of angiotensin-converting enzyme inhibitors on long-term survival of older adults with heart failure and perceived contraindications.

Objectives: The purpose of this study is to determine the association between discharge use of angiotensin-converting enzyme (ACE) inhibitors in patients with perceived contraindications to these drugs and 4-year post-discharge survival among hospitalized older adults discharged alive with a primary discharge diagnosis of systolic heart failure.

Background: Perceived contraindications to the use of ACE inhibitors are often associated with underuse of these life-saving drugs.

Methods: Chronic renal insufficiency, hypotension, hyperkalemia, and severe aortic stenosis were conditions perceived as contraindications.

Re-examination of the cost-effectiveness of surgical versus medical therapy in patients with gastroesophageal reflux disease: the value of long-term data collection.

Objectives: For patients with reflux esophagitis, long-term therapeutic options include proton pump inhibitor (PPI) therapy and/or antireflux surgery. An earlier cost-effectiveness analysis concluded that at 5 yr, medical therapy was less expensive but similarly effective to fundoplication, but the results were sensitive to estimates on quality of life and long-term medication usage, which were derived from "expert opinion." Recently, data from randomized controlled trials addressing these variables have become available.

Nurse staffing and mortality for Medicare patients with acute myocardial infarction.

Context: Recent hospital reductions in registered nurses (RNs) for hospital care raise concerns about patient outcomes.

Objective: Assess the association of nurse staffing with in-hospital mortality for patients with acute myocardial infarction (AMI).

Design, Setting, And Patients: Medical record review data from the 1994-1995 Cooperative Cardiovascular Project were linked with American Hospital Association data for 118,940 fee-for-service Medicare patients hospitalized with AMI.

Diffusion of troponin testing in unstable angina patients: adoption prior to guideline release.

Background: We examined diffusion of troponin testing in Medicare patients with unstable angina before the release of year 2000 American College of Cardiology/American Heart Association guidelines recommending measurement in all patients with acute coronary syndromes.

Methods: We identified unstable angina admissions from Medicare administrative files for 22 Alabama hospitals over two time periods: 03/1997-02/1998 and 01/99-12/1999. Data were obtained from chart abstraction.

American internal medicine in the 21st century: can an Oslerian generalism survive?

American internal medicine suffers a confusion of identity as we enter the 21st century. The subspecialties prosper, although unevenly, and retain varying degrees of connection to their internal medicine roots. General internal medicine, identified with primary care since the 1970s, retains an affinity for its traditional consultant-generalist ideal even as primary care further displaces that ideal.

Atypical presentations among Medicare beneficiaries with unstable angina pectoris.

Chest pain is a hallmark symptom in patients with unstable angina pectoris (UAP). However, little is known regarding the prevalence of an atypical presentation among these patients and its relation to subsequent care. We examined the medical records of 4,167 randomly sampled Medicare patients hospitalized with unstable angina at 22 Alabama hospitals between 1993 and 1999.

Physician Internet medical information seeking and on-line continuing education use patterns.

Introduction: Although physician Internet use patterns have been studied, little attention has been paid to how current physician learning and change theories relate to physician Internet information seeking and on-line learning behaviors. The purpose of this study was to examine physician medical information-seeking behaviors and their relevance to continuing education (CE) providers who design and develop on-line CE activities.

Methods: A survey concerning Internet use and learning was administered by facsimile transmission to a random sample of 2,200 U.