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Graduate medical education in the United States has been criticized for fragmentation of responsibility, inadequate funding, variation in quality, inadequate response to physician manpower needs, lack of inservice evaluation, and use of foreign medical graduates. One solution is to establish a graduate-medical-education system that is organized, controlled, and financed on a statewide basis. Such a system could centralize responsibility, adequately finance the educational component of training, respond to the needs of the individual states, and standardize the content and evaluation of the educational programs. A widely representative governing board could determine the nature of the program and work with appropriate state fiscal organizations to handle budgetary needs. Such a system, if implemented, might have certain disadvantages, but would, on balance, greatly mitigate the problems now besetting graduate medical education. (N Engl J Med 291:701–706, 1974)

Tests useful in the assessment of intestinal absorption include measurement of the amount of ingested d-xylose in the urine, fasting serum carotene concentration, and fecal fat. The present investigation examines certain aspects of these tests, including the interrelation among them, the relation between the clinical severity of a disease of malabsorption and the variation of each test, and the determination of the most efficient application of the tests as a group. Subjects and Methods Seventy-two-hour fecal fat excretion, 4hour excretion of d-xylose in the urine, and fasting serum carotene concentration were obtained at approximately the same time in each of 45 patients with functional diarrhea but without steatorrhea and in 33 patients with steatorrhea. Of the 33 pa­ tients with steatorrhea, 10 had nontropical sprue, 9 had exocrine pancreatic insufficiency resulting from pancreatitis, and 14 had had partial gastrectomy. Examples of uncom­ plicated mucosal block, enzyme deficiency, or altered gastric function were used be­ cause differences could be more easily ex­ plained in well delineated cases. Patients with functional diarrhea were considered as ideal controls since they represent the most common problem in differential diagnosis. A group of 9 patients with regional enteritis was included in our original data but is reported for the purpose of contrast only and not in the same detail as the groups already mentioned. The functional diagnosis was established in the usual manner. A diagnosis of non­ tropical sprue was made by history, physical

The prothrombin consumption time was assayed in 40 patients suffering from ulcerative colitis and compared with that of 30 control patients who did not have clinical evidence of a hemorrhagic disease. Prothrombin time was also measured in each patient. Platelets were examined on a blood smear, and peripheral capillary fragility was evaluated in the diseased patients.

Cineradiographs were taken before and after implantation of four strain transducers on the muscle of the distal esophagus of each of 10 healthy female beagles. After appropriate physiologic studies, the dogs were sacrificed and necropsied. A transition zone of mucosa, 1.4±0.6 mm wide, was found caudad to the squamocolumnar junction. Thickening of the circular muscle started 1.4±0.3 mm distal to the squamocolumnar junction and was 10.7±0.4 mm wide. The circular striated muscle of the esophagus terminated abruptly at the proximal edge of the muscle thickening. The striated longitudinal muscle continued its progress to the distal end of this muscle thickening, covering it like a mantle. The phrenoesophageal membrane was inserted 6.3±0.9 mm distal to the squamocolumnar junction. Transducers implanted over the muscle thickening showed relaxation with a swallow; those placed 1 cm proximal to the insertion of the phrenoesophageal membrane showed only contractions. Cineradiographic studies revealed a biconcave area in the portion of the esophagus that showed relaxation on physiologic study. The area of muscle thickening represented the inferior esophageal sphincter which, in the dog, is composed of smooth rather than striated muscle. Relating the findings to those in man, it was noted that the squamocolumnar junction of man is more caudad. Man does not have a well defined smooth muscle band as a sphincter, although opinions vary concerning the presence of muscle thickening in the distal esophagus. He does have a biconcave area but this is 2–3 cm orad to the position in the dog. Man has a vestibule distal to the biconcave area, but the dog does not. The peristaltic wave in the dog stops at the biconcave area and, in this respect, it is similar to that in man. In the preparation studied, the sphincter did not move proximally with a swallow as some believe it does in man.

Summary Two cases of pyogenic abscess formation in the right lobe of the liver secondary to sigmoid diverticulitis are presented and discussed. The rarity of such a combination is pointed out.

In 8 cases of narrow lower esophageal ring, which occurs chiefly in men between 50 and 60 years old, the cardinal symptom was dysphagia. Reflux was uncommon and weight loss absent.

Strain transducers were permanently implanted on the proximal and distal portions of the colon of each of 12 healthy female beagles. This allowed the in vivo measurements of isometric muscle contraction in the healthy dog. The responses of the longitudinal and circular muscles as well as the proximal and distal portions of the colon were compared. Morphine and bethanechol were the stimuli. Morphine did not change the motor activity or tension of the longitudinal muscle but did increase the motor activity and tension of the circular muscle. Bethanechol increased the motor activity and tension of both longitudinal and circular muscles. This was true of both proximal and distal colon. Bethanechol caused a greater motor response of the longitudinal muscle of the distal than of the proximal colon. Both drugs caused a greater increase in the tension of the circular muscle of the distal than of the proximal colon. The linear displacement and motility index methods were both used to measure motility, because it was not clear from the literature which was preferable. Both methods were equally sensitive to change in motility. The linear displacement method had a smaller coefficient of variation and for this reason was preferable. The findings raise some interesting possibilities for studies of propulsion in the colon.

Clinical, radiologic, manometric, and endoscopic data were applied to distinguish achalasia in a group of 52 patients complaining of dysphagia or chest pain or both. Endoscopically, achalasia was characterized by a non-relaxing lower esophageal sphincter that would yield to gentle but firm forward thrust of the instrument. The finding of hiatal hernia or esophagitis was against a diagnosis of achalasia. Manometry was particularly helpful in achalasia patients with little or no esophageal dilation by radiography. Peroral endoscopy was found to add essential information leading to the correct diagnosis of patients with dysphagia or esophageal chest pain.

In 9 patients the inferior esophageal sphincter was identified manometrically and simultaneously by direct vision at endoscopy. It was related to the squamocolumnar junction which was identified visually. The average length of the sphincter was 1.6cm and it was proximal to the hiatus and squamocolumnar junction in all but 1 of the patients. The method described makes it possible to study the closing mechanism of the distal esophagus in vivo.

The Case Mix System (CMS) was developed as a broad-based decision support system for planning and managing effectiveness in the product line environment. CMS is proven in a range of hospital settings and provides the information needed to meet todays health care management challenges.

The clinical, radiologic, duodenoscopic, and pathologic findings in thirteen patients with nonspecific duodenitis are presented. The majority of patients had vague epigastric distress, duodenal bulb spasm, nodular or friable mucosa, and variable degrees of inflammatory cell infiltration of the lamina propria. Treatment is nonspecific with a favorable outlook expected. No clear relationship to duodenal ulcer could be determined. These observations are taken to support the contention that nonspecific duodenitis is probably a distinct clinical entity.

A solution is offered to the problem of adjudicating between two different mathematical models for patient profiles differently diagnosed by such models. The solution depends on finding that subset of attributes which is most effective in discriminating between the two competing disease entities, and then using that subset as the arbiter between the two computed diagnoses. The method is illustrated by using Bayes's theorem and Discriminant Analysis as the two mathematical models on a set of 11 subjective attributes for 300 gastroenterological patients having one of six diseases. These 300 patients were independently radiographically diagnosed. The method was successful in correctly diagnosing 30 out of the 48 patients for whom the radiographically determined diagnosis was actually one of the competing diagnoses.

On the basis of 11 dichotomously valued attributes of upper abdominal pain, two different mathematical techniques, i.e., Bayes's Theorem and Discriminant Analysis, were used to diagnose 300 patients having one of six gastroenterological diseases. As was done in a previous study for Bayes's Theorem, Discriminant Analysis was used in an attempt to choose objectively an optimal subset of attributes from the entire set. Diagnostically, no subset was found to be superior to the entire set, though many yielded equal diagnostic accuracy. Both mathematical models were used to deduce the “superior” profiles for each disease, i.e., those profiles of attributes whose mathematical value was maximal for that disease. These “superior” profiles were compared for each mathematical model separately, using sex as a distinguishing characteristic. Diagnostic comparisons for the two mathematical models were also made over the entire 2048 possible profiles, and agreement was noted for 1417 of these. Finally the accuracy of diagnosis on the 300 patients was evaluated by comparing the number of correct and incorrect diagnoses with the numerical differences between the maximal values and the competing values of the probabilities and discriminant functions. Results showed that diagnostic accuracy increased dramatically with increases in such numerical differences.

Excerpt It is not generally appreciated that alteration of the muscular component of viscera can be a dominant feature of myotonic dystrophy. Twelve patients with varying degrees of clinically evid...

Three balloons of different size were used to obtain pressures in the esopha-geal sphincters of 21 healthy young subjects. In 12 of these we had the opportunity to repeat the studies using perfused open-tip methods, and in 10 of these 12, three methods were correlated. The constantly perfused open-tip tubes were pulled through the sphincter intermittently and continuously. The balloons were pulled through the sphincter continuously.

Thirty patients, normal or with hiatal hernias, were examined, using simultaneous recording on the same cine film of the radiographic appearance and manometry of the distal esophagus and adjacent stomach. A closed sphincter measuring 1 to 2 em in length was found. A high-pressure zone longer than 2 cm was due to factors other than the intrinsic sphincter. The primary peristaltic wave terminated at the sphincter. The sphincter moved 1 to 4 cm cephalad with swallowing. Detection of a small segment of stomach above the diaphragm during and shortly after swallowing is normal.

Excerpt Malabsorption of hemopoietic factors is an important source of disability in regional enteritis. Six patients with established diagnoses of regional enteritis were studied in detail to eluc...

Excerpt The process of choosing a diagnosis from subjective symptoms has not been examined in detail. Previous studies which have concerned themselves with this mechanism have been devoted to check...

Excerpt This study consists of clinical, physiologic, and histologic information obtained from eight patients with non-neoplastic narrowing of the esophagogastric junction. Seven of the patients we...