Recent Publications by CFE Educators

A patient with Waldenström's macroglobulinemia who presented with pleuropulmonary manifestations is described. The course was complicated by recurrent Streptococcus pneumoniae infections despite pneumococcal immunization.

Although the midbrain periaqueductal gray (PAG) is thought to have a major role in an endorphin-mediated analgesia system, little is known about its neuroanatomical organization. To determine the microcircuitry within the PAG through which exogenous and endogenous opiates may act, we analyzed the synaptic organization of normal and immunoreactive enkephalin (ENK)-labeled profiles in the caudal PAG, a region of particular interest because of its effectiveness in generating analgesia. Examination of the normal fine structure of this region demonstrated that there is no characteristic synaptic morphology that distinguishes individual regions of the caudal PAG (ventromedial, ventrolateral and dorsolateral) from one another. In all 3 regions of the caudal PAG, axodendritic synapses are the predominant form of synaptic interaction making up 93-97% of all synapses counted. Axosomatic synapses are much less common, as are presumed axoaxonic and dendrodendritic synapses. In the caudal ventral PAG, the largest population of ENK-labeled axonal boutons are found presynaptic to unlabeled, centrally placed dendrites. Much less frequently, immunoreactive ENK-containing boutons are found presynaptic to neuronal perikarya or vesicle-containing profiles. Thus, these results suggest that the dendrites of neurons intrinsic to the PAG are the most probable site of opiate action in the caudal ventral PAG.

Eighteen patients with lupus erythematosus (LE) and pleural effusions were evaluated. Fourteen patients had lupus pleuritis and four had pleural effusions of other etiologies. All patients were symptomatic, and the presenting signs and symptoms did not help distinguish between lupus pleuritis and pleural effusions of other causes. The presence of LE cells confirmed the diagnosis of lupus pleuritis in seven of eight patients. In 11 of 13 patients with lupus pleuritis, the pleural fluid antinuclear antibody (ANA) titer was greater than or equal to 1:160, and in nine of 13 patients with lupus pleuritis, the pleural fluid to serum (PF/S) ANA ratio was greater than or equal to 1. In the four patients with LE and a pleural effusion of another etiology, the pleural fluid ANA titer was negative in two and low titer in two (1:40, 1:80); the pleural fluid to serum ANA titer was always less than one. Of 67 patients with pleural effusions of other etiologies, the pleural fluid ANA was negative. The signs and symptoms of lupus pleuritis are nonspecific, however; the findings of LE cells in pleural fluid confirms the diagnosis and a high pleural fluid ANA titer (greater than or equal to 1:160) and a PF/S ANA ratio of greater than or equal to 1 strongly supports the diagnosis.

The component parts and development of a comprehensive system to evaluate and improve teaching in a school of medicine are described by the author in this paper. This system integrates quantitative measures of teaching (student/resident ratings of classroom and clinical teaching), descriptive documentation (faculty teaching load, innovations, and research on teaching), and qualitative judgments (peer review) on the full spectrum of instruction in medicine. Medical school policies have standardized evaluation criteria, instrumentation, and procedures while granting departments flexibility in conducting peer review. The results of two studies indicate that the evaluation system described here has had a positive impact both on the improvement of teaching and on academic promotions.

To clarify the circuitry through which opioid compounds modulate spinal and trigeminal nociceptive transmission, we have examined the synaptic associations formed by leucine-enkephalin-containing (enkephalin) neurons in the superficial dorsal horn of the cat. As described previously, punctate enkephalin immunoreactivity is concentrated in the marginal layer (lamina I) and in both the outer and inner layers of the substantia gelatinosa (lamina IIo and IIi). In colchicine treated cats, enkephalin perikarya are most numerous in lamina I and at the border between laminae I and II. Ultrastructural analysis reveals that enkephalin cells receive a diverse afferent input. The majority of afferent inputs are presynaptic to the enkephalin dendrites; few axosomatic synapses are seen. Among these presynaptic axonal profiles are unlabeled axons which resemble primary afferent terminals, including the characteristic central axonal varicosity. Enkephalin dendrites are also postsynaptic to enkephalin immunoreactive axons. Two types of enkephalin axonal profiles appear in the superficial dorsal horn. Class I profiles are only found in lamina I. These are large profiles which form few synapses; those synapses made are axodendritic. Class II enkephalin axons are smaller and are distributed in both layers I and II. While Class II axons most commonly form axo-dendritic synapses, they also form axo-axonic synapses with flat vesicle-containing profiles; the latter are generally presynaptic to the enkephalin terminals. Serial analysis further revealed that both the enkephalin and the flat vesicle-containing profile synapse onto a common dendrite. Although enkephalin axons frequently lie adjacent to round vesicle-containing profiles, anatomical evidence that opioid axons form synapses with this type of ending was not found. An additional type of enkephalin vesicle containing-profile is found in layer IIi; its morphological features do not clearly distinguish its axonal or dendritic origin. These endings are typically postsynaptic to unlabelled central endings, and provide minimal presynaptic input to other elements in the neuropil. Like some class II axons, these labelled profiles contain vesicles which cluster at the membrane immediately adjacent to unlabelled central axons. These results indicate that spinal enkephalin neurons receive a variety of synaptic inputs. These include inputs which may derive from primary afferent axons. Enkephalin neurons, in turn, influence nociceptive transmission predominantly through postsynaptic mechanisms. Finally, while we did not observe enkephalin terminals presynaptic in an axoaxonic relationship, the possibility that enkephalin neurons modulate the excitability of fine fiber nociceptive and nonnociceptive afferents via "nonsynaptic interactions" is discussed.

This study was designed to investigate the frequency and diagnostic importance of the pleuropulmonary manifestations of the postcardiac injury syndrome. A retrospective study of 35 patients (2 to 76 years old) with clearly defined postcardiac injury syndrome is presented. Twenty-one cases followed cardiac surgery, and 14 appeared after myocardial infarction. The onset of the syndrome was an average of 20 days following injury. The major clinical findings were pleurisy (91 percent; 32/35), fever (66 percent; 23/35), pericardial rub (63 percent; 22/35), dyspnea (57 percent; 20/35), rales (51 percent; 18/35), pleural rub (46 percent; 16/35), elevated erythrocyte sedimentation rate (96 percent; 25/26), and leukocytosis (49 percent; 17/35). The chest roentgenogram was abnormal in 94 percent (33/35). Pleural effusion was present in 83 percent (29/35), parenchymal infiltrates in 74 percent (26/35), and an enlarged cardiac silhouette in 49 percent (17/35). Analysis of pleural fluid was performed on 16 samples from 12 patients and revealed a bloody exudate with a pH greater than 7.40. The data presented document that pleuropulmonary involvement is a common manifestation of postcardiac injury syndrome. In addition, we discuss how these findings can be used to differentiate this syndrome from other clinical entities that may appear following cardiac injury, ie, parapneumonic effusions, congestive heart failure, and pulmonary embolism.

Despite the important contribution of the midbrain periaqueductal gray (PAG) to endogenous pain suppression systems, little is known about the neuroanatomical basis of its functional organization. In a previous study of the distribution of the endogenous opiate leucine-enkephalin (ENK) in the PAG (Moss, M. S., E. J. Glazer, and A. I. Basbaum (1983) J. Neurosci. 3: 603-616), we found that immunoreactive ENK-containing neurons and terminals are clustered in discrete populations. In this study we have extended our analysis of the neurochemical organization of the PAG by using immunocytochemistry to map the distribution of two non-opiate peptides that produce potent analgesia when administered at central gray levels: substance P (Sub P) and vasoactive intestinal polypeptide (VIP). Immunoreactive Sub P neurons and terminal fields are clustered in discrete populations throughout the PAG. The distribution pattern of these populations changes at different rostral-caudal levels of the PAG. For example, there is a ventral-to-dorsal shift in the location of Sub P-like immunoreactivity from the caudal to the rostral PAG. Few immunoreactive Sub P neurons are found in the nucleus raphe dorsalis although moderately dense terminal field staining is present. The staining pattern of immunoreactive VIP is totally different from that of Sub P. Regardless of the rostral-caudal level examined, VIP-containing neurons are found tightly clustered in the subependymal neuropil of the ventromedial PAG. Only a few immunoreactive VIP-containing neurons are found in the ventral PAG or nucleus raphe dorsalis. The striking differences between the distribution of Sub P- and VIP-like immunoreactivity in the PAG indicates that the neural circuitry underlying pain suppression by Sub P and VIP may also differ.

The design, development, and implementation of procedures for peer review of teaching are described. Peer review is one component of a comprehensive system to evaluate and improve teaching in a school of medicine. Colleague observations and judgments are used to augment student/resident ratings of teaching for purposes of instructional improvement and academic promotions. School policies have standardized evaluation criteria and instrumentation while granting departments flexibility in conducting peer review. Three different departmental peer review committee structures and procedures are reviewed. With the emphasis upon improvement, faculty acceptance of peer review of teaching has been positive. Peer review reports have had a positive impact on academic promotions. The inherent strengths and limitations of peer review of teaching are discussed in relation to the literature and to the medical school environment.