Publications

The author explains why primary care is especially beleaguered today (e.g., growth in specialization and widening income gaps between specialists and generalists, growth of managed care, cutbacks in Medicare and Medicaid payments to academic medical centers, and pro-technology biases in fee-for-service payment). Medical students sense primary care's troubles; primary care residency matches continue to decline. Attempts to encourage generalist practice cannot compete with such forces as pro-specialist reimbursement policies, the way research is funded, the dominance of specialist role models, and the daunting knowledge demands of the generalist mandate. Can generalists find a niche in the current health care marketplace? How will the under-65 population influence the future of primary care practice? (The author predicts a scenario based on patients' degrees of affluence.) Will consumers be willing to pay for the services that primary care is uniquely well positioned to offer? The author explains why increasingly important issues of cost, quality, and convenience could help create a niche for primary care. He also maintains that academic medicine must rededicate itself to producing well-trained generalists, despite all the pressures not to, and discusses the challenges that family practice, internal medicine, and pediatrics must face if they are to flourish. He concludes that if generalism fails the market test, something very precious will be lost-and that generalist physicians would be so badly missed that they might have to be reinvented.

T cells probe a diverse milieu of peptides presented by molecules of the major histocompatibility complex (MHC) by using the T-cell receptor (TCR) to scan these ligands with high sensitivity and specificity. Here we describe a physical basis for this scanning process by studying the residues involved in both the initial association and the stable binding of TCR to peptide-MHC, using the well-characterized TCR and peptide-MHC pair of 2B4 and MCC-IE(k) (moth cytochrome c, residues 88 103). We show that MHC contacts dictate the initial association, guiding TCR docking in a way that is mainly independent of the peptide. Subsequently, MCC-IE(k) peptide contacts dominate stabilization, imparting specificity and influencing T-cell activation by modulating the duration of binding. This functional subdivision of the peptide-MHC ligand suggests that a two-step process for TCR recognition facilitates the efficient scanning of diverse peptide-MHC complexes on the surface of cells and also makes TCRs inherently crossreactive towards different peptides bound by the same MHC.

The upper airway serves as air conditioner, filter, and warning device. Two neurological modalities, olfaction and trigeminal chemoreception, inform us of the chemical qualities of the air we breathe. A number of poorly understood conditions, including nonallergic rhinitis, irritant-induced rhinitis, odor-triggered asthma, odor-triggered panic attacks, chemical-induced olfactory dysfunction, and irritant-associated vocal cord dysfunction, involve induction of symptoms by odorant and/or irritant chemicals in the upper airway. This article is a summary of the knowledge and theories about these various conditions, and highlights those aspects of nasal anatomy, physiology, and pathophysiology relevant to their understanding.

We investigated the effect of chronic administration of morphine on noxious stimulus-induced antinociception (NSIA) produced by intraplantar capsaicin injection. In the untreated (naive) rat, we previously found that NSIA depends on activation of dopamine, nicotinic acetylcholine, and mu- and delta-opioid receptors in nucleus accumbens. Rats chronically implanted with subcutaneous morphine pellets demonstrated tolerance to the antinociceptive effects of acute systemic morphine administration but did not show cross-tolerance to NSIA. Morphine pretreatment, however, significantly reduced NSIA dependence on intra-accumbens opioid receptors but not on dopamine or nicotinic acetylcholine receptors. As observed in naive rats, intra-accumbens microinjection of either the dopamine receptor antagonist flupentixol or the nicotinic receptor antagonist mecamylamine blocked NSIA in rats tolerant to the antinociceptive effects of morphine, but, in contrast to naive rats, intra-accumbens microinjection of either the mu-receptor antagonist Cys2,Tyr3,Orn5,Pen7 amide or the delta-receptor antagonist naltrindole failed to block NSIA. These findings suggest that although NSIA is dependent on nucleus accumbens opioid receptors in the naive state, this dependence disappears in rats tolerant to the antinociceptive effects of morphine, which may account for the lack of NSIA cross-tolerance. In separate experiments, intra-accumbens extracellular dopamine levels were measured using microdialysis. Dopamine levels increased after either capsaicin or systemic morphine administration in naive rats but only after capsaicin administration in morphine pretreated rats. Thus, intra-accumbens dopamine release paralleled antinociceptive responses in naive and morphine pretreated rats.

Overexpression of urokinase plasminogen activator (uPA) in endothelial cells can decrease intravascular thrombosis. However, expression of uPA is increased in atherosclerotic human arteries, which suggests that uPA might accelerate atherogenesis. To investigate whether elevated uPA expression accelerates atherogenesis, we cloned a rabbit uPA cDNA and expressed it in carotid arteries of cholesterol-fed rabbits. uPA gene transfer increased artery-wall uPA activity for at least 1 week, with a return to baseline by 2 weeks. One week after gene transfer, uPA-transduced arteries were constricted, with significantly smaller lumens and thicker walls, but no difference in intimal or medial mass. Two weeks after gene transfer, uPA- and control-transduced arteries were morphologically indistinguishable. By 4 weeks, however, uPA-transduced arteries had 70% larger intimas than control-transduced arteries (P < 0.01) and smaller lumens (P < 0.05). Intimal lesions appeared to be of similar composition in uPA- and control-transduced arteries, except that degradation of elastic laminae was evident in uPA-transduced arteries. These data suggest that elevated uPA expression in atherosclerotic arteries contributes to intimal growth and constrictive remodeling leading to lumen loss. Antagonists of uPA activity might, therefore, be useful in limiting intimal growth and preventing constrictive remodeling. Overexpression of uPA in endothelial cells to prevent intravascular thrombosis must be reconsidered, because this intervention could worsen underlying vascular disease.