Volume 94, Issue 12

Magnetic resonance imaging studies were performed in six patients with chronic head and neck pain and in five control subjects to determine whether irreversible atrophic changes resulting in destruction of muscle fibers have a role in patients with chronic pain specific to the cervical spine. Both groups of subjects had medical history obtained and underwent physical examination and proton density-weighted (PD-weighted) magnetic resonance imaging. Subjects with chronic pain had substantial restriction of motion. Axial proton density-weighted images of the rectus capitis major and minor muscles were examined. In the subjects with chronic pain, the muscles had high signal intensity, indicating replacement of dead suboccipital skeletal muscle with fatty tissue. This infiltration was not observed in the control subjects who were free of significant motion restrictions and had no history of recurring neck and head pain. Analysis of pixel intensity values confirmed this finding. The reduction in proprioceptive afferent activity in affected muscles may cause increased facilitation of neural activity that is perceived as pain. A least mean squares algorithm was used to define a linear estimating equation for each subject. linear regression analysis, using an alpha level <.005, was used to determine how well each subject's data fit the estimating equation. This preliminary work indicates substantial infiltration of fatty tissue into suboccipital muscles of some subjects being treated for chronic head and neck pain.

Physicians have identified malpractice reform as their first priority during the recent flurry of national reform initiatives. Their focus on malpractice, however, tends to obscure the relationship between malpractice and the systemic problems wracking our healthcare delivery system. Because malpractice has an impact on all three foci of comprehensive reform-quality, cost, and access-it is reasonable to expect healthcare reform to include some manner of tort reform. However, it is important to realize the tangential nature of the relationship and keep the focus of reform on the underlying issues of system reform. The authors define the areas of physician liability under tort law (both malpractice and product liability), point out the misperceptions that inform physician behavior, and review the individual reforms proposed. They identify the stakeholders and their positions on each proposal, while imploring a cooperative, systemwide approach to tort reform.

The American Osteopathic Board of Internal Medicine has been examining various factors that may affect candidate performance on subspecialty certifying examinations. To see whether taking subspecialty training in an osteopathic compared with an allopathic institution could predict better performance on the certifying examinations, the authors analyzed examination performance for all candidates from 1984 through 1992. There was no significant difference between the mean scores for the two groups for any of the nine subspecialty certifying examinations. When the results from all nine examinations were pooled, the mean first-time examination takers' score for candidates in allopathic subspecialty programs (n=201) was 78.3 and for those in osteopathic subspecialty programs (n= 153), 77.4 (P> O.2). On the basis of these results, we cannot conclude that osteopathic subspecialty training is a factor that predicts better performance on the subspecialty certifying examination.