Invasive bladder cancer: tumor configuration, lymphatic invasion and survival

The pathologic slides of 86 patients who underwent radical cystectomy for invasive (stage T2 plus) bladder carcinoma were reviewed. The tumors were classified according to the demonstration or absence of small vessel invasion and the papillary or solid configuration. Of the 86 patients regional nodal metastases were noted in 24. Eighteen of 48 patients (38 per cent) with small vessel invasion also had nodal metastases compared to 6 of 38 (16 per cent) without small vessel invasion. Of the 62 patients without nodal metastases the crude 5-year survival was 52 per cent for 32 without small vessel involvement compared to 30 per cent for 30 with small vessel involvement.     

Minocycline diffusion into benign prostatic hyperplasia.

Minocycline, a broad-spectrum, highly lipid soluble tetracycline that has generated interest in the treatment of chronic prostatitis, was evaluated for its possible ability to be concentrated in benign prostatic hyperplasia. Drug levels in the prostate, plasma, fat, muscle and urine were measured in patients undergoing open prostatectomy after preoperative intravenous minocycline. The concentrations of the drug in the prostate and serum were close (4.16 versus 3.01 microgram. per gm.), while drug levels in striated muscle and fat were consistently lower (2.92 and 0.77 microgram. per gm). Higher preoperative doses of drug yielded higher tissue levels. Drug delivery closer temporally to the operation yielded higher serum and prostatic levels as opposed to striated muscle and fat, suggesting a rapid diffusion of the drug into benign prostatic hyperplasia.     

Proton radiation as boost therapy for localized prostatic carcinoma.

A 160-MeV proton beam has been modified to irradiate patients with localized tumors by using convention treatment schedules. This proton beam has the physical advantage of megavoltage x-rays of reducing the radiation dose to normal tissues adjacent to the tumor volume. A perineal proton technique used as boost therapy (2,000 to 2,500 rads) was evaluated in the definitive irradiation of 17 patients with localized prostatic carcinoma. This technique allows repeated daily treatment of the carefully defined target volume with a precision of +/- 2 mm. Total dose to the prostatic tumor, but not to the posterior rectum, has been increased by 500 to 700 rads. After 12 to 27 months of observation, no noteworthy rectal reaction has developed in a patient, easily managed urethral strictures have developed in two patients, and all but one are locally controlled.     

Treating complex trauma in women within community mental health

Community mental health clinicians are likely to find their case loads composed of women who have complicated trauma histories. In response to the absence of comprehensive treatment for trauma survivors within the community mental health system, an alternative model, Overcoming Pain and Adversity in Life (OPAL) is offered. As an intensive treatment program, OPAL is structured in a triphase format to accommodate the individual needs of each woman and to promote symptom reduction and/or resolution.     

Validating medical students' self-report of smoking-related communication skills and educational experiences.

OBJECTIVE: Pediatric clerkships can be important settings for medical students to learn how to perform smoking assessments and counseling with parents. In evaluating an educational intervention that promotes this skill, we assess whether students' self-report of this counseling skill was a valid measure of actual behavior. METHODS: A trained observer evaluated student smoking assessment and counseling practices during pediatric well-child visits at 5 clinical sites in eastern Massachusetts. The external observations of behavior were used as a gold standard, and we determined the accuracy of the students' self-report of their smoking counseling practices with families and of their preceptors' educational interventions. RESULTS: We observed 38 pediatric preceptors and 85 Boston University School of Medicine (BUSM) III students in 85 clinical encounters. Sensitivities of the students' report of assessing smoking practices and counseling parents and children ranged from 0.60-1.00, and specificities ranged from 0.41-0.88. Specifically, with regards to the students' report of performing a smoking assessment with the family, the sensitivity was 0.97 (95 per cent confidence interval, 0.89-0.99) and the specificity was 0.88 (95 per cent confidence interval, 0.72-0.97). For measures where the observer could not determine practice, agreement between the student and preceptor was between 57 per cent and 83 per cent . Specifically, with regard to whether the preceptor made expectations clear with the student, students and preceptors agreed 83% of the time. CONCLUSION: Although direct observations of behavior may still be the most accurate report of true practice, when this is not feasible, student self-report appears to be a valid measure of smoking assessment and counseling practices during pediatric clerkships.     

Challenges facing general internal medicine in the 99th Congress

Since 1976, federal support for training in general internal medicine has been provided through the primary care residency programs under Title VII of the Public Health Service Act. Continuation of these programs is now in jeopardy because of severe fiscal pressures and the response of Congress to the resulting budgetary stringency. General internal medicine faces immediate problems in the budgetary, authorization, and appropriations arenas. However, Congressional proposals for changing the method by which Medicare pays for all graduate medical education may provide an important opportunity. Under a revised method of financing graduate medical education, general internal medicine could eliminate its historical dependence on increasingly unstable federal grant funds and could contribute to the development of new federal incentives for training in the primary care specialties.     

Meniscal injuries: detection using MR imaging

Both retrospective and blinded analyses of thin-section, high-resolution magnetic resonance (MR) images of the knee joint, produced using a solenoid surface coil, indicate that MR imaging is an effective technique for evaluating meniscal injuries. Images of 49 patients were evaluated, and the results were correlated with those of subsequent arthroscopy. A grading scale was developed to rate the index of suspicion of a meniscal tear based on the MR images. Overall, approximately 80% of menisci rated grade 4 (definite tear) or 3 (probable tear) were found to have corresponding tears at arthroscopy. In many other patients with a grade 4 or 3 meniscus in whom a corresponding tear was not found arthroscopically, meniscal tears at other sites or other abnormalities were correctly diagnosed using MR. A majority of the false-positive MR images involved the posterior horns of the menisci, the sites of most false-negative arthroscopic diagnoses. The predictive value of a negative MR image was almost 100%. Even in patients with moderate-to-large effusions, the menisci were accurately evaluated. The results imply that MR imaging is useful in the preoperative evaluation of suspected meniscal tears.     

Percutaneous drainage access: a simplified coaxial technique

We describe an access technique that we have used in 150 nephrostomy and biliary drainage procedures and for access to some abscesses and viscera. The system provides safe coaxial access with a 22-gauge removable hub needle, which then acts as a guide wire and is replaced by an 18-gauge cannula. A major advantage is that only one guide wire is used (0.038-inch) for the entire drainage procedure. No significant complications have occurred to date with this method.     

Interventional radiology in the spleen

Despite the widespread use of interventional radiologic techniques, there has been reluctance to apply these to the spleen. Concern for bleeding and difficulty in negotiating around the colon and pleura have limited its use. The authors report their experience with interventional radiology of the spleen in 35 cases, including percutaneous biopsy (n = 5), diagnostic and therapeutic fluid aspiration (n = 14), and catheter drainage of abscesses (n = 9), hematomas (n = 2), intrasplenic pancreatic pseudocysts (n = 2), and necrotic tumor (n = 1). Transsplenic fluid aspiration and biopsy of the pancreas and adrenal gland were performed as well (n = 2). All procedures were performed under computed tomographic or ultrasound guidance. Biopsies were performed with 22- or 20-gauge needles only; no complications were encountered. Diagnoses included primary and secondary malignancies and an infectious process. Drainages were successful in 11 of 14 patients; pleural effusions occurred in two cases, but neither required specific therapy. Interventional radiologic procedures in the spleen are feasible, and the authors discuss methods to promote their safe application.