Congress 2000: a continuing medical education summit with implications for the future

The expectations of attendees, the evaluations of themes, and the implications for continuing medical education (CME) identified by "Congress 2000: A Continuing Medical Education Summit on the Practices, Opportunities and Priorities for the New Millennium" are reviewed. A vision was identified with significant opportunities for CME to become a more valuable partner in and contributor to quality health care. The vision suggests that CME should be linked more closely to physician learning at the point of care and that technology might be used more successfully to address physician-learner needs by helping them to manage volumes of evidence for treating patients more effectively. At the same time, health care outcome data to analyze the need for and measure the effectiveness of educational interventions should become integrated into standards of practice for CME providers. Continuous improvement based on research about effective learning processes and outcomes should become an essential construct of the CME culture. Implications are summarized for the profession, organizational CME providers, individual CME professionals, and CME research from this new vision of CME crafted at Congress 2000.     

Epidemiology of Wilms tumor

Wilms tumor affects approximately one child per 10,000 worldwide before the age of 15 years. Incidence rates appear to be slightly elevated for U.S. and African Blacks in comparison to Whites, but are only half as great among Asians. Several case-control studies have suggested that paternal occupational or maternal hormonal exposures during pregnancy may increase the risk of Wilms tumor, but small numbers of subjects and inconsistencies in the patterns of exposures do not permit firm conclusions to be drawn. It is unlikely that such environmental exposures play a major role in the etiology of Wilms tumor. The median age-at-onset of Wilms tumor is 38 months in the U.S. National Wilms Tumor Study series, with cases in girls occurring on average 6 months later than in boys. Patients with bilateral tumors, aniridia, cryptorchism/hypospadias, Beck-with-Wiedemann syndrome, or intralobar nephrogenic rests tend to be diagnosed much younger than average (median 17–27 months). Those with familial disease or multicentric tumors have intermediate age-at-onset distributions, while those with perilo-bar nephrogenic rests are diagnosed at older ages. The epidemiologic features suggest that somatic mosaicism, rather than a germ-line mutation, may be responsible for some of the bilateral and multicentric cases. © 1993 Wiley-Liss, Inc.     

Position paper: Imaging methods for primary renal tumors of childhood: Costs versus benefits

The patterns of disease distribution at diagnosis and during follow-up were cataloged for the primary renal tumors of childhood. These data, derived from more than 1,500 patients, were used to define the most rewarding and cost-effective imaging methods required for patient management. The basic information needed prior to surgery includes whether there is a functioning kidney on the opposite side, and whether there are lung metastases or inferior vena cava thrombi. Simple X-ray examinations and ultrasonography (US) will provide the necessary data. Postoperatively, when the histology is known, examination of the brain (MRI or CT scan) is needed for patients with the rhabdoid tumor and clear cell sarcoma of the kidney (CCSK) who are prone to develop brain lesions; and the skeletal system (bone scan, X-ray skeletal survey) for CCSK and for renal cell carcinoma patients who tend to develop bone metastases. Continuing examination of the lung (chest films) is required for all histologies except perhaps for mesoblastic nephroma, which seldom metastasizes. The opposite kidney needs follow-up (US) for 5 or more years to exclude metachronous involvement if nephrogenic rests are present in either kidney. Sophisticated imaging studies, which cost five times or more than simple X-ray examinations or US, are not warranted routinely, and should be reserved for those cases where simpler, less expensive studies do not suffice for reaching patient management decisions. © 1993 Wiley-Liss, Inc.     

SIOP working committee on psychosocial issues in pediatric oncology

Recognizing the importance of psycho-social issues in the care and cure of the child with cancer, the board of the International Society of Pediatric Oncology (SIOP) in 1991 constituted a Working Committee on Psychosocial Issues in Pediatric Oncology, with Giuseppe Masera as chair and John Spinetta as co-chair. This committee met for the first time in Rhodes, Greece, in October 1991. The committee discussed various psychosocial issues and developed a document on Aims and Recommendations, summarizing the experiences of major centers. This document was approved by the SIOP board, which recommended diffusion of the document to the pediatric oncology community. © 1993 Wiley-Liss, Inc.     

Human autopsy tissue distribution of the epipodophyllotoxins etoposide and teniposide

Autopsy tissues were collected from ten patients who had received etoposide, 150–3480 mg, from 1 to 412 days antemortem and from five patients who had received teniposide, 234–1577 mg, from 3 to 52 days antemortem. Tissues were assayed for etoposide and teniposide using high-pressure liquid chromatography with electrochemical detection. Etoposide was detectable in tissues of three of four patients dying <5 days after their last etoposide treatments to cumulative doses of 150–432 (median, 280) mg but was detectable in tissues of only one of six patients dying 7–412 (median, 37) days after their last etoposide treatment to a cumulative dose of 607–3600 (median, 1553) mg. The highest tissue concentrations were in the small bowel, prostate, thyroid, bladder, spleen, and testicle. Intermediate concentrations were found in the lymph node, skeletal muscle, adrenal gland, stomach, tumor, liver, lung, pancreas, and kidney, and the lowest concentrations were found in the heart, brain, diaphragm, vagina, and esophagus. Teniposide was detectable in one patient dying 3 days after a cumulative teniposide dose of 576 mg (spleen, prostate, heart > large bowel, liver, pancreas > thyroid, adrenal, stomach, small bowel, bladder, testicle, and skeletal muscle) but was not detectable in any tissue from four patients dying 5–52 (median, 8) days after their last treatment to a cumulative teniposide dose of 234–1577 (median, 520) mg. The very short tissue half-life contrasts with our previous observations for human autopsy tissue concentrations of mitoxantrone, doxorubicin, menogaril metabolites, diaziquone, and amsacrine. The short tissue half-life may help explain the schedule dependency of epipodophyllotoxin efficacy and may also help explain the lack of visceral toxicity of these compounds.This work was supported in part by a grant from Bristol-Myers Squibb Pharmaceutical Company     

Human autopsy-tissue distribution of menogaril and its metabolites

Autopsy-tissues were obtained from eight patients who had last received menogaril (total cumulative dose, 175–1080 mg/m²) intravenously (one patient) or orally (seven patients) from 1 to 285 days prior to death. Tissue samples were assayed for menogaril and its metabolities by high-pressure liquid chromatography. Unchanged menogaril was found only in a single lung-tissue sample from a patient who had died < 24 h after receiving his last treatment.N-Demethylmenogaril was found in two lung-tissue samples and in single samples of the thyroid, lymph node, pancreas, cerebellum, and tumor. The major menogaril metabolite found in human autopsy-tissues was 7-deoxynogarol. The highest 7-deoxynogarol concentrations were found in the large bowel (median, 201 ng/g), liver (median, 183 ng/g), and lung (median, 177 ng/g). The heart ranked as the 9th of 18 organs in median 7-deoxynogarol concentration, after the large bowel, liver, lung, tumor, thyroid, skeletal muscle, adrenal gland, and kidney. The lowest concentrations were detected in brain tissue. Our results suggest that the low degree of cardiac toxicity and the possible pulmonary toxicity of menogaril may be related to relative tissue concentrations of menogaril metabolites. Tumor 7-deoxynogarol concentrations were comparable with those in normal tissues, except that concentrations in intracerebral tumors were higher than those in the normal brain. Tissue 7-deoxynogarol concentrations appeared to be directly related to the cumulative dose and inversely related to the time from the last treatment to death; the value obtained by dividing dose by time correlated (P<0.05) with tissue 7-deoxynogarol concentrations.     

Tympanometry interpretation by primary care physicians. A report from the International Primary Care Network (IPCN) and the Ambulatory Sentinel Practice Network (ASPN)

BACKGROUND: The accuracy of data gathered by primary care clinicians in practice-based research networks (PBRNs) has been questioned. Tympanometry, recently recommended as a means of improving accuracy of diagnosing acute otitis media, was included as an objective diagnostic measure in an international PBRN study. We report the level of agreement of interpretations of tympanograms between primary care physicians in PBRNs and experts. METHODS: Primary care physicians in PBRNs in the Netherlands, United Kingdom, United States, and Canada enrolled 1773 children aged 6 to 180 months who contributed 6358 tympanograms during 3179 visits. The physicians were trained in the use and interpretation of tympanometry using the Modified Jerger Classification. We determined the level of agreement between physicians and experts for interpretation of tympanograms. One comparison used the 6358 individual ear tracings. A second comparison used the 3179 office visits by children as the unit of analysis. RESULTS: The distribution of expert interpretation of all tympanograms was: 35.8% A, 30% B, 15.5% C1, 12% C2, and 6.8% uninterpretable; for visits, 37.8% were normal (A or C1), 55.6% abnormal (B or C2), and 6.6% could not be classified. There was a high degree of agreement in the interpretation of tympanograms between experts and primary care physicians across networks (kappa=0.70-0.77), age groups of children (kappa=0.69-0.73), and types of visits (kappa=0.66-0.77). This high degree of agreement was also found when children were used as a unit of analysis. CONCLUSIONS: Interpretations of tympanograms by primary care physicians using the Modified Jerger Classification can be used with confidence. These results provide further evidence that practicing primary care physicians can provide high-quality data for research purposes.     

Assessing the Health Attitudes, Beliefs, and Behaviors of African Americans Attending Church: A Comparison from Two Communities

Public health officials and researchers continue to be increasingly concerned about the health of populations of color, especially African Americans. A survey was administered in African American churches in two communities (Wichita, KS and Tuscaloosa, AL) to gather information concerning health behaviors and beliefs and to design interventions that might improve their health status. The study examined the homogeneity of attitudes, beliefs, and behaviors across these samples and to determine the readiness to change using the Transtheoritical Model. Individuals completed a 33-item survey: 6 demographic questions, 12 health behavior questions, 8 health belief questions, 3 church attendance questions, and 4 church-based health promotion program questions. The total sample consisted of 429 respondents. The results showed that 93% of respondents have had their blood pressure checked in the past 2 years. While only 44% indicated eating a high fiber diet during the week. Thirty percent of respondents indicated that their health was dependent on fate or destiny. The findings from this study confirm that among both samples that health attitudes, beliefs, and behaviors need to be changed to lower the risk of certain diseases and disorders. The findings also indicate that both samples have similar beliefs about health that may have important implications for disseminating information to the community. Innovative and culturally sensitive programs are needed in the African American community if disparities in health are to diminish.     

Inability to view the heart through the subxiphoid echocardiographic window: A harbinger of disaster

Summary Two case reports of critically ill neonates, one with pneumomediastinum, the other with pneumopericardium, illustrate how the inability to view the heart through the subxiphoid echocardiographic window occurs only in pneumopericardium. This echocardiographic nonfinding should alert the echocardiographer and neonatal team of impending pericardial tamponade.     

Surgical management of previously untreated glomus jugulare tumors

The treatment of glomus jugulare tumors is controversial. Changes in the surgical treatment of glomus jugulare tumors at The House Ear Clinic have allowed complete resection in 85% of patients with minimal morbidity and no surgical mortalities. Our experience with 52 previously untreated patients with glomus jugulare tumors is reviewed. Two primary surgical techniques were used. The mastoid/neck approach was used in 9 patients with small tumors limited to the jugular bulb. The infratemporal fossa approach was used in the remaining 43 tumors. Lower cranial nerve preservation was possible in the majority of patients with normal preoperative function. Modifications in the management of the facial nerve during the infratemporal fossa approach have resulted in good recovery of facial function (House grade I/VI or II/VI) in 95% of patients. Most patients (85%) were able to fully resume all preoperative activities. Our results suggest that surgical management is the treatment of choice in younger patients with glomus jugulare tumors.