The art of medicine: subjective measures as predictors of outcome in stroke and traumatic brain injury.

This study was designed to explore new ways of predicting the functional outcomes of stroke and brain injury patients. Upon admission and initial assessment of functional performance, we used an on-line computer program to indicate the most important and subjective judgment items to set rehabilitation goals for patients. The functional performance and discharge outcomes of patients from an inpatient program were measured by using five nonmedical functional items from the patient evaluation conference system (PECS). For stroke patients we most frequently selected motor loss, perceptual/cognitive deficit, spasticity, sensory deficit (PECS medical items), and comprehension (subjective cue). For traumatic brain injury patients, however, we selected motor loss, perceptual/cognitive deficit, spasticity (PECS medical items), communication, and comprehension (subjective cues). Data were statistically analyzed using the Fisher Exact Test. Of the medical function items, a level of independence in the sensory deficit function in stroke patients at admission was associated with a patient achieving independence in ambulation at discharge. Demonstrating a moderate or maximum level of attention, concentration, and realism was positively related to a patient achieving a level of independence in ambulation at discharge. Independence in the function items of behavior and interaction was associated with moderate or maximum levels of comprehension at admission. In traumatic brain injury patients, none of the subjective cues were associated with achieving independence at discharge in any of the functional levels. This paper demonstrates the value of developing a way to assess subjective measures that are based on their ability to predict outcomes. Using such a method, new predictive measures can be developed.

Prognostic significance of nuclear sizing in renal cell carcinoma.

Nuclear grading has been reported to be a useful prognostic indicator in renal cell carcinoma (RCC). One of the components of nuclear grading, the size or cross-sectional area of cancerous nuclei, might by itself be a determinant of biologic behavior in RCC. To examine this possibility, a retrospective qualitative analysis of clinical and histopathologic parameters in 32 patients with Robson Stage 3 RCC was conducted. Patients with disproportionately larger nuclei in their RCC cells had a statistically shorter median survival (p less than 0.009). The examination of the relative areas of cancerous nuclei, herein termed nuclear sizing, appears to be a prognostic discriminant in primary RCC.

Induction of mammary tumors, estrous cycle abnormalities and endometrial hyperplasia in rats exposed to different doses of N-nitrosomethylurea.

Groups of female Sprague--Dawley strain rats were given 3 i.v. injections of N-nitrosomethylurea in doses of 0.5, 1, 2, 3, 4 or 5 mg/100 g body weight at 4-week intervals. The first dose was given when they were 50 days old. By 23 weeks after the first injection, mammary tumors had developed in 0, 0, 33, 54, 72 and 100% of animals respectively. There was a direct relationship between the total dose of carcinogen administered and the degree of tumor anaplasia observed on histological examination. All of the tumors contained assayable amounts of estrogen and progesterone receptors, and the receptor concentrations were not related to the dose of carcinogen. Twenty-one rats, all exposed to the 4 highest doses of N-nitrosomethylurea, had arrest of the estrous cycle at the stage of estrus. In 15 of the 21 the walls of the uterine horns were thickened and grossly distended by fluid. Histological examination demonstrated the presence of endometrial hyperplasia. These uterine abnormalities were usually accompanied by polycystic disease of the ovaries. Both endometrial hyperplasia and abnormal estrous cycles without uterine changes were associated with elevated progesterone receptor to estrogen receptor ratios in the corresponding mammary carcinomas.

Systemic treatment of advanced prostatic cancer: development of a new system for defining response.

The low incidence of measurable or evaluable metastases in patients with prostatic cancer makes evaluation of response difficult. This is particularly true in patients with bone metastases only. With a digital model it is possible to measure quantitatively from the radioisotope bone scan the total area of skeletal involvement by metastatic tumor. Definitions of response in bone have been derived from this model. These response criteria have been compared to response in acid phosphatase determinations and clinical status in a study of 44 patients with advanced prostatic cancer treated with estramustine phosphate. Based on serial quantitative bone scans, serial measurements of acid phosphatase levels and repeat clinical evaluations a system is proposed for defining response to systemic therapy that is applicable to the majority of patients with metastatic prostatic cancer.

The use of serial bone scans in assessing response of bone metastases to systemic treatment.

The accuracy levels of serial radioisotope bone scans and conventional bone radiographs in assessing the response of bone metastases to systemic therapy were compared in 34 women with metastatic breast cancer. Each patient had measurable or evaluable nonosseous metastases, which were assessed independently of skeletal disease. The bone scan was found to be more accurate and sensitive indicator of the status of bone metastases than the radiograph. The bone scan correlated well with response of soft tissue or visceral disease, while the results of repeated bone radiographs were frequently misleading. With use of a digital model, it was possible to accurately measure the area of skeletal involvement of the bone scan, and from this derive quantitative criteria for response in bone metastases analogous to response criteria currently in use for soft tissue and visceral disease. It is suggested that serial quantitative bone scans be done, in preference to radiographs, to assess the response of bone metastases to systemic therapy.

The relation between physician and patient age in family practice.

A study of 100 selected Wisconsin family physicians demonstrated that younger physicians generally had more contact with younger patients, middle-aged physicians had an even distribution of patient age contacts, and older physicians had more contact with older patients. The increase in older patients became pronounced for 56 to 60-year-old physicians. Generally a ten-year increase in physician age was accompanied by a five-year increase in patient age. The rising average age of the American population, combined with the direct physician-patient age relationship demonstrated here suggest that geriatrics will become increasingly relevant not only in the continuum of medical education but also for the individual practicing physician.