A comparative study of measures to evaluate medical students' performance.

PURPOSE: To assess how new National Board of Medical Examiners (NBME) performance examinations--computerbased case simulations (CBX) and standardized patient exams (SPX)-compare with each other and with traditional internal and external measures of medical students' performances. Secondary objectives examined attitudes of students toward new and traditional evaluation modalities. METHOD: Fourth-year students (n = 155) at the University of California, Los Angeles, School of Medicine (including joint programs at Charles R. Drew University of Medicine and Science and University of California, Riverside) were assigned two days of performance examinations (eight SPXs, ten CBXs, and a self-administered attitudinal survey). The CBX was scored by the NBME and the SPX by a NBME/Macy consortium. Scores were linked to the survey and correlated with archival student data, including traditional performance indicators (licensing board scores, grade-point averages, etc.). RESULTS: Of the 155 students, 95% completed the testing. The CBX and the SPX had low to moderate statistically significant correlations with each other and with traditional measures of performance. Traditional measures were intercorrelated at higher levels than with the CBX or SPX. Students' perceptions of the various evaluation methods varied based on the assessment. These findings are consistent with the theoretical construct for development of performance examinations. For example, to assess clinical decision making, students rated the CBX best, while they rated multiple-choice examinations best to assess knowledge. CONCLUSION: Examination results and student perception studies provide converging evidence that performance examinations measure different physician competency domains and support using multipronged assessment approaches.

Surgeon's workshop: a simple method of antegrade collagen placement for postprostatectomy incontinence.

We describe a modified method for antegrade placement of periurethral collagen in incontinent men. In this technique, a flexible cystoscope is used to guide the placement of a specially designed needle into the bladder neck and external sphincter region via an antegrade transvesical approach. The 19-gauge, 28-cm long needle is passed suprapubically without a sheath. The procedure may be performed with local anesthesia and intravenous sedation only and takes less than 30 minutes.

Development of a multidisciplinary primary care program at the Drew University of Medicine and Science.

This article describes a required primary care curriculum for all third and fourth year medical students at the Drew/UCLA Medical Education Program. The curriculum is a supplement to the traditional medical school clinical requirements. Key features of the primary care core curriculum in the third year include a weekly half-day multidepartmental continuity clinic in a community health center serving underrepresented minority populations, a weekly didactic conference on primary care and society, a weekly clinical workshop on primary care skills, a weekly case review conference, and an orientation to primary care research methods. Fourth year medical students select a primary care subinternship that extends half days for 10 weeks in a community-based ambulatory care clinic. Fourth-year students also are required to select a mentor and conduct a research project on a primary care topic. Continuity of care records suggest that this program has been successful in allowing medical students to assume primary responsibility for a set of patients and to maintain significant levels of continuity of care over the course of the year. The evolution of the program, problems encountered, and anticipated changes in the curriculum are discussed.

Transurethral vaporization of ureterocele: case report.

A large ureterocele accompanying a bladder stone was vaporized with a large rollerball electrode, permitting electrohydraulic lithotripsy. Conventional endoscopic incision of this lesion had failed.

Diagnosis of postoperative urinary ascites using renal scintigraphy.

Nuclear medicine biliary studies have been routinely used to identify bile leaks that occur after laparoscopic cholecystecomy. The use of a Tc-99m mercaptoacetyltriglycine (MAG3) renal scan to diagnose a case of urinary leakage that occurred after a laparoscopic-assisted colectomy is shown in this report. Laparoscopic surgery is widely used in place of conventional laparotomy to minimize recovery time and discomfort after surgery. The complication rate for laparoscopic colectomy has been reported as approximately 6% to 10%. In particular, ureteral leak has been reported in 2% of procedures. Ascites of unknown origin can become a diagnostic dilemma. We present a case of postoperative ascites of unknown origin that was successfully diagnosed as urinary leakage using renal scintigraphy.

Schistosomal myelopathy as a cause of neurogenic bladder dysfunction.

Schistosoma hematobium most commonly affects the bladder and S. mansoni has a predilection for the liver, spleen, and the mesenteric territories. Schistosomal spinal cord involvement is an extremely unusual primary presentation of schistosomiasis, especially in the United States. We report 2 patients with documented schistosomiasis who presented with urinary incontinence as their chief urologic complaint. One patient had no sensorimotor deficit and presented with isolated incontinence as the harbinger of spinal involvement. The other patient presented 5 years after initial exposure, emphasizing the possibility of a long latent period between exposure and onset of symptoms.

Implications of prostate micrometastases in pelvic lymph nodes: an archival tissue study.

OBJECTIVES: In the United States, radical retropubic prostatectomy for adenocarcinoma usually includes a staging pelvic lymphadenectomy. If frozen section analysis of the lymph nodes fails to reveal any evidence of metastases, the prostate is removed. We have previously noted that as many as 56% of patients undergoing radical prostatectomy demonstrate rising serum prostate-specific antigen (PSA) levels by 4 years postoperatively. This report was designed to determine whether micrometastases undetectable by conventional pathologic methods: could have accounted for these biochemical failures. METHODS: A retrospective analysis of formalin-fixed paraffin-embedded pelvic lymph node material was undertaken using a reverse transcription-polymerase chain reaction (RT-PCR)-based assay designed to amplify messenger RNA from PSA. All specimens were obtained from a group of 57 patients with prostate cancer who had undergone staging pelvic lymphadenectomy at the time of radical prostatectomy, and whose long-term follow-up was known. RESULTS: Although all of these nodes appeared to be free of tumor by conventional pathologic methods, a RT-PCR assay was used to identify evidence of prostate metastases in 44% of evaluable samples. Of these, 14 of 16 went on to manifest rising serum PSA values by 5 years postoperatively. CONCLUSIONS: These results suggest that molecular staging of pelvic lymph nodes prior to planned therapy for clinically organ-confined prostate cancer may better distinguish between patients with local disease and those for whom local therapy alone will not be curative. To our knowledge, this is the first large-scale retrospective gene expression study published.

The long-term urological response of neonates with myelodysplasia treated proactively with intermittent catheterization and anticholinergic therapy.

PURPOSE: Urinary tract management in children with myelodysplasia is controversial. Some advocate observation alone, while others believe that the prophylactic institution of intermittent catheterization and anticholinergic therapy may help to prevent deterioration. MATERIALS AND METHODS: A nonrandomized prospective study was instituted to compare the urological outcomes of a cohort of children who were at risk for urological deterioration on the basis of bladder-sphincter dyssynergia and/or high filling or voiding pressures. Those at risk were observed until deterioration occurred, or were placed on prophylactic intermittent catheterization with or without anticholinergic medication. RESULTS: Of 44 children at risk 35 followed by observation alone had urinary tract deterioration, whereas only 3 of 20 at risk treated with prophylactic intermittent catheterization had deterioration with time. CONCLUSIONS: Proactive bladder treatment significantly reduced the incidence of upper urinary tract deterioration and need for surgical intervention.

A rapid and simple method for the detection of prostate-specific antigen mRNA in archival tissue specimens using a reverse transcription-polymerase chain reaction assay.

OBJECTIVES: Polymerase chain reaction (PCR) amplification of DNA from archival, fixed tissue sources is now performed routinely. In this report, we describe a reproducible technique for mRNA amplification from archival tissues. METHODS: Archival, fixed tissue was treated with a modification of a rapid, acid guanidinium technique. The RNA yielded was reverse transcribed and subjected to 40 cycles of two-step PCR, using a panel of primers designed to encompass relatively short (less than 250 bp) cDNA fragments. PCR products were analyzed by agarose gel electrophoresis followed by ethidium bromide staining. RESULTS: Using fixed, paraffin-embedded specimens of human prostate, we have demonstrated a reproducible pattern of reverse transcription (RT)-PCR products using several different primer sets. Our data suggest that RNA degradation proceeds to fragments approximately 250 bp or shorter in length but that many of these fragments survive intact over extended periods of time and are of suitable quality to serve as a template for RT and subsequent PCR amplification. CONCLUSIONS: We describe a technique that will allow the retrospective analysis of archival tissues for gene expression. These methods are generally applicable to a wide variety of systems. Such a method will make it possible to perform retrospective studies of gene expression in the archival tissues of patients whose eventual clinical course is already known, greatly shortening the time needed for genetic outcome studies in slowly growing tumors, such as prostate cancer.

Management of gunshot injuries to the penis and anterior urethra.

OBJECTIVE: To verify the appropriate methods of diagnosis and treatment of gunshot injuries to the penis and anterior urethra. DESIGN: Retrospective study. MATERIALS AND METHODS: Fourteen patients presented over 5 years with gunshot wounds to the male genitalia with injuries involving the penis and or the anterior urethra. All patients underwent a full physical examination and retrograde urethrogram to fully stage suspected injuries. RESULTS: Of the nine patients sustaining penile wounds, four were superficial, requiring only debridement, and five involved the corpus cavernosum, necessitating formal repair. Physical findings of an expanding hematoma, a palpable corporeal defect, and excessive bleeding via the wounds were indicative of cavernosal injury and warranted a penile exploration. All patients were potent in follow-up, although two patients with extensive injuries did complain of curvatures. Retrograde urethrograms noted anterior urethral injuries in eight patients, three of whom also had sustained cavernosal injuries. Five were repaired primarily, and three were treated by urinary diversion via a suprapubic tube. Three patients developed urethral strictures: one in the primary repair group and two in the diversion group. CONCLUSIONS: The preferred method of handling low-velocity gunshot wounds to the penis and anterior urethral includes debridement of superficial wounds, repair of cavernosal defects, and primary repair of urethral injuries wherein tissue loss is not extensive to result in high-potency rates and lower rates of urethral stricture disease.

Radical prostatectomy for adenocarcinoma of the prostate: the influence of preoperative and pathologic findings on biochemical disease-free outcome.

OBJECTIVE: This retrospective study evaluated the outcome for a cohort of men undergoing radical retropubic prostatectomy alone as primary treatment for clinical T1-2 prostate adenocarcinoma. METHODS: Sixty-two patients treated at Boston University Medical Center between 1987 and 1992 underwent radical prostatectomy alone without adjuvant or neoadjuvant endocrine therapy. Actuarial and multivariate analyses were made of disease-free outcome according to preoperative tumor T stage, prostate-specific antigen (PSA), and biopsy grade, and according to the pathologic findings at surgery. Recurrence was defined as the persistence or recurrence of detectable serum PSA four or more weeks following surgery. RESULTS: Of all patients judged clinically to have localized disease (T1-2), 52 percent proved to have pathologic T3 tumors. Of these, 81 percent had positive surgical margins. The strongest preoperative predictors of pT3 disease were the biopsy Gleason grade and the initial serum PSA value. Actuarial analysis showed the overall likelihood of remaining free from detectable PSA at four years to be 43 percent (75% for those with organ-confined disease and 27% for those who were pT3). The poorest prognosis was seen in those with seminal vesicle involvement. Biopsy Gleason grade and initial PSA were independent preoperative predictors of biochemical failure in a Cox regression analysis but clinical T stage was not. CONCLUSIONS: The biopsy Gleason grade and initial PSA were identified as strong preoperative predictors of disease-free outcome. We confirmed the favorable prognosis of men with organ-confined disease, but emphasize the high likelihood of relapse in those with positive surgical margins or seminal vesicle invasion.

Arteriocaliceal fistula from prolonged nephrostomy tube drainage.

We report a case of an arteriocaliceal fistula that occurred after 21 months of continuous nephrostomy drainage. Hemorrhage was successfully controlled with selective angiography and embolization. Although unusual, arterial injury should be considered when patients with indwelling nephrostomy tubes present with new onset of bleeding.

Detection of human androgen receptor mRNA expression abnormalities by competitive PCR.

A competitive polymerase chain reaction (PCR) method for analysis of androgen receptor (AR) mRNA expression is described. The technique involves the use of an in vitro-transcribed RNA (cRNA) corresponding to a region of the AR mRNA transcript as a competitor in reverse transcription and PCR (RT-PCR) using total cellular RNA. The competitor RNA contains a site-directed mutation that produces a restriction fragment length polymorphism after RT-PCR and endonuclease digestion. We demonstrate that incorporation of the competitor RNA into RT-PCR reactions allows rapid semiquantitative determination of relative AR mRNA levels without the necessity of following PCR product formation kinetically; reaction products are assessed at the conclusion of the reaction sequence and without the use of radioactive probes or other specialized detection systems. We have used competitive PCR to demonstrate low levels of AR mRNA in an androgen-unresponsive human prostate cell line (PC3). In addition, we have also used this method to confirm that genital fibroblasts obtained from a subject with penoscrotal hypospadias (a non-intersex masculinization defect) that exhibit low levels of high-affinity androgen binding also exhibit abnormally low AR mRNA levels. These last results suggest that some non-intersex malformations of the urogenital tract are associated with abnormalities in the expression of the androgen receptor.

Managing prostate cancer. Part II: Disseminated disease.

Each year in the United States, approximately 100,000 men are found to have prostate cancer. Of these, about half show evidence of bony metastases at the time of presentation. Each year, too, some 30,000 American men die of prostate cancer. Conceptually, the treatment of metastatic prostate cancer has changed little in the 50 years since Charles B. Huggins and Clarence V. Hodges discovered the hormone-dependent nature of prostate cancer cells. Still, as the years have passed, several therapeutic options have become available. For the most advanced cases, treatment centers on relief of urinary obstruction and amelioration of the pain of bony metastases, along with vigilance for the potentially disastrous sequelae of acute neurologic change due to spinal fractures. In Part I of this article, which appeared in the April 15 issue of Hospital Practice, we discussed the assessment and management of localized carcinoma of the prostate. In this part, the focus shifts to disseminated disease (Figure 1). We again present two cases representing distinctly different points on the spectrum of disease and discuss how management would proceed in each case. This strategy affords an opportunity to review the various available treatment options, with their advantages and drawbacks.

Trends in measures of computer experience and computer anxiety for students in three successive medical school classes.

Computer-related variables, including measures of computer anxiety and computer experience, were evaluated for three successive classes of matriculating medical students. Across the three classes, average computer anxiety measures declined and differences in the levels of computer anxiety for males and females diminished. Average measures of computer experience rose over time and were comparable for males and females, although there was a trend toward increasing divergence in the range and distribution of students' computer experience scores. Implications of these findings for addressing computer literacy in the medical curricula are discussed.

Cholesteryl ester storage disease: a patient with massive splenomegaly and splenic abscess.

Cholesteryl ester storage disease (CESD), a rare lysosomal storage disorder characterized by functional deficiency of acid lipase activity, classically features hepatomegaly in conjunction with lipid-laden macrophages containing excessive quantities of cholesteryl esters. We present a patient whose clinical course was complicated by massive, symptomatic splenomegaly, and an unsuspected splenic abscess. Computed tomographic and magnetic resonance imaging are correlated. Histologic, electron microscopic, and biochemical features are presented. To our knowledge, this is the first report of splenic abscess in CESD.

Mechanisms of intrinsic tone in bullfrog lung: relaxant effects of indomethacin, ouabain and potassium.

Bullfrog hemilungs showed minimal relaxation (9 +/- 2% of the maximal relaxant effect of theophylline, Imax) after a 16 h incubation in 10(-5) M indomethacin, indicating that prostaglandin synthesis plays little or no role in the high intrinsic tone characteristic of this preparation. A higher concentration of indomethacin (10(-4) M) produced greater relaxation (23 +/- 3% of Imax), but also markedly potentiated isoprenaline-induced relaxation. The interaction with isoprenaline was similar to that previously found for papaverine, a phosphodiesterase inhibitor. Ouabain (10(-5) and 10(-4) M) produced an initial contraction followed by marked relaxation (50% of Imax), indicating that a ouabain-sensitive mechanism is of major importance in the maintenance of intrinsic tone. Ouabain-treated hemilungs showed reversal (relaxation) of the normal contractile response to 26 mM potassium and marked impairment of the contractile response to calcium in calcium-depleted preparations. These effects suggest that ouabain-induced relaxation reflects a drug action on calcium movements. The marked relaxation (30 to 40% of Imax) produced by 26 mM potassium in ouabain-treated hemilungs is of particular interest in that it indicates a mechanism of potassium-induced relaxation distinct from stimulation of sodium-potassium ATPase.

Thiobarbiturate-induced histamine release in human skin mast cells.

Human skin mast cell preparations were incubated with thiopental, thiamylal, methohexital, and pentobarbital in concentrations ranging from 10(-5) M to 10(-3) M. Both thiopental- and thiamylal-induced dose-related histamine release, with thiamylal having a significantly greater effect than thiopental (P less than 0.05). In contrast, incubation of skin mast cell preparations with the same concentrations of pentobarbital and methohexital failed to increase histamine release above spontaneous levels at any concentration. The release of histamine by thiopental and thiamylal was not accompanied by the leakage of lactic dehydrogenase (LDH). Although a demonstration of histamine release in vitro is not proof that clinical symptoms are causally related to histamine release in vivo, methohexital may be preferred as the induction agent in patients showing extreme sensitivity to histamine (asthmatics) or increased histamine releasability (atopics).