Internal medicine residents reject "longer and gentler" training.

BACKGROUND: Increasing complexity of medical care, coupled with limits on resident work hours, has prompted consideration of extending Internal Medicine training. It is unclear whether further hour reductions and extension of training beyond the current duration of 3 years would be accepted by trainees. OBJECTIVE: We aimed to determine if further work-hour reductions and extension of training would be accepted by trainees and whether resident burnout affects their opinions. DESIGN: A postal survey was sent to all 143 Internal Medicine residents at the University of Colorado School of Medicine in May 2004. MEASUREMENTS: The survey contained questions related to opinions on work-hour limits using a 5-point Likert scale ranging from strongly agree to strongly disagree. Burnout was measured using the Maslach Burnout Inventory, organized into three subscales: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment, with burnout defined as high EE or DP. RESULTS: Seventy-four percent (106/143) of residents returned the survey. The vast majority (84%) of residents disagreed or strongly disagreed with extending training to 4 or 5 years. Burnout residents were less averse to extending training (strongly agree or agree, 18.9% vs 4.3%, P = .04). The majority of residents (68.9%) disagreed or strongly disagreed with establishing a 60-hour/week limit. Residents who met the criteria for burnout were more likely to agree that a 60-hour limit would be better than an 80-hour limit (strongly agree or agree, 22% vs 8%, P = .02). CONCLUSIONS: In this program, most Internal Medicine residents are strongly opposed to extending their training to 4 or 5 years and would prefer the current 80 hours/week cap. A longer, less intense pace of Internal Medicine training seems to be less attractive in the eyes of current trainees.

[Bulbourethral sling. The experience of our service]. / Sling bulbouretral. Experiencia del servicio.

OBJECTIVES: The authors present the clinic results obtained with the bulbourethral sling application with pubic bone anchorage (Invance) in patients with stress urinary incontinence. MATERIAL AND METHODS: From July to December 2003, 10 slings were implanted in men between the 60's and the 83 years old (average 72.6 years), whose incontinence appeared after prostatic surgery (retro pubic radical prostatectomy, perineal radical prostatectomy, radical cystoprostatectomy with Camey II neobladder, transurethral resection, transvesical prostate adenomectomy). RESULTS: After 9 months follow-up (3 to 7 months), 8 patients (80%) are continent (without need of using any pad) and 2 (20%) show minimum leakage with effort (need of 1 to 2 daily pads). All are satisfied with the surgery result. Two patients referred perineal pain, which was solved with Paracetamol. There was no case of perineal haematoma, infection, rejection or urethral erosion. CONCLUSION: The bulbourethral sling with bone anchorage is a rather invasive procedure, of easy technical execution, with high continence rates and associated to low morbidity. Although the presented results been an incentive to the technique prolongation, it would be necessary a higher tracking: and higher global experience in order that this sling affirm and transform itself in an alternative to the artificial sphincter in selected cases.

[Acute renal ischemia--unusual cause of lumbar pain]. / Isquemia renal aguda--causa rara de lumbalgia.

Acute renal artery occlusion is rarely found in daily clinical practice. Its rarity and inespecific clinical presentation are responsible for late diagnosis or diagnostic errors, with symptoms frequently being erroneously attributed to other more common entities. There is no consensus in what concerns therapeutic options. Multiple treatment modalities are described in the available literature. Some defend anticoagulant therapy and support measures only while others recommend other more invasive alternatives reaching even open surgery. The authors present two additional case reports of acute embolic renal ischemia. A thorough literature review is also presented comprehending etiological, clinic, diagnostic and therapeutic aspects.

Escherichia coli MTC, a NADPH cytochrome P450 reductase competent mutagenicity tester strain for the expression of human cytochrome P450: comparison of three types of expression systems.

Currently three different methods have been taken to develop new mutagenicity tester strains containing human cytochrome P450s (CYPs). Each of these use a single expression vector. In this paper we describe a fourth approach, i.e., the coexpression of a CYP and its electron-transfer flavoprotein, NADPH CYP reductase (RED), encoded by two different expression vectors. The Escherichia coli mutagenicity tester strain BMX100 has been expanded to a strain, MTC which stably expresses human RED. This new tester strain permits the biplasmid coexpression of human CYP1A2 and RED (MTC1A2). This novel strain can be used for the determination of the mutagenicity of chemicals known to be procarcinogens and metabolized by CYP1A2. The mutagenicity tester strain MTC1A2 was compared with: (i) BMX100 using the post-mitochondrial rat liver fraction (S9); (ii) BMX100 with expressing CYP1A2 alone (iii) or with expressing CYP1A2 fused to rat RED or (iv) with expressing CYP1A2, bicistronically coexpressed with rat RED. The biplasmid RED/CYP coexpression system generated a strain with the highest methoxy- and ethoxy-resorufin dealkylase activities and the highest mutagenic activities for the procarcinogens 2-aminoanthracene (2AA), aflatoxin B1 (AFB1) and 2-amino-3-methylimidazo(4,5-f)quinoline (IQ). Furthermore, the metabolism of 2AA and IQ was detected more efficiently using the MTC1A2 strain than with the BMX100 strain plus the standard rodent liver S9 metabolic system.

Escherichia coli MTC, a human NADPH P450 reductase competent mutagenicity tester strain for the expression of human cytochrome P450 isoforms 1A1, 1A2, 2A6, 3A4, or 3A5: catalytic activities and mutagenicity studies.

We report here on the genetic engineering of four new Escherichia coli tester bacteria, coexpressing human CYP1A1, CYP2A6, CYP3A4 or CYP3A5 with human NADPH cytochrome P450 reductase (RED) by a biplasmid coexpression system, recently developed to express human CYP1A2 in the tester strain MTC. The four new strains were compared for CYP- and RED-expression levels and CYP activities with the formerly developed CYP1A2 expressing strain. CYP1A2 and CYP2A6 were expressed at the highest, CYP1A1 at the lowest and CYP3A4 and CYP3A5 at intermediate expression levels. Membranes of all five tester bacteria demonstrated similar RED-expression levels, except for the two CYP3A-containing bacteria which demonstrated slightly increased RED-levels. CYP-activities were determined as ethoxyresorufin deethylase (CYP1A1 and CYP1A2), coumarin 7-hydroxylase (CYP2A6) and erythromycin N-demethylase (CYP3A4 and CYP3A5) activities. Reaction rates were comparable with those obtained previously for these CYP-enzymes, except for CYP3A5 which demonstrated a lower activity. Benzo[a]pyrene and 7,12-dimethylbenz[a]anthracene demonstrated mutagenicity in the CYP1A1 expressing strain with mutagenic activities, respectively, approximately 10-fold and 100-fold higher as compared with those obtained with the use of rat liver S9 fraction. Aflatoxin B1 demonstrated a significant mutagenicity with all CYP expressing strains, albeit lower as compared to those obtained with the use of rat liver S9. CYP1A2 was approximately 3-fold more effective in generating a mutagenic response of AFB1 as compared to CYP3A4. CYP3A5 and CYP3A4 demonstrated comparable capacities in AFB1 bioactivation which was equal as found for CYP1A1. It is concluded that these four new strains contain stable CYP- and RED-expression, significant CYP-activities and demonstrated significant bioactivation activities with several diagnostic carcinogens.

[Inverted papillomas--cases at our service and review of the literature]. / Papilomas invertidos--casuística del servicio y revisión de la literatura.

Inverted papillomas are rare tumours representing about 2.2% of all urothelial tumours (benign or malignant). Inverted papillomas are predominantly seen in the bladder but these tumours have also been described in other locations, all over the urinary tract. The authors report six additional cases of such tumours describing the individual characteristics of each case, presenting symptoms, treatment employed and follow up available. A review of the literature relative to aetiology, clinical signs and symptoms, diagnostic criteria, treatment options and outcome has also been carried out.

[Solitary fibrous tumor. Two additional cases with urologic implications]. / Tumor fibroso solitario. Dos casos adicionales con implicaciones urológicas.

Solitary fibrous tumour is a well defined pathological entity originally described as a tumour of the pleura, but the occurrence of this neoplasm has increasingly been described at other sites. At present the development of these tumours is recognized as possible in virtually all anatomical sites. The rarity of this type of pathology has not allowed up to the present time clarification of the histogenesis, clinical behaviour, treatment and prognosis of these tumours. Differential diagnosis becomes important, especially in extra-thoracic sites so as not to mistake them for much more aggressive mesenquimal tumours. Two additional cases of this neoplasm are presented, one of them responsible for obstructive uropathy, accidentally found in a patient suffering renal trauma. The second tumour was located in the spermatic cord. A review of the theme is presented based on the available literature.

[Imperforate syringocele of the Cowper's glands laparoscopic treatment]. / Siringocele imperforado de las glándulas de Cowper. Tratamiento por vía laparoscópica.

OBJECTIVES: The authors present a clinical report of an imperforate syringocele diagnosed on a male patient and treated by laparoscopic surgery. MATERIAL AND METHODS: A forty-four year old patient attends the emergency room with acute urinary retention. With a former history of mild obstructive voiding symptoms, he presented, at rectal examination, a bump on the left rectal wall. This patient also underwent urethrocistoscopy, sonography and retrograde urethrography. To establish the diagnose, Computerized Tomography (CT) scan and MRI were used. RESULTS: The syringocele marsupialization by laparoscopic surgery, allowed the resolution of the clinical problem, with a good outcome. The patient was discharged 48 hours after surgery, with no need of a vesical catheter. A six month follow-up showed no recurrence. CONCLUSIONS: The syringocele is a rare deformity which usually is asymptomatic. Of acquired or congenital etiology, it can be classified in four different morphological types: simple, perforate, imperforate and ruptured. The most frequent treatment is the marsupialization of the syringocele by endoscopic surgery, leaving a broad opening of the cavity to the urethra. Some authors recommend an open surgery excision, specially in the presence of an abscess. The laparoscopic approach becomes a minimally invasive alternative with good therapeutically outcome. In the incidentally discovered asymptomatic patients, an expectant approach is the correct approach.

Comparison of two doses of interferon-alpha-2b in intravesical prophylaxis of superficial bladder tumors. Portuguese Genito-Urinary Group.

The purpose of the study was to compare two doses of interferon-alpha 2b (60 and 100 million units, MU) and to define the recurrence rate per year, tumor rate per year and the toxicity for both treatment arms. 127 patients were admitted to the study and randomized between the two treatments: 64 patients in the 60-MU regimen (28 single primary, 8 multiple primary, 28 recurrent), and 63 patients (22 single primary, 10 multiple primary, 31 recurrent) in the 100-MU regimen. Of the 64 patients receiving 60 MU, 26 patients had recurrences (33 recurrences with a follow-up of 2,478 months). Of the 63 patients receiving 100 MU, 21 patients had recurrences (26 recurrences with a follow-up of 2,329 months). The recurrence rate per year for 60 MU is 0.13 and 0.11 for 100 MU and the tumor rate per year is 0.34 and 0.36, respectively. In conclusion the quality of life of the patients is very good with no side effects, and, using Fisher's exact test for statistical comparison, there was no difference in the recurrence rate per year and the tumor rate per year between the 2 groups.