Multicenter assessment of neoadjuvant chemotherapy for muscle-invasive bladder cancer.

BACKGROUND: The efficacy of neoadjuvant chemotherapy (NAC) for muscle-invasive bladder cancer (BCa) was established primarily with methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC), with complete response rates (pT0) as high as 38%. However, because of the comparable efficacy with better tolerability of gemcitabine and cisplatin (GC) in patients with metastatic disease, GC has become the most commonly used regimen in the neoadjuvant setting. OBJECTIVE: We aimed to assess real-world pathologic response rates to NAC with different regimens in a large, multicenter cohort. DESIGN, SETTING, AND PARTICIPANTS: Data were collected retrospectively at 19 centers on patients with clinical cT2-4aN0M0 urothelial carcinoma of the bladder who received at least three cycles of NAC, followed by radical cystectomy (RC), between 2000 and 2013. INTERVENTION: NAC and RC. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The primary outcome was pathologic stage at cystectomy. Univariable and multivariable analyses were used to determine factors predictive of pT0N0 and ≤pT1N0 stages. RESULTS AND LIMITATIONS: Data were collected on 935 patients who met inclusion criteria. GC was used in the majority of the patients (n=602; 64.4%), followed by MVAC (n=183; 19.6%) and other regimens (n=144; 15.4%). The rates of pT0N0 and ≤pT1N0 pathologic response were 22.7% and 40.8%, respectively. The rate of pT0N0 disease for patients receiving GC was 23.9%, compared with 24.5% for MVAC (p=0.2). There was no difference between MVAC and GC in pT0N0 on multivariable analysis (odds ratio: 0.89 [95% confidence interval, 0.61-1.34]; p=0.6). CONCLUSIONS: Response rates to NAC were lower than those reported in prospective randomized trials, and we did not discern a difference between MVAC and GC. Without any evidence from randomized prospective trials, the best NAC regimen for invasive BCa remains to be determined. PATIENT SUMMARY: There was no apparent difference in the response rates to the two most common presurgical chemotherapy regimens for patients with bladder cancer.

Dialogue as skill: training a health professions workforce that can talk about race and racism.

Efforts in the field of multicultural education for the health professions have focused on increasing trainees' knowledge base and awareness of other cultures, and on teaching technical communication skills in cross-cultural encounters. Yet to be adequately addressed in training are profound issues of racial bias and the often awkward challenge of cross-racial dialogue, both of which likely play some part in well-documented racial disparities in health care encounters. We seek to establish the need for the skill of dialoguing explicitly with patients, colleagues, and others about race and racism and its implications for patient well-being, for clinical practice, and for the ongoing personal and professional development of health care professionals. We present evidence establishing the need to go beyond training in interview skills that efficiently "extract" relevant cultural and clinical information from patients. This evidence includes concepts from social psychology that include implicit bias, explicit bias, and aversive racism. Aiming to connect the dots of diverse literatures, we believe health professions educators and institutional leaders can play a pivotal role in reducing racial disparities in health care encounters by actively promoting, nurturing, and participating in this dialogue, modeling its value as an indispensable skill and institutional priority.

Acculturation and its association with health-risk behaviors in a rural Latina population.

PURPOSE: To evaluate the performance of proxy measures of acculturation and to examine the association between acculturation and selected health-risk behaviors. METHODS: Participants were 1062 Latina pregnant women who received prenatal care at clinics in San Joaquin County, California between 1999 and 2001. We used the receiver-operating characteristic (ROC) curve to characterize the sensitivity and specificity of proxy measures and regression analysis to examine health-risk behaviors. RESULTS: Using the ARSMA-II short version scale as a reference, age at immigration had the highest percentage of correctly classified individuals. Acculturation was significantly associated with a lifetime history of substance use, risky sexual behavior, low fruit consumption, and high fast-food meal consumption. CONCLUSIONS: Acculturation is an important predictor of health-risk behavior among women. Further research is needed to better understand the phenomenon and to avert associated adverse health consequences.

Self-reflection in multicultural training: be careful what you ask for.

Self-reflection in multicultural education is an important means to develop self-awareness and ultimately to change professional behavior in favor of more equitable health care to diverse populations. As conceptualized by scholars in the field of psychology, racial identity theory is critical to understanding and planning for the potentially wide range of predictable reactions to provocative activities, including those negative reactions that do not necessarily herald a flaw in programming. Careful consideration of racial identity developmental phases can also assist program planners to optimally meet the needs of individual physician trainees in their ongoing constructive professional and personal development, and in strategically mobilizing and having ready the type of institutional leadership that supports trainees' change processes. The authors focus on white physician trainees, the largest racial group of U.S. physicians and medical students. They first explain what they mean by the terms white and nonwhite. Racial identity theory is then applied, with true case examples, to explore such issues as where the self-proclaimed "color-blind" trainee fits into this theoretical schema, and how medical educators can best serve trainees who are resistant or indifferent to discussions of racism in medicine and equity in health care delivery. Ultimately, the authors' goal is to demonstrate that engendering genuine self-reflection can substantively improve the delivery of health care to the nation's diverse population. To help achieve that goal, they emphasize what to anticipate in effecting optimal trainee education and how to create an institutional climate supportive of individual change.

Patient preferences for physician characteristics in university-based primary care clinics.

OBJECTIVE: To examine patient preferences for age-,gender-, and racial/ethnic-concordant primary care physicians. DESIGN: Focus group interviews. PATIENTS AND SETTING: Forty-nine adults (African Americans, Caucasians, and Latinos) receiving their outpatient medical care in university-based primary care clinics in Northern California. MAIN MEASURES AND RESULTS: Guiding questions were designed to elicit information about what patients look for in establishing and maintaining a therapeutic relationship with a primary care physician. Patients were prompted to provide examples and to discuss demographic-concordance factors. Many participants felt that their continuity of care was poor and that they could not choose their own primary care physicians in the academic system. Most reported tolerating these inconveniences for what they perceived to be a higher quality of care linked to medical innovations at academic medical centers. Patients' views regarding age concordance were varied and unrelated to gender or racial/ethnic group. Women in all English-proficient groups described gender concordance as important to their relationships with primary care physicians. Spanish-speaking participants uniformly preferred Spanish-speaking providers. African-American participants and Spanish-speaking Latino men felt that race/ethnic concordance contributed to a practitioner's empathy, and some were concerned by the lack of race/ethnic- or language-concordant doctors. CONCLUSIONS: Examining patients' preferences for patient-physician demographic concordance provides insight into the patient-physician relationship. Addressing areas where these preferences affect communication patterns and perceptions of quality of care may lead to overall improvements in patient-physician relationships and health outcomes.

Potentially avoidable rehospitalizations following acute myocardial infarction by insurance status.

Few studies have explored the impact of health insurance on patients with severe, chronic diseases. This retrospective study examined the association between health insurance and the risk of potentially avoidable rehospitalization in the 3 years following validated acute myocardial infarction (AMI) for a community-based probability sample of 683 patients admitted to 30 California hospitals in 1990-1991. In a multivariate analysis adjusted for measures of comorbidity burden, severity of illness, and AMI-related inpatient care, the risk of readmission was not significantly different among patients with no insurance, Medicare insurance, and non-Medicaid, non-Medicare ("private or other") insurance. However, compared to the latter group, patients with Medicaid were 2.6 times more likely to be readmitted for an AMI-related process (risk ratio. 2.61; 95% confidence interval, 1.33 to 5.11). Additional studies are needed to define the role of health insurance on clinical outcomes and health care access across a broader range of conditions and communities.

From enrichment to equity: comments on diversifying the K-12 medical school pipeline.

Educating a physician workforce that reflects the increasing racial and ethnic diversity of our nation is an ongoing challenge of urgent concern. Many medical school kindergarten through 1 2th grade (K-12) pipeline programs focus on "enriching" underrepresented minority (URM) students using strategies to change or "improve" individual students. This discussion raises concerns over longstanding racial and ethnic inequities in America's public schools that, in part, result in the predictable and systematic underachievement of URM students. These insidious processes can disqualify URM students from successful participation in the medical school pipeline at its earliest stages. The paper also discusses the cultural challenges URM students often face in aspiring to exceptional academic achievement within America's schools. Finally, this paper highlights the need for illustrative examples of medical school-public school partnerships that pursue an agenda of equity to balance the current downstream focus on the enrichment of individual students.

When the bough breaks: a 10-year review of logging injuries treated at a rural trauma center in Pennsylvania.

The purpose of this study was to describe logging-related injuries at a Pennsylvania trauma center and evaluate the impact of helmets and profession. Charts of patients from 1990 through 1999 admitted after logging accidents were retrospectively reviewed. Most injuries were to the head (71 in 28 patients). Injury Severity Score was greater for helmeted loggers (21.0 vs 11.8; P = 0.02) but did not differ by profession. Mean hospital stay was not significantly different for helmeted loggers (9.6 vs 5.4 days, P = 0.499). Mean length of stay was 8.2 days and 3.5 days for professionals and nonprofessionals, respectively (P = 0.01). Professional loggers tended to remain hospitalized longer. Helmet use does not appear to affect injury severity; however, this could be a result of the catastrophic nature of many logging accidents. Most loggers in this study were not wearing helmets, which suggests that improved educational efforts are needed to improve safety in this dangerous occupation.

Clinical rib fractures: are follow-up chest X-rays a waste of resources?

Rib fractures (RFs) are estimated to be present in 10 per cent of all traumatic injuries. However, up to 50 per cent of all fractures go undetected on the screening chest X-ray (CXR). The purpose of this study was to identify the incidence of clinical (CRFs) and objective rib fractures (ORFs) as well as to examine the utility of the routine follow-up CXR with regard to patient recovery and healthcare cost. We identified patients sustaining RF in addition to other traumatic injuries with an Injury Severity Score (ISS) < or = 15 and RF as the primary pathology. Five hundred fifty-two patients sustained blunt thoracic trauma with resultant RF. Two hundred nine patients had RFs and an ISS < or = 15. The average ISS was 8. Follow-up films illustrated that 93 per cent of CRFs had resolution of any pathology, 4 per cent had persistent X-ray findings, and 4 per cent were lost to follow-up. Ultimately 93 per cent of patients with CRF were able to resume daily activities without disability and 3 per cent incurred lifestyle changes at home or work, which was significantly better than those with ORFs (P < 0.05). Follow-up films produced no change in clinical management and cost approximately $2000/year. The prognosis for CRFs is excellent if treatment consists of appropriate pain management and pulmonary rehabilitation. We do not advocate routine follow-up CXRs in addition to physical examination for the evaluation of CRFs unless clinical deterioration is evident.