Four ways to teach PHC in a changing world.

Nurse educators are challenged to revise teaching/learning methods to support community-based primary health care (PHC) systems. The key elements are: integrating education with the realities of practice and people's needs; moving communities to strive towards solving their own health problems; and recognizing the socioeconomic health determinants. Described below are four educational methods based on PHC: inquiry-based learning, IMPACTS (a game to encourage multisectoral collaboration), distance education and community-based education.

Meeting the need. A primary health care model for a community-based/nurse-managed health center.

Long before the World Health Conference at Alma-Ata, when 113 nations agreed to incorporate the concepts and principles of primary health care in their health care systems (World Health Organization [WHO], 1978), nurses were practicing primary health care. Indeed, such care has been practiced since the time of Florence Nightingale. Here, in the United States, the records show that public health nurses were involved in numerous primary health care activities in the early and mid-1900s (Fitzpatrick, 1975).

Primary lymphoma of the male urethra.

An elderly man presented with urinary outflow obstruction and a smooth mass arising from the bulbar urethra. Biopsy revealed large cell lymphoma, B cell subtype. A literature review revealed no previous cases of undisseminated lymphoma arising within the male urethra. The obstructing mass and symptoms resolved with multiagent chemotherapy.

Bladder pheochromocytoma with ring calcification.

A case of a 19-year-old male with a paraganglioma (pheochromocytoma) arising in the prostate and involving the urinary bladder is presented. The radiological studies, including computed tomography, demonstrated ringlike calcification of the tumor, a rare finding that is highly suggestive of the diagnosis of pheochromocytoma. The tumor was excised and found to be malignant at surgery.

Neoadjuvant chemotherapy for invasive bladder carcinoma: disease outcome and bladder preservation and relationship to local tumor response.

Thirty-nine patients with locally advanced transitional cell carcinoma of the bladder received presurgical combination chemotherapy in an effort to improve survival, reduce local tumor recurrence and distant failure, and enhance surgical resectability and potentially salvage the bladder. One to six cycles (median 2.8) of M-VAC (methotrexate, vinblastine, doxorubicin, cisplatin), CMV (cisplatin, methotrexate, vinblastine), or VP16 CDDP (etoposide, cisplatin) were administered after initial diagnosis and clinical staging of the bladder cancer and transurethral resection of the tumor. Clinical staging was repeated before each cycle of chemotherapy. Transurethral resection and systemic neoadjuvant chemotherapy clinically downstaged 31 of 39 patients (79%). Subsequently, 26 patients underwent radical cystectomy and 13 patients received bladder salvage (6 received a partial surgical resection and 7 observation). At 41 months' median follow-up, 4-year overall survival was 63 +/- 17%, cancer-specific survival was 71 +/- 19%, local recurrence-free survival was 66 +/- 22%, and metastasis-free survival was 73 +/- 16%. Patients with a complete clinical and pathologic response had far better survival than those without a complete response; for pathologic stage, survival was 100% vs. 45% for those with residual tumor (p = 0.003). Local recurrence (Ta or TiS) occurred in 46% of those with their bladder salvaged and still in situ. These data suggest that with neoadjuvant chemotherapy bladder salvage seems feasible in selected patients, although they appear to be at higher risk for tumor recurrence. Accurate selection of the group of patients most likely to benefit is difficult and may not be possible in a predictable manner with currently available selection methods.

Growing edges of a new paradigm: the future of nursing in the health of the nation.

Areas of growth in nursing are to be found at the points of interprofessional and community contact. The principles of primary health care can guide us toward empowerment to seek "Health for All."

Accuracy in staging of renal cell carcinoma involving vena cava.

Accurate preoperative staging of renal cell carcinoma is necessary to determine patient prognosis and surgical approach, particularly when tumor thrombus invades the vena cava. The pathologically-confirmed tumor stage was compared with the radiographic preoperative stage in 44 patients undergoing surgery for renal cell carcinoma invading the vena cava (T3cNxMx). Nine patients (20%) were upstaged as the result of extracapsular tumor extension. Twelve patients (27%) were upstaged due to unrecognized regional lymphadenopathy, and 1 patient was downstaged. Only 1 patient was upstaged as the result of unrecognized metastases. The level of tumor thrombus extension for surgical approach was accurately determined in all but 2 patients. Overall, 15 patients (34%) were upstaged as a result of pathologic studies, 28 patients (64%) were correctly staged, and 1 patient was downstaged. Radiographic staging of extracapsular tumor extension and regional lymphadenopathy is unreliable, but current radiographic techniques delineate the level of thrombus extension for surgical approach with high accuracy.

Surgical management and prognosis of renal cell carcinoma invading the vena cava.

A total of 44 patients with renal cell carcinoma and vena caval tumor thrombus underwent surgical resection. Of these patients 27 had primary tumor confined within Gerota's fascia, negative lymph nodes and no distant metastases (stage T3cN0M0). Patients who underwent extraction of a mobile tumor thrombus from the vena cava had a 69% 5-year survival rate (median 9.9 years) but patients with tumor thrombus directly invading the vena cava had a 26% 5-year survival rate (median 1.2 years), which improved to 57% (median 5.3 years) if the involved vena caval side wall was resected successfully. Of these patients 17 had renal cell carcinoma with vena caval thrombus as well as extrafascial extension, regional lymphadenopathy or distant metastases, and the 5-year survival rate was less than 18% in all groups (median survival less than 0.9 years). Prognosis was determined by the pathological stage of the renal cell carcinoma and by the presence or absence of vena caval side wall invasion but not by the level of tumor thrombus extension. Patients with incomplete resection of localized renal cell carcinoma with tumor thrombus do not survive any longer than those with extensive cancer, positive lymph nodes or distant metastases. However, when partial venacavectomy establishes negative surgical margins then survival markedly improves.

Natural history of fetal and neonatal hydronephrosis.

Since pyelocalicectasis alone is common in fetuses, we reviewed reports of fetal hydronephrosis that resolved spontaneously or at birth. Severe fetal hydronephrosis with calicectasis or parenchymal thinning rarely resolves spontaneously before or after birth. We also reviewed the clinical and experimental literature on renal hypertrophy. After unilateral nephrectomy in neonatal animals or after birth with congenital absence of one kidney in humans, the remaining kidney hypertrophies very quickly. In infants and young animals, the eventual size of the remaining kidney is inversely proportional to the age at which one kidney is lost. This improvement in residual renal function seen after renal loss in infancy, compared with older children, itself constitutes a strong argument for early relief of obstruction. If contralateral renal hypertrophy has occurred, the treated damaged kidney may resume growth in parallel with its hypertrophied mate but does not become as large or recover normal potential for growth. In other words, if correction of a unilateral obstruction is deferred until contralateral hypertrophy occurs, the obstructed kidney then has less potential for recovery of function.

Fibromuscular hyperplasia of the seminal vesicle.

Examination of tissue removed during seminal vesiculectomy typically reveals few pathological abnormalities, although some tumors and cysts have been described. We report a case of seminal vesicle enlargement and pain due to fibromuscular hyperplasia. Complete pain relief ensued after seminal vesiculectomy.

Transplantation of the entire small bowel in inbred rats using cyclosporine.

Inbred strains of rats were used to analyze unidirectional host-versus-graft disease (transplant rejection) without graft-versus-host disease in small intestinal transplants and the immunosuppressive properties of cyclosporine (CsA). Forty-six Lewis rats received heterotopic transplants of the entire small bowel in four groups: Lewis-to-Lewis isografts, without CsA; Lewis-to-Lewis isografts, with CsA (15 mg/kg/day); (Lewis X ACI)F1-to-Lewis allografts, without CsA; (Lewis X ACI)F1-to-Lewis allografts, with CsA. Small bowel rejection was associated with gross morphological changes that preceded all other findings. A histologic scoring system assessed the degree of transplant rejection. A characteristic transient weight loss was seen in animals rejecting their bowels. Glucose absorption was impaired and polyethylene glycol absorption increased during rejection. Cyclosporine inhibited all of these changes in allografted rats. It is concluded that daily administration of cyclosporine is effective in preventing the morphologic and functional changes of acute transplant rejection in intestinal allografts and does not change these parameters in transplants that are not rejecting.

Surgical aspects of intestinal injury due to pelvic radiotherapy.

Seventy-one patients with intestinal injury secondary to pelvic irradiation had predominantly large bowel lesions. Seventeen cases were treated conservatively and 54 came to surgery, 28 patients having more than one operation. Following this essentially salvage surgery there were more ileal than colonic anastomotic leaks. Thirty-four patients died during the follow-up period (2-12 years), 19 from recurrent malignancy, and nine as a result of continuing radiation effects. Seventy per cent of the patients who had a radiation fistula died as a result of malignancy. Of 42000 cases of pelvic malignancy treated by irradiation over the decade 1972-1982, surgical referrals for complications constituted 1.7%, with an overall radiation-related mortality of 0.2%. It is our opinion that colostomy alone has little part to play in this condition, and a policy based on excisional surgery is suggested.

Location of peptide fragments in the fibrinogen molecule by immunoelectron microscopy.

Antibodies to the disulfide knot fragment of bovine fibrinogen have been used to locate the site of this fragment within the intact fibrinogen molecule. The antibodies were isolated from rabbit antifibrinogen antisera by affinity chromatography. Electron micrographs of reaction mixtures of bovine fibrinogen and antibodies against the disulfide knot fragment showed pairs of fibrinogen molecules crosslinked by antibody molecules as well as higher order antibody-fibrinogen complexes. From an electron microscopic investigation of the crosslinked material, we conclude that the disulfide knot lies within the central nodule of the trinodular fibrinogen molecule. Antibodies to fragment H were used in the same manner to locate this fragment within the outer nodules of the human fibrinogen molecule.