Buprenorphine became available for office-based treatment of opiate dependence in January 2003, at which time the Underwood-Memorial Hospital Family Practice Residency Program began offering buprenorphine treatment at its family practice center. This article describes the patient selection process, outcomes, and obstacles to treatment. Patients who had a pharmaceutical benefit were much more likely to remain in treatment than those who had to pay for the medication. The authors are not aware of other residency programs currently providing buprenorphine training, and postulate reasons why family physicians in the United States have not readily adopted the office-based opiate treatment model.
Pure small cell carcinoma of the prostate is extremely rare. When it does occur, it is usually in concordance with prostatic adenocarcinoma. Early diagnosis is difficult as the carcinoma tends to spread early to visceral organs without concordant elevation of prostate-specific antigen (PSA). Because this condition is rare, no standard treatment regimen has been established, and the overall prognosis remains poor.This case report describes clinical characteristics of a 67-year-old man with pure small cell carcinoma of the prostate. The unique clinical and biological features of this histologic type of prostate cancer are discussed. Case ReportA 67-year-old man came to the emergency department complaining of a 2-week history of progressively worsening, right, upper quadrant abdominal pain associated with night sweats and a recent 15-pound weight loss. He denied any obstructive or irritative urinary symptoms, change in bowel habits, jaundice, or overseas travel.He was under the care of a urologist for benign prostatic hypertrophy and 4 years earlier had had benign findings on a prostate biopsy. His last PSA test 4 months before his current illness was normal. Other than benign prostatic hypertrophy, his medical history was notable only for mild hypertension, which was well controlled with metoprolol. He was a social drinker, nonsmoker, and had no family history of malignancies.When examined, he was a well-nourished older adult man who was anicteric, afebrile, and had no adenopathy. Important findings were confined to his abdomen, where he had mild right upper quadrant fullness and tenderness, but no guarding or rebound tenderness. A firm, nontender prostate with an enlarged left lobe was found during a digital rectal examination. His stool was positive for occult blood.Laboratory investigations included normal complete blood count, electrolyte levels, serum urea nitrogen level, creatinine level, and coagulation studies. Findings of liver function tests were normal except for an elevated alkaline phosphatase of 239 U/L (normal, 38 -126 U/L). His PSA was 1.3 ng/mL (normal, 0 -4 ng/mL); carcinoembryonic antigen, ␣-fetoprotein, and CA 19 -9 were also within normal limits.Computerized tomography (CT) of his abdomen and pelvis showed an abnormal density in the left lobe of the prostate and multiple hypoechogenic lesions in the liver consistent with extensive metastatic disease.After evaluation in the emergency department, he was subsequently admitted to the hospital for pain control and further evaluation of what appeared to be metastatic tumor. A CT scan of the chest showed right hilar adenopathy and a small peripheral nodule of the right lung. His head CT scan was negative for metastatic disease. Upper gastrointestinal endoscopy and colonoscopy findings were benign. Immunohistochemical findings from a CT-guided liver biopsy were consistent with a diagnosis of small cell (neuroendocrine) carcinoma. The malignant cells were positive for neuron-specific enolase and chromogranin. Subsequently, a transrectal sonograph-guide...
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