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To assess the role of endorectal coil magnetic resonance imaging (MRI) staging for patients undergoing seed implantation (SI) with or without external beam radiotherapy (EBRT).Between October 1994 and December 1998, 390 patients underwent prostate SI (98% Pd-103, 2% I-125). Seventy-six percent of patients had a prostate serum antigen (PSA)10, 17% had PSA of 10-20, and 7% of patients had PSA of20. Ten percent of patients had a Gleason score (GS) of 4-5, 54% had GS 6, 29% had GS 7, and 7% had GS/= 8. Monotherapy was employed in 46% of patients, and the remaining 54% received combined EBRT and SI. Three hundred twenty-seven were staged by high-resolution phased array pelvic coil, or in most cases, an endorectal coil MRI. The MRI findings were used to guide stage-appropriate treatment recommendations, and to assist in the preplanning and optimization of seed distributions. The criteria utilized to determine MRI-based stage were founded on the reported literature from the University of Pennsylvania. All MRI studies were reviewed by C.A., D.B., or W.H., who were unaware of clinical stage at the time of their review. The biopsy report was available to them as the only clinical correlate.Of the 327 patients staged by MRI, 70% were upstaged from the digital rectal examination-based clinical stage; 26% of T(1), T(2) patients were upstaged to T(3). Perineural invasion and the percentage of positive cores predicted for T(3) MRI stage (p0.0001 for both variables). MRI findings changed the overall treatment recommendation in 60/327 (18%) patients. The majority of these patients were advised to receive combined therapy instead of monotherapy after the MRI documented more extensive disease. The seed distribution was modified in 183/327 (56%) patients, mostly related to preplanned extracapsular coverage of bulky or extraprostatic disease seen on MRI. With a mean follow-up of 38 months (range 3-72), PSA freedom from progression (FFP) was 94% at 5 years. Cox regression analysis showed that only the percentage of positive cores (p = 0.001) and failure to have MRI staging (p = 0.0008) predicted for failure. Pretreatment PSA level, Gleason score, perineural invasion, and external beam radiotherapy did not significantly predict for PSA failure. We compared our MRI T(3) intermediate-risk group patients treated by combined therapy with a previous study of T(3) intermediate-risk group treated by radical prostatectomy (RP) at the University of Pennsylvania. Our 36-month PSA FFP was 94% compared with 21% for the previous study's RP patients.MRI is a valuable staging procedure for prostate cancer patients treated by SI. PSA FFP results appear to be improved by MRI staging. MRI T(3) disease can be treated more effectively by SI + EBRT than by RP.

Asthma is a common disease characterized by hyperreactivity of airways to a variety of stimuli. Efficacy studies have shown that while in adults there is no positive predictive value between radiographic abnormalities and certain clinical parameters, in children there may be some correlation with age and the presence of rales. In the Yale-New Haven Emergency Service it is suggested that certain clinical criteria be used to determine which patients receive chest radiographs. A retrospective review of 563 adult asthmatics who presented to the Yale Emergency Room revealed that one third of the patients were radiographed; 50% of these were over 50 years of age, and the overall incidence of radiographic abnormalities that would change patient management was only 3%. Radiographic findings have been categorized into two groups, uncomplicated and complicated asthma, depending on whether bronchodilators will effect a response.

Esophagoatrial fistula formation is a rare and heretofore fatal event. A patient presented with esophageal reflux and stricture that later developed into a right atrial-esophageal fistula during biweekly esophageal dilation. Clinical recognition and surgical therapy led to a successful outcome. There were several unique features of this case, including fistulous connection to the right rather than the left atrium, concomitant hydropneumopericardium and esophagoatrial fistula, occurrence during esophageal dilation and surgical cure.