First Dark Matter Search Results from the LUX-ZEPLIN (LZ) Experiment

The LUX-ZEPLIN experiment is a dark matter detector centered on a dual-phase xenon time projection chamber operating at the Sanford Underground Research Facility in Lead, South Dakota, USA. This Letter reports results from LUX-ZEPLIN's first search for weakly interacting massive particles (WIMPs) with an exposure of 60 live days using a fiducial mass of 5.5 t. A profile-likelihood ratio analysis shows the data to be consistent with a background-only hypothesis, setting new limits on spin-independent WIMP-nucleon, spin-dependent WIMP-neutron, and spin-dependent WIMP-proton cross sections for WIMP masses above 9  GeV/c^{2}. The most stringent limit is set for spin-independent scattering at 36  GeV/c^{2}, rejecting cross sections above 9.2×10^{-48}  cm at the 90% confidence level.

Sociodemographic characteristics associated with a higher wish to complain about health care

OBJECTIVES

Previous research has shown that patients who are older, less educated, or have lower income are less likely to lodge complaints about health care. This variation may reflect less wish to complain or inequitable access to complaint channels or remedies. We aimed to investigate associations between sociodemographic characteristics and health users' wish to complain.

STUDY DESIGN

This was a randomized case vignette survey among 6756 Danish men aged 45-70 years (30% response rate).

METHODS

Assuming they received the care in vignettes about prostate cancer (prostate-specific antigen) testing, participants rated their wish to complain on a 5-point Likert scale. Information on sociodemographic characteristics was obtained through self-reports and municipality-level information from national registries.

RESULTS

Lower education was associated with an increased wish to complain (mean Likert difference 0.44 [95% CI 0.36-0.51]; P < .001). The wish to complain was higher among unemployed men (difference 0.16 [95% CI 0.04-0.28]; P < .011) and those with a chronic illness (difference 0.06 [95% CI 0.02-0.10]; P < .004). Given the same healthcare scenarios, there was no difference in wish to complain among health users who were retired, living rurally, or from lower income groups.

CONCLUSIONS

Health users who are less educated, lower income, elderly, or from rural or minority communities appear to be as likely, or more likely, to wish to complain about health care as others. Yet, younger, well-educated, and higher income citizens are overrepresented in actual complaint statistics. The finding suggests persisting inequalities in the suitability or accessibility of complaint processes for some groups of patients.

Short-Term Concerns Primarily Determine Patient Preference for Abdominal Aortic Aneurysm Repair

INTRODUCTION

Abdominal aortic aneurysm (AAA) repair may be performed through open or endovascular approaches, but the factors influencing a patient's repair-type preference are not well characterized. Here we performed a qualitative analysis to better understand factors influencing patient preference within the Preference for Open Versus Endovascular Repair of AAA Trial.

METHODS

Open-ended responses regarding primary (n = 21) and secondary (n = 47) factors influencing patient preference underwent qualitative analysis using the constant comparative method with iterative reviews. Codes were used to generate themes and themes grouped into categories, with each step conducted via consensus agreement between three researchers. Relative prevalence of themes were compared to ascertain trends in patient preference.

RESULTS

Patient responses regarding both primary and secondary factors fell into four categories: Short-term concerns, long-term concerns, advice & experience, and other. Patients most frequently described short-term concerns (23) as their primary influence, with themes including post-op complications, hospitalization & recovery, and intraoperative concerns. Long-term concerns were more prevalent (20) as secondary factors, which included themes such as survival, and chronic management. The average age of patients voicing only long-term concerns as a primary factor was 11 years younger than those listing only short-term concerns.

CONCLUSION

Short-term concerns relating to the procedure and recovery are more often the primary factor influencing patient preference, while long term concerns play a more secondary role. Long-term concerns are more often a primary factor in younger patients. Vascular surgeons should consider this information in shared decision making to reach an optimal outcome.

Radial scars and complex sclerosing lesions on core needle biopsy of the breast: upgrade rates and long-term outcomes

PURPOSE

Radial scars and complex sclerosing lesions of the breast are part of a group of "indeterminate" breast lesions, which are excised due to risk of coexistent carcinoma. The aim of this study was to assess rate of upgrade of these lesions to invasive and in situ carcinoma and to quantify the risk of development of subsequent cancer in women diagnosed with these lesions.

METHODS

A retrospective review of a prospectively maintained breast screening database was performed. All patients with radial scar identified at either core biopsy or final excision biopsy between January 2006 and July 2012 were identified. Full pathological reports for both core biopsy and final excision biopsy were reviewed. Patient outcomes were followed for a mean of 117.1 months.

RESULTS

Of 451 B3 biopsies performed at our screening unit, 95 (22%) were found to have a radial scar or complex sclerosing lesion (CSL) on core needle biopsy. Within this group, 77 had no atypia on CNB, with 7 (9%) upgraded to invasive/in situ carcinoma on final excision. Of nine with definite atypia on CNB, 3 (33%) were upgraded. In those patients without atypia or malignancy on final excision, 7.5% developed cancer during 10-year follow-up.

CONCLUSION

Patients with radial scar with atypia have a higher risk of upgrade to malignancy. Further research is needed to identify which patients may safely avoid excision of radial scar. Patients with a diagnosis of radial scar on CNB are at increased subsequent risk of breast cancer and may benefit from additional screening.

Outcomes of conservatively managed localized prostate cancer

5010

Background: The natural history of screen-detected prostate cancer has not been well described. Methods: Cancer-specific and overall mortality, assessed through competing risk analyses, were determined for 14,516 men aged 65 years or older diagnosed between 1992–2002 and did not receive surgery or radiation within 6 months of cancer diagnosis. The population-based cohort was identified from US cancer registries, which had 98% completeness in case ascertainment. Results: Compared to earlier era studies, survival has improved considerably for conservatively managed patients diagnosed in the contemporary prostate specific antigen (PSA) era ( Table ). Conclusions: Men diagnosed with prostate cancer in the PSA era have survival outcomes significantly better than those in the past. Patients and healthcare providers may need to reassess some treatment options in light of these data.

[Table: see text]

No significant financial relationships to disclose.

Paediatric pelvic fractures: 10 years experience in a trauma centre

Fractures of the skeletally immature pelvis are relatively rare. We performed a retrospective analysis of 10 years experience of paediatric pelvic fractures in patients admitted a Level 1 Trauma Centre in London. All patients evacuated to the Royal London Hospital by the Helicopter Emergency Medical Service (HEMS) were entered on a comprehensive trauma database. This contains data about the time, date and mechanism of injury; nature of the injuries sustained; Injury Severity Score (ISS), Revised Trauma Score (RTS) and Glasgow Coma Scale (GCS). Patients were studied to obtain the following information in addition to that available from the trauma database: management of the pelvic fracture, length of stay in the intensive care unit and on the ward, and clinical outcome. Pelvic fractures were classified as open type or closed type and stable or unstable type in the database. 44 patients with pelvic fracture were admitted via HEMS in 10 years and seven patients died in that group. The mean age was 11.4 (range 6-16) and 28 male and 16 female patients. Commonest mechanism of injury was pedestrian hit by the car and predominantly stable type of injury was found in skeletally immature pelvis. Commonest associated injury was long bone fracture followed by head injury. ISS, GCS and RTS were significantly (p<0.05) altered in the non-survivors compared to the surviving group. All patients save one were treated conservatively allowing gradual mobilisation. In conclusion, pelvic fractures in children may themselves have a good long term outcome with conservative management, but they are an indicator of serious other bodily injuries which carry a high mortality.

A decision analytic model of prostate cancer screening using prostate-specific antigen and digital rectal exam

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Background: PSA-based screening has been widely adopted in the US although a mortality benefit has yet to be demonstrated. The disutility of screening and quality of life of men diagnosed and treated after screening are critical issues in assessing its benefit and harm. The purpose of this model is to estimate the effect of one-time screening for prostate cancer using Prostate Specific Antigen (PSA) and DRE (digital rectal exam) on life expectancy (LE) and Quality Adjusted Life Expectancy (QALE) in the context of current diagnostic and treatment practice. Methods: A semi-Markov state transition simulation describes the relevant health states. Two strategies were compared: 1) Screening - single screening PSA and DRE; 2) No Screening - patients diagnosed after developing symptoms. Markov cycle length was 1 year. Transition probabilities and utility weights were developed from review of the literature and expert opinion. Sensitivity analyses were performed on all parameters. A PSA threshold of 4 ng/mL and age 65 were used for the base case. The model was created using TreeAge software. Results: For our base case, a single screening conferred a LE benefit of 0.37 y (15.86 vs 15.49 y) and a QALE benefit of 0.20 QALYs (15.62 vs 15.42 QALYs). Predicted 10 y cancer specific survival for screen-diagnosed men was 95.7% vs SEER 97.7%. The model predicted 9.5% of screened patients would have metastatic disease at diagnosis vs 5% in SEER (4% unknown stage); in unscreened men, this rate was 18/100,000 vs 15/100,000 in SEER. Sensitivity Analyses of Utilities (SA): The single screen model was relatively insensitive to SA of utilities: a 20% single cycle toll on one-time PSA screening disutility was required to eliminate the benefit of screening. The disutility of positive PSA with negative biopsy slightly affected QALE: a toll of 0.25 QALYs decreased QALE from 15.62 to 15.61 QALYs. Conclusions: Our model reveals a modest benefit to one-time screening for prostate cancer. This one-time screening model is relatively insensitive to utility SA; however, the importance of incorporating psychological effects of PSA screening in recurrent screening is to be determined. The impact of serial screening, lead time, PSA threshold, and cost effectiveness on LE and QALE is being analyzed.

No significant financial relationships to disclose.

Prostate cancer screening, treatment, and outcomes— A population-based study

10017

Background: It remains unknown whether more intense prostate cancer screening and treatment reduces prostate cancer mortality. We describe the experiences of two population-based cohorts with 15-years follow-up (1987–2001) to address the following questions: 1) does more intense screening and treatment for prostate cancer lead to lower mortality in community settings, and 2) do older men (age ≥75–79) benefit from more intense prostate cancer screening and treatment. Methods: Population-based cohort study consisting of white male Medicare beneficiaries who resided in the regions covered by the Seattle (N=88,863) and Connecticut (N=114,785) cancer registries. Inclusion criteria are age 65–79 and free of prostate cancer on January 1, 1987. All study subjects were followed through death or the end of 2001. The main outcomes are rates of screening for prostate cancer, treatment with radical prostatectomy, external beam radiotherapy, and prostate cancer specific mortality. Results: Between 1987 and 1990, compared to men in Connecticut, men in the Seattle region were 5.4 times (95% C.I. 4.8 - 6.1) more likely to undergo PSA testing, 2.2 times (95% C.I. 1.8 - 2.7) more likely to under go prostate biopsy, 5.9 times (95% C.I. 5.5 - 6.9) more likely to have radial prostatectomy, and 2.3 times (95% C.I. 2.2 - 2.5) more likely to have external beam radiation. The cumulative risk of radical prostatectomy or external beam radiation reached 9.1% in the Seattle cohort and 5.0% in the Connecticut cohort in 2001. After 15 years of follow-up, prostate cancer mortality rates were similar for subjects in the two study regions (hazard ratio of Seattle to CT: 1.01, 95% C.I. 0.93 - 1.09). For older men (aged 75–79 in 1987), however, the prostate cancer mortality rate was slightly higher in the Seattle than the Connecticut cohort (hazard ratio: 1.16, 95% C.I. 1.02 - 1.32). Conclusion: More intense screening for prostate cancer, surgery or radiation among a cohort of Medicare beneficiaries in the Seattle area compared with their counterparts in Connecticut has not lead to significantly lower mortality from prostate cancer over 15 years of follow-up.

No significant financial relationships to disclose.

Misunderstanding of prostate cancer (CaP) among African American (AA) men of lower socioeconomic status (Lo-SES)

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Background: CaP disproportionately affects AA men. The objective of this investigation was to assess understanding of the prostate and CaP among Lo-SES, predominantly AA men. Methods: We performed cross sectional, semistructured interviews of 105 men, age 40 and older, in two low-income medical clinics. CaP knowledge was assessed using a subset of questions by Mercer et al. Can J of Public Health 88(5):327, 1997. Patients were shown two male anatomic figures and asked to identify the prostate, bladder, bowels, and penis: 1) Please point to the _____ on the picture of the man. 2) What does the ____ do? Patients’ understanding of sexual, urinary, and bowel function was evaluated using semi-qualitative methods coded by two independent investigators. Demographic data were collected and literacy measured using REALM. Results: Patients’ median age was 58 and 87% self-identified their race as AA. Median annual household income was $16,000. Median reading level was 4th-6th grade. Although 87% of patients had heard of the prostate, only 24% could locate the prostate, and 3% could explain prostate function. Because many men learn about the prostate in the context of CaP screening during physical exam, 23% of patients thought the prostate was synonymous with prostate cancer, 15% of patients believed the prostate is located in the rectum and 4% confused prostate cancer with colorectal cancer. Prostate cancer knowledge was poor and the concept of a risk factor was not understood well. Only 7% could name a single risk factor for CaP including 3% who named race. Just 22% of men cited surgery or radiation therapy as treatments for CaP and 11% could name a side effect of early CaP treatment. Domain confusion was common: 43% of patients confused bowel function with urinary function, 21% confused urinary with sexual function, and 20% confused bowel with sexual function. Conclusions: Baseline understanding of CaP, anatomy, bowel, urinary, and sexual function is poor among older, lo-SES AA men. Substantial patient education is required for CaP screening and treatment efforts in this population with consideration for low literacy.

[Table: see text]

Metastatic malignant melanoma presenting with hypercalcaemia and bone marrow involvement

We report a 75-year-old female patient with a background of malignant melanoma who presented with hypercalcaemia to our institution. She was aggressively treated but declined clinically. Computed tomography head and X-ray studies were suggestive of multiple myeloma, but bone marrow examination was significant for metastatic malignant melanoma. Very few patients with melanoma present with these features, and it further exemplifies the importance of close follow-up and the aggressive nature of this disease process.

DEVELOPMENT OF A MULTIREGIONAL UNITED STATES SPANISH VERSION OF THE INTERNATIONAL PROSTATE SYMPTOM SCORE AND THE BENIGN PROSTATIC HYPERPLASIA IMPACT INDEX

PURPOSE

The International Prostate Symptom Score (I-PSS) and Benign Prostatic Hyperplasia Impact Index (BII) have gained widespread use in clinical practice and clinical trials. Although Spanish translations of the I-PSS are available, to our knowledge none was developed for the Spanish speaking population in the United States using a methodology to ensure appropriateness for the diverse United States Spanish speaking population. An existing translation intended for another Spanish speaking country, such as Mexico, or a translation developed without input from each language group may not be understood by those who immigrated from other Latin American regions. Hence, the development of a Spanish translation for the United States should involve input from translators from each region of Latin America.

MATERIALS AND METHODS

We reviewed and modified an existing United States Spanish translation of I-PSS using a multiregional reconciliation panel comprised of representatives from each of the major Spanish language groups in the United States. For BII full translation methodology was used to develop a translation for the United States, including 2 forward translations using translators from more than 1 region, a multiregional reconciliation panel meeting, a back translation evaluation, cognitive debriefing interviews with representatives from each language group, developer review, a final evaluation for consistency and proofreading.

RESULTS

The revised I-PSS better reflects common Spanish wording in the United States, while the BII translation was confirmed to be comprehended by Spanish speakers in the United States originating from multiple regions of Latin America.

CONCLUSIONS

United States Spanish translations of patient reported outcome measures should consider the diversity of the growing Spanish speaking population in the United States to ensure comprehension across the broad population originating from the multiple regions of Latin America.

Clinical inertia in the management of Type 2 diabetes metabolic risk factors

AIMS

Delays in the initiation and intensification of medical therapy may be one reason patients with diabetes do not reach evidence-based goals for metabolic control. We assessed intensification of medical therapy over time, comparing the management of hyperglycaemia, hypertension, and hyperlipidaemia.

METHODS

Prospective cohort study of 598 adults with Type 2 diabetes receiving primary care in an academic medical centre from May 1997 to April 1999. We assessed whether patients failing to achieve standard treatment goals for haemoglobin A1c (HbA1c), systolic blood pressure (SBP), or low density lipoprotein (LDL) cholesterol when last measured during 12 months (Year 1, 5/97-4/98) had increases in their corresponding medical regimen during the following 12 months (Year 2, 5/98-4/99).

RESULTS

Among untreated patients in Year 1, seven of 12 (58%) of those above goal for HbA1c were initiated on medical therapy in Year 2, compared with 16 of 48 (34%) above SBP goal (P=0.02) and 26 of 115 (23%) above LDL cholesterol goal (P=0.02). Among patients on therapy and above goal, 124 of 244 (51%) patients with elevated HbA1c had their regimen increased in Year 2, compared with 85 of 282 (30%) with elevated SBP (P<0.001) and 22 of 79 (30%) with elevated LDL cholesterol (P<0.001). From Year 1 to Year 2 there was a decline in the overall proportion of patients above goal for LDL cholesterol (from 58% to 45%, P=0.002) but not for HbA1c or blood pressure.

CONCLUSIONS

Greater initiation and intensification of pharmaceutical therapy, particularly for elevated blood pressure or cholesterol, may represent a specific opportunity to improve metabolic control in Type 2 diabetes.

Fecal occult blood testing for colorectal cancer: a perspective

Colorectal cancer is an important health problem in western countries. Early detection of colorectal cancer reduces mortality. The best evidence for the effectiveness of screening for colorectal cancer is with annual or biennial fecal occult blood testing. While the benefit of fecal occult blood testing is small in absolute terms, the incremental cost-effectiveness of this screening strategy appears acceptable. Combining fecal occult blood testing with periodic flexible sigmoidoscopy or replacing it altogether with infrequent colonoscopy are theoretically attractive screening strategies, but the incremental costs and effectiveness of these more intensive screening strategies have not been well defined. Whether and how to implement population-based screening for colorectal cancer depends largely on available resources.

Treatments for prostate cancer in older men: 1984-1997

OBJECTIVES

To examine the temporal trends in radical prostatectomy (RP), brachytherapy (BT), and external beam radiotherapy (EBRT) rates among men aged 65 years or older for the period 1984 to 1997.

METHODS

We used the retrospective population-based analysis of treatments for prostate cancer among Medicare beneficiaries. The rates of RP were obtained from Part A (hospital) Medicare data for 20% of the national sample for 1984 to 1997. The BT and EBRT rates for the period 1993 to 1997 were obtained from a 5% national sample of Physician/Supplier Part B data. The rates of treatment, 30-day mortality, and readmissions were included.

RESULTS

The rate of RP peaked in 1992. From 1993 to 1997, its use decreased by 6% among men aged 65 to 69 years, 34% among men aged 70 to 74 years, and 50% for men aged 75 years or older. However, by 1997, the RP + BT treatment rate again approached the 1992 levels of RP alone; BT was used twice as often as RP in men aged 75 years or older. By 1997, the RP + BT + EBRT rate exceeded the 1993 rate for men aged 65 to 69 years and was again approaching the 1993 rate for men aged 70 to 74 years. From 1984 to 1997, the presence of comorbid conditions gradually declined for RP and accounted for more than 60% of the decrease in the short term mortality during this period. Variations in RP use by geographic region have also decreased.

CONCLUSIONS

RP is now more selectively targeted for treatment of prostate cancer in men older than 70 years than in the past. However, since BT has been substituted for radical surgery in many of these older men, the total population-based treatment rates have changed very little over time.

A frequently used patient and physician-directed educational intervention does nothing to improve primary care of prostate conditions

OBJECTIVES

To measure the impact of an educational intervention directed at both patients and their primary care physicians about prostate-related conditions.

METHODS

We used a randomized, control design for 50 physicians in 33 rural primary care practices from New England and Arkansas and a probability sample of 2402 of their male patients. For the physicians, we mailed two newsletters, conducted two face-to-face research staff visits, and provided printed educational manuals about the management of prostate conditions. For the patients, mailed educational pamphlets were targeted to the baseline symptom levels. After 18 months, 87% of patients and 92% of physicians completed a final survey. The patient survey measured health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The final physician survey asked them about their management of common prostate conditions.

RESULTS

Before randomization, most men (59%) said they knew little or nothing about prostate problems that affect urination, and 63% also reported "little" or "no" knowledge about prostate-specific antigen testing. Eighteen months later, we observed no differences between the intervention and control patients in the measures of health status, urinary symptoms and bother, treatments received, and prostate-related knowledge. The intervention, physicians' knowledge, and self-reported practices for managing common prostate conditions were no better than the control physicians'.

CONCLUSIONS

This commonly used education strategy had no measurable impact on prostate-related care.

Evaluation of symptoms and quality of life in men with benign prostatic hyperplasia

Benign prostatic hyperplasia (BPH) is a common histologic condition among older men, which conveys its morbidity through lower urinary tract symptoms and complications, such as acute urinary retention, obstructive uropathy, and urinary tract infections. The mechanisms linking the histologic process and lower urinary tract symptoms remain uncertain; prostatic enlargement and bladder outlet obstruction are involved. However, measurements of prostate size and the severity of bladder outlet obstruction correlate poorly with the severity of lower urinary tract symptoms. The severity of lower urinary tract symptoms associated with BPH can be measured reliably, from the patient's perspective, with a number of validated questionnaires, including the International Prostate Symptom Score, the Danish Prostate Symptom Score, and the International Continence Society (ICS)male questionnaire. In the clinical setting, these questionnaires can be used (1) to assess the severity of symptoms in men with lower urinary tract symptoms that may be attributable to BPH, based on their age and clinical characteristics; and (2) to follow changes in symptoms over time and with treatment. None of these questionnaires can accurately determine whether a symptomatic patient has underlying bladder outlet obstruction. Additional questionnaires are available to measure the impact of lower urinary tract symptoms on men's lives, as well as associated phenomena, such as continence and sexual function, which may be affected by BPH and its treatments. Men with a severe burden of lower urinary tract symptoms often have measurable decrements in overall health-related quality of life, which can be ameliorated by treatment.

Intrathecal baclofen for generalized dystonia

The aim of this study was to evaluate the effects of intrathecal bacolfen (ITB) on patients with severe generalized dystonia. Eighty-six participants ranging in age from 3 to 42 years (median age 13 years) with generalized dystonia refractory to oral medications were offered treatment with ITB. Dystonia was associated with cerebral palsy in 71% of participants. Response to ITB was tested by continuous infusions in 72%, and by bolus injections in 17% of participants who had both dystonia and spasticity. Ninety-one percent of participants responded to the screening infusion and 93% to the bolus injections. Pumps were implanted in 77 participants. Dystonia scores at 3, 6, 12, and 24 months were significantly decreased (p<0.005) compared with baseline scores. Dystonia scores were significantly lower in those with intrathecal catheters positioned at T4, or higher than in those with catheters at T6 or lower (p=0.005). Ninety-two percent of participants implanted with a pump retained their responses to ITB during a median follow-up of 29 months. Patient questionnaires indicated that quality of life and ease of care improved in 86% and speech improved in 33%. Side effects of ITB occurred in 26% of participants. Surgical complications occurred in 38% and included CSF leaks, infections, and catheter problems. ITB is probably the treatment of choice for generalized dystonia if oral medications are ineffective.

Preliminary toxicity assessment of water after treatment with UV-irradiation and UVC/H2O2

Photooxidation (UV radiation) and enhanced photooxidation (UVC/H2O2) are water treatment technologies which remove aquatic natural organic matter (NOM) by photodegradation, producing lower molecular weight components and CO2. Since these technologies are being investigated for the treatment of drinking water, knowledge of the potential toxicity of the photooxidation by-products is vital. The potential toxicity of UVA-, UVB-, UVC-irradiated, and UVC/H2O2-treated aquatic NOM in two spot samples from two Australian reservoirs was analysed in two spot samples using Vibriofischeri in the Microtox test, African green monkey kidney cells (AS/NZS 4020:1999), and Daphnia carinata in an acute immobilisation test. Toxicity was not apparent for both the Microtox procedure and cytotoxicity analyses for the UVC-irradiated and UVC/H2O2-treated NOM samples, while UVA- and UVB-irradiated water samples were non-toxic to D. carinata. In contrast, acute toxicity was observed for UVC- and UVC/H2O2-treated water samples. The observed toxicity was attributed to photooxidative degradation of NOM-metal binding sites, which resulted in the release of bioavailable copper ions, as evidenced by higher concentrations of free copper ions in photooxidised water. As the total copper concentrations of the two raw water samples were well below the Australian Water Quality Guidelines for metals in domestic supplies, the release of copper from photooxidised NOM is unlikely to cause health concerns in these samples.

The prevalence and implications of incidental findings on ED abdominal CT scans

We reviewed reports from 321 consecutive emergency department (ED) noncontrast, helical "renal stone" abdominal CT scans obtained at a single medical center between April 1996 to June 1997 for incidental findings. Incidental findings were common (45% of scans), and approximately half were rated of "moderate" or "serious" concern by 2 independent reviewers (kappa = 0.72). ED records indicated that only 21% of incidental findings were documented, and only 11 (18%) of cases with findings of "moderate/severe" concern had evidence of follow-up on hospital chart review. Although work-up of these 11 cases did not yield any serious diagnoses, many potentially serious incidental findings without follow-up remain worrisome.

Risk factors for clinical benign prostatic hyperplasia in a community-based population of healthy aging men

We defined risk factors for a clinical diagnosis of benign prostatic hyperplasia (BPH) among subjects of the population-based Massachusetts Male Aging Study. In 1987-89 1709 men aged 40-70 provided baseline risk factor data and were followed for a mean of 9 years; 1019 men without prostate cancer provided follow-up data. We classified men with clinical BPH at follow-up if they reported (1) frequent or difficulty urinating and were told by a health professional that they had an enlarged or swollen prostate or (2) if they reported having surgery for BPH. At follow-up the prevalence of clinical BPH was 19.4%, increasing from 8.4% of men aged 38-49 years to 33.5% of men aged 60-70 years (P < 0.001 for trend). Elevated free PSA levels (age- and total PSA-adjusted OR, top vs. bottom quartile ng/mL 4.4, 95% CI 1.9-10.5), heart disease (age-adjusted OR 2.1, CI 1.3-3.3), and use of beta-blocker medications (OR 1.8, CI 1.1-3.0) increased odds for BPH, while current cigarette smoking (OR 0.5, CI 0.3-0.8) and high levels of physical activity (top vs. bottom quartile kcals/day OR 0.5, CI 0.3-0.9) decreased odds of BPH. All but the medication effects persisted in fully adjusted multivariable models. Total or fat calorie intake, sexual activity level, alcohol intake, body mass index, waist-hip ratio, diastolic blood pressure, a history of diabetes, hypertension, vasectomy, or serum levels of androgens or estrogens did not individually predict clinical BPH. We conclude that physical exercise and cigarette smoking appear to protect against development of clinical BPH. Elevated free PSA levels predict clinical BPH independent of total PSA levels. Risk associated with heart disease does not appear to be due solely to detection bias or to effects of heart disease medications. A wide variety of other characteristics appear to have no influence on risk for clinical BPH.

Selective serotonin reuptake inhibitors: Their effect on high-intensity exercise performance

OBJECTIVE

To determine the neuromuscular and performance effects of acute and long-term exposure to selective serotonin reuptake inhibitors (SSRIs).

DESIGN

Two randomized, double-blind, crossover studies.

SETTING

Departments of Kinesiology and Medicine, McMaster University, Hamilton, Ont, Canada.

PARTICIPANTS

Eleven healthy, college-aged men in the acute study; 12 healthy, college-aged men in the chronic study.

INTERVENTIONS

In the acute study, subjects were given a placebo and fluoxetine (40 mg) 6 hours before testing, in the chronic study, they were given fluoxetine (40mg/d) and an identical placebo for 2 weeks before testing.

MAIN OUTCOME MEASURES

Target measures were maximum voluntary contractions (MVCs), evoked peak torque, and percentage of motor unit activation for muscle strength and central drive. Repeated Wingate cycle ergometer tests were used to measure anaerobic power, capacity, and fatigue index. VO2max tests (80%, 90%) were used to measure time to exhaustion and cardiorespiratory responses.

RESULTS

In the acute study phase, MVC was lower for fluoxetine versus placebo (p =.05) and a slight fatigue resistance was measured in the repeated Wingate tests for the fluoxetine group; however, there were no affects on any other measured variable. In the chronic study phase, minute ventilation was lower for the fluoxetine trial (p <.05); however, there were no treatment affects on any of the other measurements.

CONCLUSION

Acute and chronic SSRI intake does not effect strength or high-intensity exercise performance in young adult men.

Outcomes for men with clinically nonmetastatic prostate carcinoma managed with radical prostactectomy, external beam radiotherapy, or expectant management: a retrospective analysis

BACKGROUND

With a lack of data from randomized trials, the optimal management of men with nonmetastatic prostate carcinoma is controversial. The authors sought to define the outcomes of three common strategies for managing patients with nonmetastatic prostate carcinoma: expectant management, radiotherapy, and radical prostatectomy.

METHODS

The authors conducted a retrospective cohort study with standardized collection of key prognostic data, including centralized assignment of Gleason grades from original biopsy specimens. Participants included all Connecticut hospitals (the expectant management cohort) and three academic medical centers in other states (the radiotherapy and surgery cohorts). Two thousand three hundred eleven consecutive men ages 55-74 years who were diagnosed during 1971-1984 with nonmetastatic prostate carcinoma and were treated at the participating sites were included.

RESULTS

Kaplan-Meier estimates with 95% confidence intervals (95% CI) of overall survival at 10 years for each cohort were as follows: expectant management cohort, 42% of patients (95% CI, 38-46%); radiotherapy cohort, 52% of patients (95% CI, 46-58%); and radical prostatectomy cohort, 69% of patients (95% CI, 67-71%); for disease specific mortality, the estimates were as follows: expectant management cohort, 75% of patients (95% CI, 71-79%); radiotherapy cohort, 67% of patients (95% CI, 61-73%); and radical prostatectomy cohort, 86% of patients (95% CI, 84-88%). There were large differences in distributions of important prognostic factors among men in the different treatment groups.

CONCLUSIONS

These data provide precise estimates of the outcomes of patients who have been treated with different modalities for nonmetastatic prostate carcinoma in the recent past. Direct comparisons of outcomes between treatment groups are inadvisable because of the different characteristics of patients who select these alternative management strategies.

ANCA pattern and LTA haplotype relationship to clinical responses to anti-TNF antibody treatment in Crohn's disease

BACKGROUND & AIMS

In the clinical trial, a lower response to infliximab was observed in some patients after multiple infusions, suggesting that clinical subgroups of Crohn's disease (CD) exist based on response to anti-tumor necrosis factor (anti-TNF). The aim of this study was to characterize these subgroups further by antineutrophil cytoplasmic antibody (ANCA) pattern and TNF genotype.

METHODS

Crohn's Disease Activity Index (CDAI) data from the North American patients in the clinical trial (n = 59) were evaluated as the response parameter. Speckled ANCA (sANCA) subjects were ANCA positive by ELISA with a speckling over the entire neutrophil on indirect immunofluorescence. Genotypes were determined for polymorphisms in the TNF/lymphotoxin alpha (LTA) region.

RESULTS

Response to infliximab as median change in CDAI was placebo (least response) < perinuclear ANCA (pANCA) < not pANCA or sANCA < sANCA (greatest response) (P(overall) = 0.003; 4 weeks). The response of subjects with sANCA was significantly different from that of placebo at all time points; that of pANCA subjects was not. Homozygotes for the LTA NcoI-TNFc-aa13L-aa26 haplotype 1-1-1-1 did not respond (P(overall) = 0.007).

CONCLUSIONS

These observations suggest that sANCA may identify a CD subgroup with a better response to infliximab and that pANCA and homozygosity for the LTA 1-1-1-1 haplotype may identify subgroups with a poorer response.

The acute and chronic toxicity of lanthanum to Daphnia carinata

The rare earth elements (REEs) are increasingly being used as trace supplements in agriculture. This study measured the acute and chronic toxicity of one REE, lanthanum (La), to Daphnia carinata. The 48-h EC50 of La to Daphnia was measured in three media of differing composition and hardness. Lanthanum was most toxic to Daphnia in soft tap water (TW) with an acute 48-h EC50 of 43 microg/l compared with 1180 microg/l in ASTM hard water (ASTM). In the third daphnid growth medium (DW), based on diluted sea water, the acute 48-h EC50 was 49 microg La/l, however, there was significant precipitation of La in this media. The chronic toxicity of La to Daphnia was measured in the DW and ASTM media. Nominal exposure concentrations were 100, 200, 400, 600, 800, and 1000 microg La/l. Mortality was a more sensitive endpoint than growth or reproduction in both chronic experiments. Very little La was detected in either media after 24 h and the measured concentrations below were estimated by logarithmic mean of nominal and measured values. There was 100% mortality at concentrations > or = 80 microg La/l (400 microg/l nominal) by day six of the experiment using DW media, but no effect on survival growth or reproduction at lower concentrations. In the ASTM media, La caused significant mortality to Daphnia at concentrations > or = 39 microg/l (200 microg/l nominal), however, at least one animal survived to the end of the study at each of the tested concentrations. There was no effect of La on growth of surviving daphnids at concentrations < or = 57 microg/l (400 g/l), however, second brood clutch sizes were significantly increased at 30, 39, and 57 microg/l (100, 200, 400 g/l nominal) compared with controls. Lanthanum also caused a delayed maturation in Daphnia.

Filling and voiding symptoms in the American Urological Association symptom index: the value of their distinction in a Veterans Affairs randomized trial of medical therapy in men with a clinical diagnosis of benign prostatic hyperplasia

PURPOSE

We used data from a large Veterans Affairs trial of medical therapy for men with benign prostatic hyperplasia to evaluate the value of calculating separate filling and voiding subscores of the American Urological Association (AUA) symptom index.

MATERIALS AND METHODS

We performed factor analysis to assess the psychometric validity of separating the 7 items of the AUA symptom index into filling and voiding subsets. To assess the clinical usefulness of calculating these subscores we correlated them against baseline measurements of symptom interference as well as urodynamic and anatomical measures of disease severity, and used them for predicting the response to medical therapy.

RESULTS

Factor analysis confirmed the psychometric validity of separating the AUA symptom index into a 3-item filling and a 4-item voiding subscale. However, calculating filling and voiding subscores did not result in differential correlations with measures of disease interference or severity. It also did not enable us to predict a better symptomatic or uroflowmetry response to medical therapy.

CONCLUSIONS

Calculating separate filling and voiding subscores of the AUA symptom index is psychometrically valid but not clinically useful.

Transurethral resection of the prostate among medicare beneficiaries: 1984 to 1997. For the Patient Outcomes Research Team for Prostatic Diseases

PURPOSE

We examine the epidemiology and associated risks of transurethral resection of the prostate among Medicare beneficiaries for the period 1984 to 1997.

MATERIALS AND METHODS

We used hospital claims for transurethral resection of the prostate from a 20% national sample of Medicare beneficiaries for the period 1991 to 1997. Risk of mortality and reoperation were evaluated using life table methods and compared to those for the period 1984 to 1990. We also examined the association between surgical volume and adverse outcomes following resection using unique urologist identifier codes from the 1997 part B Medicare claims.

RESULTS

Compared to 1984 to 1990, age adjusted rates of transurethral resection for benign prostatic hyperplasia (BPH) during 1991 to 1997 declined by approximately 50% for white (14.6 to 6.72/1,000) and 40% for black (11.8 to 6.58/1,000) men. Of the men who underwent resection for BPH during the recent period 53% were 75 years old or older but 30-day mortality in men 70 years old or older was significantly lower than that in 1984 to 1990. Since 1987 the 5-year risk for reoperation following transurethral resection for BPH has remained 5%. For resection performed in 1997 we observed no statistically significant association between urologist surgical volume and risks of reoperation or 30-day mortality.

CONCLUSIONS

Compared to the peak period of its use in the 1980s, older men are now undergoing transurethral resection of the prostate. Nevertheless, outcomes for men 65 years old or older continue to be good.

Age-related changes in preschool children's systematic use of private speech in a natural setting

This study set out to explore the contexts in which preschool children use private speech, or self-talk, in the naturalistic setting of the preschool classroom, and age-related changes in the contexts in which preschoolers talk to themselves. A total of 2752 naturalistic observations of fourteen three-year-old and fourteen four-year-old children were conducted using a time-sampling procedure in two preschool classrooms over the course of one semester. Results from logistic regression analyses revealed that both age groups were (a) more likely to use private speech during the self-selected activity classroom context as opposed to both large group and outside free play classroom contexts, and (b) most likely to talk to themselves when alone, next likely in the presence of peers, and least likely when in the presence of a teacher. Although the probability of private speech among three-year-old children did not vary as a function of the child's immediate activity, four-year-old children's private speech was more likely to occur during sustained and focused goal-directed activity as opposed to rapidly-changing and non goal-directed activity. The findings suggest that private speech appears systematically in young children and that, in several ways, four-year-old children use private speech more selectively than three-year-olds.

Health-care workers and latex allergy

Latex hypersensitivity can pose a threat to anyone, but health-care providers are among the high-risk groups for developing latex hypersensitivity. Latex hypersensitivity likely results from health-care workers' increased use of gloves following implementation of universal precautions. It is also believed that the antigenic load of latex gloves causes an increase in latex hypersensitivity resulting from massive production of gloves. Although there are many studies on the prevalence of latex hypersensitivity among health-care workers, there appear to be discrepancies, which may affect the different apparent prevalence. Testing for latex hypersensitivity raises another problem. Latex allergens cannot be identified specifically; therefore, there is no standard test or testing solution that can identify hypersensitive persons. Although latex glove hypersensitivity was first identified in the late 1970s, there remain many uncertainties associated with it; as a result, there is a growing concern among health-care providers. The authors offer several precautions to avoid the development of latex hypersensitivity.

Comparison of recommendations by urologists and radiation oncologists for treatment of clinically localized prostate cancer

CONTEXT

Multiple treatment options are available for men with prostate cancer, but therapeutic recommendations may differ depending on the type of specialist they consult.

OBJECTIVE

To define and contrast the distribution of management recommendations by urologists and radiation oncologists for a spectrum of men with prostate cancer.

DESIGN, SETTING, AND PARTICIPANTS

Mail survey sent in 1998 to a random sample of physicians in the United States, who were listed as urologists (response rate 64%, n=504) and radiation oncologists (response rate 76%, n=559) in the American Medical Association Registry of Physicians and practicing at least 20 hours per week.

MAIN OUTCOME MEASURE

Questionnaire addressing beliefs and practices regarding prostate cancer management.

RESULTS

Forty-three percent of radiation oncologists vs 16% of urologists would recommend routine prostate-specific antigen testing for men aged 80 years and older. For men with moderately differentiated, clinically localized cancers, and a more than 10-year life expectancy, 93% of urologists chose radical prostatectomy as the preferred treatment option, while 72% of radiation oncologists believed surgery and external beam radiotherapy were equivalent treatments. For most tumor grades and prostate-specific antigen levels, both specialty groups were significantly more likely to recommend the treatment in their specialty than the other treatment. Both groups reported giving patients similar estimates of the risks of complications due to surgery and radiation. Neither group favored watchful waiting in their treatment management except for a subset of men with life expectancies of less than 10 years and cancers with very favorable prognoses (Gleason score of 3 or 4 and prostate-specific antigen level </=5 ng/mL).

CONCLUSIONS

Based on this study, while urologists and radiation oncologists do agree on a variety of issues regarding detection and treatment of prostate cancer, specialists overwhelmingly recommend the therapy that they themselves deliver. JAMA. 2000;283:3217-3222

Diagnosing and treating chronic prostatitis: do urologists use the four-glass test?

OBJECTIVES

To examine the diagnosis and treatment of chronic prostatitis, we conducted a national mail survey of practicing urologists in 1998.

METHODS

Probability samples were drawn from the American Medical Association Registry of Physicians.

RESULTS

Five hundred four urologists responded (response rate 64%). Urologists reported seeing a median of 30 patients (interquartile range 11 to 60) newly diagnosed with chronic prostatitis in the previous 12 months. Eighty percent of urologists responded that they "rarely" (47%) or "never" (33%) performed the Meares-Stamey four-glass diagnostic test. Only 4% answered "almost always." Forty percent of urologists responded that they treat "all" their patients with antibiotics and 42% more responded that they treat "more than half" with antibiotics. Physicians who routinely performed the four-glass test did not differ in antibiotic use from those who used the test less often; however, they were more likely to use treatment other than antibiotics. For example, alpha-blockers were used in one half or more of the patients by only 35% of physicians who never do the four-glass test compared with 42% who rarely do the test and 57% who do the test more often (P = 0.002). Results were similar for treatment with natural remedies.

CONCLUSIONS

Urologists frequently diagnose chronic prostatitis but rarely perform the four-glass diagnostic test. Use of the four-glass test does not appear to affect urologists' antibiotic treatment patterns. Although bacterial prostatitis is thought to be rare, antibiotic use in the population of men with prostatitis is not. The four-glass test and empiric antibiotics are practices in the diagnosis and treatment of prostatitis that deserve scrutiny.

Age-specific patterns of prostate-specific antigen testing among primary care physician visits

BACKGROUND

Early detection of prostate cancer is thought to be effective, and indirect evidence suggests that men aged 50 to 69 years will benefit most while those aged 70 and older will benefit least from it. The goal of our study was to describe usual care patterns for prostate-specific antigen (PSA) testing by primary care physicians in the United States.

METHODS

We analyzed office visits made by adult men to family physicians, general internists, general practitioners, and geriatricians recorded by the 1995 and 1996 National Ambulatory Medical Care Surveys. Our outcome measure was the probability of a primary care physician ordering a PSA test during a visit.

RESULTS

Seventeen percent of the tests reported were among men aged younger than 50 years, 50% were for men aged 50 to 69 years, and 33% were for men aged 70 years and older. The frequency of PSA testing was highest during visits by men aged 60 to 64 years (7.1%), 65 to 69 years (7.0%), 70 to 74 years (7.0%), and 75 to 79 years (6.3%) but lower for men aged older than 80 years (3.1%).

CONCLUSIONS

Our findings suggest that during the mid-1990s prostate cancer screening decisions by primary care physicians were not sensitive to patients' ages.

Incidence rates and risk factors for acute urinary retention: the health professionals followup study

PURPOSE

We define incidence rates and risk factors for acute urinary retention.

MATERIALS AND METHODS

In 1992, 41,276 United States male health professionals 45 to 83 years old self-reported baseline health data and American Urological Association symptom index scores. In 1995 a subset reported the year of any episode of acute urinary retention requiring catheterization. Of 8,418 respondents 6,100 without a history of prostate cancer, prostatectomy or acute urinary retention before 1992 provided data. Incidence rates from 1992 to 1995 were calculated and risk factors were assessed using logistic regression.

RESULTS

During 15,851 person-years of followup 82 men reported an episode of acute urinary retention (sampling weighted incidence 4.5/1,000 person-years, 95% confidence intervals 3.1 to 6.2). Rates increased with age and baseline symptom severity. In men with symptom score 0 to 7 (none or mild lower urinary tract symptoms) the incidence of acute urinary retention increased from 0.4/1,000 person-years for those 45 to 49 years old to 7.9/1,000 person-years for those 70 to 83 years old. In men with symptom score 8 to 35 (moderate or severe lower urinary tract symptoms) rates increased from 3.3/1,000 person-years for those 45 to 49 years old to 11.3/1,000 person-years for those 70 to 83 years old. Men with a clinical diagnosis of benign prostatic hyperplasia and a symptom score 8 or greater had the highest rates (age adjusted incidence 13.7/1,000 person-years). All 7 lower urinary tract symptoms comprising the American Urological Association symptom index individually predicted acute urinary retention (age adjusted odds ratio 1.8 to 2.9 for symptoms occurring more than 25% of the time during the last month). The sensation of incomplete bladder emptying, having to void again after less than 2 hours and a weak urinary stream were the best independent symptom predictors. Use of medications with adrenergic or anticholinergic side effects also predicted acute urinary retention.

CONCLUSIONS

Acute urinary retention occurred relatively infrequently but older age, moderate or severe lower urinary tract symptoms, a diagnosis of benign prostatic hyperplasia and specific drug therapies significantly increased the risk of occurrence.

Reliability and responsiveness of the Barry-Albright Dystonia Scale

The reliability and responsiveness of the Barry-Albright Dystonia (BAD) Scale, a 5-point ordinal severity scale for secondary dystonia, was assessed. For interrater reliability, 13 raters scored 10 videotaped patients; for intrarater reliability, two raters rated the videotape again. For test-retest reliability, patients were rated on two occasions. Four inexperienced raters scored patients, received training, then scored additional patients. To assess responsiveness, we compared patient and physician global ratings of change (better, same, and worse) with BAD Scale score changes for 18 patients on intrathecal baclofen (ITB) trials. We assessed reliability with the intraclass correlation coefficient (ICC). The mean ICC for total BAD Scale scores were as follows: interrater reliability 0.866, intrarater reliability 0.967 and 0.978, test-retest reliability 0.978 (before training) and 0.967 (after training). We found the BAD Scale responsive to change, with most improved scores in patients rated by the patient, family, and neurosurgeon as 'better'. The total scores were reliable for experienced raters. We recommend training for clinicians interested in using the scale.

Distinguishing chronic prostatitis and benign prostatic hyperplasia symptoms: results of a national survey of physician visits

OBJECTIVES

The morbidity of chronic prostatitis results from a constellation of genitourinary symptoms. A recent study classified 21 of these symptoms into three categories: pain, voiding complaints, and sexual dysfunction. Pain symptoms predominated among patients with prostatitis. Using data from a nationwide survey of physician visits, we examined the most common symptoms reported by men at chronic prostatitis visits and contrasted the results with visits for benign prostatic hyperplasia (BPH).

METHODS

We analyzed 81,034 visits by men (18 years and older) to office-based physicians of all specialties in the National Ambulatory Medical Care Surveys of 1990 to 1996, using sampling weights to make national estimates. U.S. physicians selected by random stratified sampling completed visit forms that included patients' reasons for visits and physicians' diagnoses.

RESULTS

In 1990 to 1996, there were 765 visits (national estimate 1.5 million visits/yr; 95% confidence interval = 0.9 to 2.1) with a diagnosis of chronic prostatitis. Among chronic prostatitis visits, 20% were for pain, 19% for urinary symptoms, and 1% for sexual dysfunction. Among 2271 BPH visits, 2% were for pain, 33% for voiding complaints, and 1% for sexual dysfunction. The most common reason coded for chronic prostatitis visits was painful urination (14% of chronic prostatitis visits, but only 1.7% of BPH visits).

CONCLUSIONS

Pain was slightly more common than voiding complaints, but much more common than sexual dysfunction among chronic prostatitis visits. The most common reason for chronic prostatitis visits was painful urination, which was uncommon among patients with BPH. Pain distinguished chronic prostatitis from BPH better than any other urinary symptom.

PSA screening for prostate cancer: the current controversy--a viewpoint. Patient Outcomes Research Team for Prostatic Diseases

Prostate cancer is an important health problem. Randomized trials have not yet proven whether or not screening with prostate-specific antigen measurements reduces morbidity or mortality. The potential for overtreatment of prostate cancers not destined to cause future mortality, the uncertainty about the benefits of aggressive treatment of screen-detected cancers, and the relatively high costs of prostate cancer screening programs are all areas of concern. A shared approach to decisions about screening individual patients pending better evidence is one strategy for clinicians to consider in dealing with this controversial problem.

The impact of medical therapy on bother due to symptoms, quality of life and global outcome, and factors predicting response. Veterans Affairs Cooperative Studies Benign Prostatic Hyperplasia Study Group

PURPOSE

We determine the effect of placebo, finasteride, terazosin and a combination of drugs on bother due to symptoms, quality of life and patient perception of improvement, and identify baseline clinical factors that predict clinical response to medical therapy.

MATERIALS AND METHODS

A total of 1,229 subjects with clinical benign prostatic hyperplasia (BPH) were randomized to 1 year of placebo, finasteride, terazosin or drug combination. The primary outcome measures were American Urological Association (AUA) symptom score and peak flow rate. Relevant secondary outcome measures were symptom problem score, BPH impact score and global rating of improvement.

RESULTS

Group mean differences in symptom problem and BPH impact scores between the finasteride versus placebo, and terazosin versus combination groups were not statistically or clinically significant. Group mean differences in all outcome measures were highly statistically significant between the terazosin and finasteride, and combination and finasteride groups. The percentage of subjects who rated improvement as marked or moderate with placebo, finasteride, terazosin and combination was 39, 44, 61 and 65%, respectively. In the subsets of men in the placebo, finasteride, terazosin and combination groups with prostates greater than 50 cm.3 group mean decrease from baseline in AUA symptom score was -2.5, -3.6, -6 and -7, group mean increase in peak flow rate was 0.6, 2.7, 3.6 and 3.7 ml. per second, group mean decrease in symptom problem score was -2.2, - 1.9, -3.1 and -4.5, and group mean decrease in BPH impact score was -0.6, -0.3, -1.1 and -1.5, respectively. A correlational analysis failed to show a significant relationship between baseline prostate volume and treatment response to finasteride. There was a significant but weak relationship between change in AUA symptom score and peak flow rate in the finasteride and combination groups. The symptom responses with terazosin were independent of baseline peak flow rate.

CONCLUSIONS

In men with clinical BPH finasteride and placebo are equally effective, while terazosin and combination are significantly more effective. In men with clinical BPH and large prostates the advantage of finasteride over placebo in terms of symptom reduction, impact on bother due to symptoms and quality of life is small at best, while the advantage of terazosin and combination over finasteride and placebo is highly significant. Baseline prostate volume was not a predictor of response to finasteride in the overall study population. On the basis of our results alpha1 blockers, such as terazosin, should be first line medical treatment for BPH.

Competing risk analysis of men aged 55 to 74 years at diagnosis managed conservatively for clinically localized prostate cancer

CONTEXT

The appropriate therapy for men with localized prostate cancer is uncertain. Until results of clinical trials are available, men and their physicians need guidance.

OBJECTIVE

To estimate survival based on a competing risk analysis stratified by age at diagnosis and histologic findings for men diagnosed as having clinically localized prostate cancer and who were managed conservatively.

DESIGN

Retrospective cohort study.

SETTING

Connecticut Tumor Registry.

PATIENTS

A total of 767 men with localized prostate cancer diagnosed between 1971 and 1984, aged 55 to 74 years at diagnosis, either not treated or treated with immediate or delayed hormonal therapy, and followed up for 10 to 20 years after diagnosis.

MAIN OUTCOME MEASURES

Estimates of the probability of dying from prostate cancer or other competing hazards.

RESULTS

Men with tumors that have Gleason scores of 2 to 4, 5, 6, 7, and 8 to 10 face a 4% to 7%, 6% to 11%, 18% to 30%, 42% to 70%, and 60% to 87% chance, respectively, of dying from prostate cancer within 15 years of diagnosis depending on their age at diagnosis.

CONCLUSIONS

Men whose prostate biopsy specimens show Gleason score 2 to 4 disease face a minimal risk of death from prostate cancer within 15 years of diagnosis. Conversely, men whose biopsy specimens show Gleason score 7 to 10 disease face a high risk of death from prostate cancer when treated conservatively, even when cancer is diagnosed as late as age 74 years. Men with Gleason score 5 or 6 tumors face a modest risk of death from prostate cancer that increases slowly over at least 15 years of follow-up.

Prevalence of bothersome genitourinary symptoms and diagnoses in younger men on routine primary care visits

OBJECTIVES

To assess the prevalence of bothersome genitourinary (GU) symptoms in younger men on routine primary care physician visits.

METHODS

One hundred six men aged 18 to 50 years were approached to complete a brief, self-administered survey that included the American Urological Association Symptom Index, a benign prostatic hyperplasia (BPH) Impact Index, and additional questions about GU pain and sexual dysfunction and about a history of GU diseases. Men with GU symptoms had their outpatient records reviewed.

RESULTS

Of the 101 respondents (mean age 36 years), 50% reported GU symptoms. Of these men, 25% were bothered by their symptoms and 17% wanted to talk about them with their physicians; 22% were worried that their GU symptoms might be due to prostate cancer; 27% of all men reported a history of at least one GU disease and 17% had more than one; 16% of all men had been to a urologist. Chart review for the 51 men with symptoms revealed physician documentation of GU symptoms in only 24% of cases and an abnormal GU examination in 8%. One third of reviewed charts documented a GU problem that visit. A broad spectrum of GU diagnoses was documented; no one cause predominated. Ninety percent of all men reported that primary care physicians should routinely ask younger men GU questions as part of their general healthcare.

CONCLUSIONS

The high prevalence of bothersome GU symptoms and diagnoses in younger men suggests that information about the clinical, functional, and quality of life implications of these symptoms needs to be collected in this population.

High rates of prostate-specific antigen testing in men with evidence of benign prostatic hyperplasia

PURPOSE

Benign prostatic hyperplasia is common among men who may be candidates for prostate cancer screening using prostate-specific antigen (PSA) testing. Patterns of PSA testing among men with evidence of benign prostatic hyperplasia have not been studied.

METHODS

We examined the prevalence and correlates of a self-reported history of PSA testing. In 1994, 33,028 US health professionals without prostate cancer aged 47 to 85 years provided information on prior PSA testing, lower urinary tract symptoms characteristic of benign prostatic hyperplasia, history of prostatectomy, and prostate cancer risk factors. In 1995, a subset of 7,070 men provided additional information on diagnosis and treatment of benign prostatic hyperplasia.

RESULTS

From 39% of men in their 50s to 53% of men in their 80s reported PSA testing in the prior year (P <0.0001 for trend with age). Men were more likely to report PSA testing if they had lower urinary tract symptoms characteristic of benign prostatic hyperplasia (age-adjusted odds ratio for severe symptoms 2.2, 95% confidence interval 1.8 to 2.6), a prior history of prostatectomy (age-adjusted odds ratio 1.1, 95% confidence interval 1.02 to 1.2), or a physician diagnosis of benign prostatic hyperplasia (odds ratio 1.9, 95% confidence interval 1.7 to 2.2; adjusted for age, signs or symptoms of benign prostatic hyperplasia, and prostate cancer risk factors).

CONCLUSIONS

These US health professionals reported preferential use of PSA testing among men least likely to benefit from early cancer detection (older men) and among men most likely to have a false-positive PSA result (men with benign prostatic hyperplasia). Physician and patient education are needed to promote more rational and selective use of this screening test.

Prostate cancer screening and beliefs about treatment efficacy: a national survey of primary care physicians and urologists

PURPOSE

To describe practice patterns and beliefs of primary care physicians and urologists regarding early detection and treatment of prostate cancer.

SUBJECTS AND METHODS

National probability samples of primary care physicians (n=444) and urologists (n=394) completed mail survey instruments in 1995. Physicians were asked about their use of prostate-specific antigen (PSA) testing for men of different ages and their beliefs about the value of radical prostatectomy, external-beam radiation therapy, and watchful waiting for men with differing life expectancies.

RESULTS

Most primary care physicians report doing PSA tests during routine examination of men older than 50 years of age. The majority say they continue to do them on patients over 80 years and to refer men with abnormal values for biopsy. In contrast, only a minority of urologists would recommend PSA tests or biopsy for abnormal values for men over 75 years of age. More than 80% of primary care physicians and urologists doubt the value of radical prostatectomy for men with < 10 years of life expectancy; more primary care physicians than urologists see probable survival benefit in radiation therapy for patients with life expectancy < 10 years (48% versus 36%) or > 10 years (67% versus 53%). Thirteen percent of primary care physicians and only 3% of urologists consider watchful waiting to be as appropriate as aggressive therapy for men with > 10 years of life expectancy.

CONCLUSIONS

Primary care physicians are more aggressive about PSA testing and referral for biopsy than most urologists recommend. Both groups recommend PSA testing and believe that aggressive treatment is more beneficial than existing evidence indicates.

Androgen deprivation therapy for asymptomatic advanced prostate cancer in the prostate specific antigen era: a national survey of urologist beliefs and practices

PURPOSE

The use of androgen deprivation for prostate cancer without symptomatic metastases to the skeleton is controversial. However, by 1995 the use of medical androgen deprivation by injection was the thirteenth largest category of physician reimbursement by Medicare. To what degree do urologist attitudes towards androgen deprivation account for this growth?

MATERIALS AND METHODS

A survey was mailed to 582 United States urologists practicing at least 20 hours per week in 1995 which asked about use of androgen deprivation therapy when prostate specific antigen (PSA) levels rise after primary therapy (surgery or radiation). They were also asked whether they believed androgen deprivation provided a survival benefit for patients with asymptomatic stages C and D disease.

RESULTS

The response rate was 68%. Of the respondents 68% reported that they recommend androgen deprivation at least half of the time for men whose PSA is newly or persistently elevated following radical prostatectomy. Most (81%) urologists who believe that androgen deprivation offers a survival benefit for stage C disease said they prescribed it but more than half (53%) who do not believe in the efficacy of this treatment also said they still prescribe it.

CONCLUSIONS

Many urologists maintain an inclination to prescribe androgen deprivation for a rising or elevated PSA despite the absence of information about the benefit of this approach and their own conflicting beliefs.