Influence of preseason training, fitness, and existing injury on subsequent rugby injury

OBJECTIVES

To examine the influence of preseason fitness, existing injury, and preseason rugby training on subsequent injury.

METHODS

Players were eligible for the survey if they were a member of a Scottish Rugby Union (SRU) affiliated rugby club in the Border Reivers District of the SRU during the 1997-1998 season. A total of 803 (84%) players from 22 (88%) participating clubs provided details of rugby training, injuries sustained, and physical activity undertaken during the 16 week summer period (26 April to 16 August 1997) and their perceived fitness before the start of the season. Observers at participating clubs reported all injury episodes occurring to club players throughout the 1997-1998 season.

RESULTS

One fifth of players did not attend any rugby training during the 16 week summer period; the remainder attended a median of 14 sessions. Throughout the 1997-1998 season, 675 injury episodes occurred to 423 (53%) players during training or in matches. After adjustment for whether players held a professional contract or were amateurs, Cox regression showed a 3.9% relative increase (95% confidence interval (CI) 1.9 to 5.9%) in the risk of injury over the season for each additional preseason training week attended, and a 61% relative increase (95% CI 32 to 97%) for those players who had been injured or were carrying an injury at the end of the previous season.

CONCLUSIONS

Injury risk is more likely to be related to rugby training (type of activities undertaken in rugby training, or personalities and characteristics of players undertaking training more frequently) than to overall player fitness. Players who were injured at the end of the previous season were more likely to be injured in the following season. This may be because they do not allow previous injuries to heal sufficiently before returning to the game, or the intensity of their participation may increase their risk of injury.

Influence of rugby injuries on players' subsequent health and lifestyle: beginning a long term follow up

OBJECTIVES

To describe the current rugby playing status of a cohort of 1,169 men who had previously participated in an epidemiological survey of rugby injuries during the 1993-1994 season, and assess the consequences of rugby injuries sustained.

METHODS

In May 1998, 911 (78%) men completed a questionnaire reporting their current involvement in rugby and the influence that the 324 (71%) injuries they had sustained four years earlier had since had on their health and wellbeing.

RESULTS

The most common reasons given by the 390 (43%) ex-players for ceasing to play rugby were family (10%), employment (25%), and an injury sustained while playing rugby (26%), 80% of which were dislocations, strains, and sprains, mainly to the knee (35%), back (14%), and shoulder (9%). A significantly (chi2 test 21.7, df = 1, p<0.001) higher proportion of current players (90%) undertook (non-rugby) sporting activities compared with ex-players (78%). Few ex-players undertook coaching (12%) and refereeing (2%). Only 22 (9%) men reported significant negative effects to employment, family life, and health up to mid-1998 from injuries that occurred during the 1993-1994 season, although the impact on their lifestyle had been substantial in some cases.

CONCLUSIONS

With the recent increase in the incidence of dislocation, strain, and sprain injuries in rugby football, the findings of this follow up could have a great impact on the game in the future. Although this survey has shown that, so far, only a small proportion of players suffer significant effects of rugby injuries, four years is not long enough to assess the long term effects. This cohort of rugby players need to be followed up for at least a further 20 years to determine whether there is a higher incidence of subsequent degenerative joint disease or other long term sequelae to injuries sustained while playing rugby.

Impact of professionalism on injuries in rugby union

OBJECTIVES

To measure the frequency and nature of injuries occurring in competitive matches since professionalism was introduced in rugby union.

METHODS

The cohort study previously conducted in players from senior rugby clubs in the Scottish Borders in 1993-1994 when rugby union was an entirely amateur sport was repeated in 1997-1998. The same injury definition, outcome criteria, and method of calculating playing hours were used. In total, 803 (84%) of 960 eligible players participated, including all 30 adult players who played professionally for the Scottish Rugby Union or Border Reivers District. The 576 injury episodes in 381 of these players in competitive matches were compared with the 373 injuries in 266 players out of 975 (94%) who were eligible and registered with the same senior rugby clubs in 1993-1994. Outcomes were the occurrence of injury episodes, days away from playing or training for rugby, and time lost to employment or attendance at school/college as a consequence of being injured.

RESULTS

The proportion of players who were injured almost doubled from 1993-1994 to 1997-1998, despite an overall reduction of 7% of the playing strength of participating clubs. Period prevalence injury rates rose in all age specific groups, particularly in younger players. This translated into an injury episode every 3.4 matches in 1993-94, rising to one in every 2.0 matches in 1997-1998. An injury episode occurred in a professional team for every 59 minutes of competitive play. Professional players sustained a higher proportion of recurrent injuries, particularly in the early part of the season. Some 56% of all their days lost to the game were caused by injuries to the muscles, ligaments, and joints of the knee, hip, and thigh.

CONCLUSIONS

The introduction of professionalism in rugby union has coincided with an increase in injuries to both professional and amateur players. To reduce this, attention should be focused on the tackle, where many injuries occur. The International Rugby Board should place a moratorium on the use of protective equipment in competitive matches until its contribution to player morbidity has been fully assessed.

The influence of environmental factors on rugby football injuries

The aim of this study was to establish the influence of weather and pitch conditions on the frequency and nature of rugby injuries. Observers at 26 senior rugby clubs in the Borders District of the Scottish Rugby Union reported all injuries to 1169 (96%) registered players at Saturday home and away matches during the 1993-94 season (August 1993 to April 1994). Weather and pitch conditions at 112 grounds were recorded on 605 occasions; 1268 Borders teams played at these grounds, with 344 injury episodes being sustained. Matches were played in dry weather for three-quarters of these occasions. There was a moderate association between weather and the state of the pitch (Spearman's rank correlation, r = -0.46, P < 0.001), with heavier pitches occurring in wetter weather. Logistic regression revealed that there were significant month-of-season (P = 0.003), wind strength (P = 0.008) and temperature (P = 0.011) effects on the risk of injury. On four of five occasions when matches were played in a downpour of rain, at least one injury episode occurred. Our results show that the month of the season and the weather may influence the occurrence of rugby injuries, but that the state of the pitch does not. Further studies are required to investigate these factors in more detail.

Factors influencing tackle injuries in rugby union football

OBJECTIVES

To assess the influence of selected aspects of lifestyle, personality, and other player related factors on injuries in the tackle. To describe the detailed circumstances in which these tackles occurred.

METHODS

A prospective case-control study was undertaken in which the tackling and tackled players ("the cases") involved in a tackle injury were each matched with "control" players who held the same respective playing positions in the opposing teams. A total of 964 rugby matches involving 71 senior clubs drawn from all districts of the Scottish Rugby Union (SRU) were observed by nominated linkmen who administered self report questionnaires to the players identified as cases and controls. Information on lifestyle habits, match preparation, training, and coaching experience was obtained. A validated battery of psychological tests assessed players' trait anger and responses to anger and hostility. The circumstances of the tackles in which injury occurred were recorded by experienced SRU coaching staff in interviews with involved players after the match.

RESULTS

A total of 71 tackle injury episodes with correct matching of cases and controls were studied. The following player related factors did not contribute significantly to tackle injuries: alcohol consumption before the match, feeling "below par" through minor illness, the extent of match preparation, previous coaching, or practising tackling. Injured and non-injured players in the tackle did not differ in their disposition toward, or expression of, anger or hostility. Some 85% of tackling players who were injured were three quarters, and 52% of injuries occurred when the tackle came in behind the tackled player or within his peripheral vision. Either the tackling or tackled player was sprinting or running in all of these injury episodes. One third of injuries occurred in differential speed tackles--that is, when one player was travelling much faster than the other at impact. The player with the lower momentum was injured in 80% of these cases. Forceful or crunching tackles resulting in injury mostly occurred head on or within the tackled player's side vision.

CONCLUSIONS

Attention should be focused on high speed tackles going in behind the tackled player's line of vision. Comparative information on the circumstances of the vast majority of tackles in which no injury occurs is required before any changes are considered to reduce injuries in the tackle.

The natural history of untreated lower urinary tract symptoms in middle-aged and elderly men over a period of five years

OBJECTIVES

To describe changes in untreated lower urinary tract symptoms (LUTS), levels of bothersomeness and interference in selected living activities arising from LUTS in a cohort of men followed up for a period of 5 years.

METHODS

1,994 men aged 40-79 years registered in four health centres in Scotland completed a urinary symptom questionnaire in the community. 1,177 (71% of original eligible participants) were followed up at 5 years.

RESULTS

The mean level of LUTS and the level of bothersomeness they caused increased universally between baseline and 5 years. The largest increases in mean symptom levels occurred for straining, hesitancy, incomplete emptying, weak stream and nocturia, and for mean levels of bothersomeness, i.e. dribbling, incomplete emptying, weak stream, frequency, nocturia and intermittency. The increase in mean interference level in selected living activities arising from LUTS was less marked. The progression of LUTS over time in individual men was very variable; however, the overall trend was one of continuing deterioration.

CONCLUSION

If left untreated, overall levels of middle-aged and elderly mens' LUTS, bothersomeness and interference in selected activities caused by these symptoms will increase over time.

Pathophysiological relationships between lower urinary tract symptoms and the prostate do not strengthen over time

BACKGROUND

The aim of this survey was to examine the relationships among baseline prostate gland volume and changes in urinary symptomatology 3 years later.

METHODS

A Scottish community-based cohort of 193 men aged 40-79 years who had prostate volume measured by transrectal ultrasound (TRUS) were followed-up at 3 years.

RESULTS

Only baseline nocturia correlated with prostate volume (r = 0.202, P = 0.0057), although some relationships existed for the antero-posterior dimension of the prostate gland. More statistically significant relationships were evident for adenoma volume rather than prostate volume, but they still had relatively low correlations (range, 0.19-0.31).

CONCLUSIONS

This study demonstrates the lack of relationships between prostate gland variables and lower urinary tract symptoms (LUTS). Those relationships that are statistically significant (at the P < 0.01 level) are weak, and only explain at most 9% of the total variation of prostate or adenoma volume or their dimensions.

Health-related quality of life associated with lower urinary tract symptoms in four countries

OBJECTIVES

To describe health-related quality of life (HRQL) associated with lower urinary tract symptoms (LUTS) assessed by validated questionnaires in four countries.

METHODS

More than 6000 men, recruited by using community- or population-based sampling in four countries, completed questionnaires soliciting information about urinary symptom frequency, bother, degree of interference with daily activities, and other measures of HRQL.

RESULTS

In all countries, disease-specific HRQL worsened with increasing age. Adjusting for age, most disease-specific HRQL measures were significantly worse with increasing symptom severity. The correlation between symptoms and HRQL was strongest in countries with higher prevalence of symptoms, such as Japan or the United States, and less pronounced in countries with lower prevalence (France, Scotland), possibly reflecting the lower variability in scores.

CONCLUSIONS

HRQL measures are worse in older men, and increased urinary symptom severity is associated with worse disease-specific HRQL in all countries, despite potential cross-cultural differences in disease prevalence, medication use, perceptions, or willingness to report symptoms or worse HRQL. This cross-cultural consistency suggests that an assessment of symptom bother or interference with daily activities may be useful in patient evaluation.

Influence of players' physique on rugby football injuries

OBJECTIVES

To determine whether there is an association between a player's physique and injuries incurred while playing rugby football.

METHODS

A cohort study was carried out involving all senior rugby clubs in the Scottish Borders during the 1993-1994 rugby season. Somatotype estimates were determined for 1152 (95%) of the 1216 eligible players. Body mass index (BMI), chest to waist ratio, and the ponderal index (PI) were used to classify players' physique as endomorphic (obese), mesomorphic (muscular), and ectomorphic (linear).

RESULTS

A strong association was found between physique and age (chi 2 test: chi 2 = 317.2, df = 10, P < 0.0001). More younger players were ectomorphs. Older players were more often endomorphic. The physiques of forwards and backs were significantly different (chi 2 test: chi 2 = 58.6, df = 2, P < 0.0001), with forwards being of a heavier build than three-quarters, even after adjustment for age. Endomorphic players were more likely than ectomorphs to be injured in a match after adjustment for age (age-adjusted mean BMI for players who were injured in a match was 25.4 compared with 24.6 for players who were not injured in a match, P < 0.0001; adjusted chest to waist ratio means were 1.136 and 1.125 respectively, P = 0.0307; adjusted PI means were 0.414 and 0.417 respectively, P = 0.0056). Increased risk of injury may occur when players play out of position, since one fifth of all injuries occurred in this circumstance.

CONCLUSIONS

Further research needs to be conducted using a more objective method of measuring somatotype on a further cohort of players so that the risk of injury for different body types can be examined more closely and related to other potential confounding factors. The level of increased risk for individuals playing out of their usual playing position needs to be established with a greater degree of certainty.

Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound

OBJECTIVES

To correlate prostate size estimates performed by single or multiple examiners through digital rectal examination (DRE) with volume measured by transrectal ultrasound (TRUS) and to propose measures for predicting prostate volume using DRE estimates in clinical settings.

METHODS

Data from four sources were analyzed: (1) the Olmsted County community study of 397 patients examined by a single urology nurse, with TRUS measurements done by multiple examiners; (2) a community study in Stirling, Scotland, involving 480 patients with DRE and TRUS performed by one urologist; (3) baseline data from the Veterans Affairs Cooperative Study No. 359 in 1222 patients with DRE and TRUS measurements by multiple personnel at 31 centers; and (4) a clinical series of 100 men with DRE and TRUS by a single urologist.

RESULTS

DRE estimates and TRUS volumes were significantly correlated (r = 0.4 to 0.9), but prostate size was underestimated by 25% to 55% for men with a prostate volume over 40 mL, depending on the study, with greater variability for studies involving multiple examiners. In one study that assessed prostate dimensions by DRE, posterior surface area (SA) correlated with overall TRUS volume (r = 0.4). According to receiver operating characteristic curves, SA showed a 70% and 76% chance of correctly identifying men with prostate volume greater than 30 or 40 mL, respectively; those with larger prostates were best distinguished by SA greater than 7 cm2 (sensitivity greater than 0.74, specificity greater than 0.50).

CONCLUSIONS

DRE underestimates prostate size, particularly if TRUS volume is greater than 30 mL. However, DRE estimates may help identify prostates likely to be larger than certain cutpoints by TRUS. Posterior SA may be useful as a preliminary assessment when prostate size is an important predictor of therapeutic response.

Epidemiological comparison of injuries in school and senior club rugby

OBJECTIVE

To determine the frequency, nature, circumstances, and outcome of schoolboy rugby injuries and to compare these injuries with those occurring in senior rugby clubs.

METHODS

The study was a prospective cohort study, conducted on 1705 (98%) of 1736 eligible players from nine Edinburgh schools and 1169 (96%) of 1216 eligible players from all 26 senior Scottish Rugby Union clubs (South District) who provided personal details before the 1993-1994 rugby season. Adult linkpersons were appointed to notify the circumstances of all injury episodes occurring in matches or in rugby related training.

RESULTS

154 school players (9%) experienced 210 separate injuries in 186 injury episodes, 80% of which arose in matches. The prevalence rate of schoolboy match injuries was 86.8 (95% confidence interval 73.4 to 100.2) per 1000 player-seasons. Senior club match injury prevalence was much higher at 367.0 (339.4 to 394.6) per 1000 player-seasons. Club players had a higher rate of match injury than school-boys for all injury types. One third of schoolboy match injury episodes occurred in September and the majority of match injury episodes were associated with tackling (40%) or with being tackled (24%). Nine per cent of schoolboy match injury episodes were classified as severe, compared to 13% for clubs. Sixteen per cent (n = 23) of all schoolboy match injury episodes resulted in missed school attendance compared with 27% (n = 117) of all senior club match injury episodes which involved loss of employment or education.

CONCLUSIONS

Schoolboy rugby is much safer than senior club rugby and the outcome of injuries that do occur is less disruptive. The relatively high rate of match injury in September migh be reduced by a more intensive period of preseason training.

Perceptions of urinary symptoms and health-care-seeking behaviour amongst men aged 40-79 years

BACKGROUND

Little is known about why men fail to seek medical help for urological symptoms.

AIM

This study was designed to document men's perceptions of urinary symptoms and to increase understanding of health-care-seeking behaviour.

METHOD

A stratified random sample of men aged 40-79 years was drawn from the age-sex register of a health centre in Central Scotland. Two hundred men were interviewed using semi-structured qualitative techniques and asked to complete a symptom questionnaire. The response rate was 65%.

RESULTS

Urinary symptoms reported to be most bothersome were dribbling, hesitancy and straining. All but the youngest age group (40-49 years) associated developing urinary symptoms with ageing. This was considered to be a reason not to consult a doctor. Most symptoms were not thought to be serious. Pain, haematuria and acute retention gave cause for concern, and were perceived as reasons for seeking medical help. Although urinary symptoms interfered with selected activities in daily life, this was not a worry to the men and was not seen to be a sufficient reason alone to consult their general practitioner.

CONCLUSION

The insidious development of urinary problems over time reinforces the belief that it is part of getting older and accounts for the accommodation of symptoms within men's everyday living experiences. Bothersomeness associated with urinary symptoms was not synonymous with worry or problems. Doctors must be prepared to initiate discussion about urinary function in order to assess the impact of symptoms on an individual's daily life.

Three-year follow-up of a community-based cohort of men with untreated benign prostatic hyperplasia

OBJECTIVE

To describe changes over 3 years in urinary symptom severity and bothersomeness and in interference caused by symptoms in selected everyday activities in a cohort of men with untreated benign prostatic hyperplasia (BPH).

METHODS

A prospective study of a community-based cohort of 217 men from Forth Valley, Scotland, which satisfied a working clinical definition of symptomatic BPH and had not received treatment, were followed up at 1 and 3 years.

RESULTS

Significant increases occurred in both mean symptom and bothersome levels for nocturia, urgency, dribbling, intermittency and incomplete emptying. Considerable proportions of men recorded changes in symptom levels, with the most fluctuation occurring for dribbling, weak stream and frequency-changes in bothersome levels showed a similar pattern. An increased number of men experienced some degree of interference in two or more selected everyday activities, but mean interference levels showed little change.

CONCLUSIONS

Increasing trends in symptom prevalence, bother-someness and in the proportions of men experiencing interference in everyday activities were established over the 3 years, despite considerable within-subject variation.

Regression to the mean occurs in measuring peak urinary flow

OBJECTIVE

To investigate the anomalous rises in maximum urinary flow rates seen in a prostate-diagnostic clinic.

SUBJECTS AND METHODS

The study comprised 1994 men aged 40-79 years registered at five health centres in Central Scotland, participating in a study of the natural history of benign prostatic hyperplasia (BPH), who completed a urodynamic assessment on up to three occasions: in the community, on referral to a prostate-diagnostic clinic and at a one-year follow-up.

RESULTS

Subjects referred to the diagnostic clinic on the basis of maximum flow rate (Qmax < 15 mL/s) and/or urinary symptomatology showed a mean increase in Qmax (P < 0.001) when tested at the clinic and at the one-year follow-up. In health centres which referred men to the clinic with no pre-selection, there were no significant changes in Qmax.

CONCLUSION

Regression to the mean occurs when patients are selected on the basis of a low Qmax. The use of isolated low values of Qmax in the process of diagnosing BPH should be avoided.

Reproducibility and observer variability of transrectal ultrasound measurements of prostatic volume

Transrectal ultrasound (TRUS) is an established investigation in benign and malignant prostatic disease though the level of reproducibility of TRUS volume measurements is not known. A group of observers in the UK and the USA who were participating in linked prospective studies of benign prostatic hyperplasia each carried out measurements during real-time scanning and on a series of static TRUS images. Results demonstrated good reproducibility for measurements of antero-posterior, transverse, and longitudinal dimensions of the prostate by an experienced UK urologist; only a minor degree of interobserver variation occurred in measurements made between experienced UK and USA observers. Using static images, USA observers obtained results that were in good agreement, whereas the UK observers, only two of whom used TRUS regularly, were in poor agreement with each other. This study demonstrates a high level of reproducibility for TRUS volume measurements performed by experienced observers.

Consultation patterns in a community survey of men with benign prostatic hyperplasia

BACKGROUND

The Stirling benign prostatic hyperplasia natural history group have previously reported a prevalence of this condition of 255 per 1000 in a community study of 1610 men aged 40-79 years.

AIM

It was decided to examine the consultation patterns of men with benign prostatic hyperplasia in greater detail.

METHOD

All participating men were invited to complete a previously validated lifestyle questionnaire including questions on consultations with their general practitioner during the previous year and previous history of prostatic problems. The men who had a urinary symptom score greater than 11, or who had a urinary flow rate of less than 15 ml per second were examined by transurethral ultrasonography for prostate size.

RESULTS

Of 364 men with benign prostatic hyperplasia, 89% had not consulted their doctor about urinary symptoms in the year prior to the study. Men with moderate to severe urinary symptoms were six times more likely to have consulted their doctor than those with mild symptoms. Moderate to severe symptoms and greater interference with daily living activities were both associated with a greater likelihood of consultation, independent of age. Of all the men in the study referred to the specialist clinic for assessment of prostate size by transurethral ultrasonography, two thirds were referred because of low urinary flow rate and one third because of high urinary symptom scores. The reported consultation data showed a reverse ratio of one third of those consulting having a low urinary flow rate and approximately two thirds having urinary symptoms.

CONCLUSION

While mass screening is unjustified, there is a need for patient education about benign prostatic hyperplasia in general and the recognition of declining strength of urinary flow as a symptom of benign prostatic hyperplasia and not of ageing alone. Furthermore, evaluation of primary care use of urinary flowmeters and the development of local protocols are suggested as elements of a case finding strategy for benign prostatic hyperplasia based on patient led consultation.

Prostatism and the burden of benign prostatic hyperplasia on elderly men

All men aged 40-79 years registered with two group general practices in Central Scotland were enumerated. Four hundred and ten men (249 in the working age group 40-64 years and 161 in retirement ages 65-79 years satisfied predetermined criteria for clinical benign prostatic hyperplasia (BPH) of prostatic weight > 20 g in the presence of urinary dysfunction and without evidence of malignancy. Despite a higher prevalence of BPH among the retirement group (428/1000) compared with men of working ages (202/1000), there were virtually no statistically significant differences between the two groups in terms of annoyance and interference in daily living activities caused by urinary dysfunction, frequency of urinary symptoms, or medical consultations for BPH. Although elderly men with BPH changed their lifestyle as a result of urinary dysfunction, only a low proportion of them disclosed their difficulties to a doctor. Increased education of the public and health care professionals about the nature and magnitude of the problem of BPH in elderly men is required.

Use of a 7-day diary for urinary symptom recording

A cohort of 254 men, aged 40-79 years, was followed up at 1 year in a community-based survey of benign prostatic hyperplasia. Immediately after completing a questionnaire about the occurrence of 12 urinary symptoms over the previous month, the men were invited to keep a prospective diary asking about the same symptoms over 7 consecutive days in order to assess the amount of day-to-day variation in symptoms and to examine to what extent the findings reflected those of the retrospective questionnaire. The majority of men reported minor degrees of daily fluctuations in symptoms. Only modest correlations existed between the diary mean and maximum score for each symptom and the corresponding retrospective questionnaire score. Where repeated assessments of urinary symptom status are considered necessary a prospective diary may be more appropriate than a retrospective questionnaire.

Similar levels of urological symptoms have similar impact on Scottish and American men--although Scots report less symptoms

Urinary symptoms and the extent to which they interfere with living activities were compared in 2 community-based investigations that enrolled men 40 to 79 years old who were randomly sampled from Olmsted County, Minnesota (2,119) and the Forth Valley of Scotland (1,385). Both investigations included symptom questions with wording that is nearly identical to that of the American Urological Association (AUA) symptom index. Following AUA scoring conventions we grouped scores into mild (AUA score 0 to 7), moderate (score 8 to 19) and severe (score 20+) categories. Minnesota men had symptoms that were more frequent, more bothersome and caused greater interference with living activities than did Scottish men of comparable age (p < 0.0002). However, within each symptom score category, the extent to which symptoms interfered with living activities was essentially the same in both populations. Although there appear to be important differences in urinary symptom prevalence between Scotland and Minnesota, the AUA symptom index provides a consistent measure of the extent to which urinary symptoms interfere with living activities in both populations. These findings support use of the AUA symptom index in the diagnostic evaluation of men with benign prostatic hyperplasia.

Prostatic surgery for benign prostatic hyperplasia: meeting the expanding demand

We describe changes in the pattern of surgery for benign prostatic hyperplasia (BPH) in Scotland between 1971 and 1989. The data are based on an analysis of routinely collected Scottish hospital in-patient statistics for primary prostatic operations on men with a diagnosis of BPH (ICD Code 600.0). Primary operation age-adjusted rates for BPH increased from 8.9 to 15.8 per 10,000 male population from 1971 to 1989. This was accompanied by a reduction in bed day use for BPH surgery from 49,500 bed days in 1971 to 36,000 in 1989. Case fatality for all surgery for BPH also fell steadily and can no longer be regarded as a relevant measure of prostatectomy outcome. Virtually all surgical intervention is now transurethral resection (TUR), forming 94% of surgery for BPH in 1989 compared with only 32% in 1971. The increase in surgical procedures carried out for BPH has been greater in younger age groups. If the pattern of increasing surgical intervention in the management of BPH over the past few years continues and there is an increased demand for treatment, and if the reported demographic changes occur, there will be a need for an additional 9 new consultant urologists in Scotland by 2001. Even if present operation rates hold steady, population changes alone will produce enough work for 2 more urologists.

Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men

To assess the importance of benign prostatic hyperplasia on activities of daily living, a cross-sectional survey of 1627 men aged 40-79 years (representing a 65% response rate) registered with two health centres in central Scotland was carried out, using a urinary symptom questionnaire and uroflowmetry to identify men more likely to have benign prostatic hyperplasia. The condition was defined as a prostate gland of more than 20 g in the presence of symptoms of urinary dysfunction and/or a peak flow rate of less than 15 ml s-1, without evidence of malignancy. Transrectal ultrasonography was used to measure the volume (and by inference weight) of prostate glands. A total of 410 men satisfied the criteria for benign prostatic hyperplasia. Overall, 51% of men with benign prostatic hyperplasia reported interference with at least one of a number of selected activities of daily living as a result of urinary dysfunction, compared with 28% of men who did not have this condition. In 17% of men of working age (40-64 years) with benign prostatic hyperplasia, this interference occurred most or all of the time for at least one activity of daily living compared with only 3% of men in the same age group who did not have this condition. If the criteria of unmet need for treatment of benign prostatic hyperplasia constitutes interference by urinary dysfunction most or all of the time in at least one activity of daily living, then the findings of this survey suggest that a substantial number of middle aged and elderly men living in the United Kingdom may be in need of assessment and treatment for this condition.

Follow-up of a cohort of men with untreated benign prostatic hyperplasia

A cohort of 266 men with untreated benign prostatic hyperplasia (BPH) identified in a community-based survey were followed for a period of 1 year. Although the overall prevalence of urinary symptoms increased during the year, substantial within-subject variation in urinary symptomatology occurred, with up to a quarter of men reporting urgency and dribbling to have improved whilst one third of men reported other urinary symptoms to have deteriorated. Levels of bothersomeness caused by urinary symptoms did not show much change during the period of follow-up. An overall increase of 19% in urinary peak flow which was also consistent across all age groups was present at 1 year compared with baseline, even after adjusting for increased urinary void volume. A slow progression in the extent to which interference with selected activities of daily living by urinary dysfunction occurred. This was greater in men of working age (40-64 years), compared with men of retirement age (65-79 years). A longer period of observation is required in order to determine the extent to which a consistent pattern of urinary symptomatology exists in untreated BPH, as well as whether interference with daily living activities continues to progress over time.

Impact of benign prostatic hyperplasia on general well-being of men

Little is known about the impact of benign prostatic hyperplasia (BPH) on the general well-being of men with this condition. All men aged 40-79 years registered with a group general practice were enumerated. BPH was defined as enlargement of the prostate gland of equivalent weight > 20 g in the presence of symptoms of urinary dysfunction and/or a urinary peak flow rate < 15 ml/s, without evidence of malignancy. Four hundred and ten men (20% of those who participated) satisfied these criteria. The proportion of men with a negative feeling of well-being was higher in men with BPH than in men who did not have BPH. The difference was consistent for all aspects of well-being (anxiety, depression, self-control, vitality, being worried or being bothered by illness). Men with BPH had a higher level of bothersomeness attributed to urinary symptoms, and more interference in selected daily living activities caused by urinary dysfunction. These were related to worry or concern over urinary function and prostate cancer, together with a higher level of embarrassment caused by urinary dysfunction, compared with men who did not have BPH. Patients' feelings of well-being should be taken into account in the clinical management of BPH.

High prevalence of benign prostatic hypertrophy in the community

There is a strong suspicion among urologists that the prevalence of benign prostatic hyperplasia is higher than has been reported in clinical retrospective and necropsy studies. To find out the prevalence in one community all men aged 40-79 years registered with a group general practice were invited to complete a urinary symptom questionnaire and to undergo uroflowmetry. 705 men (77% of those eligible) participated. 214 men (84% of those invited) with signs and symptoms of prostatic dysfunction subsequently underwent transrectal ultrasonography (TRUS) for assessment of the volume (and by inference weight) of their prostates. The prevalence rate of benign prostatic hypertrophy (BPH), defined as enlargement of the prostate gland of equivalent weight greater than 20 g in the presence of symptoms of urinary dysfunction and/or a urinary peak flow rate less than 15 ml/s and without evidence of malignancy, was 253 (95% CI 221-285) per 1000 men in the community, rising from 138 per 1000 men aged 40-49 years to 430 per 1000 men aged 60-69 years. Thus apparently well men have a much higher frequency of BPH than was previously thought to be the case.

The quality of health services research in medical practice in the United Kingdom

STUDY OBJECTIVE

The aim was to determine the scope and quality of published health services research concerned with medical practice in the United Kingdom.

DESIGN

Scope of health services research was reviewed in articles published in 41 medical and public health journals in 1985. In random sample of 60 papers stratified by study design, 18 key research parameters were assessed for the quality of reporting and application in the studies.

MAIN RESULTS

Over 80% of the research described in 246 articles was carried out by clinicians, mostly without acknowledged epidemiological or statistical assistance. More than half the studies were descriptive and only 17% were trials. In studies of hospital services, 4% covered long term care, in contrast to 67% concerned with inpatient care. One third of studies were conducted in general practice but only 10% of these included an assessment of clinical outcome. Important research parameters were often not reported; for example, response rates were missing in 52% of the studies, and comparability of cases and controls was not stated in 42% of relevant studies. Major inadequacies were found in the conduct of research, particularly in the selection of controls, allowance for confounding factors, objectivity of measurements, application of statistical tests, and conclusions reached.

CONCLUSIONS

Published health services research concerned with medical practice in the United Kingdom is often conducted by clinicians without expert assistance. The quality of reporting and methods employed are deficient in many respects. Short training courses and other initiatives are required to enhance the quality of health services research in medical practice.

Hypertension management and stroke recurrence in a community (Rochester, Minnesota, 1950-1979)

The purposes of this study were to determine the trend in stroke recurrence over time and the effect of the prestroke blood pressure and management of hypertension on stroke recurrence in 1,680 incidence cases of stroke in residents of Rochester, Minnesota. Recurrent, primarily ischemic, stroke occurred in 267 cases. Stroke recurrence rates did not change during the 30-year period 1950-1979, in contrast to the decline in initial stroke incidence rates during this time. The overall stroke recurrence rates were less than 5%/yr, with cumulative rates of 5.7%, 19.3%, and 28.8% at 1, 5, and 10 years, respectively. Neither level of blood pressure before the first stroke nor management of hypertension had any apparent effect on stroke recurrence rates throughout the follow-up.

The changing pattern of hypertension and the declining incidence of stroke

We studied whether changes in recognition and control of hypertension could be detected in the population of Rochester, Minn, from 1950 to 1979, a period in which a major decrease in the incidence rate of stroke was observed. Prevalence of diastolic blood pressure greater than or equal to 105 mm Hg fell 26% and 70% in men and women, respectively, between 1950 to 1959 and 1970 to 1979. Prevalence of pressures greater than or equal to 95 mm Hg decreased 5% in men and 58% in women. Increasing control of hypertension had an almost inverse linear relationship with the decreasing incidence of stroke in women, but the incidence of stroke in men did not decrease until ten years after improvement in the control of blood pressure began. We conclude that improvements in the detection and control of hypertension contributed to the declining incidence of stroke and that differences in management of hypertension could account for the difference between men and women in the trend of stroke decline.

Neurologic examination in stroke rehabilitation: adequacy of its description in clinical textbooks

Medical textbooks were reviewed to establish how well they presented those aspects of examination of the nervous system which are important in stroke rehabilitation. In addition, information was sought concerning such factors as the presence of instructions for the examiner and patient, grading and interpretation of results, and the importance of observer variation which can influence results of periodic neurologic examination of stroke patients. Study results demonstrated that the description of the neurologic examination which should be used in stroke rehabilitation was often incomplete and poorly defined. Material provided little interpretation for the physical signs which might be found. Factors which might influence results of periodic examination of the nervous system in stroke patients received little attention. There is an urgent need to develop a standardized form of clinical examination to meet the needs of practitioners who assess neurologic status in stroke rehabilitation.

Motor function after stroke

Two hundred and eighty-seven patients who had survived an acute stroke for up to one week after admission to hospital were examined for loss of motor function in the arm and leg. There was a highly significant difference in problem-solving, spatial neglect, communication and postural function between those with significant motor loss and those without. There was no significant difference in memory impairment. Significant loss in motor power had a bad prognosis for functional outcome, length of stay in hospital and survival. If recovery was to occur, it had done so by eight weeks.

The natural history of hemispheric and brainstem infarction in Rochester, Minnesota

All cases of first episodes of brain infarction occurring in the population of Rochester, Minnesota, from 1960 through 1979 were categorized as hemispheric or brainstem (including cerebellar) on the basis of clinical criteria, autopsy evidence, and the results of computed tomography (from 1973 on). Hemispheric infarction was 5 times more frequent than infarction of the brainstem and/or cerebellum. The magnitude of the decline in incidence was the same in each group during the 20-year period of the study. Thirty-day case fatality was similar in each group, but patients with brainstem infarction had a better long-term survival. Functional outcome among survivors of brainstem infarction was also better, 35% having returned to independent living by 1 year after onset compared with 22% of survivors of hemispheric infarction. This may have been a consequence of the higher proportion of residual cognitive and sensory impairments present in survivors of hemispheric infarction.

Primary intracerebral hemorrhage: impact of CT on incidence

From 1975-1979, the incidence of primary intracerebral hemorrhage (PIH) increased in Rochester, MN, when compared with a previously decreasing incidence. Judging from patients with PIH who were alert at diagnosis, we estimated that 24% of the hemorrhages in earlier years had been mislabeled as infarction. The 30-day survival rate increased from 8% in 1945-1974 to 44% in 1975-1979. The incidence rate was about 45% higher in patients receiving anticoagulant treatment than in those who did not. The increased incidence rate and improved survivorship were attributed to more frequent identification of small PIH by CT.

The dichotomy of myocardial and cerebral infarction

The Mayo Clinic medical record linkage and indexing system was used to examine changes in incidence and case fatality of myocardial infarction (MI), sudden unexpected death (SUD), and cerebral infarction (CI). The average annual age and sex adjusted incidence rates for MI (including SUD) and CI declined by 14% and 55%, respectively, between 1950-54 and 1975-79. The decline in the incidence of MI was due to a reduction in sudden unexpected death (SUD), greatest in younger persons. 30-day case fatality after MI declined from 50% to 35% during this period.

The changing pattern of survival following stroke

This study, compared survivorship for first episodes of cerebral infarction, intracerebral hemorrhage and subarachnoid hemorrhage which occurred in residents of Rochester, Minnesota during 5-year periods from 1945-49 through 1975-79. The progressive improvement in long-term survival following cerebral infarction which occurred between 1945-49 and 1970-74 was such that a higher proportion of patients survived for six years in 1970-74 (45%) than survived for three years in 1945-49 (42%). A modest improvement in short-term survival following cerebral infarction occurred up to 1975-79 but a marked improvement in 30-day survival following intracerebral hemorrhage was noted. The reasons for the improvement in survival have not been established, but possible changes in the diagnosis and management of stroke which might have been contributory factors are discussed.

The continuing decline in the incidence of stroke

The incidence of stroke has continued to decline in the population of Rochester, Minnesota, up to the end of the last decade. The rate of occurrence of new episodes of stroke in the period 1975-1979 was only 46% of the equivalent rate during the period 1945-1949. The magnitude of the decline in incidence rates was similar in both sexes, but the timing differed. Females showed a progressive decline beginning early in the period of observation, but most of the decline in males occurred in the last 10 years of the study.

Proprioception and spatial neglect after stroke

Proprioception and neglect were studied in 287 patients surviving up to one week after the onset of their stroke. The presence of proprioceptive loss indicated a more extensive lesion and a larger proportion of these patients had impairment of intellectual function, motor power in the upper and lower limb, and postural function. Proprioceptive loss also had an adverse effect on the level of independence achieved by discharge, final placement, mortality and length of stay in hospital. In 87% of the survivors recovery of proprioception had occurred by eight weeks. Significant neglect was associated with high mortality and poor outcome for functional recovery.

Predicting functional outcome following acute stroke using a standard clinical examination

In a series of 149 patients admitted to a stroke unit, the outcome of the acute phase of stroke rehabilitation, assessed by the patients' return to independence, was found to be related to the results of standardized weekly clinical examinations of mental, motor, sensory and communication function. The prediction of subsequent independence was estimated just as accurately using the results from three of these tests (upper limb motor function, postural function and proprioception) as when using the entire set of tests. A group of patients with little chance of responding to rehabilitation was identified.

Therapy impact on functional outcome in a controlled trial of stroke rehabilitation

In a randomized controlled trial of management of acute stroke in the elderly, a higher proportion of patients were assessed as independent in self-care in a stroke unit compared with patients with similar levels of neurologic impairment treated in medical units. The use of physical therapy and occupational therapy in the stroke unit and medical units was compared. Patients in the stroke unit received less therapy over a shorter period of time; however, a higher proportion had occupational therapy beginning at a much shorter interval after admission. Early introduction of rehabilitation by therapists may be more important than the amount of duration of treatment.

The use of health and social services in the management of stroke in the community: results from a controlled trial

The use of hospital and community services during the follow-up of a controlled trial which evaluated the effectiveness of a stroke unit and medical units in the management of acute stroke in the elderly is described. Patients from the stroke unit received more health and social services compared with medical unit patients, particularly in the initial follow-up period. The use of services was not related to the functional outcome of patients at hospital discharge. No overall difference occurred between stroke unit and medical unit patients in hospital bed days used throughout the study.

The triage of stroke rehabilitation

In this paper we describe the use of triage to select patients for a trial in which a comparison was made of the effectiveness of a stroke unit and medical units in the rehabilitation of acute stroke. Completing the triage for hospital admission of stroke enabled an estimate to be made of the size of a stroke unit per unit of population.

Management of acute stroke in the elderly: follow-up of a controlled trial

Follow-up of a controlled trial of the management of acute stroke in the elderly showed that the improvement in functional outcome at the time of discharge from hospital that had been achieved through establishing a stroke unit had disappeared by one year. Factors that might have contributed to this included overprotection by the families of patients who had been treated in the stroke unit, who were not permitted to carry out activities of daily living in which they were independent, and the early discharge from medical units of patients whose full rehabilitation potential had not been realised. Prolonging the benefits of short-term gains in functional outcome through the intervention of a stroke unit requires that all the links in the chain of stroke rehabilitation are maintained, including the proper orientation of patients' families before discharge from hospital.

Management of acute stroke in the elderly: preliminary results of a controlled trial

A randomised controlled trial compared the management of elderly patients with acute stroke in a stroke unit and medical units. A significantly higher proportion of patients discharged from the stroke unit (78 of the 155 admitted) were assessed as independent compared with patients discharged from medical units (49 of the 152 admitted). The intensive use of treatment that might have been implied by creating a stroke unit did not occur, although almost all the patients admitted to the unit received occupational therapy while only 47% of the patients admitted to medical units received occupational therapy. The delay before starting treatment was significantly shorter in the stroke unit. Results of this trial show that the stroke unit improved the natural history of stroke by increasing the proportion of patients who were returned to functional independence.

Changing pattern of cerebral infarction: 1945--1974

This study has identified all persons in the population of Rochester, Minnesota, who had a diagnosis of cerebral infarction during the period Jan. 1, 1970, through Dec. 31, 1974, and has confirmed the continuing decline in the incidence rate previously reported. The decline in the rate has been accelerating, with a relatively greater reduction occurring in women and in the more elderly age groups. There has been a decline in the prevalence rate in women which was not seen in men. The over-all impact of cerebral infarction was to reduce the proportion of those persons who were completely independent from 57% before cerebral infarction to 16% after infarction. Comparison of survival among patients with cerebral infarction occurring in the two quinquennia 1945--49 and 1970--74 showed only a 2% increased probability of survival at 30 days; the difference in survival increased progressively to 16% at 5 years. The reason for the declining incidence and increased survival in cerebral infarction in this population has not been established, but evidence of increased community surveillance and treatment of hypertension among persons before the onset of cerebral infarction is presented.