Estimating the impact on prostate cancer mortality of incorporating prostate-specific antigen testing into screening

OBJECTIVES

Whether early detection using prostate-specific antigen (PSA) and digital rectal examination (DRE) compared with DRE alone will reduce prostate cancer mortality awaits the results of ongoing prospective randomized trials. However, the impact that early detection could have on prostate cancer-specific survival can be estimated by assuming that PSA failure after radical prostatectomy (RP) will translate into death from prostate cancer.

METHODS

The study population consisted of 1274 men with clinically localized prostate cancer who underwent RP in Boston, Massachusetts or Philadelphia, Pennsylvania between 1989 and 2000 and had a preoperative PSA level greater than 4 but not more than 10 ng/mL. The primary endpoint was actuarial freedom from PSA failure (defined as PSA outcome).

RESULTS

The relative risk of PSA failure after RP for patients diagnosed with a PSA of greater than 4 to 5, 5 to 6, 6 to 7, or 7 to 8 ng/mL compared with greater than 8 up to 10 ng/mL was 0.3 (95% confidence interval [CI] 0.2 to 0.5), 0.5 (95% CI 0.4 to 0.8), 0.6 (95% CI 0.4 to 0.9), or 0.9 (95% CI 0.6 to 1.3), respectively. On the basis of the estimates of the 5-year PSA outcome, patients with a biopsy Gleason score of 5 or 6 (781 of 1274; 61%) consistently benefited from RP performed when the PSA at diagnosis was greater than 4 to 7 ng/mL compared with greater than 8 to 10 ng/mL (93% versus 78%, P <0.0001). A benefit to early detection was not found for the vast majority (266 of 312; 88%) of patients who had a biopsy Gleason score of 7 or higher.

CONCLUSIONS

Early detection using both PSA and DRE-based screening may benefit men who present with biopsy Gleason score 5 or 6 prostate cancer and a PSA level greater than 4 to 7 ng/mL compared with greater than 8 up to 10 ng/mL. This finding awaits validation from ongoing prospective randomized trials.

Bioabsorbable implants in orthopaedics: new developments and clinical applications

The use of bioabsorbable implants in orthopaedic surgical procedures is becoming more frequent. Advances in polymer science have allowed the production of implants with the mechanical strength necessary for such procedures. Bioabsorbable materials have been utilized for the fixation of fractures as well as for soft-tissue fixation. These implants offer the advantages of gradual load transfer to the healing tissue, reduced need for hardware removal, and radiolucency, which facilitates postoperative radiographic evaluation. Reported complications with the use of these materials include sterile sinus tract formation, osteolysis, synovitis, and hypertrophic fibrous encapsulation. Further study is required to determine the clinical situations in which these materials are of most benefit.

Quantitation of vital bleaching by computer analysis of photographic images

BACKGROUND

The authors investigated the use of computer processing of photographic images to monitor changes in tooth brightness after nightguard vital bleaching, or NGVB.

METHODS

Photographs of shade guides and clinical cases (patients' teeth) were taken on 35-millimeter film with electronic flash illumination and processed commercially. A slide scanner was used to digitize images as red, green and blue, or RGB, files, with constant brightness, contrast and linearity settings; the images were then analyzed with commercial software. Relevant image components (that is, teeth or shade guide tabs) were separated, and histograms of various numerical color descriptors were generated for each image component.

RESULTS

Analysis of shade tab images showed that the mean pixel intensity for the RGB blue channel, or MPIb, was the most satisfactory brightness descriptor, with clear sequential MPIb increments from lighter to darker shades in each series of colors (A through D) and close correlation with the manufacturer's brightness scale (r = .83). Mathematical analysis of MPIb data for shade tabs in the same image yielded a brightness index that was reproducible and correlated well with the manufacturer's brightness scale. Sequential measurements of this index in three subjects whose teeth were bleached with carbamide peroxide for 14 days correlated well with assessments made by visual shade guide comparisons.

CONCLUSIONS

The authors conclude that computer analysis of digitized photographic images with internal color controls provides an index of tooth brightness that is reproducible from image to image.

CLINICAL IMPLICATIONS

A brightness index derived from computer analysis of digitized photographic images may be useful for monitoring the effectiveness of NGVB.

Ocular abnormalities in Alagille syndrome

OBJECTIVE

To assess the type and frequency of ocular abnormalities occurring in Alagille syndrome (AS) in a large group of affected patients and their parents and the potential pathogenetic role of fat-soluble vitamin deficiency.

DESIGN

Observational case series.

PARTICIPANTS

Twenty-two children with AS and 23 of their parents participated.

MAIN OUTCOME MEASURES

Participants underwent full ophthalmic examination, including refraction, orthoptic examination, keratometry, slit-lamp examination, and funduscopy. Corneal diameter measurement was performed in a subset of nine and fluorescein angiography in a subset of six. Serum levels of vitamins A and E and cholesterol were measured.

RESULTS

The most common ocular abnormalities in patients with AS were posterior embryotoxon (95%), iris abnormalities (45%), diffuse fundus hypopigmentation (57%, a previously unreported finding), speckling of the retinal pigment epithelium (33%), and optic disc anomalies (76%). Microcornea was not associated with large refractive errors, and visual acuity was not significantly affected by these ocular changes. Vitamin levels were normal. Ocular abnormalities including posterior embryotoxon, iris abnormalities, and optic disc or fundus pigmentary changes were detected in one parent in 36% of cases.

CONCLUSIONS

Alagille syndrome is associated with a characteristic group of ocular findings without apparent serious functional significance and probably unrelated to fat-soluble vitamin deficiency. Simple ophthalmic examination of children with neonatal cholestatic jaundice and their parents should allow early diagnosis of AS, eliminating the need for extensive and invasive investigations.

The management of lymph node tuberculosis notified in England and Wales in 1993

We have compared the management of 219 cases of lymph node tuberculosis reported to the 1993 national notification survey with the recommended standards of treatment. The diagnosis was supported by positive histology and bacteriology in 81 cases (37%), positive histology in 70 (32%), positive bacteriology in 26 (12%), and on only clinical grounds in 40 (18%). Most patients (88%) were under the care of thoracic physicians. Almost all (97%) were commenced on a recommended drug combination, but only 81% continued to receive it, with thoracic physicians more likely than other physicians to use a recommended combination. Non-standard durations of the initial and/or continuation phases of treatment were used in 83 patients, but in only 49 cases was a satisfactory reason given for the modification. Definite or suspected drug toxicity was reported in 22 cases (10%), and was significantly more likely with non-standard regimens. There were no deaths. Of the 209 patients observed to treatment completion, 129 (62%) were then discharged. There were adequate reasons for follow-up after the end of treatment in all but 32 (15%) of those so managed. Further education is required to increase the percentage of patients treated with evidence-based regimens and durations of chemotherapy.

The management of pulmonary tuberculosis notified in England and Wales in 1993

We have compared the management of 925 cases of pulmonary tuberculosis reported to the 1993 national tuberculosis notification survey with the recommended standards of treatment. Forty-eight per cent of patients were white, 36% came from the Indian subcontinent (ISC) and 15% were of other ethnic origin. Most patients (86%) were under the care of thoracic physicians. Sputum microscopy was positive in 44%, and culture confirmation was obtained in 64% of cases. Drug resistance was reported in 30/582 isolates (5%), ranging from 13% in Black-Africans to 4.5% in ISC ethnic groups and 2% in the whites, with none reported in those of Black-Caribbean origin. Almost all patients (94.5%) were started on a recommended drug combination, but only 74% continued to receive one, with thoracic physicians significantly more likely than other physicians to use a recommended combination. Non-standard durations of either initial and/or continuation phase therapy were used in 303 patients, but in only 167 was a satisfactory reason given for the modification. Definite or suspected drug toxicity was reported in 79 (9%) and was significantly more likely with non-standard regimens. Seventy-two patients died before the survey was carried out one year after their notification, only 15 of them directly due to tuberculosis. Of the 815 cases observed to treatment completion, 430 (53%) were then discharged. There were adequate reasons for follow-up after the end of treatment in all but 98 of those so managed. Although the results were satisfactory overall, continued efforts are required to increase the percentage of patients treated with evidence-based recommended regimens and durations of chemotherapy.

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. I. Mortality and cardiovascular morbidity

The impact of perfusion technique and mode of pH management during cardiopulmonary bypass has not been well characterized with respect to postoperative cardiovascular outcome.

METHODS

This double-blind, randomized study comparing outcomes after alpha-stat or pH-stat management and pulsatile or nonpulsatile perfusion during moderate hypothermic cardiopulmonary bypass was undertaken in 316 patients undergoing coronary artery bypass operations.

RESULTS

Cardiovascular morbidity and mortality were not affected by pH management, and the incidence of stroke (2.5%) did not differ between groups. Overall in-hospital mortality was 2.8%, eight of the nine deaths occurring in the nonpulsatile group (5.1% versus 0.6%; p = 0.018). The incidence of myocardial infarction was 5.7% in the nonpulsatile group and 0.6% in the pulsatile group (p = 0.010), and use of intraaortic balloon pulsation was significantly more common in the nonpulsatile group (7.0% versus 1.9%; p = 0.029). The overall percentage of patients having major complications was also significantly higher in the nonpulsatile group (15.2% versus 5.7%; p = 0.006). Duration of cardiopulmonary bypass, age, and use of nonpulsatile perfusion all correlated significantly with adverse outcome.

CONCLUSIONS

Use of pulsatile perfusion during cardiopulmonary bypass was associated with decreased incidences of myocardial infarction, death, and major complications.

A randomized study of the influence of perfusion technique and pH management strategy in 316 patients undergoing coronary artery bypass surgery. II. Neurologic and cognitive outcomes

This double-blind, randomized comparison of pulsatile or nonpulsatile perfusion and alpha-stat or pH-stat management during cardiopulmonary bypass was designed to assess postoperative central nervous system outcomes.

METHODS

Neurologic and cognitive testing was conducted before the operation and 7 days and 2 months after the operation in 316 patients having coronary artery bypass and in a reference cohort of 40 patients having major vascular and thoracic operations.

RESULTS

As detailed in part I of this study, mortality in patients having coronary bypass was 2.8%. The incidence of stroke was 2.5% and did not differ among bypass groups. Mortality was 2.5% for the major surgery cohort. The incidence of cognitive (p = 0.003) and either neurologic or cognitive dysfunction (p = 0.0002) was higher at 7 days for the coronary bypass group than for the major surgery cohort. The incidence of neurologic dysfunction remained higher (p = 0.050) at 2 months in the coronary bypass group. Cognitive dysfunction at 2 months was less prevalent after 90 minutes of cardiopulmonary bypass in patients managed with alpha-stat than with pH-stat strategy (27% versus 44%, p = 0.047).

CONCLUSIONS

Postoperative central nervous system dysfunction is more prevalent in patients having coronary bypass than in those having major operations. Pulsatility has no effect on central nervous system outcomes, but alpha-stat management is associated with a decreased incidence of cognitive dysfunction in patients undergoing prolonged cardiopulmonary bypass.

Antipodal alpha-N-(methyl through decyl)-N-normetazocines (5,9 alpha-dimethyl-2'-hydroxy-6,7-benzomorphans): in vitro and in vivo properties

The enantiomeric (-)- and (+)-N-(methyl through decyl) normetazocines (5,9 alpha-dimethyl-2'-hydroxy-6,7-benzomorphans) were synthesized and their in vitro and in vivo activities determined. Increasingly bulky enantiomeric N-alkyl homologs were prepared until their interaction with the sigma 1 receptor decreased and their insolubility became a hindrance to their evaluation in vivo and/or in vitro. The (-)-methyl, -pentyl, -hexyl, and -heptyl homologs were essentially as potent as, or more potent than, morphine in the tail-flick, phenylquinone, and hot-plate assays for antinociceptive activity; the (-)-propyl homolog had narcotic antagonist activity between that of nalorphine and naloxone in the tail-flick vs morphine assay, and it also displayed antagonist properties in the single-dose suppression assay in the rhesus monkey. The antinociceptively potent (-)-heptyl homolog did not substitute for morphine in monkeys but did show morphine-like properties in a primary physical-dependence study in continuously infused rats. All five potent compounds showed high affinity for the mu opioid receptor from both rat and monkey preparations and the kappa opioid receptor (< 0.05 microM), and all except the (-)-methyl homolog interacted reasonably well at the delta receptor (K(i) < 0.1 microM). The (-)-propyl compound was equipotent (K(i) 1.5-2.0 nM) at mu and kappa receptors. The pattern of interaction of the (-)-enantiomeric homologs with mu receptors from rat and monkey preparations was similar, but not identical. The enantioselectivity of the homologs for mu receptors was greater in the rat than in the monkey preparation for all but the N-H and butyl compounds, and the enantioselectivity of the lower homologs (methyl through butyl) for the mu (monkey) receptor was greater than for the kappa or delta receptors. However, bulkier homologs (hexyl through decyl) displayed higher enantioselectivity at kappa or delta receptors than at the mu (monkey) receptor. The (+)-butyl through (+)-octyl homologs were essentially equipotent with, or more potent than, (+)-pentazocine at the sigma receptor. Only the (+)-H and (+)-methyl homologs had high affinity (< 0.05 microM) at PCP binding sites.

Reasons for restoration replacement: differences in practice patterns

Patients receive varying types and amounts of restorative treatment, depending on the prescribing dentist. The aim of this study was to enhance the understanding of the variation of the restoration replacement practices of dentists. Three dentists in private practice in similar semirural communities with comparable practice demographics were asked to gather data on all restorations they replaced over a period of 1 month. They recorded the tooth number, number of restored surfaces, restorative material being replaced, number of surfaces in the replacement restoration, the replacement restorative material, and the reasons for the replacement restoration. Statistically significant differences were found among the dentists as to the reasons for posterior restoration replacement, replacement materials used, and increase in size of the replacement restorations. Differences were attributed to individual practice philosophies, demonstrating that clinical information was not the sole determining factor as to type of replacement restorations that patients received.

Primary health care in northwestern Somalia: a case study

This paper examines the problem of initiating health care programmes in areas where there is no effective infrastructure. The problem is examined using Northwestern Somalia as a case study. The project focussed on the establishment of well-trained and well-supported CHWs at the community level. Many of these communities are (semi-)nomadic. The roles of middle-level management staff, community leaders and committees, CHW remuneration and health effects of the project are discussed.

Analytical and physiological variability of salivary microbial counts

Quantitation of mutans streptococci (MS) and Lactobacillus has been proposed as a method for the identification of patients at high risk for dental caries. The purpose of the present study was to investigate the analytical and physiological variability of this procedure. Variability due to specimen collection and processing was investigated by repeated sampling studies. Sample stability was investigated over storage periods of up to 72 hr at 5 degrees C, room temperature, and 37 degrees C. Physiological variability was investigated by performance of serial analyses on ten individuals, who collected six samples at intervals on a single day, and rising and noon samples on ten subsequent days. Sample collection, rather than sample processing, was found to be the major factor determining the imprecision of salivary microbial analysis in the majority of cases. However, individual subjects varied considerably in the consistency with which they provided saliva samples. Imprecision due to sample processing was relatively small, with coefficients of variations of 2.3% for MS counts and 2.1% for Lactobacillus counts. Samples were generally stable over a wide temperature range for at least 72 hours, although there was some loss of viability of lactobacilli on prolonged storage at room temperature or 37 degrees C in one experiment. Rising samples yielded higher counts than samples collected after breakfast and toothbrushing. Day-to-day variability was considerable, with 95% confidence limits exceeding 1 log in 28% of data sets for MS count and 39% of data sets for Lactobacillus.

Longevity of restorations in a dental school clinic

The longevity of 1,207 restorations placed by students was studied in 70 adult patients. The overall percentage of restorations lasting ten years or more (P10) was 75.4 percent and survival times were longer than in most previous restoration longevity studies. Cast restorations lasted significantly longer than amalgams, which in turn lasted significantly longer than composites. P10 values were 91.1 percent, 72.0 percent, and 55.9 percent, respectively. Analysis by surfaces involved indicated that single-surface lasted longer than multisurface restorations. The survival of restorations placed in patients aged 60 or more was less favorable (P10 = 56.8 percent) than for younger patients (P10 = 78.3 percent). A subset of the population was identified on the basis of a restoration failure rate of greater than 4.0 X 10(-2) failures/restoration year. This group, comprising 18.6 percent of the population, accounted for 56.1 percent of all restoration failures. The P10 value for this high-risk group was 55.8 percent, as compared with 83.9 percent for the remainder of the population.