Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. The American College of Physicians

PURPOSE

To estimate the prevalence of clinically important prostate cancer and to evaluate the effectiveness of digital rectal examination and measurement of prostate-specific antigen (PSA) in early detection of prostate cancer.

DATA SOURCES

Relevant studies were identified from a structured MEDLINE search (1966 to 1995), reviews, bibliographies of retrieved articles, author files, and abstracts.

STUDY SELECTION

Articles selected for analysis of test effectiveness were prospective cohort studies of early detection that did not have obvious selection bias.

DATA EXTRACTION

Likelihood ratios for digital rectal examination and PSA measurement were estimated from studies that specified the age distribution of participants.

DATA SYNTHESIS

In patients who have abnormalities on digital rectal examination, the risk for a large intracapsular tumor is increased twofold but the risk for extracapsular disease is increased threefold to ninefold. An elevation in PSA level greater than 4 ng/mL increases the odds of intracapsular tumors by as much as threefold and the odds of extracapsular tumors by threefold to fivefold. For studies in which biopsies were done if results of either test were abnormal, 18% to 26% of screened patients had suspicious results, cancer detection rates were approximately 4%, and the positive predictive value of the tests combined was 15% to 21%. Men who have lower urinary tract symptoms that are consistent with benign prostatic hyperplasia are not more likely to harbor prostate cancer; the specificity of PSA measurement is considerably lower among these men.

CONCLUSIONS

Larger-volume tumors of the prostate are common among older men. Available tests for the early detection of cancer have limited specificity, which necessitates a relatively high biopsy rate. The positive predictive value of combined digital rectal examination and PSA measurement has been defined, but the negative predictive value is less clear. Measurement of PSA is the most sensitive noninvasive test for prostate cancer. However, digital rectal examination detects cancer that would otherwise be missed by PSA measurement.

A pilot diabetes awareness and exercise programme in a multiethnic workforce

AIMS

To evaluate the acceptability and impact of a pilot diabetes awareness and exercise programme in a mainly Polynesian workforce.

METHOD

Comparison of change in questionnaire and anthropometric measurements in two hospital ancillary workforces. One group (n = 108) received one community diabetes educator presentation, one video presentation and a 4 month exercise programme. The other group (n = 99) served as controls.

RESULTS

Baseline diabetes knowledge was poor (total score 26 (SD 13%)) and subjects were largely unfit with a high body mass index (31.5 (7.1) kg/m2). The exercise sessions were well attended, although attendance declined over the 4 months. Increased diabetes knowledge was retained in the intervention group after 6 months when compared with controls (total score 35(14)% vs 26(12)% respectively, p < 0.001). One month after the termination of the programme, the proportion reporting regular exercise activity (at least 30 minutes for 3 days per week) had increased by 2% in the intervention group but declined by 9% in the control group (p < 0.05).

CONCLUSIONS

Diabetes knowledge and exercise can be increased in unfit subjects by the combination of culturally tailored exercise techniques and community diabetes educator/video presentations.

Ethnic differences in diabetes care in a multiethnic community in New Zealand

Residents of two districts of South Auckland, New Zealand with a high proportion of Maori and Pacific Islands people were visited door to door to ascertain the prevalence of known diabetes and its tissue damage. The household survey canvassed 55,518 residents in 12,770 (91%) of 14,002 residences. Diabetes interviews were available for 176,214 (82%) Europeans, 286,336 (85%) Maori and 495,585 (85%) Pacific Islands diabetic patients. Europeans were older than Maori and Pacific Islands patients currently and at diagnosis. When compared with Europeans, Maori and Pacific Islands patients had a higher chance of having had their diabetes diagnosed in pregnancy, were least likely to be receiving antihypertensive or insulin therapy, were more likely to be blind, and were more likely to have received retinal photocoagulation. There were no ethnic differences in either the proportion of those receiving no ongoing care or in the proportion seen at least once by the diabetes services. Maori people were most likely to be current smokers, were most likely to have defaulted from the diabetic diet and to be dissatisfied with the diabetes service. Pacific Islands people were least likely to have neuropathic symptoms in their feet or to report a known myocardial infarction. Significant ethnic differences in diabetes and its care exist in South Auckland.

Pre-treatment characteristics, program philosophy and level of ancillary services as predictors of methadone maintenance treatment outcome

Predictors of methadone maintenance treatment outcome have not been extensively studied as they relate to variations in program philosophy, nor have such predictors received much examination among recently treated, older cohorts of opioid addicts for whom drug use patterns have changed. Predictors of outcome were examined at 18 months post-treatment entry for 353 admissions to methadone maintenance who received random assignment to one of three counseling conditions: (1) medication only, (2) standard counseling and (3) enhanced services; and one of two contingency conditions: (1) no contingencies, and (2) contingency contracting in a six-cell 3 x 2 design. Subjects in contingency contracting conditions were placed on contingency contracts for positive urine toxicology results and ultimately discharged for unremitting drug use. All subjects completed the Addiction Severity Index (ASI) and provided weekly urine specimens. Predictors of urinalysis results and treatment retention were determined using bivariate and multivariate techniques. Interactions between subject characteristics by experimental condition assignment were also examined as predictors. Higher rates of total positive urine specimens were predicted by younger age, greater pre-treatment frequency of smoking cocaine, lower ASI psychiatric composite scores, and higher ASI legal composite scores. Higher rates of opiate positive specimens were predicted by younger age, lower pre-treatment frequency of alcohol intoxication, higher ASI legal and lower ASI employment and psychiatric composite scores, and assignment to medication only/no contingencies condition. Higher rates of cocaine positives were predicted by younger age, black race, lower ASI psychiatric composite score, greater pre-treatment frequency of intravenous and smoked cocaine use, less pre-treatment frequency of marijuana use, and lower methadone dose level. Assignment to enhanced/contingency contracting predicted lower rates of cocaine positives. Treatment retention was predicted by older age, non-black race, lower ASI legal composite score, higher methadone dose level and assignment to non-contingent conditions. While subject variables over which treatment providers have little control were, thus, related to outcome, type of treatment provided and methadone dose also influenced outcome.

Quality improvement of diagnostic microbiology through a peer-group proficiency assessment program. A 20-year experience in Ontario. The Microbiology Committee

OBJECTIVE

To evaluate the microbiology laboratory performance in Ontario over a 20-year period of participation in a quality assessment program and to assess the impact of quality improvement strategies.

DESIGN

Longitudinal review of isolation, identification, and antimicrobial susceptibility testing of bacteria from lyophilized, simulated patient samples.

SETTING

Ontario medical laboratories, licensed by the Ministry of Health, have been subjected to mandatory testing by the Laboratory Proficiency Testing Program of the Ontario Medical Association since 1974. Survey reports, information bulletins, correspondence, on-site consultations, educational assistance tutorials, and teleconference education are used as quality improvement strategies.

PARTICIPANTS AND INTERVENTIONS

Laboratories were subjected annually to 20 external quality assessment challenges. Performance was assessed against consensus reference values. Single survey and cumulative profiles were reviewed by a peer-group panel for acceptable or unacceptable performance. Specific interventions are used to improve collective and individual laboratory performance.

RESULTS

The number of microbiology laboratories declined from 335 in 1974 to 190 in 1994. Twenty-one percent failed expected performance standards on initial review. One hundred forty-two on-site consultations and 61 educational assistance tutorials have been provided. Twenty-five laboratories were declared nonproficient. Since 1989, 50% of the laboratories have scored at or above 80% for isolation and identification, but 25% have scored at or below 50% on susceptibility testing, and 10% or fewer have scored at or above 80%. Poor susceptibility testing performance is due to inappropriate agent selection, not testing errors.

CONCLUSIONS

The emphasis of the Laboratory Proficiency Testing Program is on quality improvement, not punishment. Performance has improved, but poor performers have the same characteristics as in 1974. Identification to species is common owing to the use of commercial systems. Automated susceptibility testing has increased to 45% of participants.

Impaired implantation after in vitro fertilisation treatment associated with hydrosalpinx

OBJECTIVE

To study whether the presence of hydrosalpinx affected success after in vitro fertilisation (IVF) in women with inflammatory tubal damage.

DESIGN

Retrospective, nonrandomised study.

SETTING

University private IVF clinic with complete fertility services.

PARTICIPANTS

Two study groups (79 women with hydrosalpinges and 198 women with inflammatory tubal damage but no hydrosalpinx) and a third group (22 sterilised, previously fertile women) for comparison.

MAIN OUTCOME MEASURES

Clinical pregnancy and livebirth rates per embryo transfer cycle; implantation and live baby rates per individual embryo transferred.

RESULTS

The hydrosalpinx group had a significantly lower implantation rate per embryo (8.2%) and chance of a live baby per embryo transferred (5.6%), compared with the nonhydrosalpinx group (14.9% and 11.2%, respectively). The hydrosalpinx group also had a lower clinical pregnancy rate (23%) and live birth rate per transfer cycle (17%) compared with the nonhydrosalpinx group (30% and 26%), but these differences were not significant.

CONCLUSIONS

The presence of a hydrosalpinx halves the chance of an embryo implanting, probably due to physical or toxic chemical effects of fluid draining from the hydrosalpinx into the uterine cavity. Women with hydrosalpinges may benefit from distal salpingostomy or salpingectomy as a drainage procedure before in vitro fertilisation treatment, even though such surgery may not increase the chances of natural conception.

An evaluation of the efficacy of supervised cognitive behavioral self-help bulimia nervosa

Eighty two patients with bulimia nervosa were managed by providing them with supervision in the use of a highly structured cognitive behavioral self-help manual. Their progress was assessed in an open clinical trial. The 67 patients who completed the course of self-help experienced considerable benefit; the frequency of bulimic episodes and self-induced vomiting decreasing by 80% and 79%, respectively. Compared to those who benefited, those who had a poor outcome or dropped out of treatment were more than twice as likely to have had anorexia nervosa in the past and were somewhat more likely to have a personality disorder. Three-quarters of those who persisted with the programme of supervised self-help were followed up a year after commencing treatment. Clinical gains were well maintained: almost two thirds were abstinent with respect to both bulimic episodes and self-induced vomiting. It would seem appropriate that, as part of a stepped care approach to the management of bulimia nervosa, supervised cognitive behavioral self-help should routinely be the first line treatment.

How--and when--to obtain consent for do-not-resuscitate orders. Clinical guidelines and strategies for resolving conflicts

Consider a do-not-resuscitate (DNR) order when a patient's presumed consent for cardiopulmonary resuscitation (CPR) is in question, the patient has an illness that is terminal or severe and irreversible, or he or she is permanently unconscious or likely to have cardiac or respiratory arrest. The patient with decisional capacity has the right to give or withhold consent for a DNR order. State law may limit a surrogate's authority to request that CPR be withheld. Remember, a DNR order does not restrict a patient's access to intensive care. Nurses, patient advocates, social workers, and clergy members may help mediate disputes. If necessary, seek advice from an ethics committee on how to resolve the conflict.

Ethnic differences in the perception of a video developed for a multiethnic diabetes prevention programme in south Auckland, New Zealand

Videos were developed to help increase diabetes awareness among local Maori, Pacific Islands and European communities. The Maori and Pacific Islands versions incorporated modifications to the basic content to make them more appropriate for the target audience. Lay audiences, comprising 108 Europeans, 94 Maori and 90 Pacific Islands people in 12 different sites, viewed the version of the video tailored to their ethnic group. The Maori version was also viewed by 32 Diabetes Nurse Specialists. Likert scale ratings and open-ended questions were used to evaluate the video. The video was rated highly by all audiences and most subjects were able to repeat the main messages of the video. Compared with Maori and Pacific Islands subjects, Europeans found the video the easiest to understand but gained the least information. Maori and Pacific Islands subjects would have preferred a longer video ( > 17 minutes). Different viewing sites revealed evidence of within-ethnic-group heterogeneity. Pacific Islands subjects particularly appreciated the educational components, while Maori and Europeans were more likely to comment on presentation. Audio-visual material is perceived differently by different ethnic groups, such differences need to be addressed when embarking on diabetes awareness campaigns.

Using advance directives effectively in the intensive care unit. Terminating care in the presence--or absence--of directives

When a patient is admitted to the ICU, determine whether the person has decisional capacity and whether an advance directive exists. If so, discuss treatment options and the directive with the patient--as well as with family members and appointed surrogates; clarify the patient's wishes. If no directive has been drawn up, encourage the patient to do so. If a patient lacks decisional capacity but has a directive, determine whether it applies to the current situation. If it does, follow its instructions. If no directive exists or if it does not apply, consult with family members to determine the patient's wishes, and ascertain whether these substitute judgments meet state laws.

Frequency of diabetes in family members of probands with non-insulin-dependent diabetes mellitus

OBJECTIVES

To describe the prevalence of known diabetes in a multi-ethnic community in South Auckland, New Zealand, in relation to family history of diabetes and past history of diabetes in pregnancy.

DESIGN

A cross-sectional, household survey comparing ascertainment with local general practice diabetes registers where they existed.

SETTING

An inner-city community with a high proportion of Maori, Pacific Islands people and Europeans.

SUBJECTS

A total of 55,518 residents (91% response). Comparison with diabetes registers showed 91% ascertainment of known diabetic residents. More detailed interviews with 176/214 (82%) Europeans, 286/336 (85%) Maori and 495/585 (85%) Pacific Islands people with known diabetes. Fifty subjects had insulin-dependent diabetes mellitus on clinical criteria and were excluded from analyses.

MAIN OUTCOME MEASURES

Prevalence of diabetes.

RESULTS

Those with non-insulin-dependent diabetes mellitus were more likely to have a diabetic mother than father (Europeans, 21.7% vs. 9.9%; Maori, 17.6 vs. 11.4%; Pacific Islands, 15.7 vs. 5.3%). Diabetic women had a similar likelihood of having a diabetic father as diabetic men but were 1.84 times as likely to have a diabetic mother (95% CI, 1.27-2.69). Diabetic women with past diabetes in pregnancy had 2.05 (95% CI, 1.01-4.15) times the chance of a diabetic offspring as women who had not had past diabetes in pregnancy, who in turn had 2.69 (95% CI, 1.17-6.18) times the likelihood of having a diabetic offspring as diabetic men.

CONCLUSIONS

The mother is a more important conduit for inheritance of diabetes than the father in these three ethnic groups. A history of diabetes in pregnancy confers an extra risk to the offspring above this usual maternal excess.

How to determine decisional capacity in critically ill patients. Presume the patient can make decisions unless proven otherwise

Decisional capacity includes ability to comprehend information, to make an informed choice, and to communicate that choice; it is specific to the decision at hand. Presume a patient has decisional capacity; an evaluation of incapacity must be justified. Administer a standardized mental status test to help assess alertness, attention, memory, and reasoning ability. A patient scoring below 10 on the Folstein Mini-Mental State Examination (maximum score, 30) probably does not have decisional capacity; one scoring from 10 to 15 probably can designate a proxy but not make complex health care decisions. Obtain psychiatric consultations for a patient who exhibits psychological barriers to decision making.

Contingency management of urinalysis results and intensity of counseling services have an interactive impact on methadone maintenance treatment outcome

In a 3 x 2 factorial design, 360 new admissions to methadone maintenance were randomly assigned to one of three levels of counseling: (1) "medication only," (2) "standard" counseling, and (3) "enhanced" services; and one of two contingency contracting conditions: (1) no contingencies (NC), and (2) contingency contracting (CC). Contingency contracting included discharge for continuous positive urines; subsequently CC subjects were discharged at a greater rate than the NC group. However, CC subjects were more likely to be readmitted. NC subjects provided more urines positive for any illicit drug use than did CC subjects. For opiate positives a significant level of counseling by contingency contracting interaction was found with medication only/CC subjects obtaining fewer opiate positives than medication only/NC subjects. The impact of reduced or enhanced services and of contingency contracting will not be fully understood until longer term follow-up (18 and 24 month) is completed. Results suggest that contingency management procedures could be utilized in settings offering minimum services (e.g., "interim methadone") to achieve treatment outcomes similar to programs offering standard counseling services.

Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit

Inappropriate benzodiazepine dosing in patients exhibiting signs of alcohol withdrawal cause staff and patient safety problems. Our primary goal was to develop an alcohol withdrawal protocol based on objective measures, and then to coordinate benzodiazepine dosing with those measures and improve care of the patient withdrawing from alcohol. A secondary goal was to give the primary care nurse the flexibility to administer benzodiazepine doses as needed to improve patient and staff safety. We developed and implemented a modified version of a published withdrawal symptomatology scale; a corresponding scale was developed for benzodiazepine dosing by observing the usual lorazepam doses needed to control withdrawal symptoms. Both scales and care guidelines for the patient withdrawing from alcohol were organized in the form of preprinted orders. Since implementation of the alcohol withdrawal protocol, complaints regarding patient and staff safety have decreased. Other patient care units are beginning to use the protocol. A hospital-wide task force is developing patient care plans based on the protocol for all patients withdrawing from alcohol.

Users of free treatment slots at a community-based methadone maintenance clinic

At a community-based methadone clinic in Seattle, WA, 360 opiate-addicted individuals were enrolled in a treatment demonstration project. The treatment slots were free to clients and, unlike other funded treatment slots, did not require proof of eligibility based on documentation of indigence. The clients were compared with 70 clients enrolled in a research project begun 2 years earlier in which the sample was drawn from a population using normal funding sources at the same program. Subjects in the later demonstration project were older and had fewer years of education. A higher percentage of the demonstration project subjects were African American. These differences indicate that introduction of free treatment opened opportunities to individuals who have difficulty accessing treatment under normal circumstances. Subjects in the treatment demonstration project were more likely to have obtained needles from legal sources and used bleach to clean needles. These findings probably reflect the impact of needle exchange and outreach programs, established in the year prior to the demonstration project.

Nursing-based protocol for treatment of alcohol withdrawal in the intensive care unit

Inappropriate benzodiazepine dosing in patients exhibiting signs of alcohol withdrawal cause staff and patient safety problems. Our primary goal was to develop an alcohol withdrawal protocol based on objective measures, and then to coordinate benzodiazepine dosing with those measures and improve care of the patient withdrawing from alcohol. A secondary goal was to give the primary care nurse the flexibility to administer benzodiazepine doses as needed to improve patient and staff safety. We developed and implemented a modified version of a published withdrawal symptomatology scale; a corresponding scale was developed for benzodiazepine dosing by observing the usual lorazepam doses needed to control withdrawal symptoms. Both scales and care guidelines for the patient withdrawing from alcohol were organized in the form of preprinted orders. Since implementation of the alcohol withdrawal protocol, complaints regarding patient and staff safety have decreased. Other patient care units are beginning to use the protocol. A hospital-wide task force is developing patient care plans based on the protocol for all patients withdrawing from alcohol.

Self-help for bulimia nervosa: a preliminary report

Eighteen patients with DSM-III-R bulimia nervosa were treated by providing them with supervision in the use of a self-help manual based on the cognitive behavioral treatment for the disorder. The patients were assessed before beginning the self-help program, and again 4 to 6 months later, using standardized measures of psychopathology. The findings were encouraging. At follow-up one half of the patients had ceased bulimic episodes and self-induced vomiting, and most of the remainder had made significant improvements. These preliminary findings, together with related published work, suggest that supervised self-help might be an appropriate first line treatment for patients with bulimia nervosa and that for many patients it could be sufficient.

Increasing melanoma incidence: putatively explainable by retrotransposons. Experimental contributions of the xiphophorine Gordon-Kosswig melanoma system

The worldwide accelerating increase of neoplasia in humans is difficult to explain. We use the Xiphophorus tumor model to approach this problem by melanoma provocation with X-rays. Melanoma develops following inappropriate expression of x-erb B-conducted developmental genes and their controllers. These oncodeterminants are inherited according to Mendelian rules. We detected a new type of oncodeterminants that, following a single treatment of embryos with X-rays, generates a self-generating non-Mendelian melanoma transmission and accelerating increase of its incidence in succeeding generations (e.g., 0-->18-->33-->52%). To localize these oncodeterminants, we crossed nonirradiated fish having half of their chromosomes irradiated with nonirradiated fish having none of, half of, or all of their chromosomes irradiated. Because tumor rate and expression in the following generations correspond to the rates of treated chromosomes, we conclude that the new oncodeterminants are distributed over the chromosomes of the fish, where they may increase in the changing generations. By means of xiphophorine-specific retroviral DNA, we isolated two retrotransposons that behave hereditarily like the new transgenerational oncodeterminants. Sequence analysis revealed three ORFs flanked by LTRs containing motives of regulatory sequences typical for known retroviral and retrotransposal LTRs. Pol- and env-resembling sequences are lacking. Southern and in situ hybridization showed their multiple and repetitive nature distributed throughout the chromosomes and indications for their capability to increase in number without further treatment. Their transcripts are expressed in concert with those of most of the other known xiphophorine tumor determinants. Their expression is extremely high in cell cultures from tumorous embryos derived from ancestors treated as embryos with X-rays.

Evaluation of a diabetes knowledge and behaviour (DKB) questionnaire

The primary prevention of type 2 (non-insulin-dependent) diabetes is now considered possible through adopting lifestyle changes. Population strategies for preventing diabetes are now being developed. The South Auckland Diabetes Project has developed a questionnaire to assess the impact of a diabetes awareness, exercise/healthy eating programme in the local communities. The questionnaire was evaluated among local adult Europeans (n=127), Maori (n=103) and Pacific Islands people (n =167). The questionnaire is interviewer-directed and takes approximately 30 min to administer. Diabetes knowledge was assessed using four open questions and 31 closed true/false questions which had good reliability (Cronbach's a range: 0.59-0.90), reproducibility (Pearson's r range: 0.39-0.74) and external validity (r range: 0.28-0.56) among all ethnic groups. Median scores increased by 7-13% on re-testing. The open and closed question scores were 7-13% and l0-26% higher respectively among those with diabetes or a family history of diabetes (n = 78). Important dietary habits were assessed using four tools: (1) a seven-item food preparation/fat content 'fat index'; (2) a four-item high-fat/high-refined-carbohydrate score had good reliability (Cronbach's α 0.51-0.74), reproducibility (r = 0.37-0.70) and external validity when compared with a dietetic assessment (total fat r = 0.44-0.90); (3) a 12-item food frequency questionnaire based on standard portion sizes also shared good reproducibility (Pearson's r = 0.45-0.52) and correlated well with the dietetic assessment of total calories (r = 0.48 0.64) and of calories due to fat (r = 0.41-0.65), and (4) a simple question related to the frequency of fruit consumption correlated negatively with the fat index in Europeans (r = 0.25, P<0.05) and Maori (r = -0.33, P<0.01). While the questionnaire does not give a quantitative assessment of nutritional habits, it does offer a speedy tool for evaluating population-based lifestyle and diabetes awareness interventions directed at the prevention and control of type 2 (non-insulin-dependent) diabetes.