"I Wasn't Expecting That Question": Responses to Requests for Abortion Referral at College Student Health Centers

BACKGROUND

Women 18-24 years of age have the highest proportion of unintended pregnancies of any age group, and thus represent a significant population in need of abortion services. Prior research indicated that only half of college student health centers provide appropriate abortion referrals. Our objective was to better understand the referral experience and barriers to abortion referral at college student health centers.

PROCEDURES

We conducted a "secret caller" study at all 4-year colleges in Pennsylvania between June 2017 and April 2018, using a structured script requesting abortion referral. Calls were transcribed, coded using an iteratively developed codebook, and analyzed for themes related to barriers and facilitators of abortion referral.

MAIN FINDINGS

A total of 202 completed transcripts were reviewed. Themes that emerged were knowledge, experience, and comfort with abortion referral; support, empathy, and reassurance; coercion; misleading language; questioning the caller's autonomy; and institutional policy against referral. Most staff lacked knowledge and comfort with abortion referral. Although some staff members made supportive statements toward the caller, others used coercive language to try to dissuade the caller from an abortion. Many staff cited religious institutional policies against abortion referral and expressed a range of feelings about such policies.

CONCLUSIONS

Abortion referrals at student health centers lack consistency. Staff members frequently did not have the knowledge needed to provide appropriate abortion referrals, used coercive language in responding to requests for referrals, and perpetuated abortion stigma. Some health staff used coercive or evasive language that further stigmatized the caller's request for an abortion referral. College health centers should improve training and resources around abortion referral to ensure they are delivering appropriate, high-quality care.

The challenge of risk stratification in hypertrophic cardiomyopathy: Clinical, genetic and imaging insights from a quaternary referral centre

BACKGROUND

Hypertrophic cardiomyopathy (HCM) is the commonest genetic cardiomyopathy and may result in sudden cardiac death (SCD). Clinical risk stratification scores are utilised to estimate SCD risk and determine potential utility of a primary prevention implantable cardioverter defibrillator (ICD).

METHODS

Patients with a confirmed diagnosis of HCM from a quaternary HCM service were defined according to clinical characteristics, genetic profiles and cardiac imaging results. European Risk-SCD score and American Heart Association / American College of Cardiology (AHA/ACC) Score were calculated. The primary outcome was cardiac arrest.

RESULTS

380 patients with HCM were followed up for a median of 6.4 years. 18 patients (4.7%) experienced cardiac arrest, with predictive factors being younger age (37.2 vs 54.4 years, p = 0.0041), unexplained syncope (33.3% vs 9.4%, p = 0.007), non-sustained ventricular tachycardia (50.0% vs 12.7%, p < 0.0001), increased septal thickness (21.5 vs 17.5 mm, p = 0.0003), and presence of a sarcomeric gene mutation (100.0% vs 65.8%, p = 0.038). The Risk-SCD and AHA/ACC scores had poor agreement (kappa coefficient 0.38). Risk-SCD score had poor sensitivity (44.4%), classifying 55.6% of patients with cardiac arrest as low-risk but was highly specific (93.7%). AHA/ACC risk score did not discriminate between groups significantly. 20 patients (5.3%) died, with most >60-year-olds having a non-cardiac cause of death (p = 0.0223).

CONCLUSION

This study highlights limited (38%) agreement between the Risk-SCD and AHA/ACC scores. Most cardiac arrests occurred in ostensibly low or medium-risk patients under both scores. Appropriate ICD selection remains challenging. Incorporating newer risk markers such as HCM genotyping and myocardial fibrosis quantification by cardiac MRI may assist future risk refinement.

Diagnosis and Management of an Intramyometrial Ectopic Pregnancy Within a Septate Uterus

BACKGROUND

An intramyometrial pregnancy is a rare form of ectopic pregnancy, making up an estimated 1% of all ectopic pregnancies. Previously described management options have included surgical excision in the emergency setting.

CASE

A 32-year-old woman, gravida 4 para 0, at 6 0/7 weeks of gestation by last menstrual period, was noted to have a gestational sac implanted entirely within the uterine myometrium. Ultrasonography and magnetic resonance imaging confirmed the presence of an intramyometrial ectopic pregnancy within a septate uterus. The patient's abnormal pregnancy was successfully treated with multidose methotrexate.

CONCLUSION

Intramyometrial pregnancy is a rare entity that should be considered when it is suggested by ultrasonography or if an intrauterine pregnancy is surgically inaccessible from the endometrial cavity. In a stable patient, multidose systemic methotrexate may be a feasible management strategy.

Feasibility and acceptability of virtual group contraceptive counseling prior to abortion care

OBJECTIVES

This study aimed to evaluate the feasibility and acceptability of virtual group contraceptive counseling in the abortion care setting.

STUDY DESIGN

Patients seeking abortion care at an urban university hospital were invited to participate in this cohort study. Prior to their clinical appointments, groups of two to six patients participated in 45-minute virtual contraceptive counseling visits facilitated by study staff. Contraceptive method use, effectiveness, and side effects were reviewed according to group interest. Participant satisfaction scores were collected immediately following the sessions. After their appointments, providers estimated the time spent on contraceptive counseling during the clinical visit.

RESULTS

Of 195 patients approached, 86 (44%) were enrolled. Fifty-seven (66%) enrolled patients completed a session. The most common reason for declining enrollment was concern about the time commitment. Most (93%) participants reported being "satisfied" or "very satisfied" overall, and 96% would recommend group contraceptive counseling to a friend. Providers reported that compared to typical counseling, participants required a shorter amount of time during the clinical visit than nonparticipants (time spent <5 minutes: 74% vs 54%).

CONCLUSIONS

Virtual group contraceptive counseling for patients seeking abortion was feasible and acceptable in this study. Group virtual visits may reduce provider time burden, add value when virtual care delivery is desired or required, and deserve further study.

IMPLICATIONS

Family planning clinics can consider incorporating virtual group counseling as a person-centered and efficient approach to contraceptive counseling at the time of abortion care.

Spontaneous Coronary Artery Dissection in an Orthotopic Heart Transplant Recipient

We present the case of acute myocardial infarction secondary to spontaneous coronary artery dissection in a patient 2 weeks post orthotopic heart transplantation. (Level of Difficulty: Advanced.)

Telemedicine to Timor-Leste: implementing an international cardiac telehealth service during population dislocation, floods and COVID-19

Background

The East Timor Hearts Fund (ETHF) has provided cardiac services in Timor‐Leste since 2010, conducting three clinics yearly. With international border closures due to the COVID‐19 pandemic, development of collaborative telehealth services was required.

Methods

Scoping discussions identified major challenges (structural, patient‐related and medical system‐related). At two pilot clinics, patient history, investigation and management were collated. Clinic metrics were compared to an index face‐to‐face clinic in February 2019. Post‐clinic discussions identified areas of success and shortfall in the conduct of the telehealth clinics.

Results

23 patients were reviewed at the online telehealth clinics held onsite at Timorese medical facilities. Compared to an index 2019 clinic,there were markedly lower numbers of new referrals (2 vs 190 patients, 8.7% vs 59.4%). Patients seen at the online clinic were predominantly female (17/23, 73.9%) and Dili‐based (18/23, 78.3%) with a mean age of 25.9 ± 7.2 years old. The majority (12/23, 52.2%) had isolated rheumatic mitral valve disease. Investigations including electrocardiography, pathology, echocardiography and 6‐minute walk tests were conducted in select patients. Medication advice was provided for 10 (43.5%) patients. 11 patients (47.8%) were deemed to require urgent intervention. Post‐clinic discussions indicated general satisfaction with telehealth clinics, although frustration at current inability to provide interventional services was highlighted.

Conclusion

Our pilot telehealth clinics indicate that capacity‐building telemedicine can be rapidly implemented in an emergency setting internationally. Clinic design benefits from careful identification and resolution of challenges to optimise flow. Cardiac patients in Timor‐Leste have a significant burden of disease amenable to intervention.

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The Association between Implementation of an Enhanced Recovery after Cesarean Pathway with Standardized Discharge Prescriptions and Opioid Use and Pain Experience after Cesarean Delivery

OBJECTIVE

This study was aimed to evaluate opioid use after cesarean delivery (CD) and to assess implementation of an enhanced recovery after CD (ERAS-CD) pathway and its association with inpatient and postdischarge pain control and opioid use.

STUDY DESIGN

We conducted a baseline survey of women who underwent CD from January to March 2017 at a single, urban academic hospital. Patients were called 5 to 8 days after discharge and asked about their pain and postdischarge opioid use. An ERAS-CD pathway was implemented as a quality improvement initiative, including use of nonopioid analgesia and standardization of opioid discharge prescriptions to ≤25 tablets of oxycodone of 5 mg. From November to January 2019, a postimplementation survey was conducted to assess the association between this initiative and patients' pain control and postoperative opioid use, both inpatient and postdischarge.

RESULTS

Data were obtained from 152 women preimplementation (PRE) and 137 women post-implementation (POST); complete survey data were obtained from 102 women PRE and 98 women POST. The median inpatient morphine milligram equivalents consumed per patient decreased significantly from 141 [range: 90-195] PRE to 114 [range: 45-168] POST (p = 0.002). On a 0- to 10-point scale, median patient-reported pain scores at discharge decreased significantly (PRE: 7 [range: 5-8] vs. POST 5 [range: 3-7], p < 0.001). The median number of pills consumed after discharge also decreased significantly (PRE: 25 [range: 16-30] vs. POST 17.5 [range: 4-25], p = 0.001). The number of pills consumed was significantly associated with number prescribed (p < 0.001). The median number of leftover pills and number of refills did not significantly differ between groups. Median patient-reported pain scores at the week after discharge were lower in the POST group (PRE: 4 [range: 2-6] vs. POST 3[range: 1-5], p = 0.03).

CONCLUSION

Implementing an ERAS-CD pathway was associated with a significant decrease in inpatient and postdischarge opioid consumption while improving pain control. Our data suggest that even fewer pills could be prescribed for some patients.

KEY POINTS

· An ERAS-CD pathway was associated with decreased opioid use.. · Outpatient opioid consumption after cesarean warrants further study.. · Physician prescribing drives patients' opioid consumption..

The Role of Subcutaneous Depot Medroxyprogesterone Acetate in Equitable Contraceptive Care: A Lesson From the Coronavirus Disease 2019 (COVID-19) Pandemic

Since the beginning of the coronavirus disease 2019 (COVID-19) pandemic, health care professionals have made swift accommodations to provide consistent and safe care, including emphasizing remote access to allow physical distancing. Depot medroxyprogesterone acetate intramuscular injection (DMPA-IM) prescription is typically administered by a health care professional, whereas DMPA-subcutaneous has the potential to be safely self-injected by patients, avoiding contact with a health care professional. However, DMPA-subcutaneous is rarely prescribed despite its U.S. Food and Drug Administration approval in 2004 and widespread coverage by both state Medicaid providers and many private insurers. Depot medroxyprogesterone acetate users are disproportionately non-White, and thus the restriction in DMPA-subcutaneous prescribing may both stem from and contribute to systemic racial health disparities. We review evidence on acceptability, safety, and continuation rates of DMPA-subcutaneous, consider sources of implicit bias that may impede prescription of this contraceptive method, and provide recommendations for implementing DMPA-subcutaneous prescribing.

Work-life balance: a comparison of women in cardiology and other specialties

OBJECTIVE

Significant gender disparities exist in some medical specialties, particularly cardiology. We assessed work, personal life and work-life balance in women in cardiology in Australia and New Zealand (NZ), compared with other specialties, to determine factors that may contribute to the lack of women in the specialty.

METHODS

This study is a prospective survey-based cohort study comparing cardiology and non-cardiology specialties. An online survey was completed by female doctors in Australia and NZ, recruited via email lists and relevant social media groups. The survey included demographics, specialty, stage of training, work hours/setting, children and relationships, career satisfaction, income and perceptions of specialty.

RESULTS

452 participants completed the survey (median age 36 years), of which 57 (13%) worked in cardiology. Of all respondents, 84% were partnered and 75% had children, with no difference between cardiology and non-cardiology specialties. Compared with non-cardiology specialties, women in cardiology worked more hours per week (median 50 hours vs 40 hours, p<0.001), were more likely to be on call more than once per week (33% vs 12%, p<0.001) and were more likely to earn an annual income >$3 00 000 (35% vs 10%, p<0.001). Women in cardiology were less likely to agree that they led a balanced life (33% vs 51%, p=0.03) or that their specialty was female friendly (19% vs 75%, p<0.001) or family friendly (20% vs 63%, p<0.001).

CONCLUSIONS

Compared with other specialties, women in cardiology reported poorer work-life balance, greater hours worked and on-call commitments and were less likely to perceive their specialty as female friendly or family friendly. Addressing work-life balance may attract and retain more women in cardiology.

Acute electrical, autonomic and structural effects of binge drinking: Insights into the 'holiday heart syndrome'

BACKGROUND

Binge drinking is a common atrial fibrillation (AF) trigger, however the mechanisms are poorly understood.

OBJECTIVE

To investigate the effects of alcohol intoxication and hangover with rhythm monitoring and cardiac MRI.

METHODS

Patients underwent serial cardiac MRI pre- and post-binge with continuous Holter monitoring. Time periods analyzed: baseline (24 h pre-binge), consumption, hangover (0- 24 h post-consumption) and post-hangover (24-48 h post-consumption).

RESULTS

50 patients (age 49 ± 15 years, 40% paroxysmal AF) completed the study (intake 8.4 ± 3.1 standard drinks). Mean heart rate increased from 72 ± 10 to 80 ± 13 beats per minute (bpm) during consumption (p < 0.001). The hangover period was characterised by higher daily atrial ectopic count (50, IQR 10-132 vs baseline 43, IQR 10-113; p = 0.04) and reduced heart rate variability (SDNN 55 ms, IQR 40-65 versus 62 ms, IQR 51-66; p = 0.007). There was evidence of heightened parasympathetic activity post-hangover with heart rate slowing (mean HR 54 ± 6 bpm; p = 0.03) and increased activity in the High frequency band when separating the complex heart rate variability waveform into its component rhythms (291 ms², 97-538 versus baseline 237 ms², IQR 104-332; p = 0.04). Three patients developed AF 11, 29 and 34 h post-binge. Cardiac MRI (2.7 ± 0.7 days post-binge) demonstrated a decrease in left atrial (LA) emptying fraction (57.9 ± 8.5 to 53.5 ± 6.7%; p = 0.003) but no change in LA volume, left ventricular ejection fraction or markers of ventricular inflammation.

CONCLUSION

Binge drinking is associated with sympathetic activation followed by a 'rebound' parasympathetic response and atrial mechanical dysfunction which may explain the propensity and temporal association between binge drinking and AF.

Cerebrospinal fluid amounts of HLA-G in dimeric form are strongly associated to patients with MRI inactive multiple sclerosis

Background:

The relevance of human leukocyte antigen (HLA)-G in dimeric form in multiple sclerosis (MS) is still unknown.

Objective:

To investigate the contribution of cerebrospinal fluid (CSF) HLA-G dimers in MS pathogenesis.

Methods:

CSF amounts of 78-kDa HLA-G dimers were measured by western blot analysis in 80 MS relapsing–remitting MS (RRMS) patients and in 81 inflammatory and 70 non-inflammatory controls.

Results:

CSF amounts of 78kDa HLA-G dimers were more frequent in RRMS than in inflammatory ( p<0.01) and non-inflammatory controls ( p<0.001) and in magnetic resonance imaging (MRI) inactive than in MRI active RRMS ( p<0.00001).

Conclusion:

Our findings suggest that HLA-G dimers may be implicated in termination of inflammatory response occurring in MS.

The impact of primary Gleason pattern on survival following brachytherapy for Gleason score 7 prostate cancer

15588

Background: A recent radical prostatectomy series reported lower rates of biochemical control and cause-specific survival in Gleason score 7 patients with primary Gleason pattern 4. In this study, we evaluated the impact of Gleason 4+3 versus 3+4 on cause-specific, biochemical progression-free and overall survival in patients managed with permanent prostate brachytherapy. Methods: From April 1995 to June 2003, 530 prostate cancer patients underwent brachytherapy for clinical stage T1b-T3c (2002 AJCC) prostate cancer with Gleason score 3+4 (n=300) or Gleason score 4+3 (n=230) histology. All patients underwent brachytherapy more than three years prior to analysis. The mean and median follow-up was 6.0 and 5.7 years, respectively (range 3.2–11.2 years). Of the evaluated cohort, 412 (77.7%) received supplemental XRT and 177 (33.4%) received androgen deprivation therapy. No statistical differences were discerned between the use of XRT, however, Gleason 4+3 patients were more likely (37.4% versus 30.3%, p=0.002) to receive ADT. Multiple clinical, treatment and dosimetric parameters were evaluated as predictors of cause-specific, biochemical progression-free and overall survival. Results: At 10 years, primary Gleason 3+4 versus 4+3 did not predict for cause-specific survival (96.7% versus 93.3%, p=0.506), biochemical progression-free (97.0 versus 92.9%, p=0.085) or overall survival (77.0% versus 78.0%, p=0.9333). Cox linear regression analysis demonstrated no significant predictors for cause-specific survival while pre-treatment PSA, prostate volume and clinical stage predicted for biochemical progression-free survival. Patient age, tobacco use and diabetes were the strongest predictor for overall survival. To date, 57 patients have died (25 with Gleason 4+3 and 32 with Gleason 3+4). Of the deaths, 76% were due to cardiovascular events or second malignancies. To date, 4 patients (2 in each cohort) have died of metastatic prostate cancer. Conclusions: Following brachytherapy, the primary Gleason pattern did not impact cause-specific, biochemical progression-free or overall survival in Gleason score 7 prostate cancer. Cardiovascular disease and second malignancies were responsible for 9 times more deaths than prostate cancer.

No significant financial relationships to disclose.

Prostate cancer distribution in patients diagnosed by transperineal template-guided saturation biopsy: Implications for brachytherapy treatment planning

15533

Background: Prostate cancer remains undetected in approximately one-third of patients following standard transrectal ultrasound-guided biopsy. In this study, we evaluated prostate cancer incidence, anatomic distribution, Gleason score profile and tumor burden in patients diagnosed by transperineal template-guided saturation biopsy (TTSB). Methods: One hundred and seventeen patients underwent TTSB. TTSB was performed under general anesthesia. All but one patient had undergone at least one prior negative TRUS biopsy. Criteria for inclusion included an elevated PSA and/or the diagnosis of ASAP or high-grade PIN on prior biopsy. The prostate gland was divided into 24 regional biopsy locations with 1–3 biopsies per region. The median number of biopsy cores was 50. Multiple clinical parameters were evaluated as predictors for prostate cancer diagnosis. Results: The mean patient age was 64.8 years with a mean PSA of 9.1 ng/mL and a prostate volume of 78.6 cm3. On average, patients had undergone 2.1 prior negative TRUS biopsies with a mean of 22.4 core biopsies. Prostate cancer was diagnosed in 49 patients (41.9%) with a Gleason score distribution of 6–9. Patients with a prostate volume of = 60 cm3 had a higher rate of cancer diagnosis compared to patients with larger glands (66% vs. 30%). Although no anatomic region of the prostate gland was spared of cancer, there was a preponderance of anterior-based malignancies. In patients with prostate cancer, an average of 9.9 cores were involved. In multivariate analysis, pre-saturation biopsy diagnosis and prostate volume were the best predictors for prostate cancer diagnosis. Conclusions: Transperineal template-guided saturation biopsy diagnosed prostate cancer in 41.9% of previously biopsied patients. Considerable anatomic variability in prostate cancer distribution was documented. Based on this and other reports, cancer eradication will be dependent on treatment of the entire prostate gland.

No significant financial relationships to disclose.

Prediction of PSA spikes by isotope and patient age following permanent prostate brachytherapy

15535

Background: To evaluate prostate specific antigen (PSA) spikes (bounces) following permanent prostate brachytherapy in low-risk patients randomized to Pd-103 or I-125. Methods: The study population consisted of 164 prostate cancer patients who were part of a prospective randomized trial comparing Pd-103 with I-125 for low-risk disease. Sixty-one patients (37.2%) received short course cytoreductive androgen deprivation therapy (ADT). No patient received supplemental XRT. The median follow-up was 5.4 years. All patients were implanted at least 3 years prior to analysis. On average, 10.1 post-treatment PSA’s were obtained per patient. Biochemical disease-free survival was defined as a PSA = 0.40 ng/mL after nadir. A PSA spike was defined as a rise of = 0.2 ng/mL followed by a durable decline to pre- spike levels. Multiple clinical, treatment and dosimetric parameters were evaluated as predictors for a PSA spike. Results: Forty- four patients (26.9%) developed a PSA spike including 45.7% (21/46) of the hormone naïve I-125 patients and 14.0% (8/57) of the hormone naïve Pd-103 patients. In hormone naïve patients, the mean time between implant and spike was 22.6 months and 18.7 months for I-125 and Pd-103 patients, respectively. In patients receiving neoadjuvant ADT, the incidence of spikes was comparable between isotopes (28.1% for I- 125 and 20.7% for Pd-103). The incidence of spikes was substantially different in patients < 65 vs = 65 years of age (16.3% vs. 38.5%). In multivariate Cox regression analysis, patient age at implant (p < 0.001) and isotope (p = 0.002) were significant predictors for spike. Conclusions: In low-risk prostate cancer patients, PSA spikes are most common in patients implanted with I-125 and/or younger than 65 years of age. Differences in isotope-related spikes are most pronounced in hormone naïve patients.

No significant financial relationships to disclose.

Long-Term Rectal Function After Permanent Prostate Brachytherapy

PURPOSE

To evaluate the effect of prostate brachytherapy with or without supplemental therapies on long-term rectal function by means of a patient-administered quality-of-life instrument.

MATERIALS AND METHODS

As part of an ongoing prospective evaluation, 164 of an initial 209 patients who remain alive were mailed the Rectal Function Assessment Score (R-FAS) with a prestamped return envelope. R-FAS range from 0 to 27 with lower scores being indicative of better bowel function. Of the 162 eligible patients, 161 (99.4%) returned the survey. Median follow-up was 9.0 years (range 8.2-11.2 years). Clinical, treatment, and dosimetric parameters evaluated for bowel function included patient age, diabetes, hypertension, tobacco consumption, clinical T stage, elapsed time since brachytherapy, ultrasound volume, planning target volume, androgen deprivation therapy, supplemental external beam radiation, isotope, rectal dose, prostate D100/D150/D200, and prostate D90.

RESULTS

For the entire cohort, the current R-FAS was 3.59, which represented a nonstatistical improvement from prior surveys in 1999 (4.29) and 2002 (3.92) (P=0.134). Only 16 patients (9.9%) reported bowel function to be worse after brachytherapy. Of the clinical, treatment, and dosimetric parameters evaluated, only the number of preimplant bowel movements, tobacco use, and diabetes correlated with R-FAS. Despite lower rectal doses with Pd, isotope did not predict for bowel function. Consistent with prior surveys, patient perception of overall rectal quality of life was inversely related to supplemental external beam radiation (P=0.027).

CONCLUSION

Prostate brachytherapy adversely affects bowel function. However, in most patients the changes are minimal and slowly resolve with time. Overall rectal quality of life is inversely related to supplemental external beam radiation.

Prostate cancer distribution in patients diagnosed by transperineal template-guided saturation biopsy

OBJECTIVES

To determine the prostate cancer incidence, anatomic distribution, Gleason score profile, and tumor burden in patients diagnosed by transperineal template-guided saturation biopsy (TTSB).

MATERIALS AND METHODS

One hundred and two patients underwent TTSB; all but one patient had undergone at least one prior negative TRUS biopsy. Criteria for inclusion included an elevated PSA and/or the diagnosis of ASAP or high-grade PIN on prior biopsy. The prostate gland was divided into 24 regional biopsy locations. The median number of biopsy cores was 50. Multiple clinical parameters were evaluated as predictors for prostate cancer diagnosis.

RESULTS

The mean patient age was 64.8 yr with a mean PSA of 9.1 ng/ml and a prostate volume of 78.6 cm(3). On average, patients had undergone 2.1 prior negative TRUS biopsies with a mean of 22.4 core biopsies. Prostate cancer was diagnosed in 43 patients (42.2%) with a Gleason score distribution of 6-9. No anatomic region of the prostate gland was spared of cancer. In patients with prostate cancer, an average of 9.9 cores were involved. In multivariate analysis, prostate volume was the best predictor for prostate cancer diagnosis.

CONCLUSIONS

TTBS diagnosed prostate cancer in 42.2% of patients. Considerable anatomic variability in prostate cancer distribution was documented. On the basis of this and other reports, cancer eradication will depend on treatment of the entire prostate gland.

Severity categories of the International Prostate Symptom Score before, and urinary morbidity after, permanent prostate brachytherapy

OBJECTIVE

To determine if the International Prostate Symptom Score (IPSS) before seed implantation, stratified into mild (0-7), moderate (8-19) and severe (>20) categories, predicts brachytherapy-related morbidity in terms of IPSS resolution, catheter dependency and the need for surgical intervention after brachytherapy.

PATIENTS AND METHODS

From January 1998 to September 2003, 1034 consecutive patients had permanent interstitial brachytherapy for clinical stage T1b-T3a NXM0 (2002 system) prostate cancer. Of the 1034 patients, 739 (71.5%) presented with an IPSS of 0-7, 287 (27.7%) of 8-19, and eight (0.8%) of > or = 20. The IPSS 8-19 cohort was further stratified into 8-14 (237 men) and 15-19 (50 men) subgroups. The median follow-up was 38.2 months. In all patients, an alpha-blocker was initiated before brachytherapy and continued at least until the IPSS normalized, the latter defined as a return to within 1 point of that before implantation. A median of 21 IPSS questionnaires were obtained per patient. Several clinical, treatment and dosimetric variables were evaluated as predictors of urinary morbidity.

RESULTS

For the entire cohort, the IPSS peaked at a mean of 0.5 months after implantation and resolved at a mean of 1.7 months. At 5 years after brachytherapy, 90.1% of patients at risk (88.8%, 95.5%, and four of eight patients with a pre-implant IPSS of 0-7, 8-19 and > or = 20, respectively) were within the IPSS 0-7 category. Compared to the pre-implant IPSS, 13 patients (8%) were assigned to a higher IPSS severity category. Neither prolonged urinary catheter dependency (>5 days; 16 patients, 1.5%) or transurethral resection of the prostate (TURP, 17 patients, 1.6%) depended on the pre-implant IPSS subgroup. In Cox regression analysis, IPSS resolution was best predicted by pre-implant IPSS, prolonged catheter dependency by patient age, and TURP by any catheter dependency, the maximum IPSS increase and the maximum urethral dose.

CONCLUSIONS

The IPSS before implantation predicted the resolution of IPSS after brachytherapy, but did not correlate with substantial urinary morbidity, including catheter dependency or the need for TURP. At 5 years after brachytherapy, 90.1% of patients at risk were assigned to the IPSS 0-7 category.

The role of Food and Drug Administration regulation of in vitro diagnostic devices--applications to genetics testing

The Food and Drug Administration (FDA) has been involved in the regulation of in vitro diagnostic devices (IVDs or laboratory tests) since the introduction of the Medical Device Amendments of 1976. IVDs developed as kits or systems intended for use in multiple laboratories require review by the FDA before being marketed to ensure appropriate performance and labeling. IVDs developed as in-house, or so-called "home-brew", tests or laboratory test services are considered medical devices, but historically have not been subject to premarket review as a matter of enforcement discretion. FDA recently established a new regulatory paradigm for in-house tests based on classification of the active ingredients or building blocks of these tests as analyte-specific reagents (ASRs). ASRs are exempt from premarket review but subject to both manufacturing and labeling controls. Currently, genetic tests are received and reviewed by the FDA in the same manner as other in vitro diagnostic tests. The FDA currently is in the process of chartering a new genetics advisory panel to provide the agency with outside expertise to deal with genetic testing issues. We are also continuing to work with other agencies within the Department of Health and Human Services to determine how we can cooperatively help foster this important new area of testing.