Application of the 2013 American Urological Association early detection of prostate cancer guideline: Who will we miss?

Purpose

The American Urological Association (AUA) published new prostate cancer (CaP) screening guidelines in 2013. We apply the guidelines to a retrospective cohort to compare tumor characteristics of those no longer recommended for screening with those who remain screening candidates.

Methods

We identified cases of screening detected CaP (stage cT1c) in the Surveillance Epidemiology and End Results database from October 2005 to December 2010. The 2013 AUA Guidelines were retrospectively applied to the cohort. Men were categorized into three groups for comparison based on whether or not they would now be recommended for CaP screening (Unscreened, Young Unscreened, and Screened). We compared clinical and pathological characteristics of CaP across study groups.

Results

A total of 142,382 men were identified. Screening would no longer be recommended for 40,160. Those no longer recommended for screening had higher median PSA (6.4 vs. 5.8 ng/mL, p < 0.01), more Gleason 7 and ≥8 CaP on prostate biopsy (36.4 vs. 34.8 %, p < 0.001; 12.4 vs. 9.2 %, p < 0.001, respectively) and slightly more Gleason ≥8 CaP (9.0 vs. 7.5 %, p = 0.03), and T3 tumors (17.3 vs. 16.5 %, p = 0.01) at prostatectomy. Nodal and distant metastasis rates were clinically equivalent among men screened and unscreened. Subgroup analysis of young patients (40–54 years old) no longer recommended for screening identified intermediate or high-risk Gleason scores at prostatectomy 57.6 % of the time.

Conclusions

Features of CaP in men no longer recommended for routine screening are largely equivalent to if not worse than those in screened men.     

The clinical diagnosis of compartment syndrome of the lower leg: are clinical findings predictive of the disorder?

OBJECTIVE: To assess whether published studies support basing the diagnosis of compartment syndrome of the lower leg on clinical findings. DATA SOURCES: A MEDLINE search of the English literature from 1966 to 2001 was performed using "compartment syndromes" as the subject. A manual search of the bibliographies of retrieved articles and of major orthopaedic texts was also performed. STUDY SELECTION AND EXTRACTION: Of 1,932 titles identified, 433 abstracts of potential relevance were reviewed, and 104 articles from relevant abstracts were examined in their entirety. Four studies met all eligibility criteria. Criteria for inclusion included the following: (a) target population, traumatic or iatrogenic tibia injuries; (b) diagnostic test, presence of data needed to calculate both the sensitivity and specificity of clinical findings; (c) outcome, the presence or absence of compartment syndrome; and (d) methodologic criteria, prospective study design. DATA SYNTHESIS: The likelihood ratio form of Bayes' theorem was used to assess the discriminatory ability of the clinical findings as tests for the compartment syndrome. CONCLUSIONS: There are limited data from which to define the usefulness of clinical findings for the diagnosis of compartment syndrome. Data from eligible studies suggest that the sensitivity of clinical findings for diagnosing compartment syndrome is low (13% to 19%). The positive predictive value of the clinical findings was 11% to 15%, and the specificity and negative predictive value were each 97% to 98%. These findings suggest that the clinical features of compartment syndrome of the lower leg are more useful by their absence in excluding the diagnosis than they are when present in confirming the diagnosis. Likelihood ratio calculations found that the probability of compartment syndrome with one clinical finding was approximately 25%, and the probability was 93% with 3 clinical findings present. However, these findings are based on limited information; because of the paucity of data available, the predictive value of the clinical findings for the diagnosis of compartment syndrome has yet to be defined.     

The American Urological Association Symptom Score in the Evaluation of Men With Lower Urinary Tract Symptoms: at 2 years of followup, does it work?

Purpose

The American Urological Association (AUA) benign prostatic hyperplasia (BPH) guidelines committee established criteria for the diagnosis and treatment of patients BPH. In a prospective study we determined the usefulness of these guidelines in 145 previously untreated patients with BPH symptoms.

Materials and Methods

Patients were evaluated initially by AUA symptom score, digital rectal examination, urinalysis, serum creatinine and prostate specific antigen. Based on symptom score, patients with mild symptoms were treated with watchful waiting, while those with moderate and severe symptoms were offered watchful waiting, finasteride alpha-blockers, or laser or transurethral prostatectomy. Minimum followup was 2 years. Patients were offered a change in therapy if they had an intolerable adverse event or no improvement. Analysis included maintenance of therapy at 1 and 2 years, number of office visits and diagnostic tests performed. In addition, all patients were queried regarding which factors influenced their therapeutic choice.

Results

Of 37 patients with mild symptoms 31 (81 percent) remained on watchful waiting at 2 years and 6 advanced to medical therapy. Among 71 patients with moderate symptoms 9 of 15 (60 percent) remained on watchful waiting, 27 of 36 (75 percent) remained on alpha-blockers and 12 of 20 (60 percent) remained on finasteride at 2 years. Of the 37 patients with severe symptoms 1 of 5 (20 percent) remained on watchful waiting, 1 of 6 (17 percent) remained on finasteride and 9 of 15 (60 percent) remained on alpha-blockers, while 3 of 5 (60 percent) who underwent laser prostatectomy and all 6 (100 percent) who underwent transurethral prostatectomy received no further treatment. At 2 years 83 percent of the men who selected either finasteride or alpha-blockers as either the primary or secondary therapeutic choice were still on medications. Most patients with mild (61 percent) or moderate (51 percent) symptoms cited adverse events as the predominant concern when selecting therapeutic options. In contrast, efficacy was the overriding concern (70 percent) in patients with more severe symptoms.

Conclusions

Overall, with these guidelines and the AUA symptom score 110 men (76 percent) were still on original therapy at 1 year and 99 (68 percent) at 2 years. Additionally, 31 patients (21 percent) changed to an alternative, nonoperative therapy. These results suggest that the AUA BPH guidelines provide a rational and balanced approach for evaluation and management of patients with symptomatic BPH. Patients can reasonably expect to remain on the initial therapeutic option for at least 2 years.     

Urological Pathology Causing Free Air Under the Diaphragm?

We report a case of long-standing, keratinising, squamous metaplasia of the bladder with undiagnosed malignant transformation to squamous cell carcinoma presenting as acute peritonitis secondary to spontaneous perforation of the bladder tumour. This presentation as an acute abdomen mimicking a perforated peptic or duodenal ulcer is the most unusual aspect of the case.     

Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of anterior cruciate ligament injury – Secondary publication

BackgroundThis clinical guideline presents recommendations for the management of patients with anterior cruciate ligament (ACL) injury, endorsed by the Japanese Orthopaedic Association (JOA) and Japanese Orthopaedic Society of Knee, Arthroscopy and Sports Medicine (JOSKAS).MethodsThe JOA ACL guideline committee revised the previous guideline based on “Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014”, which proposed a desirable method for preparing clinical guidelines in Japan. Furthermore, the importance of “the balance of benefit and harm” was also emphasized. This guideline consists of 21 clinical questions (CQ) and 23 background questions (BQ). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design.ResultsWe evaluated the objectives and results of each study in order to make a decision on the level of evidence so as to integrate the results with our recommendations for each CQ. For BQ, the guideline committee proposed recommendations based on the literature.ConclusionsThis guideline is intended to be used by physicians, orthopedic surgeons, physical therapists, and athletic trainers managing ACL injuries. We hope that this guideline is useful for appropriate decision-making and improved management of ACL injuries.     

Verification of the sensitivity of functional scores for treatment results – Substantial clinical benefit thresholds for the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ)

Background

Validity and reliability of the Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ) had already been verified as the patients' self-rating assessment of low back pain and lumbar spinal disease and, the present study demonstrated the responsiveness of this measure.

Is clinical measurement of anatomic axis of the femur adequate?

Background and purpose — The accuracy of using clinical measurement from the anterior superior iliac spine (ASIS) to the center of the knee to determine an anatomic axis of the femur has rarely been studied. A radiographic technique with a full-length standing scanogram (FLSS) was used to assess the adequacy of the clinical measurement.

Patients and methods — 100 consecutive young adult patients (mean age 34 (20–40) years) with chronic unilateral lower extremity injuries were studied. The pelvis and intact contralateral lower extremity images in the FLSS were selected for study. The angles between the tibial axis and the femoral shaft anatomic axis (S-AA), the piriformis anatomic axis (P-AA), the clinical anatomic axis (C-AA), and the mechanical axis (MA) were compared between sexes.

Results — Only the S-AA and C-AA angles were statistically significantly different in the 100 patients (3.6° vs. 2.8°; p = 0.03). There was a strong correlation between S-AA, P-AA, and C-AA angles (r > 0.9). The average intersecting angle between MA and S-AA in the femur in the 100 patients was 5.5°, and it was 4.8° between MA and C-AA.

Interpretation — Clinical measurement of an anatomic axis from the ASIS to the center of the knee may be an adequate and acceptable method to determine lower extremity alignment. The optimal inlet for antegrade femoral intramedullary nailing may be the lateral edge of the piriformis fossa.     

Are clinical photographs appropriate to determine the maximal range of motion of the knee?

Goniometry is a commonly used method for the clinical assessment of range of motion (ROM) of the knee. A digital photograph of the knee in maximal flexion and extension could provide a more objective way to assess the ROM. The aim of our study was to investigate the reliability of the use of digital photographs as a method for measuring the ROM of the knee. Four observers examined 49 patients. Digital photographs of the knee in maximal flexion and extension were compared with standard clinical goniometric measurements in the same position. We observed higher intra-observer reliability for the digital method in flexion (p < 0.0001) and extension (p = 0.005) compared to goniometry. The extension results were numerically lower when using goniometry compared to the digital method (p < 0.001). For both methods, the intra-observer reliability for extension was lower compared to flexion. The intraobserver standard error of measurement (SEM) of the digital method was smaller than the goniometric SEM; the digital method thus appeared more reliable. Measuring maximal flexion and extension on digital photographs is more reliable for both extension and flexion compared to standard goniometric measurements.     

Association of body mass index and clinical outcome 2 years after unicompartmental knee arthroplasty

Introduction  Unicompartmental knee arthroplasty (UKA) has gained in popularity during the last years. However, the body mass index (BMI) of patients undergoing UKA is controversially discussed in the literature. There is, moreover, a paucity of information available concerning the association of BMI with early clinical outcomes after UKA. Materials and methods  We retrospectively reviewed the clinical data of 83 consecutive UKA, 2 years after surgery, and investigated the potential association of BMI and the outcome variables Knee Society Score (KSS), University of California at Los Angeles (UCLA) activity levels, anterior knee pain (AKP), range of motion, and implant failure. Results  The KSS and UCLA significantly increased from 132 and 4.7 preoperatively to 187.5 and 7.1, respectively, after surgery. Knee flexion significantly improved from 123.7 to 128.4° and the prevalence of extension deficiencies significantly decreased from 28.9 to 15.7%. Three knees (3.6%) failed and were converted to total knee arthroplasty. Failures were not associated with increased BMI (P = 0.387). The BMI had no significant association with KSS values, UCLA levels, and implant failure. We found a weak negative correlation between BMI and postoperative knee flexion (r = −0.285, P = 0.009) and a moderate positive correlation between BMI and the intensity of AKP (r = 0.525, P < 0.001). Conclusion  The results of the present study suggest that the BMI of patients undergoing UKA has no major impact on the early clinical outcome 2 years after surgery. There was, however, a definite correlation between the BMI and AKP. Longer follow-up is necessary to determine if overweight and obesity may increase revision rates after UKA.     

Evidence-based practice in the utilization of knee radiographs—A survey of all members of the British Orthopaedic Association

There has been a debate amongst orthopaedic surgeons about which plain radiographs are required in common knee conditions and this is a 5-year review assessing the influence of recent publications on the use of radiographs. A postal survey of all members of the British Orthopaedic Association was performed. The response rate was 60% (990/1,650). There was a broad agreement on the use of anteroposterior and lateral radiographs. The use of the posteroanterior (PA) weight-bearing radiograph has increased from 82 to 86%. The use of skyline view for suspected arthritis and after knee replacement has increased from 23 to 41%. There is still disparity amongst orthopaedic surgeons regarding the knee flexion angle for skyline and weight-bearing views. After review of the literature we recommend that a single skyline view in 30° flexion is adequate and should be a standard investigation in knee disorders. We also stress the importance of weight-bearing PA radiograph in 30° knee flexion for adequate assessment in all patients with suspected arthritis.

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Résumé But: Il y a un débat parmi les orthopédistes au sujet des radiographies nécessaires pour un bilan de genou. Ce travail est une revue sur 5 ans étudiant l’influence des publications récentes sur ce problème. Méthode: envoi d’un questionnaire par voie postale à tous les membres de la British Orthopaedic Association. Résultats: Taux de réponse de 60%. Il y a un large agrément pour l’utilisation des radiographies antéro-postérieures et latérales. L’utilisation des radiographies postéro-antérieures en charge s’est accru de 82 à 86%. L’utilisation des incidences tangentielles pour la suspicion d’arthrose ou après remplacement prothétique a augmenté de 23 à 41%. Il persiste des disparités entre les orthopédistes pour l’angle de flexion des incidences tangentielles et dans les clichés en charge. Discussion: après une revue de la littérature nous pensons que le cliché tangentiel à 30° de flexion doit être une incidence standard et nous insistons sur l’importance des clichés postéro-antérieurs en charge à 30° de flexion dans les suspicions d’arthrose.

     

What are the clinical correlates of adequate peritoneal dialysis?

The efficacy of peritoneal dialysis in terms of the clearance of small molecules such as urea and creatinine is referred to as "adequacy." Treatment guidelines and adequacy targets have been developed and distributed by the National Kidney Foundation-Dialysis Outcomes Quality Initiative (NKF-DOQI) in an effort to reduce variations in end-stage renal disease (ESRD) treatment. Much effort has been made to determine the correlation between dialysis dose and various clinical outcome measures (eg, hospitalization, mortality) in adults in an attempt to define the optimal dialysis dose. The delineation of this issue in the pediatric ESRD population is more complex because of the small number of patients and the need to define sensitive outcome measures that are unique to children. The review addresses the possible clinical correlates of dialysis adequacy in children that exist today and the additional data on the topic that needs to be collected in the future.