Cancer-specific and other-cause mortality after radical prostatectomy versus observation in patients with prostate cancer: competing-risks analysis of a large North American population-based cohort

Background

Initial treatment options for low-risk clinically localized prostate cancer (PCa) include radical prostatectomy (RP) or observation.

Objective

To examine cancer-specific mortality (CSM) after accounting for other-cause mortality (OCM) in PCa patients treated with either RP or observation.

Design, setting, and participants

Using the Surveillance Epidemiology and End Results Medicare-linked database, a total of 44 694 patients ≥65 yr with localized (T1/2) PCa were identified (1992-2005).

Intervention

RP and observation.

Measurements

Propensity-score matching was used to adjust for potential selection biases associated with treatment type. The matched cohort was randomly divided into the development and validation sets. Competing-risks regression models were fitted and a competing-risks nomogram was developed and externally validated.

Results and limitations

Overall, 22 244 (49.8%) patients were treated with RP versus 22450 (50.2%) with observation. Propensity score-matched analyses derived 11 669 matched pairs. In the development cohort, the 10-yr CSM rate was 2.8% (2.3-3.5%) for RP versus 5.8% (5.0-6.6%) for observation (absolute risk reduction: 3.0%; relative risk reduction: 0.5%; p < 0.001). In multivariable analyses, the CSM hazard ratio for RP was 0.48 (0.38-0.59) relative to observation (p < 0.001). The competing-risks nomogram discrimination was 73% and 69% for prediction of CSM and OCM, respectively, in external validation. The nature of observational data may have introduced a selection bias.

Conclusions

On average RP reduces the risk of CSM by half in patients aged ≥65 yr, relative to observation. The individualized protective effect of RP relative to observation may be quantified with our nomogram.     

Sequelae of treatment in long-term survivors of testis cancer

Context

Testicular cancer patients are often diagnosed at a young age, and because of the advances in the treatment of this disease, the vast majority have a normal life expectancy after therapy. Thus, recognition of the long-term sequelae of treatment (ie, surgery, radiation therapy, and chemotherapy) is particularly important in these patients.

Objective

To review the adverse effects and the risk of secondary malignancy in long-term survivors of testicular cancer.

Evidence acquisition

We conducted a Medline search to identify original articles and reviews on the long-term effects of testicular cancer treatment. Although the search included articles from January 1948 to February 2011, the majority of the included articles were published in the last two decades.

Evidence synthesis

All studies examining the long-term sequelae of treatment in testicular cancer are retrospective in nature, with most classified as cohort, case-control, and/or epidemiologic studies. Given that no standardized method of reporting long-term complications exists, evidence synthesis is limited.

Conclusions

Recent evidence suggests an increased risk of cardiovascular disease, neurotoxicity, and mild reductions in renal function in survivors of testicular cancer. Treatment of testicular malignancy can also negatively affect gonadal function and fertility and has been shown to result in an increased risk of solid malignancy and leukemia.     

Validating the MSKCC nomogram and a clinical decision rule in the prediction of non-sentinel node metastases in a Portuguese population of breast cancer patients

Background

In order to assess the risk of non-sentinel node involvement in breast cancer patients, some prediction tools have been developed and tested. However, a wide range of results are observed. We tested a simplified clinical decision rule, against the complex nomogram created from the MSKCC sentinel node database.

Methods

Two single institutional consecutive series of patients with a positive SN, submitted to SN biopsy plus axillary dissection from June 1999 to October 2007, were evaluated. A receiver operating curve was drawn and the area under the curve was calculated as well as the negative predictive value for both tests, assuming discriminative values of 10 and 15%.

Results

Considering the derivation series, our results showed an area under the curve of 0.69 for both our clinical decision rule and the MSKCC nomogram. The analysis of the validation series showed an area under the curve of 0.65 for our clinical decision rule and of 0.67 for the MSKCC nomogram. The nomogram results are inferior to those found in the original population and are similar to our clinical decision rule results.

Conclusions

Individual centres should develop and prospectively test their own clinical decision rules, based on their institutional Sentinel Node data.     

Improved rates of colorectal cancer screening in an equal access population

Background

National colorectal cancer (CRC) screening averages 50% to 60%. We aimed to identify screening prevalence in select Department of Defense (DOD) beneficiaries with equal access to care.

Methods

December 2007 cross-sectional data of patients over 50 years of age included patient demographics, screening modality, and compliance.

Results

Of 17,252 patients (52% male; mean age 63.2 ± 8.1 years), 12,229 (71%) were up-to-date with national screening guidelines. Modalities included colonoscopy (83.0%), flexible sigmoidoscopy with fecal occult blood testing (FOBT) (32.2%), and air-contrast barium enema (0.7%). African American or Hispanic background (70% African American, 68% Hispanic vs 73% Caucasian), younger patients (66.1% <65 years vs 78.6% >65 years), and male gender (69.9% vs 72.1%; all P < .001) all had lower rates. Compared to 2005, more patients were current with guidelines (71% vs 64%) and colonoscopic screening (83% vs 71%).

Conclusions

Although ethnicity-, gender-, and age-related disparities were observed, screening rates are improved in an equal access healthcare system.     

Pilomatrixoma--accuracy of clinical diagnosis

Background/Purpose

Pilomatrixoma is a common tumor of skin appendages in children. The aim of the study was to assess the accuracy of clinical diagnosis and factors contributing to misdiagnosis.

Methods

A retrospective case note review of patients who had pilomatrixoma excised during a 5-year period in a tertiary referral children's hospital in the UK.

Results

From 75 patients, 78 pilomatrixomata were excised. The diagnosis was achieved preoperatively in 46% of patients. Other diagnoses included sebaceous and dermoid cysts, foreign body reaction, calcification in lymph gland, and fat necrosis.

Conclusion

Factors contributing to misdiagnosis include cystic lesions with varying consistency, punctum-like appearance, atypical location, and absence of clinically recognizable calcification. Despite close excision, the recurrence rate is low.     

Identification of side population cells (stem-like cell population) in pediatric solid tumor cell lines

Purpose

Recent evidence has supported the cancer stem cell theory that cancer contains a small number of cancer stem cells (CSC) as a reservoir of cancer cells. Only the CSC, but not most of the remaining constituent cancer cells, are thought to be responsible for tumorigenesis, progression, and metastasis as well as cancer relapse, suggesting that the CSC should be targeted to eradicate the cancer. Side population (SP) cells isolated by fluorescence-activated cell sorting (FACS) using Hoechst dye are known to be enriched in stem cells in various normal tissues as well as cancers. The authors investigated whether such stem-like SP cells may exist in pediatric solid tumors (PSTs).

Materials and Methods

Sixteen pediatric tumor cell lines including 7 neuroblastomas, 4 rhabdomyosarcomas, and 5 Ewing's sarcomas were used for FACS analysis. Analysis of SP cells based on the exclusion of the DNA binding dye, Hoechst 33342, with and without verapamil using FACS was performed.

Results

One Ewing's sarcoma cell line did not show an SP fraction, and only a small fraction of SP cells (0.12%-14.6%) was detected in the other 15 cell lines. These SP cells were all sensitive to verapamil.

Conclusions

This study suggested that most PSTs would contain a small fraction of SP cells (possible stem-like population). Targeting the CSC will provide a novel treatment strategy to eradicate refractory PSTs.     

The optimal dose of Adriamycin to create a viable rat model potentially applicable to congenital obstructive uropathy

Purpose

The Adriamycin rat model is an established model for different organ anomalies including congenital obstructive uropathy. In the current study, we carried out a dose-response analysis to find out the optimal dose of Adriamycin to create a viable rat model of obstructive uropathy.

Methods

Thirty time-mated Sprague-Dawley rats were divided into 5 groups including 1 control group and 4 different treatment groups. The 4 Adriamycin dosage regimens investigated in this study were 1.25, 1.5, 1.75, and 2 mg/(kg d). Experimental rats (n = 24) were injected intraperitoneally with different doses of Adriamycin on gestational days 7 to 9 (6 rats in each group). Control rats (n = 6) were injected with an equivalent volume of saline on the same days. Viable term fetuses were harvested on gestational day 21 by cesarean delivery and dissected under a dissecting microscope. Serial transverse sections from urinary tract system were obtained for histological examination.

Results

One hundred thirty-three viable fetuses were recovered from Adriamycin-treated rats, and 50 were from rats in the control group. There were no resorptions in the control group; however, 52 resorptions were recorded in Adriamycin groups. The rates of hydronephrosis and resorptions were 60% and 0%, 80.5% and 5.8%, 100% and 17.3%, and 100% and 76.9% at doses of 1.25, 1.50, 1.75, and 2 mg/(kg d), respectively. Histologic examination of the kidneys in the treated groups showed a significant decrease in renal parenchyma compared with the control group.

Conclusions

The dosage of 1.5 mg/(kg d) of Adriamycin yielded the highest number of viable hydronephrotic fetuses. At this dose, urinary abnormalities are milder; but the highest number of viable fetuses is provided, which is necessary to create a reproducible and viable animal model.     

Omission of routine chest x-ray after chest tube removal is safe in selected trauma patients

Background

Definitive practice guidelines regarding the utility of chest x-ray (CXR) following chest tube removal in trauma patients have not been established. The authors hypothesized that the selective use of CXR following chest tube removal is safe and cost effective.

Methods

A retrospective review of chest tube insertions performed at a level I trauma center was conducted.

Results

Patients who underwent chest tube removal without subsequent CXR had a lower mean Injury Severity Score and were less likely to have suffered penetrating thoracic injuries. These patients received fewer total CXRs and had shorter durations of chest tube therapy and shorter lengths of stay following tube removal. Subsequent reinterventions were performed more frequently in the CXR group. The annual decrease in hospital charges by foregoing a CXR was $16,280.

Conclusions

The selective omission of CXR following chest tube removal in less severely injured, nonventilated patients does not adversely affect outcomes or increase reintervention rates. Avoiding unnecessary routine CXR after chest tube removal could provide a significant reduction in total hospital charges.     

Papillary lesions of the breast diagnosed by core needle biopsy: 71 cases with surgical follow-up

Background

Papillary breast lesions comprise a spectrum of histopathologic diagnoses ranging from benign papillomas to papillary carcinomas. There is ongoing controversy regarding the management of papillary lesions diagnosed by core needle biopsy (CNB). Some authors advocate observation of papillary lesions when the CNB is benign, while others recommend surgical excision of all papillary lesions. The current study assessed the adequacy of CNB in evaluating papillary breast lesions.

Methods

A search of the pathology database at our institution identified 122 papillary lesions diagnosed by CNB. The study population consisted of 71 papillary lesions that were subsequently surgically excised.

Results

Of the 71 papillary lesions excised, 8 were malignant, 16 were atypical, and 47 were benign at the time of CNB. Of the 47 papillary lesions thought to be benign, 13 (28%) revealed atypia and 4 (9%) revealed malignancy upon surgical excision. Of the 13 atypical papillary lesions on CNB, 7 lesions (54%) were associated with malignancy upon excision. Slightly over half the upgrades were due to finding atypia or malignancy in the tissue surrounding the papillary lesion. The total rate of upgrades from the CNB diagnosis to the excisional diagnosis was 38%.

Conclusions

When a core biopsy of a papillary lesion is encountered, there is a strong likelihood of discovering atypia or malignancy in the index lesion or in close proximity. Therefore, surgical excision should be performed to avoid missing a malignancy and to allow for accurate breast cancer risk assessment that can impact survival and decisions regarding chemoprevention.     

Is the Fowler-Stephens procedure still indicated for the treatment of nonpalpable intraabdominal testis?

Purpose

There are no formal guidelines for the management of boys with nonpalpable testis. In this article, we report our experience in treating all nonpalpable intraabdominal testis (NPIT) with standard inguinal orchidopexy without dividing the spermatic vessels stating that the Fowler-Stephens technique is no longer indicated for the treatment of the intraabdominal testis.

Methods

Between June 2003 and April 2008, we treated 23 boys with NPIT confirmed by ultrasound or laparoscopy. All cases were treated through an inguinal orchidopexy without division of the spermatic vessels by fixing the testis to the scrotum by 2 absorbable stitches even if there was an upward retraction of the scrotal skin. Location and size of testis were reported at 1 week, 1 month, 3 months, and 6 months through physical examination.

Results

Average age at presentation was 24 months. Ten patients (43%) had the NPIT on the right side, 8 (35%) on the left side, and 5 (22%) were bilateral. We had no intraoperative complications. All patients were discharged on the same day. In all cases, the testis was normal in size and found in the scrotum after 6 months of follow-up.

Conclusion

On the basis of our experience, we believe that the Fowler-Stephens procedure is not indicated anymore in the management of NPIT. Orchidopexy without division of the spermatic vessels should be the treatment of choice even for the cases of very high intraabdominal testis because it does not affect normal testicular vascularization and is minimally invasive.     

Hemodynamic characteristics of midazolam, propofol, and dexmedetomidine in healthy volunteers

Study Objective

To study the effect of intravenous (IV) sedation on blood pressure (BP), heart rate (HR), and respiratory rates (RR) to determine if IV sedatives differ with respect to their effect on BP, HR, and RR.

Design

Prospective, randomized, single-blinded, placebo-controlled study.

Setting

Monitored patient care room at a clinical research center.

Subjects

60 healthy ASA physical status 1 volunteers.

Interventions

Subjects were randomized to receive, in increasing doses, one of three IV sedatives: propofol, midazolam, or dexmedetomidine; or saline control.

Measurements

Blood pressure (systolic, diastolic), HR, and RR were recorded.

Main Results

A significant dose-dependent BP reduction occurred with dexmedetomidine and, to a lesser degree, with propofol; and there was good agreement of predicted versus measured drug concentrations for all sedatives. Blood pressure and HR of participants who received midazolam did not change.

Conclusions

When administered in sedative doses, dexmedetomidine and, to a lesser extent, midazolam, reduces BP in a dose-dependent fashion. Dexmedetomidine also reduces HR. Midazolam does not affect BP or HR.     

Quality of life of adult patients with severe burns

Background

Burns are one of the most significant health problems throughout the world, leading to prolonged hospitalisation and hence increased expense for the patients, their families and society. Today, the prognosis of patients with burns is dependent, apart from adequate treatment, upon the health-care system and health-care professionals, regarding not only survival, but also lifelong quality of life. This study aims to assess quality of life of adult patients with severe burns.

Patients and methods

This study was conducted on 100 adult patients with severe burns in the burn outpatient clinic (male and female) at Mansoura University Hospital. Parameters of burn and Burn Specific Health Scale (BSHS-B) were used to assess quality of life following burns.

Results

The study revealed that burns has negative impact on most dimensions of the quality of life of patients with burns.

Conclusions

The quality of life for people who have sustained a burns should be recognised and valued by the burn team in all phases of burn care.     

Global trends in testicular cancer incidence and mortality

Background

Epidemiologic studies on testicular cancer have focused primarily on European countries. Global incidence and mortality have been less thoroughly evaluated.

Objective

Our goal was to gain a better understanding of the most recent global age-standardized incidence and mortality rates for testicular cancer and to use these values to estimate a region's health care quality.

Design, setting, and participants

Age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) for testicular cancer were obtained for men of all ages in 172 countries by using the GLOBOCAN 2008 database, reflecting the annual rate of cancer incidence and mortality per 100 000 men. These data were evaluated on a regional level to compare incidence and mortality rates. Global plots of these values were constructed to better visualize geographic distributions. Finally, the ratio of ASIR to ASMR was calculated as a method to assess each region's proficiency in diagnosing and effectively treating testicular cancer.

Measurements

ASIR and ASMR were analyzed by region, and each region's ratio of ASIR to ASMR was calculated.

Results and limitations

Testicular cancer ASIR is highest in Western Europe (7.8%), Northern Europe (6.7%), and Australia (6.5%). Asia and Africa had the lowest incidence (<1.0%). ASMR was highest in Central America (0.7%), western Asia (0.6%), and Central and Eastern Europe (0.6%). Mortality was lowest in North America, Northern Europe, and Australia (0.1-0.2%). The ASIR-ASMR ratio was highest in Australia (65.0%) and lowest in western Africa (1.0%). National reporting systems varied by country, and data quality may have fluctuated between regions.

Conclusions

Testicular cancer incidence remains highest in developed nations with primarily Caucasian populations. Variable ASIR-ASMR ratios suggest markedly different geographic-specific reporting mechanisms, access to care, and treatment capabilities.     

ATA practice guidelines for the treatment of differentiated thyroid cancer: were they followed in the United States?

Background

The aim of this study was to benchmark national practice patterns against American Thyroid Association guidelines for thyroidectomy, lymphadenectomy, and radioactive iodine (RAI) for differentiated thyroid cancer (DTC).

Methods

A cross-sectional analysis of patients with DTC in Surveillance, Epidemiology, and End Results was performed. Outcomes were practice accordance with guidelines for extent of surgery and RAI treatment. Predictors of accordance were identified.

Results

A total of 52,964 patients with DTC were included. Seventy-six percent were women, and 83% white. There was 71% accordance with surgery recommendations; among these, 15% underwent central lymphadenectomy, 31% had RAI but no lymphadenectomy, and 25% had RAI and lymphadenectomy. The highest accordance with guidelines was for patients aged <45 years with stage II disease (80%); the lowest accordance was for patients aged ≥45 years with stage II disease (52%). Patients aged >65 years and of black race had the lowest accordance (P < .001).

Conclusions

Variation in practice suggests variation in the quality of care for DTC. Greater dissemination of evidence-based recommendations is needed for elderly and minority patients.     

A survey of airway training among U.S. and Canadian anesthesiology residency programs

Study Objective

To determine the current trends in airway education in academic programs.

Design

Survey instrument.

Setting

American academic medical center.

Subjects

147 directors of American and Canadian anesthesiology residency programs.

Measurements

An invitation to complete an online questionnaire was sent. Non-responding institutions were contacted repeatedly by email and telephone to ensure a reasonable response rate.

Main Results

88 of the 147 (60%) programs completed the survey. Forty-three respondents (49%) reported that they had formal airway rotations, and 39 respondents said that a designated titled faculty member was responsible for airway training. Didactic lecture and manikin instruction were used by more than two thirds of the programs. Documentation of supervised airway experience was recorded in 71 (82%) programs. The majority of the programs (81%) had videolaryngoscopes. A fiberoptic bronchoscope was nearly universally available, and approximately one third (34%) of graduating residents were estimated to have performed more than 25 awake fiberoptic intubations. For most techniques, the estimates of the required number of procedures to ensure competence varied widely.

Conclusions

The number of programs with a formal airway management program continues to increase, and programs are incorporating newer intubation techniques. The criteria for competence have not been established.     

Significant Decrease in Glomerular Filtration Rate at 5 Years Posttransplantation in the Recipients of Live Donor Kidneys 50 Years of Age or Older

Introduction

Age is an established predictor of renal failure among recipients of cadaveric transplants; however, the impact of donor age on recipient glomerular filtration rate (GFR) among living donor kidney (LDK) transplantations is not well established.

Methods

We retrospectively analyzed recipient posttransplantation GFR at 12, 36, and 60 months among 315 LDK allograft recipients. The impact of donor age was assessed on the recipient estimated GFR (eGFR) using multivariate linear regression stratified according to donor age <50 years (n = 246) and ≥50 years (n = 69).

Results

Whites comprised the majority of both donors and recipients (77%). The majority (58.4%) of donors were female. Mean age (± SD) of the donors was 41.0 ± 10.2 years (range, 20-65 years). The mean age and body mass index (BMI) of the recipients were 43.3 ± 12.4 years and 26.0 ± 4.9, respectively. There was no statistically significant difference in the rejection rate between the 2 groups (P = .571). Mean eGFR at 12 months in the younger group was 63.3 ± 23.7 compared with 54.8 ± 19.7 in the older group (P = .015). Similarly, a significant difference was observed at the end of 36 months and 60 months of follow-up (61.5 ± 23.1 vs 49.4 ± 18.9, and 59.4 ± 23.0 vs 45.3 ± 20.8, respectively; both P = .001). Donor age was a statistically significant predictor of eGFR throughout the study period (P < .05).

Conclusion

Donor age predicts recipient renal function after living kidney transplantation and needs to be evaluated through a larger prospective investigation.     

Donor/recipient algorithm for management of the middle hepatic vein in right graft live donor liver transplantation

Background

The aim of this study was to delineate an algorithm for donor and recipient criteria and middle hepatic vein (MHV) management in right-graft live-donor liver transplantation (LDLT) on the basis of computerized 3-dimensional computed tomographic image analysis.

Methods

Data on 94 consecutive right-graft LDLTs were prospectively collected. Graft and remnant data for the first 23 cases were retrospectively evaluated by means of 3-dimensional computed tomographic reconstructions, and on the basis of that preliminary series, a graft selection algorithm using 3 parameters—hepatic vein dominance classification, graft and remnant graft volume/body weight ratios, and congestion volumes—was created. It was subsequently applied to the next 71 right-graft LDLTs.

Results

Fifty-nine right grafts contained the MHV. Four of the 12 grafts with no MHVs required MHV reconstructions. In 18 cases, small liver grafts were used. The postoperative function of liver grafts and remnants with versus without MHVs was not statistically different.

Conclusions

The proposed algorithm favored the inclusion of the MHV with the right grafts. It also allowed for the procurement of grafts that were potentially small for size without compromising donor or recipient safety.     

Cancellations in ambulatory day surgery: Ten years observational study

Background

Reasons for cancellation of booked procedures in ambulatory surgery need a detailed analysis in order to introduce corrective measures to lessen them.

Methods

Cancellations occurring the day before operation without patient replacement and procedures cancelled on the day of operation in 10 500 patients scheduled to be operated on in a multidisciplinary ambulatory surgery unit were analysed. Data were obtained from the incident register sheets and the database of the unit.

Results

A total of 424 patients were cancelled (4%). Reasons for cancellation were: acute medical conditions in 23.3% of cases, personal decision of the patient to refuse programming in 22.2%, non-attendance in 2.1%, failure to follow pre-operative guidance in 23.3% and unavailability of resources in 29%. These causes were preventable or possibly preventable in 57.1% of cases, difficult to prevent in 29% and not preventable in 13.9%.

Conclusion

More than half the cases of cancellation could be prevented. A rapid response of surgical departments to substitute patients, campaigns to increase the awareness of the population about the cost of health services and the implementation of pre-operative assessment guidelines must be considered.