Primary care physician PSA screening practices before and after the final U.S. Preventive Services Task Force recommendation

ObjectivesIn May 2012, United States Preventive Services Task Force (USPSTF) finalized its recommendation against prostate-specific antigen (PSA) screening in all men. We aimed to assess trends in PSA screening frequency amongst primary care physicians (PCPs) surrounding the May 2012 USPSTF recommendation.Methods and materialsThe electronic data warehouse was used to identify men aged between 40 and 79 years with no history of prostate cancer or urology visit who were evaluated by an internal medicine or family practice physician between 2007 and 2012. Analyses were directed toward PSA testing within 6-month time period from June to November, with particular focus on the 2011 (pre-USPSTF recommendation) and 2012 (post-USPSTF recommendation) cohorts. The primary outcome measure was proportion of men with at least 1 PSA test during the 6-month pre- and post-USPSTF recommendation periods.ResultsA total of 112,221 men met inclusion criteria. There was a significant decrease in screening frequency between the 2011 and 2012 cohorts (8.6% vs. 7.6%, P = 0.0001; adjusted odds ratio 0.89, 95% confidence interval 0.83–0.95). This decrease was most evident amongst patients aged 40 to 49 years (5.6% vs. 4.6%, P = 0.004) and 70 to 79 years (7.9% vs. 6.2%, P = 0.01). A significant decrease was also observed in patients with highest previous PSA value<1.0 (P<0.0001) and 1.0 to 2.49 ng/ml (P = 0.0074).ConclusionsSince the USPSTF recommendation was finalized, there is evidence of continuing decreases in PSA testing by PCPs. PCPs may be shifting toward more selective screening practices, as decreases in screening are most pronounced in the youngest and oldest patients and in those with history of PSA values<2.5 ng/ml.     

Treating pediatric neuromuscular disorders: The future is now

Pediatric neuromuscular diseases encompass all disorders with onset in childhood and where the primary area of pathology is in the peripheral nervous system. These conditions are largely genetic in etiology, and only those with a genetic underpinning will be presented in this review. This includes disorders of the anterior horn cell (e.g., spinal muscular atrophy), peripheral nerve (e.g., Charcot–Marie–Tooth disease), the neuromuscular junction (e.g., congenital myasthenic syndrome), and the muscle (myopathies and muscular dystrophies). Historically, pediatric neuromuscular disorders have uniformly been considered to be without treatment possibilities and to have dire prognoses. This perception has gradually changed, starting in part with the discovery and widespread application of corticosteroids for Duchenne muscular dystrophy. At present, several exciting therapeutic avenues are under investigation for a range of conditions, offering the potential for significant improvements in patient morbidities and mortality and, in some cases, curative intervention. In this review, we will present the current state of treatment for the most common pediatric neuromuscular conditions, and detail the treatment strategies with the greatest potential for helping with these devastating diseases.     

Acute appendicitis in the developing world is a morbid disease

IntroductionAcute appendicitis in the developing world has a markedly different disease profile to that in the developed world.MethodsA retrospective study was undertaken over a four-year period at a university hospital in South Africa to review the disease spectrum and the clinical outcome of acute appendicitis.ResultsA total of 1,004 patients (54% male, median age: 18 years) with intraoperatively confirmed appendicitis were reviewed. Over half (56%) were from the urban district within the city of Pietermaritzburg and the remaining 44% were from the rural health district. The median duration of illness from onset to definitive care was 4 days. Sixty per cent of appendices were perforated and associated with intra-abdominal contamination. Forty per cent of patients required reoperation to control intra-abdominal sepsis. Ten per cent required admission to the intensive care unit. The median overall length of hospital stay was 5 days. The mortality rate was 1%.Rural patients had a longer median duration of illness (3 vs 5 days, p<0.001) as well as a more advanced disease profile associated with perforation and severe intra-abdominal sepsis (19% vs 71%, p<0.001). Female patients had a longer median duration of illness (3 vs 4 days, p<0.001), were more likely to present with severe intra-abdominal sepsis (31% vs 54%, p<0.001) and were more likely to require a laparotomy (50% vs 73%, p<0.001). The total cost of managing the entire cohort of 1,004 patients over the 4-year period was £2,060,972.ConclusionsAcute appendicitis in South Africa is a serious disease associated with significant morbidity. Late presentation is common. Female and rural patients have the worst clinical outcomes, with significant cost to the health system.     

Hydrogen peroxide metabolism in human monocytes during differentiation in vitro.

The capacity of human blood monocytes to secrete hydrogen peroxide (H2O2) and superoxide (O2-) was measured as the cells differentiated during 4 wk of culture. Morphologic transformation of monocytes into macrophages, epithelioid cells, and multinucleated giant cells accompanied a steady increase in the content of protein per cell, from 0.77 mg/10(7) cells on days 0 to 11.77 mg/10(7) cells on days 20 to 29. In contrast, secretion of H2O2 by adherent monocytes was 859 +/- 73 nmol/60 min per mg protein (mean +/- SEM, n = 18) on day 0, rose 40% on day 3, and then fell rapidly, remaining below 6% of the initial values after day 10. The decline in capacity to secrete reactive oxygen intermediates was observed whether H2O2 or O2- were measured, whether the cells were challenged with phorbol myristate acetate or with opsonized zymosan, and whether the results were expressed per milligram cell protein or per cell. Superoxide dismutase activity tripled in adherent monocytes from day 0 to day 3, and thereafter remained elevated through at least day 16. In contrast, the activity of myeloperoxidase declined rapidly, catalase and glutathione peroxidase declined more gradually, and glutathione reductase and glutathione remained constant through the period of observation. Thus, the decline in capacity to secrete H2O2 could not be attributed to increases in cellular levels of these antioxidants. On the first day of culture, H2O2 release was enhanced up to fourfold by inclusion of sodium azide or potassium cyanide in the assay medium. This enhancement appeared to be due to inhibition of monocyte myeloperoxidase, rather than catalase. This conclusion was based on the kinetics and dose-response relationships for the effects of azide and cyanide on H2O2 release and on the activities of catalase and myeloperoxidase. Thus, the differentiation of human monocytes into macrophages in vitro is accompanied by an apparent reduction in the capacity to produce H2O2 and O2-. In this regard, the human monocyte-derived macrophage comes to resemble the resting tissue macrophage previously characterized in the mouse peritoneal cavity.     

An explanation for varying views about digitalis efficacy in congestive heart failure

Summary The issue is no longer whether digitalis exerts an inotropic effect in heart failure or whether one can demonstrate a sustained hemodynamic or clinical response to the drug, but whether the same favorable effect can now be achieved equally well by another agent that might not be as dangerous as digitalis.     

Hyperbaric oxygen therapy. Promoting healing in difficult cases

Inhalation of pressurized 100% oxygen is a helpful adjunctive treatment for certain patients, because the increased oxygen carried by the blood to the tissue enhances new growth of microcirculation and, thus, healing. Patients with tissue breakdown after radiation therapy, refractory osteomyelitis, gas gangrene, soft-tissue infection with necrosis from mixed aerobic and anaerobic organisms, crush injuries resulting in acute ischemia, and compromised skin grafts or non-healing wounds are likely to benefit from hyperbaric oxygen therapy.