Timing and patterns of recurrences and deaths from prostate cancer following adjuvant pelvic radiotherapy for pathologic stage T3/4 adenocarcinoma of the prostate

To determine the timing and patterns of late recurrence after radical prostatectomy (RP) alone or RP plus adjuvant radiotherapy (RT). Between 1970 and 1983, 159 patients underwent RP for newly diagnosed adenocarcinoma of the prostate and were found to have positive surgical margins, extracapsular extension and/or seminal vesicle invasion. Of these, 46 received adjuvant RT and 113 did not. The RT group generally received 45-50 Gy to the whole pelvis, then a boost to the prostate bed (total dose of 55-65 Gy). In the RP group, 62% received neoadjuvant/adjuvant androgen deprivation vs 17% in the RT group. Patients were analyzed with respect to timing and patterns of failure. Only one patient was lost to follow-up. The median follow-up for surviving patients was nearly 20 years. The median time to failure in the surgery group was 7.5 vs 14.7 years in the RT group (P=0.1). Late recurrences were less common in the surgery group than the RT group (9 and 1% at 10 and 15 years, respectively vs 17 and 9%). In contrast to recurrences, nearly half of deaths from prostate cancer occurred more than 10 years after treatment. Deaths from prostate cancer represented 55% of all deaths in these patients. Recurrences beyond 10 years after RP in this group of patients were relatively uncommon. Despite its long natural history, death from prostate cancer was the most common cause of mortality in this population with locally advanced tumors, reflecting the need for more effective therapy.     

A longitudinal assessment of bowel related symptoms and fecal incontinence following radical perineal prostatectomy

PURPOSE: Recent studies have suggested an increased incidence of fecal incontinence following radical perineal prostatectomy. We provide a prospective and longitudinal assessment of bowel related symptoms of patients undergoing radical perineal prostatectomy. MATERIALS AND METHODS: A total of 78 patients who underwent radical perineal prostatectomy between January 1 and December 31, 2001 and had a minimal followup of 6 months were included in the analysis. Patient information was obtained from the chart and the bowel domain specific questions of a validated quality of life questionnaire, the Expanded Prostate Cancer Index Composite. The questionnaire was administered to the candidates preoperatively, at 4 weeks following surgery and subsequently at 3-months intervals. A mean bowel function, bother and summary health related quality of life score was calculated at each interval. The duration of new or worsened symptoms with respect to baseline was evaluated using Kaplan-Meier analysis. RESULTS: Symptoms of involuntary stool leakage and rectal urgency were reported by 11.5% (9 of 78) and 19.2% (15) of patients preoperatively. While all bowel related symptoms transiently increased following surgery, rectal urgency was the most persistent symptom, yet normalized in more than 90% of patients within 9 1/2 months. Compared to individual baseline 15.4%, 7.7%, 5.1% and 3.9% of patients reported worsened symptoms of fecal incontinence after 3, 6, 9 and 12 months, respectively. In the subset of 69 patients who denied preoperative fecal incontinence the incidence of involuntary stool leakage was 2.9% by 12 months following radical perineal prostatectomy. Of 10 patients 9 recovered individual health related quality of life score by 6 months after prostatectomy. CONCLUSIONS: Longitudinal assessment of self-reported questionnaire data suggests that fecal incontinence and bowel related symptoms are more prevalent following radical perineal prostatectomy compared to baseline, yet resolve in the majority of patients with time in the early postoperative period.     

Mini Nutritional Assessment short-form: Validation in five Latin American cities. SABE study

Objectives

To validate the short-form of the MNA (MNA-SF) and the cut-off point of 31 cm for calf circumference (CC) in older people in Latin America.

Methods

A cross-sectional study was conducted with 5,722 community-dwelling older subjects (range: 60-102 years) in Latin America’s five main cities: Sao Paulo (Brazil), Santiago (Chile), Havana (Cuba), Mexico DF (Mexico) and Montevideo (Uruguay). All participants underwent an interview, which included anthropometric measurements, completing the MNA and obtaining socio-demographic, nutrition and health information. The short-form of the MNA consists of only six questions from the original 18. It has two versions: one using body mass index (BMI) and the second using CC as a surrogate. Cohen’s Kappa was calculated to assess the agreement between the MNA and the MNA-SF; diagnostic tests were performed, and Receiver-operating characteristic (ROC) curves were developed. Criterion-related validity was assessed in the Chilean sample.

Results

Both version of the MNA-SF showed high sensitivity and specificity with the MNA, showing good accuracy (0.88), although higher values were estimated for malnutrition and risk of malnutrition in the total sample by sex. The cut-off point of 31 cm for CC showed high sensitivity (74.6-94.4%), specificity (72.6-100%) and good area under the ROC curve (0.87-0.95) when compared with BMI. There was good agreement between MNA and both version of MNA-SF for identifying persons with malnutrition or a risk of malnutrition in the five cities (Kappa coefficient: 0.6193-0.7852).

Conclusion

Both versions of the MNA-SF are population-screening tools of easy and fast application, with good accuracy for assessing malnutrition and risk of malnutrition in Latin American older people.

     

双频双脉冲(ND:YAG)激光机和钬(Ho:YAG)激光机在结石上移和碎石效率方面的体外比较

目的为了比较FREDDY激光机、钬激光机和气压弹道碎石机在结石上移和碎石方面的临床效果。方法上移的水下试验装置包括一个水平方向放置的硅树脂导管(直径为1.3cm),和一个固定支架,使激光机的石英光纤和气压弹道碎石机的撞针可以直接接触石头。将预先称过重的圆柱状Bego石头(BegoUSA公司提供)放于该装置中,分别由FREDDY激光机、钬激光机和气压弹道碎石机进行碎石。FREDDY激光机和钬激光机都采用相近的脉冲能量和频率。为了具有可比性,气压弹道碎石机采用了半硬性撞针和单脉冲,在100、200、300kPa各档压力设置下分别对石头进行30次撞击。“平均后退距离”定义为直接测得的石头最终静止点到原点的距离(每档设置都记录测试结果)。另外,两台激光机分别对称过重的石头(熟石膏成分)进行碎石,以比较碎石效果。石头固定于一个水下装置(由一个倒置的硅注射器和一个固定装置组成)中。激光光纤(钬激光和FREDDY激光的光纤内径分别是365μm和280μm)穿过注射器的针头出来抵住石头。总共24颗石头被分成4组,每组6颗,其中两组用FREDDY激光分别以300J和400J的总能量碎石,另两组用钬激光分别以300J和480J的总能量碎石。“碎石率”定义为石头重量缺失的百分比。结果FREDDY激光机在能量设置为160mJ时,分别以5、10和15Hz的频率碎石,石头的平均后退距离为7.6、8.1和6.8cm;钬激光机在能量设置为0.8J时,分别以5和10Hz的频率碎石,石头的平均后退距离为3.3和4.9cm;气压弹道碎石机在压力设置分别为100、200、300kPa时,石头的平均后退距离为8.5、9.9和13.8cm。一般来说,FREDDY激光机造成的石头后退距离都要少于气压弹道碎石机,尽管这只有在后者处于最高压力设置时才有统计意义(p<0.05)。而FREDDY激光机造成的石头后退距离要多于钬激光机,在临床上常见的设置中有统计意义(p<0.05)。FREDDY激光机以300J和400J的总能量碎石时,石头重量的缺失率分别为44.9%和86.8%,都有统计意义(p<0.05);钬激光机以300J和480J的总能量碎石时,石头重量的缺失率分别为3.3%和7.1%,都有统计意义(p<0.05)。结论FREDDY激光机造成的石头后退距离要明显大于钬激光机(在低频设置时),但又明显少于气压弹道碎石机(在所有设置时)。因此我们建议,在进行腔内输尿管镜碎石术,或在输尿管肾盂连接处进行腔内激光碎石术时,于接近结石处使用阻断装置,如StoneCone-石椎(BostonScientific公司提供)。FREDDY激光机在体外碎石的效率要明显好于钬激光机,对于结石病人来说,前者是个更优、更经济的选择。     

Metabolic syndrome and cerebral vasomotor reactivity

Background and purpose: Metabolic syndrome has been proposed as a risk factor for stroke and transient ischaemic attack. One pathophysiological mechanism could be impairment of endothelial function. Thus, we hypothesized that cerebral vasomotor reactivity would be decreased in patients with metabolic syndrome, compared to patients without metabolic syndrome. Methods: In this retrospective analysis, 83 consecutive patients (aged 59.19 ± 15.98; 33 women) underwent Doppler examination for carotid artery disease including bi‐hemispherical vasomotor reactivity assessment using transcranial Doppler monitoring. Vasomotor reactivity data were analyzed from the hemisphere with no or low‐grade carotid stenosis (<40%). Cerebral vasomotor reactivity was calculated as percent increase in mean flow velocity per mmHg pCO₂ during 2 min of 5% CO₂ inhalation delivered by anesthesia mask (normal if ≥2%/mmHg). Univariate and multivariable linear regression models were used to determine factors, including metabolic syndrome, that were independently associated with pathologic vasomotor reactivity. Results: After adjusting for the presence of contralateral carotid stenosis and ipsilateral stroke in the multivariable model, metabolic syndrome was independently associated with lower vasomotor reactivity values (2.27 ± 1.24% vs. 2.68 ± 1.37; ß = ?0.258, P = 0.033). In this model, there was no association of cerebral vasomotor reactivity with age, gender, race, cardiac disease, current statin therapy, or small vessel disease. Conclusions: Our findings suggest that impaired cerebral vasomotor reactivity may be a mediator of stroke in patients with metabolic syndrome, a syndrome affecting a significant and growing proportion of the population. A prospective longitudinal study is warranted to study the cerebral haemodynamic effect of metabolic syndrome.     

Social Representations of Older Adults Among Chilean Elders of Three Cities with Different Historical and Sociodemographic Background

The study was aimed to explore social representations of older adults among Chilean people aged 70 or more, living in three cities with differences in historical, geographic, and sociodemographic characteristics and to explore the importance of the local context on their shaping. Multiple correspondence analysis was employed to analyze the terms produced through free-word association technique, by 741 people. The two first dimensions explained 62.4 % of the inertia and showed that the contribution of city of residence was several times higher than the average; the contribution of gender and educational level was higher than average as well. The northern city representations were characterized by positive terms, whereas more negative contents were characteristic of the city of the center, and terms without an explicitly positive or negative assessment were associated to the southern city. These findings reinforce the relevance of the local sociocultural context in shaping social representations of old age and stress the importance of considering particular regional features in the design of policies and interventions aimed to recognize and integrate older adults in Chile.     

Durability of the medical management of cystinuria

PURPOSE: Cystinuria is an autosomal recessive disorder of dibasic amino acid transport in the kidney that leads to an abundance of cystine in the urine. This molecule is poorly soluble in urine and it is prone to crystallization and stone formation at concentrations above 300 mg./l. Medical treatment in these patients has incorporated increasing urine volumes, alkalinization and thiol medications that decrease the availability of free cystine in urine. Despite a reasonable prognosis for reduced stone formation we and others have noted difficulties in patients complying with medical management recommendations. Therefore, we evaluated the durability of treatment success in our patients with cystinuria. MATERIALS AND METHODS: A retrospective chart review was performed in all patients with cystinuria referred to the comprehensive kidney stone center at our institution for an 8-year period. Medical therapy, stone recurrence rates, compliance with medications and scheduled followup, and the results of metabolic evaluations via 24-hour urine collections were reviewed. The average concentrations of urinary cystine in initial and followup 24-hour samples were compared in patients compliant and noncompliant with medical treatment. In addition, each patient was mailed a 1-page questionnaire to assess the self-perception of medical compliance. RESULTS: We identified 26 patients with a mean age of 32 years at referral (range 13 to 67) who were followed an average of 38.2 months (range 6 to 83). Females represented 58% of those with cystinuria. Overall compliance with medical recommendations was poor with a short duration of success. Of the 26 patients followed at our stone center only 4 (15%) achieved and maintained therapeutic success, as defined by urine cystine less than 300 mg./l. An additional 11 patients (42%) achieved therapeutic success but subsequently had failure at an average of 16 months (range 6 to 27). Of these patients 7 (64%) regained therapeutic success at an average of 9.4 months (range 4 to 20). Five patients (19%) never achieved therapeutic success, while an additional 6 (23%) failed to present to followup appointments or provide subsequent 24-hour urine studies despite referral to a tertiary care center. Patient self-assessment of medical compliance was uniformly high regardless of physician perceptions or treatment results.CONCLUSIONS The durability of medically treating patients with cystinuria is limited with only a small percent able to achieve and maintain the goal of decreasing cystine below the saturation concentration. Greater physician vigilance in these complicated stone formers is required to achieve successful prophylactic management. Furthermore, these patients require better insight into the own disease to improve compliance.