Pretreatment predictors of time to cancer specific death after prostate specific antigen failure

PURPOSE: Whether pretreatment factors that predict for time to prostate specific antigen (PSA) failure also predict for time to prostate cancer specific death after PSA failure for patients with competing causes of mortality treated during the PSA era was the subject of this study. MATERIALS AND METHODS: Of 415 men with a median age of 73 years who underwent external beam radiation therapy between 1988 and 2001 for clinically localized prostate cancer 160 (39%) experienced PSA failure and 96 (23%) died. In 46 men (48%) the cause of death was prostate cancer. Cox regression multivariable analyses (multivariable analysis) were performed to evaluate the ability of the pretreatment PSA and centrally reviewed biopsy Gleason score to predict time to prostate cancer specific death after PSA failure. RESULTS: When analyzed as categorical variables using multivariable analysis, biopsy Gleason score 4 + 3 (p = 0.02), 8 to 10 (p = 0.02) disease and a pretreatment PSA greater than 20 ng./ml. (p = 0.03) were significant predictors of time to prostate cancer specific death after PSA failure. Estimates of prostate cancer specific death 5 years after PSA failure were 24%, 40% and 59% (p = 0.01) for patients with a biopsy Gleason score < or = 6, 3 + 4, 4 + 3 or higher and 22%, 40% and 60% (p = 0.04) for patients with a pretreatment PSA of 10 or less, greater than 10 and 20 or less, or greater than 20 ng./ml., respectively. CONCLUSIONS: Patients at high risk for PSA failure after radiation therapy based on pretreatment PSA greater than 20 ng./ml. or biopsy Gleason score 4 + 3 or greater are also at high risk for death from prostate cancer after PSA failure despite competing causes of mortality.     

The coexistence of gestational hypertension and diabetes: influence on pregnancy outcome

Gestational hypertension (GHTN) and gestational diabetes mellitus (GDM) are both insulin resistance states. Perinatal outcome of GHTN or GDM alone are well established, but their combined effect on pregnancy outcome is underinvestigated. Our objective was to determine if pregnancies complicated by GHTN/GDM have higher rates of morbidity. We identified nulliparous women with singleton pregnancies delivering at 37 to 40 weeks of gestation from 1995 to 2004 from a database. Outcomes of pregnancies complicated by GHTN only, GDM only, or combined GHTN/GDM were compared with controls. Data analysis included the Mann-Whitney U test, the Kruskal-Wallis H test, and analysis of variance. Multivariate analysis was used to adjust for confounders. Of 14,880 patients, there were 11,349 controls, 2604 GHTN, 728 GDM, and 199 GHTN/GDM. After controlling for covariates, GHTN significantly increased cesarean section (C/S) rate (odd ratio [OR], 1.62; confidence interval [CI], 1.47 to 1.78), rates of admittance to the neonatal intensive care unit (NICU), and birth of large for gestational age (LGA) infants. GDM significantly increased C/S (OR, 1.42; CI 1.21 to 1.66), rates of NICU admission (OR, 1.32; CI, 1 to 1.75), birth of LGA (OR, 1.51; CI 1.14 to 1.98), and macrosomic infants (OR, 1.53; CI, 1.12 to 2.08). Rates of LGA infants (OR, 1.85; CI, 1.19 to 2.86) and C/S (OR, 2.03; CI, 1.52 to 2.71) were significantly increased with GHTN/GDM. We concluded that GHTN or GDM is associated with increased rates of adverse outcomes. Their coexistence further increases adverse perinatal outcomes.     

Correlates of psychosocial well-being among overweight adolescents: the role of the family

An ethnically diverse sample of at-risk-for-overweight and overweight youths (body mass index greater than the 85th percentile for age and gender; n = 667 male participants, and n = 684 female participants) completed a school-based survey measuring family variables (connectedness, mealtime environment, and weight commentary), psychosocial well-being (depressed mood, body satisfaction, and self-esteem), and unhealthy weight-control behaviors; all measures were assessed concurrently. Hierarchical linear regression analyses revealed that measures of general family connectedness, priority of family meals, and positive mealtime environment were significantly positively associated with psychological well-being and inversely associated with depressive symptoms and unhealthy weight-control behaviors. Familial weight commentary (i.e., weight-based teasing and parental encouragement to diet) was associated with many indicators of poor psychological health. The authors conclude that greater psychosocial well-being and fewer unhealthy weight-control behaviors are associated with making family time at meals a priority, creating a positive mealtime atmosphere, and refraining from weight commentary.     

Communication with our teens: associations between confidential service and parent-teen communication

PURPOSE: Many recent attempts have been made to eliminate health services minors can receive without parental consent or notification. One argument is that these "confidential" services undermine the parent-teen relationship. The objective of this study was to evaluate whether confidential services impact adolescent's communication with parents about their health. METHODS: This cross-sectional study included 59 adolescents (ages 12-21) seeking health services at an urban teen clinic in Minneapolis, MN. Participants were divided based on reasons for presenting at the clinic; confidential or non-confidential services. The main outcome variables were the following: discussion of clinic visit with parent, discussion of reason for clinic visit with parent, and communication with parent if diagnosed with a potentially serious health condition. RESULTS: The two groups were equally divided; 42.4% came for non-confidential services and 57.6% came for confidential services. Of the 59 participants, 69.5% told their parents they were coming to clinic. However, only 43.1% reported they would not tell their parent if they had a serious health problem; there was an equal split between the confidential services and non-confidential services groups. A statistical difference was not found between the confidential services and non-confidential services groups for any of the outcome variables. CONCLUSIONS: Obtaining confidential services was not a barrier to discussion with parents about clinic visit, reasons for coming to clinic, or telling their parent if they had a serious health care problem. Clinicians should continue to advocate for confidential services while encouraging open communication between adolescents and their parents.     

Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease

The management of older patients with chronic medical conditions dominates medical practice. Cardiovascular disease (CVD) and diabetes mellitus type 2 (DM) in patients aged 65 and older have reached epidemic proportions. Using elements of the Chronic Care Model (CCM), a quality improvement project was undertaken to restructure the Geriatric Ambulatory Practice at Boston Medical Center, Boston's safety net hospital, to improve the quality of care for CVD and diabetes mellitus. Two hundred eighty-three eligible patients who had CVD, DM, or both were identified. The 39-month project period was divided into a 12-month baseline period and three follow-up periods. The multifaceted intervention consisted of development of a disease registry that centralized clinical information, implementation of an electronic medical record, patient education, physician education regarding evidence-based guidelines, feedback of provider-specific and practice data to physicians, and implementation of a foot examination protocol. Clinical measures included glycosylated hemoglobin, a diabetic foot examination, lipid profile, and blood pressure measurement. These were collected at baseline and at each patient visit for the entire project period. The average age of all patients was 76; 64% were female, 64% were African American, 72% had Medicare, and 22% had state subsidized medical insurance. Patients in all disease groups showed significant improvement in all clinical measures over time, independent of the frequency of visits. Using the CCM as a quality improvement framework can improve clinical measures for older urban minority populations with CVD and DM.