Are Repeat Biopsies Required in Men with PSA Levels ≤4 ng/ml? A Multiinstitutional Prospective European Study

OBJECTIVES: Pathological and biochemical features of prostate cancers detected on repeat biopsies in men with total PSA level between 2.0 and 4 ng/ml were evaluated and compared to those cancers detected on first biopsy. METHODS: 315 men with PSA level between 2.0 and 4 ng/ml underwent transrectal ultrasound guided sextant biopsy and two additional transition zone biopsies (Octant Biopsy). All subjects whose biopsy samples were negative for prostate cancer underwent a repeat biopsy after 6 weeks. Those with clinically localized cancers were offered surgery or radiation therapy. Pathological and clinical features of patients diagnosed with prostate cancer on initial and repeat biopsy were compared. RESULTS: Cancer detection rates on first and second biopsy were 24% (75/315) and 13% (29/224), respectively. Overall, of patients with clinically localized disease (83% of cancers detected), 87% underwent radical prostatectomy, 11% opted for radiation therapy and 2% opted for watchful waiting. Cancers found in the first biopsy group were more multifocal (p = 0.01) while cancers found on second biopsy were more located in the apical-dorsal region (p = 0.003). No significant differences were noted with respect to extracapsular extension, seminal vesical invasion, positive margins, final pathological stage, Gleason score, percentage Gleason grade 4/5, serum PSA and patient age between first and second biopsy. CONCLUSIONS: With an octant biopsy regime, biochemical and pathological features of cancers detected on initial and repeat biopsy in the PSA range 2.0 to 4 ng/ml are comparable in terms of PSA, grade, stage and cancer volume suggesting identical cancer characteristics, thus advocating for a repeat prostate biopsy in case of a negative finding on initial biopsy.     

Generalized low bone mass of girls with adolescent idiopathic scoliosis is related to inadequate calcium intake and weight bearing physical activity in peripubertal period

Generalized low bone mass has been well documented in patients with adolescent idiopathic scoliosis (AIS). However, studies linking calcium-intake (CA), weight-bearing physical-activity (PA) and bone mass of AIS are lacking. We aimed to study the relationship between CA, PA and bone mass in AIS girls and compared to those of healthy non-AIS controls during the peripubertal period. Newly diagnosed AIS girls (n=596) aged 11–16 years with Cobb angle 10° were recruited to compare with age-matched healthy girls (n=302) in a cross-sectional study. Anthropometric parameters, pubertal status, CA and PA were assessed. Areal bone mass of lumbar spine and femoral neck, and volumetric bone mass of distal radius and tibia were determined by dual-energy X-ray absorptiometry and peripheral quantitative computed tomography, respectively. The results showed that weight and body mass index (BMI) of AIS were lower than the controls (P<0.05). Corrected height and arm span of AIS were longer than those of controls from 13 years onwards (P<0.02). Median CA of AIS was <410 mg/day across the ages and did not differ from the controls (P=0.063). Median PA of AIS (1.6 h/day) was lower than the controls (1.8 h/day) (P=0.025). Bone mass of AIS was on average 6.5% lower than controls across the ages (P<0.05). CA and PA were significantly correlated with bone mass of AIS (P<0.04). Multivariate analysis showed that AIS in girls was associated with lower bone mass, and that both CA and PA were independent predictors of bone mass in AIS. In conclusion, AIS girls were found to have lower body weight and BMI, longer segmental lengths and generalized low bone mass. Inadequate calcium intake and weight-bearing physical activity were significantly associated with low bone mass in AIS girls during the peripubertal period. The importance of preventing generalized osteopenia in the control of AIS progression during the peribubertal period warrants further study.     

Video assisted thoracoscopic surgery for spinal conditions

Video-assisted thoracoscopic surgery (VATS) has become an alternative treatment tool for a variety of spinal conditions in the last two decades. This endoscopic or "keyhole" approach minimizes the chest wall morbidity related to the traditional thoracotomy. The current indications for VATS are the same as in any open anterior spinal surgery. This article reviews the outcomes of VATS treatments in thoracic disc diseases, fractures, tumors and vertebral osteomyelitis. In addition, we have described our "learning curve" and surgical techniques using video-assisted thoracoscopic spinal releases and instrumentation in the treatment of 50 patients with adolescent idiopathic scoliosis.     

Effectiveness of naltrexone in a community treatment program

OBJECTIVE: In several large, well-designed, randomized, double-blind studies, the opiate antagonist naltrexone demonstrated efficacy in the treatment of alcohol dependence. Specifically, when combined with certain psychosocial therapies, naltrexone reduces the number of drinking days, heavy drinking, and time to relapse to alcohol use in alcohol-dependent individuals. Whether this efficacy can be generalized to individuals who have alcohol use disorders and present for treatment at front-line community treatment programs has not been well established. METHODS: A total of 145 patients who presented for treatment at a rural community substance abuse treatment center were randomized to receive naltrexone 50 mg daily plus usual program treatment (n = 54), placebo plus usual treatment (n = 43), or usual treatment alone (n = 48) for 12 week. A total of 133 participants had at least one follow-up visit. Primary outcome measures included percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days (four or more for women and six or more for men), and time to first heavy drinking day. Secondary measures included changes in serum biological markers (alkaline phosphatase, alanine transaminase, aspartate transaminase, and gamma-glutamyltransferase), craving, and psychosocial functioning. RESULTS: In the intention-to-treat analysis, there were no between-group differences for any of the primary drinking outcomes at 12 weeks. In post hoc exploratory analyses, the entire sample of participants was divided into two new groups: (1) people who drank during the 2 weeks before the start of medication (entry drinkers) and (2) people who did not drink during this interval (entry abstainers). Entry abstainers were at an advantage at study entry in that they were significantly more likely to have an inpatient hospitalization immediately before entry into outpatient treatment. Mixed-model analysis of variance revealed a main effect for entry group at the 12-week treatment endpoint on the primary outcome measures of percent days drinking, average drinks per drinking day, average drinks per day, heavy drinking days, and time to first heavy drinking day. Participants in any of the randomized groups who were entry abstainers had significantly better improvement on all of the primary outcome measures. The abstainer groups that were randomized to placebo and usual treatment had significantly better outcomes than the entry drinkers in those perspective groups. However, for the naltrexone-treated group, entry drinkers and entry abstainers had similar improvement in drinking-related outcomes. CONCLUSIONS: These data suggest that naltrexone may offer particular benefit to patients who continue to drink during the early stages of the trial as compared with those who have achieved abstinence before treatment entry.     

Diabetes and the outcome of infrainguinal bypass for critical limb ischaemia

Aim: To examine the influence of diabetes mellitus (DM) on the outcome of infrainguinal bypass operations performed for critical foot ischaemia in Chinese patients. Methods: A prospective audit of 265 consecutive infrainguinal bypass operations. Results: Diabetic patients suffered more frequently from ischaemic heart disease (48%vs 25%, P= 0.001) and tissue loss (90%vs 79%, P = 0.01) at presentation. Cigarette smoking was more prevalent in the non‐diabetic (NDM) group (72%vs 51%, P = 0.001). Arterial segments distal to the common femoral artery were more often used as inflow to bypass graft in DM patients (36%vs 22%, P = 0.02). Operative mortality (seven DM vs one NDM, P = 0.19). Early graft failure (7% in DM group vs 10% in NDM group, P = 0.24), wound infection rate (24% in DM group vs 17% in NDM group, P = 0.21), early limb loss (9% in DM group vs 6% in NDM group, P = 0.66) were comparable. However, hospital mortality was higher in DM patients (8%vs 1%, P = 0.04). DM patients more frequently required further surgical debridement postoperatively (20%vs 9%, P = 0.04). Long‐term, patient survival was inferior in the DM group (43% NDM vs 33% DM at 5 years, P = 0.03). Primary graft patency (46% DM vs 34% NDM at 4 years P = 0.19), secondary graft patency (57% DM vs 47% NDM at 4 years P = 0.14) and limb salvage rate (78%vs 81% at 5 years, P = 0.79) were comparable. Conclusion: Diabetes mellitus adversely affects hospital mortality and long‐term survival. Graft patency and limb salvage are not compromised by the presence of DM.