Serum leptin and pathological findings at the time of radical prostatectomy

PURPOSE: Obesity has been associated with a higher risk of progression following radical prostatectomy (RP). Obese men have higher serum leptin, a hormone produced by adipocytes, which has also been shown to be an in vitro prostate cancer growth factor. We examined whether serum leptin correlates with advanced pathological findings at RP. MATERIALS AND METHODS: Preoperative serum from 225 men treated with RP between 1998 and 1999 was examined for serum leptin. Multivariate logistic regression analysis was used to determine whether serum leptin was predictive of extraprostatic extension (pT3a). RESULTS: Serum leptin highly correlated with body mass index (Spearman r = 0.602, p <0.001). Serum leptin was not associated with total or percent free prostate specific antigen (PSA), biopsy or prostatectomy Gleason score, age or height. On multivariate analysis with total and percent free PSA, clinical stage, age, biopsy Gleason score, body mass index, serum leptin, and height as variables considered for entry into the model, serum PSA (p = 0.009), clinical stage (p = 0.019) and serum percent free PSA (p = 0.041) were the only variables predictive of extraprostatic extension. Serum leptin was not significantly associated with pathological stage (pT3a). CONCLUSIONS: In the current study of predominantly white men with mainly low risk disease there was no statistically significant association between serum leptin and pathological stage (pT3a) at RP. In this cohort serum leptin was not a good biomarker for predicting advanced stage at RP.     

Obesity and capsular incision at the time of open retropubic radical prostatectomy

PURPOSE: The goal of radical prostatectomy (RP) is complete removal of the intact prostate. Obese men can represent a technical challenge. However, to our knowledge objective data linking obesity with technically inferior surgery are lacking. Therefore, we examined the association between body mass index (BMI) and capsular incision at RP as a surrogate of a poor technical operation in men treated for prostate cancer by several high volume surgeons at a center of excellence. MATERIALS AND METHODS: The study population consisted of 7,027 men treated with anatomical retropubic RP between 1996 and 2004 by 7 high volume surgeons. We evaluated the association between BMI and capsular incision using logistic regression, adjusting for clinical and pathological variables, and for the surgeon. RESULTS: Overall capsular incision was noted in 4.6% of all RP specimens. After adjustment for preoperative prostate specific antigen, patient race, height, year of surgery, clinical stage, pathological Gleason sum, prostate weight, extraprostatic extension and seminal vesicle invasion increased BMI was associated with increased odds of capsular incision (p trend = 0.005). After further adjustment for surgeon mild obesity was associated with 30% increased odds of capsular incision (OR 1.30, 95% CI 0.92 to 1.83), while moderate and severe obesity was associated with 57% increased odds of capsular incision (OR 1.57, 95% CI 0.82 to 3.00) relative to normal weight men (p trend = 0.06). CONCLUSIONS: In a study of more than 7,000 men treated by 7 experienced surgeons BMI was positively related to capsular incision. This suggests that open retropubic RP is technically more difficult in obese men, which results in a greater likelihood of a less than technically ideal operation. Although this may be predicted to have a negative impact on disease-free survival outcomes in obese men, it is unlikely to alone explain the worse outcomes in obese men noted in previous RP series.     

Effects of short-term alendronate on bone mineral density in haemodialysis patients

BACKGROUND: Low bone mineral density (BMD) is common in dialysis patients. Low BMD predicts the fracture risk in the general population. Bisphosphonate therapy improves BMD and lowers the fracture risk in many populations, but has not been tested in dialysis patients because of concerns about toxicity. In this investigation, the effect of a short course of alendronate on BMD in haemodialysis (HD) patients is evaluated. METHODS: Thirty-one healthy HD patients were randomized to placebo versus 40 mg alendronate, taken once a week for 6 weeks. Hip and lumbar spine BMD were measured by dual energy X-ray absorptiometry at baseline and at 6 months. Osteocalcin, parathyroid hormone, calcium, phosphorous and alkaline phosphatase levels were assayed at baseline and at 1, 3 and 6 months. RESULTS: The BMD and T-scores in specific regions of the hip were stable in the treatment group and decreased in the placebo group (P=0.05). The lumbar spine density increased minimally in both groups. In the treatment group, osteocalcin levels declined significantly at 1 month (P<0.05) and remained low. The main side-effect in the alendronate group was occurrence of gastroesophageal reflux symptoms in three subjects. CONCLUSIONS: Low-dose alendronate, administered for a limited duration, appears to be well tolerated in dialysis patients. The BMD and T-scores declined at certain hip regions in the placebo group over 6 months, while remaining stable in the treatment group, suggesting a bone-preserving effect of alendronate. Further studies of longer duration, and including examination of bone histology, are needed to assess whether bisphosphonates can be used to preserve BMD in dialysis patients.     

Persistence of fluoroquinolone-resistant, multidrug-resistant Streptococcus pneumoniae in a long-term-care facility: efforts to reduce intrafacility transmission.

OBJECTIVE: We describe an effort to reduce transmission of a multidrug-resistant Streptococcus pneumoniae (MDRSP) in a long-term-care facility (LTCF). DESIGN: Longitudinal cross-sectional study. SETTING: An LTCF in New York City with ongoing disease due to an MDRSP strain among residents with AIDS since a 1995 outbreak. The MDRSP outbreak strain was susceptible to vancomycin but not to other antimicrobials tested, including fluoroquinolones. PARTICIPANTS: Residents and staff members of the LTCF during 1999 through 2001. INTERVENTION: Implementing standard infection control measures, and developing and implementing "enhanced standard" infection control measures, modified respiratory droplet prevention measures to reduce inter-resident transmission. RESULTS: Before the intervention, nasopharyngeal carriage of the MDRSP outbreak strain was detected in residents with AIDS and residents with tracheostomies who were not dependent on mechanical ventilation. The prevalence of nasopharyngeal carriage of the MDRSP outbreak strain was 7.8% among residents who had AIDS and 14.6% among residents with tracheostomies. After training sessions on standard and enhanced standard infection control measures, the staff appeared to have good knowledge and practice of the infection control measures. After the intervention, new transmission among residents with tracheostomies was prevented; however, these residents were prone to persistent tracheal carriage and needed ongoing enhanced standard infection control measures. Ongoing transmission among residents with AIDS, a socially active group, was documented, although fewer cases of disease due to the outbreak strain occurred. CONCLUSIONS: Infection control contributed to less transmission of MDRSP in the LTCE Additional strategies are needed to reduce transmission and carriage among certain resident populations.     

Influence of exercise activity on quality of life in long-term breast cancer survivors

Background: Behavioral and lifestyle factors may influence quality of life (QOL) outcomes in breast cancer survivors. Methods: Information on QOL (Short Form-36, SF-36), lifestyle and survivorship was collected during telephone interviews with 374 breast cancer patients, diagnosed between 1983 and 1988 at ages 40 years or younger and interviewed, on average 13.2 years following diagnosis. These women previously participated in a case-control study soon after their diagnoses, providing information on breast cancer risk factors including exercise activity. We examined the impact of changes in exercise activity (comparing pre- to post-diagnosis levels) on the SF-36 mental and physical health summary scales using regression analyses. Results: A positive change in exercise activity was associated with a higher score on the SF-36 physical health summary scale at follow-up (p= 0.005). Change in exercise activity was not associated with the SF-36 mental health summary scale score. Patients who increased their activity levels did not differ from those who did not in terms of medical or demographic characteristics. Conclusion: This study provides one of the longest follow-up periods of breast cancer survivors to date among studies that focus on QOL and is unique in its focus on women diagnosed at a young age. Our results confirm high levels of functioning and well-being among long-term survivors and indicate that women whose exercise activity increased following diagnosis score higher on the SF-36 physical health summary scale. These findings suggest a potential role for exercise activity in maintaining well-being after a cancer diagnosis.     

Preoperative predictors for postoperative problems in heart transplantation: psychiatric and psychosocial considerations

The psychiatric and psychosocial evaluation of the heart transplant candidate can identify particular predictors for postoperative problems. These factors, as identified during the comprehensive evaluation phase, provide an assessment of the candidate in context of the proposed transplantation protocol. Previous issues with compliance, substance abuse, and psychosis are clear indictors of postoperative problems. The prolonged waiting list time provides an additional period to evaluate and provide support to patients having a terminal disease who need a heart transplant, and are undergoing prolonged hospitalization. Following transplantation, the patient is faced with additional challenges of a new self-image, multiple concerns, anxiety, and depression. Ultimately, the success of the heart transplantation remains dependent upon the recipient's ability to cope psychologically and comply with the medication regimen. The limited resource of donor hearts and the high emotional and financial cost of heart transplantation lead to an exhaustive effort to select those patients who will benefit from the improved physical health the heart transplant confers.     

Barriers to student access to patients in a group of teaching hospitals

OBJECTIVES: To determine the number of patients in our teaching hospitals who were, on any given day, both available and willing to see medical students. DESIGN AND SETTING: Repeated cross-sectional audit in four teaching hospitals in the greater Newcastle area of New South Wales (one tertiary referral hospital, two district general hospitals, and one hospital combining general medicine and surgery with specialised oncology services). Audits were conducted three times, 2 months apart. PARTICIPANTS: All adult inpatients in the four hospitals. MAIN OUTCOME MEASURES: Numbers of patients present and accessible to students, present but inaccessible, absent, or unfit to be seen for clinical reasons; numbers of patients who agreed to history-taking and physical examination by a medical student. RESULTS: Of 1960 patients, 959 (49%) were present and accessible to students. Only 11% were absent, and the most common reason students could not see patients was that the patients were said by nursing staff to be unfit to see medical students (25%). Of those present and accessible, 70% said they would agree to provide a history, and 67% that they would agree to physical examination. CONCLUSIONS: Across all four teaching hospitals about 200-250 patients are available and willing to see medical students on any given day. This is too few to provide our current student population of 500 with extensive clinical experience.     

Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy

Context  The natural history of biochemical recurrence after radical prostatectomy can be long but variable. Better risk assessment models are needed to identify men who are at high risk for prostate cancer death early and who may benefit from aggressive salvage treatment and to identify men who are at low risk for prostate cancer death and can be safely observed. Objectives  To define risk factors for prostate cancer death following radical prostatectomy and to develop tables to risk stratify for prostate cancer–specific survival. Design, Setting, and Patients  Retrospective cohort study of 379 men who had undergone radical prostatectomy at an urban tertiary care hospital between 1982 and 2000 and who had a biochemical recurrence and after biochemical failure had at least 2 prostate-specific antigen (PSA) values at least 3 months apart in order to calculate PSA doubling time (PSADT). The mean (SD) follow-up after surgery was 10.3 (4.7) years and median follow-up was 10 years (range, 1-20 years). Main Outcome Measure  Prostate cancer–specific mortality. Results  Median survival had not been reached after 16 years of follow-up after biochemical recurrence. Prostate-specific doubling time (<3.0 vs 3.0-8.9 vs 9.0-14.9 vs 15.0 months), pathological Gleason score (7 vs 8-10), and time from surgery to biochemical recurrence (3 vs >3 years) were all significant risk factors for time to prostate-specific mortality. Using these 3 variables, tables were constructed to estimate the risk of prostate cancer–specific survival at year 15 after biochemical recurrence. Conclusion  Clinical parameters (PSADT, pathological Gleason score, and time from surgery to biochemical recurrence) can help risk stratify patients for prostate cancer–specific mortality following biochemical recurrence after radical prostatectomy. These preliminary findings may serve as useful guides to patients and their physicians to identify patients at high risk for prostate cancer–specific mortality following biochemical recurrence after radical prostatectomy to enroll them in early aggressive treatment trials. In addition, these preliminary findings highlight that survival in low-risk patients can be quite prolonged.      

Incidence of basal cell and squamous cell carcinomas in a population younger than 40 years

Context  The incidence of nonmelanoma skin cancer is increasing rapidly among elderly persons, but little is known about its incidence in the population younger than 40 years. Objectives  To estimate the sex- and age-specific incidences of basal cell carcinoma and squamous cell carcinoma in persons younger than 40 years in Olmsted County, Minnesota, and to evaluate change in incidence over time; to describe the clinical presentation, rate of recurrence and metastasis, and histologic characteristics of these tumors in this population-based sample. Design  Population-based retrospective incidence case review. Setting  Residents of Olmsted County, Minnesota, a population with comprehensive medical records captured through the Rochester Epidemiology Project. Participants  Patients younger than 40 years with basal cell carcinoma or squamous cell carcinoma diagnosed between 1976 and 2003. Main Outcome Measures  Incident basal cell carcinomas and squamous cell carcinomas and change in incidence of these tumors over time. Results  During the study period, 451 incident basal cell carcinomas were diagnosed in 417 patients and 70 incident squamous cell carcinomas were diagnosed in 68 patients. Of these tumors, 328 were histologically confirmed basal cell carcinomas and 51 were histologically confirmed squamous cell carcinomas. Overall, the age-adjusted incidence of basal cell carcinoma per 100 000 persons was 25.9 (95% confidence interval [CI], 22.6-29.2) for women and 20.9 (95% CI, 17.8-23.9) for men. The incidence of basal cell carcinoma increased significantly during the study period among women (P<.001) but not men (P = .19). Nodular basal cell carcinoma was the most common histologic subtype; 43.0% of tumors were solely nodular basal cell carcinoma and 11.0% had a mixed composition, including the nodular subtype. The incidence of squamous cell carcinoma was similar in men and women, with an average age- and sex-adjusted incidence per 100 000 persons of 3.9 (95% CI, 3.0-4.8); the incidence of squamous cell carcinoma increased significantly over the study period among both women (P = .01) and men (P = .04). Conclusions  This population-based study demonstrated an increase in the incidence of nonmelanoma skin cancer among young women and men residing in Olmsted County, Minnesota. There was a disproportionate increase in basal cell carcinoma in young women. This increase may lead to an exponential increase in the overall occurrence of nonmelanoma skin cancers over time as this population ages, which emphasizes the need to focus on skin cancer prevention in young adults.