The value of appropriate assessment prior to specialist referral in men with prostatic symptoms

Background  Referrals to Urology OPD of men with a likely diagnosis of BPH are common. Aims  To review referrals to OPD of men with lower urinary tract symptoms (LUTS) to establish how many could have been managed without specialist assessment. Methods  We reviewed records of 200 male patients referred to OPD with LUTS. We assessed whether the referral source had performed digital rectal examination (DRE), International Prostate Symptom Score (IPSS), Bother Score or PSA level. Results  74% of patients were referred by GPs. In 31.5% of cases DRE was performed prior to referral. One GP had completed an IPSS, none a Bother Score. 96% had a PSA checked before OPD. Ultimately, 88.5% of our patients were diagnosed with BPH. Conclusions  With better pre-assessment in the form of DRE, IPSS and Bother Score, allied to a PSA check, many patients with LUTS could be managed in a primary care setting.     

The Pharmaceutical Benefits Scheme and implications for paediatric prescribing

Aims:   To evaluate the impact of the Pharmaceutical Benefits Advisory Committee (PBAC) decisions on access to medicines listed on the Pharmaceutical Benefits Scheme (PBS) for children.
Methods:   We analysed all public summary documents from PBAC meetings from July 2005 to November 2006 and compared these with the Therapeutic Goods Administration (TGA) recommendations for children for the same medicine. Main outcome measures stratified by age, the total number of medicines for specific indications (accepted and rejected) by therapeutic class; estimated cost to the PBS per annum for each medicine recommended for listing; comparison of TGA-approved product information and PBS listing for recommended medicines.
Results:   Of the 102 medicines for specific indications considered by the PBAC, 7% (7/102) of submissions were for new paediatric indications. Most submissions (60%, 61/102) did not specify age for the PBS recommendation and were for conditions which only affect adults. Listings which specifically included children were more likely to have a positive PBAC recommendation. Of the six recommended medicines for children, four were estimated to cost between $10–30 million per year. There was fair concordance between PBS- and TGA-approved product information for age (kappa 0.21) but in 46%, PBAC recommendations were for age-unrestricted listing compared with adults-only use in the TGA-approved product information.
Conclusion:   Access to new subsidised medicines for children in Australia lags behind adults because most applications to the PBAC for new medicines are for conditions which only affect adults. PBS processes facilitate access for children to new medicines by avoiding age restrictions.     

Ocular manifestations of leukemia: leukemic infiltration versus infectious process

OBJECTIVE: To determine whether specific guidelines can be developed to distinguish whether retinal infiltration in leukemia patients represents infection or neoplasia. DESIGN: Retrospective noncomparative interventional case series. PARTICIPANTS: Six patients recently seen at University of California San Francisco with retinal infiltrates in a setting of leukemia, for which adequate written and photographic information of disease course was available. INTERVENTION: Observation consisted of retrospective review of clinic charts, hospital medical records, and fundus photographs. MAIN OUTCOME MEASURES: Determination of whether retinal infiltrates represented neoplasia or infection was made by review of medical records. RESULTS: In this series, neoplastic retinal infiltrates were found in patients who had newly diagnosed leukemia and those who were in blast crisis. In contrast, the two patients who were in complete remission, but had undergone bone marrow transplantation, had retinal infiltrates attributable to infection. CONCLUSIONS: Every patient with retinal infiltrates in the setting of newly or previously diagnosed leukemia requires a systemic and central nervous system workup before the initiation of ophthalmologic treatment. The systemic status of the patient is highly informative in determining whether infection or neoplasia is responsible for the infiltration.     

A Definitive Role of Ornithine Decarboxylase in Photocarcinogenesis

Excessive exposure of solar ultraviolet (UV) radiation, particularly its UVB component, to human skin is the major cause for more than a million new cases of cutaneous malignancies diagnosed annually in the United States. Photocarcinogenesis, like other cancers, is a multistep process that includes initiation and promotion. A proper understanding of the molecular events occurring during the tumor promotion phase of photocarcinogenesis could lead to the development of novel approaches for the management of skin cancer. Using a transgenic mouse model (K5/ODC mice), which overexpresses the enzyme ornithine decarboxylase (ODC) in hair follicle keratinocytes, we studied the role of this gene in photocarcinogenesis. A single UVB-exposure of 180 mJ/cm(2) to the transgenic mice resulted in a minimal increase in bifold skin thickness and ODC activity. However, in SKH-1 hairless mice, the most common and highly sensitive model for photocarcinogenesis, and in littermate nontransgenic mice, increases in skin thickness and ODC activity were substantial. In long-term experiments, mice were exposed to 180 mJ/cm(2) of UVB radiation three times a week for 2 weeks (tumor-initiating dose). At 30 weeks after this treatment, in two independent experiments, 40% of the K5/ODC transgenic mice exposed to UVB were found to develop epidermal tumors. The tumors were histologically verified as benign papillomas and squamous cell carcinomas. Interestingly, 100% of the transgenic mice also developed >20 pigmented cysts/mouse, which contained keratinocyte material with increased keratinocytic melanization. Under similar UVB-exposure protocol, the nontransgenic littermates or SKH-1 hairless mice did not develop tumors or pigmented cysts for up to 50 weeks. Oral consumption of alpha-difluoromethylornithine, an irreversible specific inhibitor of ODC, in the drinking water (1% w/v) to the transgenic mice resulted in complete prevention of UVB-mediated tumorigenesis and a substantial decrease in the formation of pigmented cysts (<10 per mouse). These data establish a definitive role of ODC in the promotion phase of photocarcinogenesis.     

Maternal Morbidity and Perinatal Outcomes Among Foreign-Born Cambodian,Laotian, and Vietnamese Americans in Washington State, 1993–2006

This study examined differences in perinatal outcomes of Southeast Asian (SEA) women compared with non-Hispanic white women in Washington. Using linked birth certificate and hospitalization discharge records for the years 1993–2006, we compared singleton births of Cambodian (3,858), Laotian (2,223), and Vietnamese (12,949) women with a random sample of white women (35,581). Associations between maternal nativity and perinatal outcomes were assessed using multivariable logistic regression. There are clear nativity differences among SEAs for gestational diabetes mellitus, anemia, placenta previa and febrile illness. SEAs had increased risks for these disorders when compared with white women. Compared with infants delivered of white women, infants of SEAs had increased risks for moderate to heavy meconium, birth injury and low birth weight. Differences in nativity among SEAs (populations that are traditionally studied in aggregate) should be considered when designing and carrying out interventions to prevent adverse pregnancy morbidity and outcomes among immigrants.