The Diagnostic Performance of Multiparametric Magnetic Resonance Imaging to Detect Significant Prostate Cancer.

PURPOSE: We assess the accuracy of multiparametric magnetic resonance imaging for significant prostate cancer detection before diagnostic biopsy in men with an abnormal prostate specific antigen/digital rectal examination. MATERIALS AND METHODS: A total of 388 men underwent multiparametric magnetic resonance imaging, including T2-weighted, diffusion weighted and dynamic contrast enhanced imaging before biopsy. Two radiologists used PI-RADS to allocate a score of 1 to 5 for suspicion of significant prostate cancer (Gleason 7 with more than 5% grade 4). PI-RADS 3 to 5 was considered positive. Transperineal template guided mapping biopsy of 18 regions (median 30 cores) was performed with additional manually directed cores from magnetic resonance imaging positive regions. The anatomical location, size and grade of individual cancer areas in the biopsy regions (18) as the primary outcome and in prostatectomy specimens (117) as the secondary outcome were correlated to the magnetic resonance imaging positive regions. RESULTS: Of the 388 men who were enrolled in the study 344 were analyzed. Multiparametric magnetic resonance imaging was positive in 77.0% of patients, 62.5% had prostate cancer and 41.6% had significant prostate cancer. The detection of significant prostate cancer by multiparametric magnetic resonance imaging had a sensitivity of 96%, specificity of 36%, negative predictive value of 92% and positive predictive value of 52%. Adding PI-RADS to the multivariate model, including prostate specific antigen, digital rectal examination, prostate volume and age, improved the AUC from 0.776 to 0.879 (p <0.001). Anatomical concordance analysis showed a low mismatch between the magnetic resonance imaging positive regions and biopsy positive regions (4 [2.9%]), and the significant prostate cancer area in the radical prostatectomy specimen (3 [3.3%]). CONCLUSIONS: In men with an abnormal prostate specific antigen/digital rectal examination, multiparametric magnetic resonance imaging detected significant prostate cancer with an excellent negative predictive value and moderate positive predictive value. The use of multiparametric magnetic resonance imaging to diagnose significant prostate cancer may result in a substantial number of unnecessary biopsies while missing a minimum of significant prostate cancers.

Developmental vulnerability--don't investigate without a model in mind.

Children who are developmentally vulnerable are at risk of a difficult start to school, and ongoing educational challenges which may adversely impact on long term health outcomes. Clinicians, researchers and service providers need a thorough understanding of both risk and protective factors and their complex interplay to understand their impact on early childhood development, in order to plan effective and comprehensive prevention and interventions strategies. In this opinion piece we recommend that investigation of developmental vulnerability should only proceed if underpinned by both a theoretical model through which the interaction between risk and protective factors may be investigated, and analytical models that are appropriate to assess these impacts.

Self-monitoring in hypertension: a web-based survey of primary care physicians.

Although self-monitoring of blood pressure is common among people with hypertension, little is known about how general practitioners (GPs) use such readings. This survey aimed to ascertain current views and practice on self-monitoring of UK primary care physicians. An internet-based survey of UK GPs was undertaken using a provider of internet services to UK doctors. The hyperlink to the survey was opened by 928 doctors, and 625 (67%) GPs completed the questionnaire. Of them, 557 (90%) reported having patients who self-monitor, 191 (34%) had a monitor that they lend to patients, 171 (31%) provided training in self-monitoring for their patients and 52 (9%) offered training to other GPs. Three hundred and sixty-seven GPs (66%) recommended at least two readings per day, and 416 (75%) recommended at least 4 days of monitoring at a time. One hundred and eighty (32%) adjusted self-monitored readings to take account of lower pressures in out-of-office settings, and 10/5 mm Hg was the most common adjustment factor used. Self-monitoring of blood pressure was widespread among the patients of responding GPs. Although the majority used appropriate schedules of measurement, some GPs suggested much more frequent home measurements than usual. Further, interpretation of home blood pressure was suboptimal, with only a minority recognising that values for diagnosis and on-treatment target are lower than those for clinic measurement. Subsequent national guidance may improve this situation but will require adequate implementation.

A comparison of doctors', parents' and children's reports of health states and health-related quality of life in children with chronic conditions.

BACKGROUND: Health-related quality of life is an important outcome. Self-report is the gold standard, but in the paediatric setting we often rely on proxy reporting. Our understanding of the differences between self- and proxy reports and the factors that influence them is limited. These differences can impact on treatment choices and the patient-doctor relationship. OBJECTIVE: To evaluate differences between children's, parents' and doctors' perceptions of health states and health-related quality of life in children with chronic illness and explore factors which explain these differences. METHODS: Consecutive families attending eligible clinics at a tertiary paediatric centre were invited to complete the Health Utilities Index (HUI) 23 questionnaire. Percentage agreement and kappas were calculated as a measure of the agreement between pairs. Chi-squared tests or Fisher's exact test, if appropriate, were performed to determine if there was an association between level of agreement and participant variables. RESULTS: Data were collected for 130 parent-doctor pairs, 59 child-parent pairs and 59 child-doctor pairs. Overall health-related quality of life scores did not differ between responders, but there was poorer agreement for subjective domains. Doctor-child agreement was lower than parent-child agreement. Children with a diagnosis of cerebral palsy or chronic neurological condition were more likely to have lower inter-rater agreement for both subjective and objective domains. On the HUI2, agreement was lower for parent-child pairs when the father was the respondent. For child-doctor pairs, an increased frequency of patient-doctor visits and doctors' seniority were predictors of poorer agreement on the HUI3 and HUI2 respectively. CONCLUSIONS: We identified factors associated with level of agreement for self- and proxy reporting on the HUI23. Parent-child agreement was higher than doctor-child agreement. Patients with significant pain or emotional distress and patients with a diagnosis of severe cerebral palsy or chronic neurological conditions were more susceptible to under-reporting of subjective aspects of well-being by doctors and parents and may benefit from formal assessment of health-related quality of life in the clinical setting.

Air temperature and the incidence of fall-related hip fracture hospitalisations in older people.

UNLABELLED: Observation-driven Poisson regression models were used to investigate mean daily air temperature and fall-related hip fracture hospitalisations. After adjustment for season, day-of-week effects, long-term trend and autocorrelation, hip fracture rates are higher in both males and females aged 75+ years when there is a lower air temperature. INTRODUCTION: This study investigated whether there was an association between fall-related hip fracture hospitalisations and air temperature at a day-to-day level, after accounting for seasonal trend and autocorrelation. METHODS: Observation-driven Poisson regression models were used to investigate mean daily air temperature and fall-related hip fracture hospitalisations for the period 1 July 1998 to 31 December 2004, inclusive, in the Sydney region of New South Wales, Australia, which has a population of 4 million people. RESULTS: Lower daily air temperature was significantly associated with higher fall-related hip fracture hospitalisations in 75+-year-olds: men aged 75-84 years, rate ratio (RR) for a 1°C increase in temperature of 0.98 with 95% confidence interval (0.96, 0.99), men 85+ years RR = 0.98 (0.96, 1.00), women 75-84 years RR = 0.99 (0.98, 1.00), women 85+ years RR = 0.98 (0.97, 0.99). Moreover, there were fewer hospitalisations on weekends compared to weekdays ranging from RR = 0.81 (0.73, 0.90) in women aged 65-74 years to RR = 0.89 (0.80, 0.98) in men aged 85+ years. CONCLUSIONS: After adjustment for season, day-of-week effects, long-term trend and autocorrelation, fall-related hip fracture hospitalisation rates are higher in both males and females aged 75+ years when there is a lower air temperature.

Spatial temporal modeling of hospitalizations for fall-related hip fractures in older people.

UNLABELLED: The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization and sociodemographic data. There was significant spatial temporal variation in hospitalized hip fracture rates in New South Wales, Australia. INTRODUCTION: The study determined the spatial temporal characteristics of fall-related hip fractures in the elderly using routinely collected injury hospitalization data. METHODS: All New South Wales (NSW), Australia residents aged 65+ years who were hospitalized for a fall-related hip fracture between 1 July 1998 and 30 June 2004 were included. Bayesian Poisson regression was used to model rates in local government areas (LGAs), allowing for the incorporation of spatial, temporal, and covariate effects. RESULTS: Hip fracture rates were significantly decreasing in one LGA, and there were no significant increases in any LGAs. The proportion of the population in residential aged care facilities was significantly associated with the rate of hospitalized hip fractures with a relative risk (RR) of 1.003 (95% credible interval 1.002, 1.004). Socioeconomic status was also related to hospitalized hip fractures with those in the third and fourth quintiles being at decreased risk of hip fracture compared to those in the least disadvantaged (fifth) quintile [RR = 0.837 (0.717, 0.972) and RR = 0.855 (0.743, 0.989) respectively]. CONCLUSIONS: There was significant spatial temporal variation in hospitalized hip fracture rates in NSW, Australia. The use of Bayesian methods was crucial to allow for spatial correlation, covariate effects, and LGA boundary changes.

Relative survival after hospitalisation for hip fracture in older people in New South Wales, Australia.

UNLABELLED: Survival after hospitalisation for hip fracture by age group and sex relative to survival in the general population was assessed in people aged 65+. Men had double the risk of death compared with women to 1 year, but age effects lasted only to 3 months. Clinical outcomes need to be improved. INTRODUCTION: We assessed the relative survival of hospitalised fall-related hip fracture patients aged 65+ years leaving hospital in New South Wales, Australia, between July 2000 and December 2003. METHOD: We carried out a population-based study of all hospital separations for NSW residents with a principal diagnosis of hip fracture (ICD-10-AM S72.0 to S72.2) and first external cause of fall (ICD-10-AM codes W00 to W19), linked to NSW death data. A total of 16,836 cases were included. Relative survival 3 to 36 months post-admission by 10-year age groups and sex was calculated, using NSW life tables for 2002-2004. Relative excess risk was modelled using a generalised linear model with Poisson error structure, using the life table data. RESULTS: One-year cumulative relative survival in 65- to 74-year-olds was 82% (men), 90% (women); in 85+-year-olds 65% (men), 80% (women). Men have a relative excess risk of death of 2.2 (95% CI 2.03-2.38) times that of women. Only 21% of deaths mention the hip fracture as contributing to death. CONCLUSION: There is a need to reduce the number of hip fractures and improve clinical outcomes for older people hospitalised with hip fractures.

Clustered data in sports research.

Clustered, or dependent, data, arise commonly in sports medicine and sports science research, particularly in studies of sports injury and biomechanics, particularly in sports injury trials that are randomised at team or club level, in cross-sectional surveys in which groups of individuals are studied and in studies with repeated measures designs. Clustering, or positive correlation among responses, arises because responses and outcomes from the same cluster will usually be more similar than from different clusters. Study designs with clustering will usually required an increased sample size when compared to those without clustering. Ignoring clustering in statistical analyses can also lead to misleading conclusions, including incorrect confidence intervals and p-values. Appropriate statistical analyses for clustered data must be adopted. This paper gives some examples of clustered data and discusses the implications of clustering on the design and analysis of studies in sports medicine and sports science research.