A clinician-centred programme for behaviour change in the optimal use of staging investigations for newly diagnosed prostate cancer.

OBJECTIVES: To improve imaging utilisation and reduce the widespread overuse of staging investigations, in the form of computed tomography (CT) and whole-body bone scans for men with newly diagnosed prostate cancer in the Hunter region of NSW, Australia, by implementation of a multifaceted clinician-centred behaviour change programme. PATIENTS AND METHODS: Records of all patients with a new diagnosis of prostate cancer were reviewed prior to the intervention (July 2014 to July 2015), and the results of this audit were presented to participating urologists by a clinical champion. Urologists then underwent focused education based on current guidelines. Patterns of imaging use for staging were then re-evaluated (November 2015 to July 2016). Patients were stratified into low-, intermediate- and high-risk groups as described by the D'Amico classification system. RESULTS: A total of 144 patients were retrospectively enrolled into the study cohort. The use of diagnostic imaging for staging purposes significantly decreased in men with low- and intermediate-risk disease post intervention. In low-risk patients, the use of CT decreased from 43% to 0% (P = 0.01). A total of 21% of patients underwent bone scans in the pre-intervention group compared with18% in the post-intervention group (P = 0.84). In intermediate-risk patients, the use of CT decreased from 89% to 34% (P < 0.001), whilst the use of bone scan decreased from 63% to 37% (P = 0.02). In high-risk patients, the appropriate use of imaging was maintained, with CT performed in 87% compared with 85% and bone scan in 87% compared with 65% (P = 0.07). CONCLUSION: Our results show that a focused, clinician-centred education programme can lead to improved guideline adherence at a regional level. The assessment of trends and application of such a programme at a state-based or national level could be further assessed in the future with the help of registry data. This will be particularly important in future with the advent of advanced imaging, such as prostate-specific membrane antigen positron-emission tomography.

Learning science as a potential new source of understanding and improvement for continuing education and continuing professional development.

Learning science is an emerging interdisciplinary field that offers educators key insights about what happens in the brain when learning occurs. In addition to explanations about the learning process, which includes memory and involves different parts of the brain, learning science offers effective strategies to inform the planning and implementation of activities and programs in continuing education and continuing professional development. This article provides a brief description of learning, including the three key steps of encoding, consolidation and retrieval. The article also introduces four major learning-science strategies, known as distributed learning, retrieval practice, interleaving, and elaboration, which share the importance of considerable practice. Finally, the article describes how learning science aligns with the general findings from the most recent synthesis of systematic reviews about the effectiveness of continuing medical education.

Primary prostate lymphoma: a rare presentation of lower urinary tract symptoms in young aged patient.

Primary prostatic lymphoma is a rare prostate malignancy that accounts for 0.09% of prostate cancer and 0.1% of lymphoma. Clinical misdiagnosis is common as majority of cases present with non-specific urinary symptoms like other prostatic diseases or prostatic cancer. Early diagnosis is of significant paramount as prognosis is dependent on histological type and tumour staging at the time of diagnosis. Urologists should remain aware of rare histological types of prostate cancer as delayed diagnosis of primary prostate lymphoma can be detrimental and lead to advanced disease causing serious sequelae i.e renal failure in addition to the primary pathology.

Red blood cell survival in long-term dialysis patients.

BACKGROUND: Shortening of red blood cell (RBC) survival contributes to the anemia of chronic kidney disease. The toxic uremic environment accounts for the decreased RBC life span. The contribution of mechanical damage caused by hemodialysis to the shortened life span is unclear. Reductions up to 70% in RBC survival have been reported in uremic patients. To date, no accurate well-controlled RBC survival data exist in dialysis patients treated using different dialysis modalities and receiving erythropoiesis-stimulating agent (ESA) therapy. The aim of this study was to determine RBC survival in hemodialysis (HD) and peritoneal dialysis (PD) patients compared with healthy persons. STUDY DESIGN: Observational study. SETTING & PARTICIPANTS: 14 HD patients and 5 PD patients were recruited from the dialysis unit. Healthy volunteers (n = 14) age- and sex-matched to HD participants were included. All dialysis patients received either ESA therapy or regular iron supplementation. PREDICTOR: Dialysis patients versus age- and sex-matched healthy controls. OUTCOMES: RBC survival. MEASUREMENTS: RBC survival was determined using radioactive chromium labeling. RESULTS: More than 85% of dialysis patients were anemic (hemoglobin, 12.0 ± 1.1 g/dL); hemoglobin concentrations were not significantly different between HD and PD patients. Median RBC survival was significantly decreased by 20% in HD patients compared with healthy controls: 58.1 (25th-75th percentile, 54.6-71.2) versus 72.9 (25th-75th percentile, 63.4-87.8) days (P = 0.02). No difference was shown between the PD and HD groups: 55.3 (25th-75th percentile, 49.0-60.2) versus 58.1 (25th-75th percentile, 54.6-71.2) days (P = 0.2). LIMITATIONS: Label loss from RBCs associated with the chromium 51 labeling technique needs to be accounted for in the interpretation of RBC survival data. CONCLUSIONS: Despite current ESA therapy, decreased RBC survival contributes to chronic kidney disease-related anemia, although the reduction is less than previously reported. There does not appear to be net mechanical damage associated with HD therapy resulting in decreased RBC life span.

Effects of bariatric surgery on urinary and sexual function.

OBJECTIVE: To investigate the effects of weight loss and time post laparoscopic gastric banding surgery (LGB) on urinary and sexual function. MATERIALS AND METHODS: 653 females and 145 males who underwent LGB over the last 10 years at a single centre in Australia were contacted by post and asked to complete validated questionnaires. RESULTS: The pre-surgery body-mass index (BMI) was higher in males than females (47.3 vs 43.5); 65% of the females and 24% of males previously had some degree of urinary incontinence (UI). There were significant weight and BMI losses in males and females (23.2 kg and 7.51 vs 22.7 kg and 8.28; P < 0.0001). In females there were significant improvements in the ICIQ-SF (P= 0.0008) and Quality of Life (P < 0.0001) scores. For each kilogram lost there was a 0.05 improvement in the ICIQ score (P= 0.03) in females. There were also postoperative improvements in all symptoms of UI and stress incontinence in females but urge incontinence worsened, when adjusted for weight loss. In males there was no improvement in UI with weight loss after LGB. There was no relationship with time and UI in either gender; 83.3% of males reported a degree of ED before LGB. There was improvement in the IIEF score in males post LGB but there was worsening of erectile index (P= 0.005) and orgasmic function (P= 0.002) when adjusted for time. More males had started using phosphodiesterase type 5 inhibitors, post-LGB. CONCLUSIONS: Surgically induced weight loss by LGB improved overall UI, quality of life and stress incontinence in females but urge incontinence worsened. There was no improvement in UI with weight-loss or overall sexual function after LGB in males. However, erectile index and orgasmic function worsened when adjusted for time. Further evaluation is required by means of larger prospective studies involving urodynamic testing.

A comparison of fatigue correlates in rheumatoid arthritis and osteoarthritis: disparity in associations with disability, anxiety and sleep disturbance.

OBJECTIVES: To investigate correlates of fatigue among individuals with RA and OA, including mood, sleep, disease activity and radiographic damage. METHODS: Fatigue was assessed using the Multidimensional Assessment of Fatigue-Global Fatigue Index (MAF-GFI) in 103 patients with RA and 103 with OA. Sleep disturbance and pain were assessed using a visual analogue scale anxiety and depression using the Hospital Anxiety and Depression scale and disability using the HAQ. In the RA cohort, the disease activity score-28 joint count (DAS-28) and the Van der Heijde modified Sharp score were calculated, and in the OA cohort, the Kellgren-Lawrence score and the WOMAC score calculated. RESULTS: The MAF-GFI scores were higher in the OA cohort (P = 0.02). This was not significant after controlling for disability (P = 0.59). OA participants reported greater pain, disability, depression and sleeplessness than those with RA (all P < 0.01). The strongest correlates of fatigue in the RA cohort were depression (P < 0.001) and anxiety (P < 0.001). There was no significant association with pain (P = 0.43), DAS-28 (P = 0.07), HAQ (P = 0.10) or Sharp score (P = 0.78). In OA, the correlates of fatigue were older age (P = 0.02), sleep disturbance (P = 0.03), depression (P = 0.04), disability (P = 0.04) and lower CRP (P = 0.001). CONCLUSIONS: Fatigue is common and severe in both RA and OA. In RA, fatigue had no significant association with pain, disease activity, disability or erosions, but was associated with depression and anxiety. The disparity in correlates indicates that generalizing the experience of fatigue between OA and RA is not appropriate. Fatigue is an important domain in the assessment of disease impact.

What arteries are detectable in the precarinal space on contrast-enhanced CT?

Although the precarinal space is critical in the interpretation of computed tomography (CT) of the thorax, vascular structures within the space have not been well documented. The aim of this study was to investigate vascular structures in the precarinal space that are detectable with contrast-enhanced CT scans. Contrast-enhanced CT chest scans from 90 patients aged 17-78 years (41 male, 49 female) were analyzed retrospectively. Twenty-two cadavers aged 54-93 years (13 male, 9 female) were used for gross anatomic study. We found that 9 of 90 cases of the contrast-enhanced CT scans had vessel-like structures detectable in the precarinal space, located primarily anterior to the right main bronchus. Single or double arteries were identified in the precarinal space of 19 cadavers. Thirteen of the 23 arteries observed were the right bronchial artery and 10 were the left bronchial artery. In two cadavers, a single right bronchial artery (2.5 and 4.0 mm in diameter), which could have been detected with contrast-enhanced CT, originated from the aortic arch and the root of the left subclavian artery and coursed in the precarinal space. Based on the variation in the location and size of the bronchial arteries observed in this study, we suggest that vascular structures are detectable in the precarinal space with contrast-enhanced CT, particularly anterior to the right main bronchus.