Consistent predictive ability of prostate-specific antigen density prediction model for clinically significant prostate cancer across age strata.

BACKGROUND: Prebiopsy prostate-specific antigen density (PSAD) is a well-known predictor of clinically significant prostate cancer (csPCa). Since prostate-specific antigen (PSA) and prostate volume (PV) increase normally with aging, PSAD thresholds may vary. The purpose of the study was to determine if PSAD was predictive of csPCa in different age strata. METHODS: We retrospectively reviewed our institutional database for patients who underwent multiparametric magnetic resonance imaging (MRI) between January 2016 and December 2021. We included patients who had post-MRI prostate biopsies. Based on age, we divided our cohort into four subgroups (groups 1-4): <55, 55-64, 65-74, and ≥75 years old. PSAD accuracy was estimated by the area under the curve (AUC) as a predictive model for differentiating csPCa between the groups. CsPCa was defined as a Gleason Grade Group 2 or higher. Three different PSAD thresholds (0.1, 0.15, and 0.2) were tested across the groups for sensitivity, specificity, and positive predictive value (PPV) and negative predictive value (NPV). Chi-square and analysis of variance tests were used for bivariate analysis. All analys were completed using R 4.3 (R Core Team, 2023). RESULTS: Among 1913 patients, 883 (46.1%) had prostate biopsies. In groups 1, 2, 3, and 4, there were 62 (7%), 321 (36.4%), 404 (45.8%), and 96 (10.9%) patients, respectively. Median PSA was 5.6 (interquartile range 3.4-8.1), 6.2 (4.8-9), 6.8 (5.1-9.7), and 9 (5.6-13), respectively (p < 0.01). Median PV was 42.3 (30-62), 51 (36-77), 55.5 (38-85.9), and 59.3 (42-110) mL, respectively (p < 0.01). No difference was observed in median PSAD between age groups 1-4 (0.1 [0.07-0.16], 0.11 [0.08-0.18], 0.1 [0.07-0.19], and 0.1 [0.07-0.2]), respectively (p = 0.393). CsPCa was diagnosed in 241 (27.3%) patients, of which 10 (16.1%), 65 (20.2%), 121 (30%), and 45 (46.7%) were in groups 1-4, respectively (p < 0.001). For groups 1-4, the PSAD AUC for predicting csPCa was 0.75, 0.68, 0.71, and 0.74. While testing PSAD threshold of 0.15 across the different age groups (1-4), the PPV vs. NPV was 39.1 vs. 93.2, 33.6 vs. 87, 50.9 vs. 80.8, and 66.1 vs. 64.7, respectively. CONCLUSIONS: PSAD prediction model was found to be similar among different age groups. In young patients, PSAD had a high NPV but low PPV. With increasing age, the opposite trend was observed, likely due to higher disease prevalence. While PSAD thresholds may be less useful in older patients to rule out higher-grade prostate cancer, the clinical consequences of these diagnoses require a case-by-case evaluation.

Development of a clinical risk calculator for prolonged opioid use after shoulder surgery.

BACKGROUND: Understanding risk factors associated with prolonged opioid use to help mitigate abuse and develop presurgical screening programs to identify at-risk patients is paramount. The purpose of this study was to develop and validate a clinical risk assessment tool to preoperatively predict prolonged opioid use after shoulder surgery. METHODS: A total of 561 patients who underwent shoulder surgery within a tertiary health care system were identified, and opioid prescription data were retrospectively collected from the Connecticut Prescription Monitoring and Reporting System. The inclusion criteria were patients aged 18 years or older, and the exclusion criteria were patients not registered in the Connecticut Prescription Monitoring and Reporting System. Quantities of opioids prescribed were documented. Demographic characteristics, surgery type, medications, and medical comorbidities were identified by chart abstraction. Logistic regression was used to calculate odds ratios of patients using opioids longer than 6 weeks, and multivariate analysis was performed on 10 identified patient factors. A concordance index was used to calculate the discriminatory ability of a nomogram to predict prolonged opioid use. RESULTS: Multivariate analysis demonstrated that opioid use prior to surgery, insurance type, procedure type, body mass index, smoking status, and psychiatric disorders were responsible for prolonged opioid use. The prediction accuracy of this model was good, with a calculated concordance index of 0.766 (95% confidence interval, 0.736-0.820). CONCLUSIONS: We present a preoperative predictive calculator to help identify at-risk patients and quantify their risk of prolonged opioid use after shoulder surgery. This is a valuable clinical decision-making tool to identify patients benefitting from referral to pain management specialists and to possibly reduce the risk of opioid abuse and addiction.

Highlighting Gender Differences in RLS: Analysis of Gender in Robotic and Laparoscopic Surgical Volume in Urology Vs Other Subspecialties.

OBJECTIVE: To evaluate the involvement of women surgeons in RLS over time and across fields. While women are an increasing proportion of the urological workforce, the overall percentage of women urologists remains low. As robotic/laparoscopic surgery (RLS) has become first-line for many surgical problems, we hypothesized that women in urology may have lower participation than other specialties. MATERIALS AND METHODS: We obtained country-wide data by surgeon from the Data.CMS.gov database for 2014-2019 for major RLS procedures in colorectal surgery, gynecology, thoracic surgery, and urology. Data were sorted by gender and CPT code. Temporal trends were assessed, and estimation was performed by exponential regression comparing means and rates of change between departments and surgeon genders. RESULTS: Surgeons across disciplines and genders showed increases in RLS volume over time (P <.05). There were significant differences between men and women surgeons between specialties in average number of surgeons (P <.0001) and rate of change over time (P = .0035). The difference of the rate of increase in the number of surgeons performing RLS between genders was significant for all disciplines, suggesting women were entering RLS surgery faster than men across specialties (P <.05). CONCLUSION: There is a disparity in RLS procedure performance in men vs women across surgical disciplines. The greatest discrepancy in participation between genders existed in Urology, despite the field having a higher percentage of women physicians than other some subspecialties. Targeted action to address barriers to women surgeons' participation in RLS will increase diversity of thought and improve clinical care.

Validation of PROMIS Global-10 compared with legacy instruments in patients with shoulder instability.

BACKGROUND: Outcomes instruments are used to measure patients' subjective assessment of health status. The Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 was developed to be a concise yet comprehensive instrument that provides physical and mental health scores and an estimated EuroQol-5 Dimension (EQ-5D) score. METHODS: A total of 175 prospectively enrolled patients with shoulder instability completed the PROMIS Global-10, EQ-5D, American Shoulder and Elbow Surgeons (ASES), Single Assessment Numeric Evaluation (SANE), and Western Ontario Shoulder Instability Index. Spearman correlations between PROMIS scores and the legacy instruments were calculated. Bland-Altman analysis assessed agreement between estimated and actual EQ-5D scores. Floor and ceiling effects were recorded. RESULTS: Correlation between actual and estimated EQ-5D was excellent-good (0.64/p < 0.0005), but Bland-Altman agreement revealed high variability for estimated EQ-5D scores (95% CI: -0.30 to +0.34). Correlation of PROMIS physical scores was excellent-good with ASES (0.69/p < 0.0005), good with SANE (0.43/p<0.0005), and poor with WOSI (0.17/p = 0.13). Correlation between PROMIS mental scores and all legacy instruments was poor. CONCLUSIONS: PROMIS Global-10 physical function scores show high correlation with ASES but poor correlation with other legacy instruments, suggesting it is an unreliable outcomes instrument in populations with shoulder instability. The PROMIS Global-10 cannot replace actual EQ-5D scores for cost-effectiveness assessment in this population. LEVEL OF EVIDENCE: Level II, study of diagnostic test.