52-year-old man • erectile dysfunction • insomnia • migraine headaches • disclosure of infidelity.

► Erectile dysfunction ►Insomnia ► Migraine headaches ►Disclosure of infidelity.

Racial Disparities in Prostate Specific Antigen Screening and Referral to Urology in a Large, Integrated Health Care System: A Retrospective Cohort Study.

PURPOSE: Contemporary trends and racial disparities in prostate cancer screening and referral to urology for prostate cancer risk are not well characterized, despite consensus that Black men are at higher risk for poor prostate cancer outcomes. The objective of this study was to characterize current racial disparities in prostate cancer screening and referral from primary care to urology for prostate cancer concern within our large, integrated health care system. MATERIALS AND METHODS: This retrospective cohort study used data from Atrium Health's enterprise data warehouse, which includes patient information from more than 900 care locations across North Carolina, South Carolina and Georgia. We included all men seen in the ambulatory or outpatient setting between 2014 and 2019 who were ≥40 years old. Clinical and demographic data were collected for all men, including age and race. Racial outcomes were reported for all groups with >2% representation in the population. Between-group comparisons were determined using chi-squared analysis, Wilcoxon rank sum testing and multivariable logistic regression, with significance defined as p <0.05. RESULTS: We observed a significant decrease in prostate specific antigen testing across all age and racial groups in a cohort of 606,985 men at Atrium Health, including 87,189 Black men, with an overall relative decline of 56%. As compared to White men, Black men were more likely to undergo prostate specific antigen testing (adjusted OR 1.24, 95% CI 1.22-1.26) and be referred to urology for prostate cancer (adjusted OR 1.94, 95% CI 1.75-2.16). CONCLUSIONS: There was a continued significant decline in prostate cancer screening between 2014 and 2019. Despite having modestly elevated odds of being screened for prostate cancer compared to White men, Black men are relatively underscreened when considering that those who undergo prostate specific antigen screening are more likely to be referred by primary care to urology for additional prostate cancer diagnostic evaluation.

Diabetes update: screening and diagnosis.

Busy primary care physicians who want their patients with type 2 diabetes to live longer and better should, as much as possible, base screening and management decisions on patient-oriented evidence that affects morbidity and mortality. Because patients with dual diagnoses of diabetes and hypertension have a high risk of cardiovascular mortality, asymptomatic patients with hypertension should be screened for type 2 diabetes. Screening is conducted using a fasting plasma glucose test, a random A1c test, or a 2-hour oral glucose tolerance test. For obese patients, efforts to prevent diabetes focus on weight reduction and moderate physical activity. In high-risk patients, use of metformin could delay diabetes onset. Diabetes is diagnosed on the basis of an abnormal A1c level, fasting plasma glucose level, or 2-hour oral glucose tolerance test or a symptomatic random plasma glucose level. After diabetes is diagnosed, the physician should obtain blood pressure, body mass index, a lipid panel (fasting not required), kidney function tests, and A1c test, and review vaccination and smoking status. Increased exercise and dietary modification should be recommended. For most patients with newly diagnosed diabetes, metformin should be initiated. Risk factors for cardiovascular disease should be evaluated; use of daily low-dose aspirin may be considered. Patients who meet treatment criteria for high cholesterol levels should take a statin, and patients with unacceptably elevated blood pressure should take an antihypertensive drug.

Diabetes update: long-term treatment of adults.

Current evidence supports a less interventional, less aggressive, and more patient-oriented approach to the care of patients with diabetes than is commonly followed. When treating an adult patient with type 2 diabetes, the physician must focus on the following (in order of importance): smoking cessation and other lifestyle interventions, blood pressure control, metformin use, lipid control, and glycemic control. Patients also should receive influenza and pneumococcal vaccinations. Management goals should be individualized, but general target values are blood pressure of 140/80 mm Hg, low-density lipoprotein less than 100 mg/dL (or 70 mg/dL in a patient with diabetes and coronary artery disease, according to consensus opinion), and A1c less than 8%. Hypertension control is important; a thiazide or angiotensin-converting enzyme inhibitor might be the best first-line treatment. Metformin is the foundation of treatment for most patients with type 2 diabetes; in patients who are overweight, use of metformin delays premature mortality regardless of achieved glucose levels. Statin drugs are superior to other drugs for cholesterol reduction. The use of combination or high-intensity drugs does not appear to confer additional benefit.

Should we be teaching information management instead of evidence-based medicine?

BACKGROUND: To encourage high-quality patient care guided by the best evidence, many medical schools and residencies are teaching techniques for critically evaluating the medical literature. While a large step forward in many regards, these skills of evidence-based medicine are necessary but not sufficient for the practice of contemporary medicine and surgery. Incorporating the best evidence into the real world of busy clinical practice requires the applied science of information management. Clinicians must learn the techniques and skills to focus on finding, evaluating, and using information at the point of care. This information must be both relevant to themselves and their patients and be valid. WHERE ARE WE NOW?: Today, orthopaedic surgery is in the post-Flexner era of passive didactic learning combined with the practical experience of surgery as taught by supervising experts. The medical student and house officer fill their memory with mountains of facts and classic references 'just in case' that information is needed. With libraries and now internet repositories of orthopaedic information, all orthopaedic knowledge can be readily accessed without having to store much in one's memory. Evidence is often trumped by the opinion of a teacher or expert in the field. WHERE DO WE NEED TO GO?: To improve the quality of orthopaedic surgery there should be application of the best evidence, changing practice where needed when evidence is available. To apply evidence, the evidence has to find a way into practice without the long pipeline of change that now exists. Evidence should trump opinion and unfounded practices. HOW DO WE GET THERE?: To create a curriculum and learning space for information management requires effort on the part of medical schools, residency programs and health systems. Internet sources need to be created that have the readily available evidence-based answers to patient issues so surgeons do not need to spend all the time necessary to research the questions on their own. Information management is built on a platform created by EBM but saves the surgeon time and improves accuracy by having experts validate the evidence and make it easily available.

Diagnosis and management of endometriosis.

Signs and symptoms of endometriosis are nonspecific, and an acceptably accurate noninvasive diagnostic test has yet to be reported. Serum markers do not provide adequate diagnostic accuracy. The preferred method for diagnosis of endometriosis is surgical visual inspection of pelvic organs with histologic confirmation. Such diagnosis requires an experienced surgeon because the varied appearance of the disease allows less-obvious lesions to be overlooked. Empiric use of nonsteroidal anti-inflammatory drugs or acetaminophen is a reasonable symptomatic treatment, but the effectiveness of these agents has not been well-studied. Oral contraceptive pills, medroxyprogesterone acetate, and intrauterine levonorgestrel are relatively effective for pain relief. Danazol and various gonadotropin-releasing hormone analogues also are effective but may have significant side effects. There is limited evidence that surgical ablation of endometriotic deposits may decrease pain and increase fertility rates in women with endometriosis. Presacral neurectomy is particularly beneficial in women with midline pelvic pain. Hysterectomy and bilateral salpingo-oophorectomy definitively treat pain from endometriosis at 10 years in 90 percent of patients.