RESUMO
OBJECTIVE: The objective of this study is to investigate primary care use by men with recent onset of lower urinary tract symptoms (LUTS) to identify differences in presentation and investigation that may explain ethnic inequality in prostate cancer outcomes. METHODS: This is a multi-method study of men presenting LUTS to primary care. Two hundred seventy-four men completed a self-administered questionnaire, and 23 participated in face-to-face interviews. Regression analyses investigated ethnic differences in (a) the period between symptom onset and first primary care presentation (patient interval) and (b) the interval between first primary care presentation and investigation with prostate-specific antigen (PSA) and digital rectal examination (DRE). Interview data were analysed using thematic analysis. RESULTS: Half (144, 53%) reported a solitary first symptom, although multiple first symptoms were also common, particularly in Asian and Black men. There was no difference between ethnicities in patient interval or time from presentation to investigation. However, Asian men were offered less PSA testing (odds ratio 0.39; 95% confidence interval 0.17-0.92; p = 0.03). Qualitative data revealed ethnic differences in general practitioners' offer of DRE and PSA testing and highlighted limitations in doctor-patient communication and safety netting. CONCLUSION: Our study showed only small differences in primary care experiences, insufficient to explain ethnic inequalities in prostate cancer outcomes.
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Antígeno Prostático Específico , Neoplasias da Próstata , Exame Retal Digital , Humanos , Londres , Masculino , Atenção Primária à Saúde , Neoplasias da Próstata/diagnósticoRESUMO
Primary care physicians frequently evaluate patients with constipation. The history is crucial in uncovering warning symptoms and signs that warrant colonoscopy. Particular elements in the history and rectal examination also can provide clues regarding the underlying etiology. Regardless of etiology, lifestyle modifications, fiber, and laxatives are first-line therapies. Patients who fail first-line therapies can be offered second-line treatments and/or referred for testing of defecatory function. In those with severely refractory symptoms, referrals to a gastroenterologist and a surgeon should be considered.
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Constipação Intestinal/diagnóstico , Constipação Intestinal/tratamento farmacológico , Adulto , Colonoscopia , Constipação Intestinal/etiologia , Constipação Intestinal/fisiopatologia , Efeitos Psicossociais da Doença , Fibras na Dieta/uso terapêutico , Exame Retal Digital , Feminino , Humanos , Laxantes/uso terapêutico , Masculino , Manometria , Pessoa de Meia-Idade , Atenção Primária à Saúde , Qualidade de Vida , Fatores de RiscoRESUMO
ABSTRACT BACKGROUND: Population-wide screening for prostate cancer remains a controversial topic, given the need for an individualized approach to patients regarding the risks and benefits of prostate-specific antigen testing and digital rectal examination. OBJECTIVE: The aim of this study was to investigate the prevalence of, and factors associated with, prostate examination among men aged 45 or older. DESIGN AND SETTING: Cross-sectional population-based study developed in the city of Rio Grande (RS), Brazil. METHODS: The outcome of interest was a history of prostate examination (prostate-specific antigen testing or digital rectal examination). The following independent variables were analyzed: age group, skin color, marital status, schooling, economic level, leisure-time physical activity, smoking habits, excessive alcohol consumption, overweight, health insurance, visits to the doctor during the preceding year, hypertension and diabetes. After a two-stage sampling process, the final sample consisted of 281 male individuals. RESULTS: The prevalence of a history of prostate-specific antigen testing or digital rectal examination was 68.3% (95% confidence interval (CI): 62.2 to 74.5). The highest prevalence rates were observed among men aged 70 years or older (88%) and the lowest among smokers (36%). The following characteristics were found to be associated with the outcome: advanced age; marital status other than single; more schooling and higher economic status; practicing physical activity; non-smoking habits; overweight; having health insurance; and having visited a doctor during the preceding year. CONCLUSION: Approximately two thirds of the study population had been screened for prostate examination, mostly older individuals, with higher socioeconomic status and a healthier lifestyle.
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Humanos , Masculino , Pessoa de Meia-Idade , Idoso , Antígeno Prostático Específico/sangue , Exame Retal Digital/estatística & dados numéricos , Detecção Precoce de Câncer/estatística & dados numéricos , Neoplasias da Próstata/diagnóstico , Fatores Socioeconômicos , Brasil , Estudos Transversais , CidadesRESUMO
BACKGROUND: Population-wide screening for prostate cancer remains a controversial topic, given the need for an individualized approach to patients regarding the risks and benefits of prostate-specific antigen testing and digital rectal examination. OBJECTIVE: The aim of this study was to investigate the prevalence of, and factors associated with, prostate examination among men aged 45 or older. DESIGN AND SETTING: Cross-sectional population-based study developed in the city of Rio Grande (RS), Brazil. METHODS: The outcome of interest was a history of prostate examination (prostate-specific antigen testing or digital rectal examination). The following independent variables were analyzed: age group, skin color, marital status, schooling, economic level, leisure-time physical activity, smoking habits, excessive alcohol consumption, overweight, health insurance, visits to the doctor during the preceding year, hypertension and diabetes. After a two-stage sampling process, the final sample consisted of 281 male individuals. RESULTS: The prevalence of a history of prostate-specific antigen testing or digital rectal examination was 68.3% (95% confidence interval (CI): 62.2 to 74.5). The highest prevalence rates were observed among men aged 70 years or older (88%) and the lowest among smokers (36%). The following characteristics were found to be associated with the outcome: advanced age; marital status other than single; more schooling and higher economic status; practicing physical activity; non-smoking habits; overweight; having health insurance; and having visited a doctor during the preceding year. CONCLUSION: Approximately two thirds of the study population had been screened for prostate examination, mostly older individuals, with higher socioeconomic status and a healthier lifestyle.
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Exame Retal Digital , Detecção Precoce de Câncer , Antígeno Prostático Específico , Idoso , Brasil , Cidades , Estudos Transversais , Exame Retal Digital/estatística & dados numéricos , Detecção Precoce de Câncer/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/diagnóstico , Fatores SocioeconômicosRESUMO
BACKGROUND: Digital rectal examination is a difficult examination to learn and teach because of limited opportunities for practice; however, the main challenge is that students and tutors cannot see the finger when it is palpating the anal canal and prostate gland inside the patients. OBJECTIVE: This paper presents an augmented reality system to be used with benchtop models commonly available in medical schools with the aim of addressing the problem of lack of visualization. The system enables visualization of the examining finger, as well as of the internal organs when performing digital rectal examinations. Magnetic tracking sensors are used to track the movement of the finger, and a pressure sensor is used to monitor the applied pressure. By overlaying a virtual finger on the real finger and a virtual model on the benchtop model, students can see through the examination and finger maneuvers. METHODS: The system was implemented in the Unity game engine (Unity Technologies) and uses a first-generation HoloLens (Microsoft Inc) as an augmented reality device. To evaluate the system, 19 participants (9 clinicians who routinely performed digital rectal examinations and 10 medical students) were asked to use the system and answer 12 questions regarding the usefulness of the system. RESULTS: The system showed the movement of an examining finger in real time with a frame rate of 60 fps on the HoloLens and accurately aligned the virtual and real models with a mean error of 3.9 mm. Users found the movement of the finger was realistic (mean 3.9, SD 1.2); moreover, they found the visualization of the finger and internal organs were useful for teaching, learning, and assessment of digital rectal examinations (finger: mean 4.1, SD 1.1; organs: mean 4.6, SD 0.8), mainly targeting a novice group. CONCLUSIONS: The proposed augmented reality system was designed to improve teaching and learning of digital rectal examination skills by providing visualization of the finger and internal organs. The initial user study proved its applicability and usefulness.
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Realidade Aumentada , Competência Clínica/normas , Exame Retal Digital/normas , Educação Médica/métodos , HumanosRESUMO
BACKGROUND: Digital rectal examination (DRE) is one of the most common strategies for prostate cancer early detection. However, the use for screening purposes has a controversial benefit and potential harms can occur due to false-positive results, overdiagnosis and overtreatment. The objective of this study is to calculate the prevalence and identify factors associated with the receipt of DRE in Brazilian men. METHODS: We selected men older than 40 from a nationwide population-based survey (13,625 individuals) excluding those with prostate cancer diagnosis. Information was extracted from the most recent database of the Brazilian National Health Survey (PNS 2013). Statistical analysis was carried out to calculate incidence rate ratios, with 95% confidence intervals and p values, through multivariate analysis with Poisson regression and robust variance. RESULTS: Men having private health insurance (63.3%; CI = 60.5-66.0) presented higher prevalence of DRE than those in the public health system (41.6%; CI = 39.8-43.4). The results show a positive association between DRE and men having private health insurance, aged 60-69, living with a spouse, never smokers, and living in urban areas. Among public health services users, this positive association was observed among men aged 70-79, living with a spouse, having bad/very bad health self-perception, abstainers, ex-smokers, with undergraduate studies, presenting four or more comorbidities, and residing in urban areas. CONCLUSIONS: Prostate cancer screening with DRE is quite frequent in Brazil, specially among men with private health plans and better access to health services, healthier lifestyle and at more advanced ages, characteristics which increase the risk of overdiagnosis and overtreatment.
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Exame Retal Digital/estatística & dados numéricos , Detecção Precoce de Câncer/métodos , Neoplasias da Próstata/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Brasil , Estudos Transversais , Humanos , Seguro Saúde/estatística & dados numéricos , Masculino , Pessoa de Meia-IdadeRESUMO
OBJECTIVES: To determine if using a digital rectal examination (DRE) human volunteer improves medical students' confidence in performing DRE in comparison to using a simulated model alone. PARTICIPANTS AND METHODS: Medical students underwent randomization into one of two groups: a control group who underwent standard teaching and an intervention group who underwent standard teaching plus further tuition involving a DRE volunteer. Standard teaching involved a 30-min lecture and a practice DRE on a simulation model. The intervention group additionally observed a tutor demonstrating DRE on a volunteer, then conducted a DRE themselves under supervision. Before and after teaching, both groups completed a survey comprised of three questions. The primary endpoint was confidence in performing a DRE, which was assessed according to the sum of the scores from the three questions. RESULTS: In total, 48 students were randomized, 22 to the control group and 26 to the intervention group. The groups were well matched prior to teaching DRE (P = 0.76) After the DRE tutorial, students in the intervention group were more confident in knowing the indications for DRE (P = 0.001), more confident in their technique for performing DRE (P < 0.001) and more confident in their ability to assess findings accurately at DRE (P < 0.001). The primary outcome measure, overall confidence (sum of the scores from all three questions) in performing DRE, was significantly better in the intervention group (score 10/15 vs 14/15; P < 0.001). CONCLUSION: This study showed that teaching DRE with the assistance of volunteer patients improves inexperienced students' confidence in performing DRE, and the incorporation of such training should be considered in the DRE education programme.
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Competência Clínica/normas , Exame Retal Digital , Simulação de Paciente , Exame Físico , Atitude do Pessoal de Saúde , Austrália , Análise Custo-Benefício , Testes Diagnósticos de Rotina , Exame Retal Digital/métodos , Exame Retal Digital/normas , Educação de Graduação em Medicina , Humanos , Estudantes de Medicina , Análise e Desempenho de Tarefas , VoluntáriosRESUMO
A recent study showed that the Prostate Health Index may avoid unnecessary biopsies in men with prostate specific antigen 4-10ng/ml and normal digital rectal examination in the diagnosis of prostate cancer in Hong Kong. This study aimed to conduct an economic evaluation of the impact of adopting this commercially-available test in the Hong Kong public health service to determine whether further research is justified. A cost-consequence analysis was undertaken comparing the current diagnostic pathway with a proposed diagnostic pathway using the Prostate Health Index. Data for the model was taken from a prospective cohort study recruited at a single-institution and micro-costing studies. Using a cut off PHI score of 35 to avoid biopsy would cost HK$3,000 and save HK$7,988 per patient in biopsy costs and HK$511 from a reduction in biopsy-related adverse events. The net cost impact of the change was estimated to be HK$5,500 under base case assumptions. At the base case sensitivity and specificity for all grades of cancer (61.3% and 77.5% respectively) all grade cancer could be missed in 4.22% of the population and high grade cancer in 0.53%. The introduction of the prostate health index into the diagnostic pathway for prostate cancer in Hong Kong has the potential to reduce biopsies, biopsy costs and biopsy-related adverse events. Policy makers should consider the clinical and economic impact of this proposal.
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Exame Retal Digital/economia , Antígeno Prostático Específico/sangue , Próstata , Neoplasias da Próstata , Idoso , Biópsia/economia , Análise Custo-Benefício , Hong Kong , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Próstata/metabolismo , Próstata/patologia , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/economiaRESUMO
BACKGROUND: Active surveillance (AS) is a viable management option for approximately 50% of men who are newly diagnosed with prostate cancer. To the authors' knowledge, no direct comparisons between the different variants of AS protocols have been conducted to date. The authors developed a microsimulation decision model to evaluate which of 3 alternative AS protocols is optimal for men with low-risk prostate cancer, and compared each of these with immediate treatment. METHODS: Men who were diagnosed with low-risk prostate cancer at age 65 years were modeled as having been treated with either immediate therapy or via each of 3 AS protocols. Modeled AS protocols represent those in the literature; a modified AS protocol was included in a sensitivity analysis. Immediate therapy included radical prostatectomy, external-beam radiotherapy, or brachytherapy. Outcome measures were quality-adjusted life-years (QALYs) and costs. Cost-effectiveness analysis and deterministic and probabilistic sensitivity analyses were performed. RESULTS: Immediate therapy produced fewer QALYs than all variants of AS. Of the AS protocols evaluated, biennial biopsy was found to be the only efficient option, with an incremental cost-effectiveness ratio of $3490 per QALY compared with immediate therapy. It delayed the need for curative therapy by a mean of 56 months, and was found to be preferred in >86.9% of cases in probabilistic sensitivity analysis. A modified version of low-intensity AS dominated all other options. CONCLUSIONS: For a 65-year-old man with low-risk prostate cancer, AS with biennial biopsy appears to be highly cost-effective compared with common alternatives. An AS protocol using triennial biopsy was found to dominate all other strategies and should be considered for men who are comfortable with a longer period between biopsies. The optimal strategy depends on a patient's tolerance for periodic biopsies and comfort with delaying radical treatment. Physicians should incorporate these patient preferences into decision making.
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Antígenos de Superfície/economia , Biópsia/economia , Exame Retal Digital/economia , Glutamato Carboxipeptidase II/economia , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Conduta Expectante/economia , Idoso , Antígenos de Superfície/análise , Braquiterapia , Tomada de Decisão Clínica , Análise Custo-Benefício , Técnicas de Apoio para a Decisão , Glutamato Carboxipeptidase II/análise , Humanos , Masculino , Cadeias de Markov , Prostatectomia , Neoplasias da Próstata/metabolismo , Anos de Vida Ajustados por Qualidade de VidaRESUMO
Asians have a lower incidence of prostate cancer (PC). We compared the performance of the Prostate Health Index (PHI) for 2488 men in different ethnic groups (1688 Asian and 800 European men from 9 sites) with PSA 2-20ng/ml and PHI test and transrectal ultrasound-guided biopsy results available. Of these, 1652 men had PSA 2-10ng/ml and a normal digital rectal examination and underwent initial biopsy. The proportions of PC (Gleason ≥6) and higher-grade PC (HGPC, Gleason ≥7) across different PHI ranges were compared. The performance of PSA and PHI was compared using the area under the receiver operating characteristic curve (AUC) and decision curve analyses (DCA). Among Asian men, HGPC would be diagnosed in 1.0%, 1.9%, 13%, and 30% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >30), 56% of biopsies and 33% of Gleason 6 PC diagnoses could have been avoided. Among European men, HGPC would be diagnosed in 4.1%, 4.3%, 30%, and 34% of men using PHI thresholds of <25, 25-35, 35-55, and >55, respectively. At 90% sensitivity for HGPC (PHI >40), 40% of biopsies and 31% of Gleason 6 PC diagnoses could have been avoided. AUC and DCA confirmed the benefit of PHI over PSA. The benefit of PHI was also seen at repeat biopsy (n=397) and for PSA 10-20ng/ml (n=439). PHI is effective in cancer risk stratification for both European and Asian men. However, population-specific PHI reference ranges should be used. PATIENT SUMMARY: The Prostate Health Index (PHI) blood test helps to identify individuals at higher risk of prostate cancer among Asian and European men, and could significantly reduce unnecessary biopsies and overdiagnosis of prostate cancer. Different PHI reference ranges should be used for different ethnic groups.
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Povo Asiático , Indicadores Básicos de Saúde , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/etnologia , População Branca , Ásia/epidemiologia , Biópsia , Exame Retal Digital , Europa (Continente)/epidemiologia , Nível de Saúde , Humanos , Calicreínas/sangue , Masculino , Gradação de Tumores , Valor Preditivo dos Testes , Prevalência , Antígeno Prostático Específico/sangue , Valores de Referência , Reprodutibilidade dos Testes , Medição de Risco , Fatores de RiscoRESUMO
OBJECTIVE: To evaluate the performance of a rapid, low cost, noncontrast MRI examination as a secondary screening tool in detection of clinically significant prostate cancer. METHODS: In this prospective single institution study, 129 patients with elevated prostate-specific antigen levels or abnormal digital rectal examination findings underwent MRI with an abbreviated biparamatric MRI protocol consisting of high-resolution axial T2- and diffusion-weighted images. Index lesions were classified according to modified Prostate Imaging - Reporting and Data System (mPI-RADS) version 2.0. All patients underwent standard transrectal ultrasound-guided biopsy after MRI with the urologist being blinded to MRI results. Subsequently, all patients with suspicious lesions (mPI-RADS 3, 4, or 5) underwent cognitively guided targeted biopsy after discussion of MRI results with the urologist. Sensitivity and negative predictive value for identification of clinically significant prostate cancer (Gleason score 3+4 and above) were determined. RESULTS: Rapid biparametric MRI discovered 176 lesions identified in 129 patients. Rapid MRI detected clinically significant cancers with a sensitivity of 95.1% with a negative predictive value of 95.1% and positive predictive value of 53.2%, leading to a change in management in 10.8% of the patients. False negative rate of biparametric (bp) MRI was 4.7%. CONCLUSION: We found that a bp-MRI examination can detect clinically significant lesions and changed patient management in 10.8% of the patients. A rapid MRI protocol can be used as a useful secondary screening tool in men presenting with suspicion of prostate cancer.
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Imagem de Difusão por Ressonância Magnética/métodos , Próstata/diagnóstico por imagem , Neoplasias da Próstata/diagnóstico , Idoso , Análise Custo-Benefício , Imagem de Difusão por Ressonância Magnética/economia , Exame Retal Digital , Reações Falso-Negativas , Humanos , Biópsia Guiada por Imagem , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Valor Preditivo dos Testes , Estudos Prospectivos , Próstata/patologia , Antígeno Prostático Específico , Neoplasias da Próstata/sangue , Neoplasias da Próstata/patologia , Sensibilidade e Especificidade , Fatores de Tempo , Ultrassonografia de IntervençãoAssuntos
Detecção Precoce de Câncer/normas , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/diagnóstico , Ensaios Clínicos Controlados Aleatórios como Assunto , Exame Retal Digital , Detecção Precoce de Câncer/economia , Humanos , Masculino , Guias de Prática Clínica como Assunto , Estados UnidosRESUMO
BACKGROUND: Clinical trial results suggested that prostate-specific antigen (PSA) screening can reduce prostate cancer mortality. Nevertheless, because the specificity of the PSA test for cancer detection is low, it leads to many negative biopsies. The Beckman Coulter Prostate Health Index (PHI) testing demonstrates improved specificity compared with the PSA-only screening and therefore may improve the cost-effectiveness of prostate cancer detection. OBJECTIVE: To examine the cost-effectiveness of adding PHI testing to improve cancer detection for men with elevated serum PSA. METHODS: A microsimulation model, based on the results of the European Randomized Study of Screening for Prostate Cancer trial, was used to evaluate the effects of PSA screening and PHI reflex testing. We predicted the numbers of prostate cancers, negative biopsies, deaths, quality-adjusted life-years gained, and cost-effectiveness of both PSA (cutoff 3 ng/mL) and PHI (cutoff 25) testing methods for a European population, screened from age 50 to 75 years at 4-year intervals. RESULTS: When the PHI test was added to the PSA screening, for men with a PSA between 3 and 10 ng/mL, the model predicted a 23% reduction in negative biopsies. This would lead to a 17% reduction in costs for diagnostics and 1% reduction in total costs for prostate cancer. The cost-effectiveness (3.5% discounted) was 11% better. Limitations found were the modeling assumptions on the sensitivity and specificity of PHI by tumor stage and cutoff values. CONCLUSIONS: Compared with PSA-only screening, the use of a PHI test can substantially reduce the number of negative biopsies and improve the cost-effectiveness of prostate cancer detection.
Assuntos
Detecção Precoce de Câncer/economia , Custos de Cuidados de Saúde , Indicadores Básicos de Saúde , Nível de Saúde , Calicreínas/sangue , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/economia , Idoso , Biópsia/economia , Simulação por Computador , Redução de Custos , Análise Custo-Benefício , Exame Retal Digital/economia , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Econômicos , Valor Preditivo dos Testes , Prognóstico , Neoplasias da Próstata/sangue , Neoplasias da Próstata/mortalidade , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo , Procedimentos Desnecessários/economia , Regulação para CimaRESUMO
PURPOSE: To investigate the impact of multiparametric magnetic resonance imaging (mpMRI) on risk group assessment of patients with prostate cancer (PCa) initially addressed to external beam radiation therapy (EBRT). MATERIALS AND METHODS: We prospectively performed mpMRI (3.0Tsystem) in 44 patients addressed to EBRT, using a multiparametric protocol (high-resolution multiplanar T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging). Risk group was assessed in accordance with the National comprehensive cancer network (NCCN) categories, by combining prostate-specific-antigen level, Gleason score and the T-stage as established by digital rectal examination (clinical risk assessment; c-RA) versus mpMRI (mpMRI-risk assessment; mpMRI-RA). The agreement between c-RA and mpMRI-RA was investigated using Cohen's kappa. RESULTS: Patients were included in very low/low risk, intermediate risk, high risk, very high risk and metastatic NCCN categories in 10 (22.7%), 18 (40.9%), 15 (34.1%), 1 (2.3%) and 0 cases using c-RA vs. 8 (18.2%), 14 (31.8%), 14 (31.8%), 4 (9.1%) and 4 (9.1%) cases using mpMRI-RA, respectively, with only moderate agreement (k=0.43). mpMRI-RA determined risk downgrading in 2/44 patients (4.5%), and risk upgrading in 16/44 patients (36.3%). After mpMRI, EBRT remained indicated in all patients. CONCLUSION: mpMRI changed clinical risk stratification in about 41% of patients with PCa, with potential impact on EBRT planning.
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Imagem de Difusão por Ressonância Magnética/métodos , Neoplasias da Próstata/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Biópsia/métodos , Meios de Contraste , Exame Retal Digital/métodos , Gadolínio , Humanos , Aumento da Imagem/métodos , Processamento de Imagem Assistida por Computador/métodos , Masculino , Meglumina/análogos & derivados , Pessoa de Meia-Idade , Gradação de Tumores , Estadiamento de Neoplasias , Compostos Organometálicos , Planejamento de Assistência ao Paciente , Estudos Prospectivos , Antígeno Prostático Específico/análise , Medição de RiscoRESUMO
INTRODUCTION: Anal cancer in men who have sex with men (MSM) living with HIV is an important issue but there are no consistent guidelines for how to screen for this cancer. In settings where screening with anal cytology is unavailable, regular anal examinations have been proposed in some guidelines but their cost-effectiveness is unknown. METHODS: Our objective was to estimate the cost-effectiveness of regular anal examinations to screen for anal cancer in HIV-positive MSM living in Australia using a probabilistic Markov model. Data sources were based on the medical literature and a clinical trial of HIV-positive MSM receiving an annual anal examination in Australia. The main outcome measures for calculating effectiveness were undiscounted and discounted (at 3%) lifetime costs, life years gained, quality-adjusted life years (QALY) gained and incremental cost-effectiveness ratio (ICER). RESULTS: Base-case analysis estimated the average cost of screening for and management of anal cancer ranged from $195 for no screening to $1,915 for lifetime annual screening of men aged ≥ 50. Screening of men aged ≥ 50 generated ICERs of $29,760 per QALY gained (for screening every four years), $32,222 (every three years) and $45,484 (every two years). Uncertainty for ICERs was mostly influenced by the cost (financially and decrease in quality of life) from a false-positive result, progression rate of anal cancer, specificity of the anal examination, the probability of detection outside a screening program and the discount rate. CONCLUSIONS: Screening for anal cancer by incorporating regular anal examinations into routine HIV care for MSM aged ≥ 50 is most likely to be cost-effective by conventional standards. Given that anal pap smears are not widely available yet in many clinical settings, regular anal exams for MSM living with HIV to detect anal cancer earlier should be implemented.
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Neoplasias do Ânus/diagnóstico , Exame Retal Digital , Infecções por HIV/complicações , Homossexualidade Masculina , Adulto , Idoso , Análise Custo-Benefício , Humanos , Masculino , Pessoa de Meia-Idade , Anos de Vida Ajustados por Qualidade de VidaRESUMO
BACKGROUND: The Oregon Medicaid lottery provided a unique opportunity to assess the causal impacts of health insurance on cancer screening rates within the framework of a randomized controlled trial. Prior studies regarding the impacts of health insurance have almost always been limited to observational evidence, which cannot be used to make causal inferences. METHODS: The authors prospectively followed a representative panel of 16,204 individuals from the Oregon Medicaid lottery reservation list, collecting data before and after the Medicaid lottery drawings. The study panel was divided into 2 groups: a treatment group of individuals who were selected in the Medicaid lottery (6254 individuals) and a control group who were not (9950 individuals). The authors also created an elevated risk subpanel based on family cancer histories. One year after the lottery drawings, differences in cancer screening rates, preventive behaviors, and health status were compared between the study groups. RESULTS: Medicaid coverage resulted in significantly higher rates of several common cancer screenings, especially among women, as well as better primary care connections and self-reported health outcomes. There was little evidence found that acquiring Medicaid increased the adoption of preventive health behaviors that might reduce cancer risk. CONCLUSIONS: Medicaid coverage did not appear to directly impact lifestyle choices that might reduce cancer risk, but it did provide access to important care and screenings that could help to detect cancers earlier. These findings could have long-term population health implications for states considering or pursuing Medicaid expansion. Cancer 2016;122:791-797. © 2015 American Cancer Society.
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Detecção Precoce de Câncer/estatística & dados numéricos , Comportamentos Relacionados com a Saúde , Nível de Saúde , Cobertura do Seguro , Seguro Saúde , Medicaid/estatística & dados numéricos , Neoplasias/diagnóstico , Adolescente , Adulto , Neoplasias da Mama/diagnóstico , Colonoscopia , Neoplasias Colorretais/diagnóstico , Exame Retal Digital/estatística & dados numéricos , Feminino , Acessibilidade aos Serviços de Saúde , Disparidades nos Níveis de Saúde , Humanos , Masculino , Mamografia/estatística & dados numéricos , Pessoa de Meia-Idade , Neoplasias/prevenção & controle , Sangue Oculto , Oregon , Teste de Papanicolaou/estatística & dados numéricos , Vacinas contra Papillomavirus/uso terapêutico , Estudos Prospectivos , Neoplasias da Próstata/diagnóstico , Autorrelato , Fatores Sexuais , Estados Unidos , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/prevenção & controle , Esfregaço Vaginal/estatística & dados numéricos , Listas de Espera , Adulto JovemRESUMO
Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with acute onset pelvic pain which may or may not be related to voiding, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors. A documented history of recurrent urinary tract infections is the key feature of chronic bacterial prostatitis. Duration of symptoms > 3 months defines chronicity. The key symptom of chronic pelvic pain syndrome is pain. Patients may describe pain during or after ejaculation as their predominant symptom. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules. In acute bacterial prostatitis the MSU is the only laboratory investigation required. Chronic pelvic pain syndrome may be multifactorial and part of a more generalised pain disorder. Pelvic floor muscle abnormalities, altered neuroendocrine pathways, chemically induced inflammation, bacterial infection, autoimmune processes, dysfunctional voiding as well intraprostatic ductal reflux mechanisms have all been identified in men with chronic pelvic pain syndrome.
Assuntos
Sintomas do Trato Urinário Inferior/diagnóstico , Dor Pélvica/diagnóstico , Prostatite , Infecções Urinárias , Adulto , Diagnóstico Diferencial , Exame Retal Digital/métodos , Gerenciamento Clínico , Humanos , Masculino , Anamnese , Pessoa de Meia-Idade , Gravidade do Paciente , Prostatite/classificação , Prostatite/diagnóstico , Prostatite/etiologia , Prostatite/fisiopatologia , Prostatite/terapia , Avaliação de Sintomas , Urinálise/métodos , Infecções Urinárias/complicações , Infecções Urinárias/diagnóstico , Infecções Urinárias/urinaRESUMO
OBJECTIVES: To determine abdominal radiograph use and frequency of digital rectal examinations in children presenting to the emergency department (ED) with abdominal pain and suspected constipation and to determine the impact of an educational module on their use. STUDY DESIGN: Retrospective chart review of patients evaluated at a pediatric ED because of the complaint of abdominal pain who had the discharge diagnosis of constipation over two 2-month periods, one before and one after an educational module. RESULTS: Comparing pre- and posteducational module periods, there was a significant decrease in abdominal radiograph utilization (69.5% vs 26.4%, respectively, P ≤ .001) and significant increase in performance of digital rectal examination (22.9% vs 47.3%, respectively, P ≤ .001). We demonstrated a 33.6% reduction in abdominal radiograph in children who had a digital rectal examination as part of their examination. Overall, we demonstrated a 43.1% decrease in patients receiving an abdominal radiograph. When time and costs of an abdominal radiograph are considered, this results in significant cost savings. CONCLUSIONS: An educational module reviewing the established criteria for the diagnosis of constipation and presented to ED providers results in increased use of digital rectal examination and decreased use of abdominal radiograph in patients evaluated for abdominal pain and ultimately diagnosed with constipation. The change also was associated with reduction in cost and time and radiation exposure in the ED for these patients.
Assuntos
Constipação Intestinal/diagnóstico , Exame Retal Digital/estatística & dados numéricos , Serviço Hospitalar de Emergência , Capacitação em Serviço , Radiografia Abdominal/estatística & dados numéricos , Dor Abdominal/etiologia , Adolescente , Chicago , Criança , Pré-Escolar , Redução de Custos , Feminino , Humanos , Masculino , Corpo Clínico/educação , Profissionais de Enfermagem/educação , Estudos RetrospectivosRESUMO
BACKGROUND: The response to chemoradiotherapy (CRT) for rectal cancer can be assessed by clinical examination, consisting of digital rectal examination (DRE) and endoscopy, and by MRI. A high accuracy is required to select complete response (CR) for organ-preserving treatment. The aim of this study was to evaluate the value of clinical examination (endoscopy with or without biopsy and DRE), T2W-MRI, and diffusion-weighted MRI (DWI) for the detection of CR after CRT. METHODS: This prospective cohort study in a university hospital recruited 50 patients who underwent clinical assessment (DRE, endoscopy with or without biopsy), T2W-MRI, and DWI at 6-8 weeks after CRT. Confidence levels were used to score the likelihood of CR. The reference standard was histopathology or recurrence-free interval of >12 months in cases of wait-and-see approaches. Diagnostic performance was calculated by area under the receiver operator characteristics curve, with corresponding sensitivities and specificities. Strategies were assessed and compared by use of likelihood ratios. RESULTS: Seventeen (34 %) of 50 patients had a CR. Areas under the curve were 0.88 (0.78-1.00) for clinical assessment and 0.79 (0.66-0.92) for T2W-MRI and DWI. Combining the modalities led to a posttest probability for predicting a CR of 98 %. Conversely, when all modalities indicated residual tumor, 15 % of patients still experienced CR. CONCLUSIONS: Clinical assessment after CRT is the single most accurate modality for identification of CR after CRT. Addition of MRI with DWI further improves the diagnostic performance, and the combination can be recommended as the optimal strategy for a safe and accurate selection of CR after CRT.