Primary intracerebral hemorrhage: impact of CT on incidence.

From 1975-1979, the incidence of primary intracerebral hemorrhage (PIH) increased in Rochester, MN, when compared with a previously decreasing incidence. Judging from patients with PIH who were alert at diagnosis, we estimated that 24% of the hemorrhages in earlier years had been mislabeled as infarction. The 30-day survival rate increased from 8% in 1945-1974 to 44% in 1975-1979. The incidence rate was about 45% higher in patients receiving anticoagulant treatment than in those who did not. The increased incidence rate and improved survivorship were attributed to more frequent identification of small PIH by CT.

The continuing decline in the incidence of stroke.

The incidence of stroke has continued to decline in the population of Rochester, Minnesota, up to the end of the last decade. The rate of occurrence of new episodes of stroke in the period 1975-1979 was only 46% of the equivalent rate during the period 1945-1949. The magnitude of the decline in incidence rates was similar in both sexes, but the timing differed. Females showed a progressive decline beginning early in the period of observation, but most of the decline in males occurred in the last 10 years of the study.

Limb fractures in a defined population. I. Frequency and distribution.

This population-based study revealed that 2,519 limb fractures occurring during a 3-year period produced an age-adjusted incidence rate for all limb fractures of 1,596 per 100,000 person-years. Fractures of the upper limb had a bimodal age distribution and were commoner than those of the lower limb, which had a J-shaped age distribution. The most frequent anatomic site was the lower end of the radius and ulna. Limb fractures occurred as solitary events in 93% of cases; only 4% were classified as open and more than half of the total were closed and undisplaced. Fractures were distributed evenly throughout all time periods of the day. The commonest place of fracture occurrence was the home, and the most important direct cause was falls, particularly in females. A wide range of sports activities were a major source of fractures, particularly in younger males. Underlying bone pathology was uncommon, other contributory causes being more important, particularly in the elderly. The increased ratio of metaphyseal to diaphyseal fractures with age indicated a relative loss of cancellous bone in the elderly, but no evidence was found to suggest that elderly women had reduced resistance of bone to impact forces in comparison with elderly men.

Limb fractures in a defined population. II. Orthopedic treatment and utilization of health care.

This study describes the orthopedic treatment and utilization of health care obtained by 2,333 patients in the population of Rochester, Minnesota, who suffered 2,519 limb fractures during the period 1969 through 1971. Overall, 24% of fracture occurrences required patient hospitalization, the remainder involving care on an ambulatory basis only. The mean number of physician visits was 4.5 per fracture, with the visits occurring during an interval of 103 days from the time of first evaluation. Fifteen percent of limb fractures were subject to at least one surgical operative procedure as part of their orthopedic treatment. The frequency of operative treatment increased markedly with patient age. Seventeen percent of patients with limb fractures received physiotherapy or occupational therapy or both, 4% were ambulatory patients, and the remainder were hospital inpatients. Fractures of the head and neck of the femur constituted only about 7% of fractures in the series, yet utilized an inordinate proportion of health care resources. Hip fractures were responsible for 27% of the hospital admissions, 52% of all bed days utilized, and 56% of the physiotherapy sessions.

Correlation between prostate size estimated by digital rectal examination and measured by transrectal ultrasound.

OBJECTIVES: To correlate prostate size estimates performed by single or multiple examiners through digital rectal examination (DRE) with volume measured by transrectal ultrasound (TRUS) and to propose measures for predicting prostate volume using DRE estimates in clinical settings. METHODS: Data from four sources were analyzed: (1) the Olmsted County community study of 397 patients examined by a single urology nurse, with TRUS measurements done by multiple examiners; (2) a community study in Stirling, Scotland, involving 480 patients with DRE and TRUS performed by one urologist; (3) baseline data from the Veterans Affairs Cooperative Study No. 359 in 1222 patients with DRE and TRUS measurements by multiple personnel at 31 centers; and (4) a clinical series of 100 men with DRE and TRUS by a single urologist. RESULTS: DRE estimates and TRUS volumes were significantly correlated (r = 0.4 to 0.9), but prostate size was underestimated by 25% to 55% for men with a prostate volume over 40 mL, depending on the study, with greater variability for studies involving multiple examiners. In one study that assessed prostate dimensions by DRE, posterior surface area (SA) correlated with overall TRUS volume (r = 0.4). According to receiver operating characteristic curves, SA showed a 70% and 76% chance of correctly identifying men with prostate volume greater than 30 or 40 mL, respectively; those with larger prostates were best distinguished by SA greater than 7 cm2 (sensitivity greater than 0.74, specificity greater than 0.50). CONCLUSIONS: DRE underestimates prostate size, particularly if TRUS volume is greater than 30 mL. However, DRE estimates may help identify prostates likely to be larger than certain cutpoints by TRUS. Posterior SA may be useful as a preliminary assessment when prostate size is an important predictor of therapeutic response.

Health-related quality of life associated with lower urinary tract symptoms in four countries.

OBJECTIVES: To describe health-related quality of life (HRQL) associated with lower urinary tract symptoms (LUTS) assessed by validated questionnaires in four countries. METHODS: More than 6000 men, recruited by using community- or population-based sampling in four countries, completed questionnaires soliciting information about urinary symptom frequency, bother, degree of interference with daily activities, and other measures of HRQL. RESULTS: In all countries, disease-specific HRQL worsened with increasing age. Adjusting for age, most disease-specific HRQL measures were significantly worse with increasing symptom severity. The correlation between symptoms and HRQL was strongest in countries with higher prevalence of symptoms, such as Japan or the United States, and less pronounced in countries with lower prevalence (France, Scotland), possibly reflecting the lower variability in scores. CONCLUSIONS: HRQL measures are worse in older men, and increased urinary symptom severity is associated with worse disease-specific HRQL in all countries, despite potential cross-cultural differences in disease prevalence, medication use, perceptions, or willingness to report symptoms or worse HRQL. This cross-cultural consistency suggests that an assessment of symptom bother or interference with daily activities may be useful in patient evaluation.

The quality of health services research in medical practice in the United Kingdom.

STUDY OBJECTIVE: The aim was to determine the scope and quality of published health services research concerned with medical practice in the United Kingdom. DESIGN: Scope of health services research was reviewed in articles published in 41 medical and public health journals in 1985. In random sample of 60 papers stratified by study design, 18 key research parameters were assessed for the quality of reporting and application in the studies. MAIN RESULTS: Over 80% of the research described in 246 articles was carried out by clinicians, mostly without acknowledged epidemiological or statistical assistance. More than half the studies were descriptive and only 17% were trials. In studies of hospital services, 4% covered long term care, in contrast to 67% concerned with inpatient care. One third of studies were conducted in general practice but only 10% of these included an assessment of clinical outcome. Important research parameters were often not reported; for example, response rates were missing in 52% of the studies, and comparability of cases and controls was not stated in 42% of relevant studies. Major inadequacies were found in the conduct of research, particularly in the selection of controls, allowance for confounding factors, objectivity of measurements, application of statistical tests, and conclusions reached. CONCLUSIONS: Published health services research concerned with medical practice in the United Kingdom is often conducted by clinicians without expert assistance. The quality of reporting and methods employed are deficient in many respects. Short training courses and other initiatives are required to enhance the quality of health services research in medical practice.

The triage of stroke rehabilitation.

In this paper we describe the use of triage to select patients for a trial in which a comparison was made of the effectiveness of a stroke unit and medical units in the rehabilitation of acute stroke. Completing the triage for hospital admission of stroke enabled an estimate to be made of the size of a stroke unit per unit of population.

Reproducibility and observer variability of transrectal ultrasound measurements of prostatic volume.

Transrectal ultrasound (TRUS) is an established investigation in benign and malignant prostatic disease though the level of reproducibility of TRUS volume measurements is not known. A group of observers in the UK and the USA who were participating in linked prospective studies of benign prostatic hyperplasia each carried out measurements during real-time scanning and on a series of static TRUS images. Results demonstrated good reproducibility for measurements of antero-posterior, transverse, and longitudinal dimensions of the prostate by an experienced UK urologist; only a minor degree of interobserver variation occurred in measurements made between experienced UK and USA observers. Using static images, USA observers obtained results that were in good agreement, whereas the UK observers, only two of whom used TRUS regularly, were in poor agreement with each other. This study demonstrates a high level of reproducibility for TRUS volume measurements performed by experienced observers.

Consultation patterns in a community survey of men with benign prostatic hyperplasia.

BACKGROUND: The Stirling benign prostatic hyperplasia natural history group have previously reported a prevalence of this condition of 255 per 1000 in a community study of 1610 men aged 40-79 years. AIM: It was decided to examine the consultation patterns of men with benign prostatic hyperplasia in greater detail. METHOD: All participating men were invited to complete a previously validated lifestyle questionnaire including questions on consultations with their general practitioner during the previous year and previous history of prostatic problems. The men who had a urinary symptom score greater than 11, or who had a urinary flow rate of less than 15 ml per second were examined by transurethral ultrasonography for prostate size. RESULTS: Of 364 men with benign prostatic hyperplasia, 89% had not consulted their doctor about urinary symptoms in the year prior to the study. Men with moderate to severe urinary symptoms were six times more likely to have consulted their doctor than those with mild symptoms. Moderate to severe symptoms and greater interference with daily living activities were both associated with a greater likelihood of consultation, independent of age. Of all the men in the study referred to the specialist clinic for assessment of prostate size by transurethral ultrasonography, two thirds were referred because of low urinary flow rate and one third because of high urinary symptom scores. The reported consultation data showed a reverse ratio of one third of those consulting having a low urinary flow rate and approximately two thirds having urinary symptoms. CONCLUSION: While mass screening is unjustified, there is a need for patient education about benign prostatic hyperplasia in general and the recognition of declining strength of urinary flow as a symptom of benign prostatic hyperplasia and not of ageing alone. Furthermore, evaluation of primary care use of urinary flowmeters and the development of local protocols are suggested as elements of a case finding strategy for benign prostatic hyperplasia based on patient led consultation.

Perceptions of urinary symptoms and health-care-seeking behaviour amongst men aged 40-79 years.

BACKGROUND: Little is known about why men fail to seek medical help for urological symptoms. AIM: This study was designed to document men's perceptions of urinary symptoms and to increase understanding of health-care-seeking behaviour. METHOD: A stratified random sample of men aged 40-79 years was drawn from the age-sex register of a health centre in Central Scotland. Two hundred men were interviewed using semi-structured qualitative techniques and asked to complete a symptom questionnaire. The response rate was 65%. RESULTS: Urinary symptoms reported to be most bothersome were dribbling, hesitancy and straining. All but the youngest age group (40-49 years) associated developing urinary symptoms with ageing. This was considered to be a reason not to consult a doctor. Most symptoms were not thought to be serious. Pain, haematuria and acute retention gave cause for concern, and were perceived as reasons for seeking medical help. Although urinary symptoms interfered with selected activities in daily life, this was not a worry to the men and was not seen to be a sufficient reason alone to consult their general practitioner. CONCLUSION: The insidious development of urinary problems over time reinforces the belief that it is part of getting older and accounts for the accommodation of symptoms within men's everyday living experiences. Bothersomeness associated with urinary symptoms was not synonymous with worry or problems. Doctors must be prepared to initiate discussion about urinary function in order to assess the impact of symptoms on an individual's daily life.

Impact of previously unrecognized benign prostatic hyperplasia on the daily activities of middle-aged and elderly men.

To assess the importance of benign prostatic hyperplasia on activities of daily living, a cross-sectional survey of 1627 men aged 40-79 years (representing a 65% response rate) registered with two health centres in central Scotland was carried out, using a urinary symptom questionnaire and uroflowmetry to identify men more likely to have benign prostatic hyperplasia. The condition was defined as a prostate gland of more than 20 g in the presence of symptoms of urinary dysfunction and/or a peak flow rate of less than 15 ml s-1, without evidence of malignancy. Transrectal ultrasonography was used to measure the volume (and by inference weight) of prostate glands. A total of 410 men satisfied the criteria for benign prostatic hyperplasia. Overall, 51% of men with benign prostatic hyperplasia reported interference with at least one of a number of selected activities of daily living as a result of urinary dysfunction, compared with 28% of men who did not have this condition. In 17% of men of working age (40-64 years) with benign prostatic hyperplasia, this interference occurred most or all of the time for at least one activity of daily living compared with only 3% of men in the same age group who did not have this condition. If the criteria of unmet need for treatment of benign prostatic hyperplasia constitutes interference by urinary dysfunction most or all of the time in at least one activity of daily living, then the findings of this survey suggest that a substantial number of middle aged and elderly men living in the United Kingdom may be in need of assessment and treatment for this condition.

Regression to the mean occurs in measuring peak urinary flow.

OBJECTIVE: To investigate the anomalous rises in maximum urinary flow rates seen in a prostate-diagnostic clinic. SUBJECTS AND METHODS: The study comprised 1994 men aged 40-79 years registered at five health centres in Central Scotland, participating in a study of the natural history of benign prostatic hyperplasia (BPH), who completed a urodynamic assessment on up to three occasions: in the community, on referral to a prostate-diagnostic clinic and at a one-year follow-up. RESULTS: Subjects referred to the diagnostic clinic on the basis of maximum flow rate (Qmax < 15 mL/s) and/or urinary symptomatology showed a mean increase in Qmax (P < 0.001) when tested at the clinic and at the one-year follow-up. In health centres which referred men to the clinic with no pre-selection, there were no significant changes in Qmax. CONCLUSION: Regression to the mean occurs when patients are selected on the basis of a low Qmax. The use of isolated low values of Qmax in the process of diagnosing BPH should be avoided.