Is the visibility of standardized inflicted bruises improved by using an alternate ('forensic') light source?

AIM: To study the visibility of standardized inflicted bruises by using an alternate ('forensic') light source compared to a white light source. METHODS: Bruises were inflicted on the flexor site of the forearm (halfway in the middle) in 76 adults, by suddenly allowing a cylindrical metal object (400g) with rounded edges to drop for 1m in a vertically positioned tube. At 0.25, 1, 2, 7 and 14days after this blunt force impact, the impact site on the forearm was photographed with a white light source and subsequently with an alternate light source at 415nm. Visibility of bruises on 170 randomized photographs was assessed on a calibrated monitor by 10 forensic medical specialists (physicians and pathologists) independently in two sessions: (1) with white light source photographs, and (2) after a mean of 11days with greyscale converted alternate light source photographs. Bruise visibility was expressed as a report mark between 1 (very bad) and 10 (excellent), or as 'no visible bruise'. To determine intra-rater agreement, 10 of 170 photographs were assessed twice (untold to the assessors). In total 3600 (180×10×2) photographs were assessed. RESULTS: 39 of 73 (53%) participants who completed the study, developed a visible bruise (women more often than men, p<0.001). Inter-rater agreement between assessors was high (mean inter-class coefficient, ICC, for white light source 0.66 (SD 0.14) and for alternate light source ICC 0.73 (0.09)). Intra-rater agreement was excellent (mean ICC 0.88 (SD 0.09)). Mean report marks for bruise visibility, recorded independently by 10 assessors on 170 unique photographs per light source, were significantly higher with an alternate light source than with a white light source, at 1 and 2days after impact: 4.4 (SD 2.0) vs 3.8 (1.8) (p<0.01) and 4.9 (2.1) vs 4.5 (2.0) (p<0.05), respectively. However, these differences were small, as the mean difference (effect size) in report marks were 0.6 (0.5) and 0.4 (0.3), at 1 and 2days after impact, respectively. The other time points showed no statistical significant differences in report marks. CONCLUSIONS: Bruises after standardized blunt force impact were slightly better visible with an alternate light source than with a white light source after 1 and 2 days, but not after 0.25, 7 and 14 days. The value of using an alternate light source at 415nm to improve bruise visibility was limited in this study.

Pediatric constrictive asphyxia a rare form of child abuse: A report of two cases.

We present two cases of infants who died under suspicious circumstances. After clinical and legal investigations, non-accidental constrictive asphyxia inflicted by one of the parents was established. The first case presents a to date not yet reported, unique mechanism of trauma. In order to stop his daughter from crying, the father admitted that he sometimes sat on his baby while she was lying on the bed. Occasionally increasing his force by pulling with his hands on the bottom of the bed. In the second case tight swaddling and encircling chest compression was the causative mechanism. In both cases the father was sentenced to imprisonment with mandate psychiatric care. Only two previous reports of this uncommon and relatively unknown cause of child abuse, called constrictive asphyxia, are known. In all reported cases static loading of the chest resulted in rib fractures and demise of the child. This rare abusive mechanism should be known to pediatric radiologists and pathologists.

Radiology in suspected non-accidental injury: theory and practice in The Netherlands.

INTRODUCTION: This study evaluates radiological imaging in suspected non accidental injury (NAI) in children below the age of 2 years in the Netherlands. MATERIAL AND METHODS: The study consisted of two parts; first an on-line questionnaire on suspected NAI, amongst radiological practices within the Netherlands. The second part of the study was a retrospective analysis of skeletal surveys in children under the age of 2 years, which were reviewed in an expert centre of forensic medicine on request of the public prosecutor. RESULTS: Out of 116 hospitals 45 (39%) radiologists completed the on-line questionnaire; 8 (8%) of the proposed skeletal surveys complied with the ACR criteria. A total of 29 skeletal surveys in 26 children were reviewed. The median age at the time of the radiographic exam was 3 months for both boys and girls. Only 2 (7%) studies complied with the ACR criteria. DISCUSSION: The results of our study show that, in theory as well as in practice, Dutch radiological practices show a large variation in imaging protocols for suspected NAI.

[Psychiatric patients at the police station in the southern South Holland region: assessment by the District Health Service forensic doctor]. / Psychiatrische patiënten op het politiebureau in de regio Zuid-Holland Zuid: beoordeling door de wachtdienstarts van de Gemeenschappelijke Gezondheidsdienst.

OBJECTIVE: To describe the epidemiological characteristics of ambulant psychiatric patients who were either brought to the police station or who came by themselves, but who were not kept in a cell, as a basis for the development of a reception protocol. DESIGN: Descriptive. METHOD: The data from the medical records from 2000 kept by the forensic doctors employed by the district health services for the Southern South Holland region were inventoried. RESULTS: On request by the police, the forensic doctors examined 203 clients. The majority of these were middle-aged men who did have a place of residence. The reason for police involvement was bizarre or confused behaviour in public. Half of the patients had received or were receiving some form of psychiatric treatment from the mental health service. In approximately half of the cases the forensic doctor found a solution together with the police. In the other half of the cases the forensic doctor asked the crisis intervention team at the mental health service for an evaluation. Two thirds of these patients were hospitalised and one third was sent away. Because examination by both the forensic doctor and the mental health service psychiatrist and other procedures were lengthy (up to 6 hours), patients had to spend a long time in a holding cell at the police station that was not designed for stays of this length of time, and often lacked toilet facilities. CONCLUSION: The forensic doctor treated about half the clients without the need of assistance from the crisis intervention psychiatrist. The temporary accommodation for these confused clients was inadequate.

Why do men refuse or attend population-based screening for prostate cancer?

BACKGROUND: The aims of this study were to investigate the motives for refusing or attending population-based screening for prostate cancer, in relation to various background characteristics. METHODS: The present study is part of the European Randomized Study of Screening for Prostate Cancer (ERSPC), and took place in 1995-1996. Men aged 55-75 years were invited using the Rotterdam population registry (100 per cent coverage), of whom 42 per cent gave written informed consent. These men were randomized to receive either determination of prostate specific antigen (PSA), digital rectal examination (DRE), transrectal ultrasound (TRUS) and biopsy on indication (screening group), or no screening (control group). To 626 consecutive men of the screening group a questionnaire was sent before the screening. To 500 randomly selected refusers (no written informed consent) a similar questionnaire was sent, followed by two reminders. In both refusers and attenders we addressed motives, knowledge of prostate cancer, attitudes towards screening, background characteristics and urological complaints (American Urological Association symptom index, AUA7). RESULTS: Response rates for questionnaires were 48 per cent in refusers and 99 per cent in attenders. Main reported motives for refusing were absence of urological complaints (57 per cent) and anticipated pain or discomfort (18 per cent). Main reported motives for attending were personal benefit (82 per cent), contribution to science (49 per cent) and presence of urological complaints (25 per cent). Compared with attenders, refusers were slightly and significantly older, less often married and had a lower level of education; they had less knowledge about prostate cancer and a less positive attitude towards screening; they had worse general health but fewer urological complaints (AUA7 median 2 versus 4, p < 0.001). CONCLUSION: In refusing or attending population-based prostate cancer screening, urological complaints but also knowledge, attitudes and sociodemographic factors seem to play a role. Therefore, the approach of the general population should be carefully considered.

Treatment choice for benign prostatic hyperplasia: a matter of urologist preference?

PURPOSE: New treatment modalities for benign prostatic hyperplasia (BPH) have considerably altered the decision making process in daily clinical practice. Guidelines provide a framework for treatment choice but leave much room for physician personal opinions. We identified and quantified determinants of treatment choice for BPH among urologists focusing on urologist treatment preferences. MATERIALS AND METHODS: The study population consisted of 670 consecutive patients with BPH 50 years old or older newly referred to 1 of 39 urologists in a stratified sample of 13 hospitals throughout The Netherlands. Data on patient characteristics were retrieved from patient questionnaires (symptomatology, bothersomeness, sexual function), medical records (diagnostic outcomes, co-morbidity) and urologist questionnaire (initial treatment choice and main considerations for this decision). Urologist treatment preferences were inventoried using a mailed questionnaire. Polychotomous logistic regression analysis was used to study the impact of patient characteristics and urologist preferences on treatment choice. RESULTS: Among the patient characteristics maximum flow rate, residual urine and prostate volume were strongly associated with the probability of surgery and watchful waiting. However, the influence of urologist preferences on actual decisions was also significant. Adjusted for case mix the differences in low and high preferences revealed a 2.2 times greater probability of surgery. For alpha-blockers and finasteride these ratios were 1.8 and 9.4, respectively. An additional independent effect was seen for urologist extent of experience. CONCLUSIONS: The influence of urologist personal preferences on treatment choice in BPH is considerable. Given the different efficacy and side effects of the various treatments, further consensus development is needed to enhance appropriate treatment decisions and eliminate undue costs.

Cervical cancer screening: spatial associations of outcome and risk factors in Rotterdam.

OBJECTIVE: Obtaining insight into the geographic distribution of attendance and smear test results at the cervical cancer screening program in Rotterdam neighbourhoods, associated with socio-economic status, marital status and the percentage migrants. DESIGN: Ecological analysis was carried out on data on cervical cancer screening outcome and population figures, provided by the Rotterdam Local Health Information System, in which health information is collected at neighbourhood level. SETTING: The cervical cancer screening program in the city of Rotterdam. PARTICIPANTS: Fifty-three neighbourhoods, with overall 569,105 inhabitants, of whom 70,621 women between 1992 and 1994 were invited for the screening program. MAIN RESULTS: Between neighbourhoods a large difference in attendance rate and the percentage positive smears exists. A high socio-economic level of a neighbourhood, and a low percentage migrants, single or divorced women correspond with high attendance. A high socio-economic status of a neighbourhood and a low percentage migrants correspond with a low percentage smear test Pap 3B or higher. Socio-economic status, percentage migrants and marital status are highly interrelated on neighbourhood level. Multivariate analysis showed a negative correlation between the attendance rate and the percentage of single and divorced women, and a positive correlation between the percentage migrants and the percentage of positive smears (Pap 3B or higher). CONCLUSION: Various risk groups, showing low attendance or a high percentage of positive smears, are clustered in neighbourhoods and can be identified by socio-economic status, marital status and nationality. Activities to improve attendance can be focused towards these neighbourhoods.

Need for consensus development in prehospital emergency medicine: effect of an expert panel approach.

The objective of this study was to look at the need for consensus development in prehospital emergency medicine, and to determine the effect of an expert panel approach. The study took place in Euregio Scheldemond, comprising Sealand Flanders, The Netherlands, and Belgian Flanders, Belgium. Firstly, seven experts rated in organized mailings 153 (random selection out of 505) existing cases of acute or critically ill patients, situated in Dutch Sealand-Flanders. Experts were asked to decide whether assistance from neighbouring Belgian Flanders, consisting of a trauma team with or without the use of a highly equipped ambulance/helicopter, was needed or not in Dutch Sealand-Flanders, at: (1) the site of the incident, and (2) for transport to the hospital. They also had to decide on: (3) the required type of destination hospital (Belgian centre/university, versus Dutch regional). In a subsequent meeting using a modified nominal group technique 23 'worst' cases from the postal rounds with the lowest agreement were discussed and re-rated. We present a framework for the consensus measurement and development procedures. Agreement among experts was poor with multiple rater (Fleiss) kappa values for all 153 postal cases for the first, second and third decisions of 0.32, 0.08 and 0.45, respectively. After group discussions of the 23 'worst' postal cases, kappa values increased significantly and substantially; for the first, second and third decisions from 0.08 to 0.51, from -0.08 to 0.39 and from 0.16 to 0.62, respectively (all p < 0.001). Agreement increased significantly for medical cases, but not for trauma cases. It is concluded that consensus development for prehospital emergency medicine is needed. An expert panel approach seems fruitful in achieving more agreement, which forms a basis for guideline or protocol development.

Positive diagnostic values and histological detection ratios from the Rotterdam cervical cancer screening programme.

BACKGROUND: In organized screening programmes for cervical cancer, pre-cancerous lesions are detected by cervical smears. However, during follow-up after a positive smear these pre-cancerous lesions are not always found. The purpose of the study is to analyse positive diagnostic values of smears of at least mild dysplasia, made under the organized screening programmes in the Rotterdam area (1979-1991), and detection ratios of histologically confirmed CIN > or =3, among women participating in these screening programmes. METHODS: Positive diagnostic values and histological detection ratios, by age and history of previous smears, recorded during the national screening programme (1989-1991), were compared with those of the experimental cervical cancer screening project (1976-1984). RESULTS: The positive diagnostic value of a smear with at least severe dysplasia (histologically confirmed CIN > or =3) remains approximately 78%. For smears with mild and moderate dysplasia only lower limits of the diagnostic value could be determined. This was 9% for a smear with mild dysplasia obtained during the national screening programme and 25% and 35% for smears with moderate dysplasia taken during the experimental and national screening programmes respectively. Histological detection ratios for CIN > or =3 in the three rounds of the experimental screening project were 4.7, 2.9 and 1.9. In the first round of the national screening programme the ratio was 4.7, and about three times higher in younger compared to older women. CONCLUSION: Immediate referral for colposcopy after a smear showing moderate dysplasia seems questionable. Whether the increased detection ratio among young women indicates a rise in the risk of cervical cancer is unclear.

Short-term effects of population-based screening for prostate cancer on health-related quality of life.

BACKGROUND: Population-based screening for prostate cancer is currently being evaluated in randomized clinical trials in the United States and in Europe. Side effects arising from the process of screening and from the earlier treatment of screen-detected prostate cancer may be important factors in the evaluation. To examine health-related quality of life (or health status) among men screened for prostate cancer, we conducted a longitudinal study of 626 attenders to the Rotterdam (The Netherlands) prostate cancer screening program and of 500 nonparticipants. METHODS: Attenders of the screening program and nonparticipants completed self-assessment questionnaires (SF-36 [i.e., Medical Outcomes Study 36-Item Short-Form Health Survey] and EQ-5D [i.e., EuroQol measure for health-related quality of life] health surveys) to measure generic health status, as well as an additional questionnaire for anxiety and items relating to prostate cancer screening. RESULTS: Physical discomfort during digital rectal examination and during transrectal ultrasound was reported by 181 (37%) of 491 men and by 139 (29%) of 487 men, respectively; discomfort during prostate biopsy was reported by 64 (55%) of 116 men. Mean scores for health status and anxiety indicated that the participants did not experience relevant changes in physical, psychological, and social functioning during the screening procedure. However, high levels of anxiety were observed throughout the screening process among men with a high predisposition to anxiety. Similar scores for anxiety predisposition were observed among attenders and nonparticipants. CONCLUSIONS: At the group level, we did not find evidence that prostate cancer screening induced important short-term health-status effects, despite the short-lasting side effects related to the biopsy procedure. However, subgroups may experience high levels of anxiety. The implication is that unfavorable health-status effects of prostate cancer screening occur mainly in the treatment phase.

Interpretation of uroflowmetry curves by urologists.

PURPOSE: Uroflowmetry has become a routine investigation in patients with symptoms of the lower urinary tract. Little is known about the variation in the use of uroflowmetry and in the interpretation of its outcomes. We investigated the diagnostic value of uroflowmetry as a freestanding test, and examined the interobserver and intra-observer variation in the interpretation of uroflowmetry curves. MATERIALS AND METHODS: A representative panel of 58 urologists was questioned about the relevance of visual inspection and flow parameters for interpretation. In addition, they individually assessed 25 randomly selected uroflowmetry curves (from patients with no abnormalities and those with various lower urinary tract symptoms) regarding normal findings and the most likely diagnosis. To investigate intra-observer agreement 4 of these curves were studied twice. RESULTS: Voided volume (81%), visual inspection (77%) and maximum flow rate (77%) were most frequently mentioned as relevant for interpretation. Large differences existed between panel opinions and actual case information. For 43% of the normal cases the panel members considered the curves as abnormal. Of the abnormal cases 6% of the curves were regarded as normal. The urologists predicted correctly the actual diagnosis in 36% of all cases. Interobserver agreement was moderate for normalcy (kappa 0.46, standard error 0.087) and poor for the most likely diagnosis (kappa 0.30, standard error 0.043). Intra-observer agreement was also not satisfactory. On average, for the 4 cases studied twice 29% of the panel members chose another option for normalcy, while 41% mentioned another diagnosis the second time. CONCLUSIONS: These results necessitate reconsideration of the diagnostic use of uroflowmetry in daily urological practice.

Costs and effects of microsurgery versus radiosurgery in treating acoustic neuroma.

This study analyses costs and effects of treating acoustic neuroma patients by using microsurgery compared to radiosurgery. Radiosurgery is the stereotactic application of radiotherapy and an innovative medical technology. Cost and effect estimates of conventional treatment were based on a retrospective study in the Netherlands. Similar data for a comparable group of patients in Sweden were collected for radiosurgery, as this treatment option is currently not available in the Netherlands. Fifty-three acoustic neuroma patients who had been operated on the University Hospital Rotterdam between November 1990 and February 1995 were included. This group was compared with 92 acoustic neuroma patients treated with radiosurgery (Gamma Knife. Stockholm, Sweden) in the same period. Data on health care use were collected from patient files. To obtain data on production losses and quality of life, a questionnaire was sent by mail in February 1995. This booklet consisted of the Health and Labour-questionnaire (HLQ), the Short Form-36 (SF36) and the EuroQol. The response rate was 92%. Direct costs for microsurgery amounted to Dfl. 20.072,- and for radiosurgery to Dfl. 14.272,-. Indirect costs were respectively Dfl. 16.400,- and Dfl. 1.020,-. General health rating was better for radiosurgery than for microsurgery. On the whole, differences in clinical outcomes between the two patient groups were small. Assuming a reasonable occupancy rate of the expensive radiosurgery equipment, we demonstrated that for the short term treating patients with acoustic neuroma with an extra-meatal tumour diameter of less than 3 centimeters, radiosurgery is more cost-effective than microsurgery.

Randomised trial of prostate cancer screening in The Netherlands: assessment of acceptance and motives for attendance.

OBJECTIVES: To assess motives for attending a randomised population based prostate cancer screening trial, and to assess acceptance of screening and invitation procedures. METHODS: First pilot of the European Randomised Study of Screening for Prostate Cancer (ERSPC; 1992/1993). Men aged 55-75 years, randomly selected from the population register of four city districts of Rotterdam, were invited by a single invitation for screening. Screening consisted of prostate specific antigen prescreening followed by either (1) digital rectal examination, transrectal ultrasound, and, on indication, biopsy, or (2) no additional screening. After screening, or in the case of non-attendance, a questionnaire was sent to a random sample of 600 attenders and 400 non-attenders, with a reminder after three weeks. OUTCOME MEASURES: In both attenders and non-attenders: knowledge of prostate cancer, attitudes towards screening, motives for attending, procedural aspects and sociodemographic characteristics. In attenders, acceptance of screening procedures. RESULTS: The response rate for the questionnaire was 76%: 94% in attenders and 42% in non-attenders. The main reasons for attending were expected personal benefit (76%) and scientific value (39%), and those for not attending were absence of urological complaints (41%) and anticipated pain or discomfort (24%). Uptake of screening was 32%, which increased to a sustained 42% in following years. Attenders, compared with non-attenders, were significantly younger, more often married, better educated, and had higher perceived health status, more knowledge about prostate cancer, and a more positive attitude towards screening. Information materials and invitation procedures were well accepted (high report marks and satisfaction, and 95% would attend for rescreening). A single prostate specific antigen determination was liked less than a combination of all three screening modalities. CONCLUSIONS: (1) The main reasons for attending are personal benefit and science, and those for not attending were absence of urological complaints and anticipated pain or discomfort; (2) knowledge, attitudes, and motives for attending are comparable with other screening programmes; hence, for population based prostate cancer screening, known health promotional aspects should be carefully considered; (3) prostate specific antigen, digital rectal examination and transrectal ultrasound are acceptable to attenders.

[Free admission to stress electrocardiography with subsequent cardiological advice and feedback to the family physician: favorable effect on referral patterns]. / Vrije toegang tot inspanningselektrocardiografie met aansluitend cardiologisch advies en feedback aan de huisarts: gunstige invloed op het verwijspatroon.

OBJECTIVE: To improve the patient referral by general practitioners to the cardiology outpatient clinic for evaluation of (possibly) anginal complaints, by giving access to in-hospital bicycle exercise testing with cardiological advice and feedback. DESIGN: Prospective. SETTING: Department of non-invasive cardiology 'De Weezenlanden' Hospital, Zwolle, the Netherlands. METHODS: Patients, with no cardiological history, were collected from two comparable groups of general practitioners: an experimental group (n = 90.000 patients), allowed to perform an in-hospital exercise test with concomitant advice of a cardiologist, and a reference group (n = 53.400 patients), who referred directly to the cardiologist without having this facility (as customary in the Dutch health care system). Data were collected prospectively from January 1st 1994 until May 1st 1995. RESULTS: In the experimental group, 615 patients underwent exercise tests; 100 were subsequently referred. In addition, 53 patients were referred directly (total 153 patients; 1.3/1000 patients/year; 95% confidence interval: 1.1-1.5). In 51% of referred patients coronary disease was present, 37% underwent coronary angiography and 23% revascularisation (PTCA or CABG). During follow-up for 2 months no cardiovascular events occurred in non-referred patients. In the reference group, 132 patients were referred directly (1.9/1000 patients/ year; 1.6-2.2; p < 0.01 when compared with the experimental group). Of these patients 13% had coronary disease, 8% underwent coronary angiography and 3% revascularisation. CONCLUSION: Free access to exercise testing with cardiological advice and feedback for general practitioners resulted in a reduction of referrals with improved efficiency.

[Follow-up not according to guidelines after an abnormal cervix smear]. / Follow-up na een afwijkend cervixuitstrijkje niet conform de adviezen.

OBJECTIVE: To investigate whether the recommendations for the follow-up after a positive cervical smear test, made within the Dutch national screening programme on cervical cancer, are followed in practice. DESIGN: Descriptive. SETTING: The Rotterdam Municipal Health Services Area. METHOD: All cytological and clinical-histological findings on women who had a Pap smear of at least Pap class IIIA in the period 1989-1991, were collected from the Pathological Anatomical National Automised Archives (PALGA). Per smear test result, the cervix-cytological and histological examinations that took place after the screening programme were arranged in order of occurrence. RESULTS: 61% of the women with Pap class IIIA had been followed according to the recommendations, in 12% no follow-up had been done. Repeat cytology was often done much later than after three months as recommended. After Pap class IIIB, IV or V smear test outcome the recommendations were followed in respectively over half, about three-quarters, and all cases. In 9% of women with Pap class IIIB or IV, no follow-up was recorded in the PALGA data base. CONCLUSION: Often, the recommendations for follow-up after a positive smear were followed poorly. Further research into the problems in the follow-up route is necessary.

[Variation in the diagnosis and treatment of benign prostatic hyperplasia in urological practice]. / Variatie in diagnostiek en behandeling van benigne prostaathyperplasie in de urologische praktijk.

OBJECTIVE: To analyse practice variation among urologists and its determinants with respect to diagnostics and therapy choice in benign prostatic hyperplasia (BPH). DESIGN: Cross-sectional. SETTING: Stratified sample of 12 urological practices throughout the Netherlands. METHODS: On 670 consecutive, newly referred BPH patients > or = 50 years, data were collected about symptomatology, discomfort and sexual functioning (patient questionnaire), diagnostic procedures and outcomes (medical record), and (considerations for) therapy choice (urologist questionnaire). Characteristics of patients as well as of urologists were integrally studied to explain the variation. RESULTS: With respect to diagnostics, highest variation (interquartile ranges) was found for ultrasonography of the prostate (19-86%), kidneys (19-68%), and bladder (42-91%), and lowest variation for digital rectal examination (97-100%) and blood tests and urinalysis (88-100% and 86-99% respectively). For therapy choice, interquartile ranges were 24-42% (surgery), 32-49% (watchful waiting), 5-29% (alpha-blockers), and 0-17% (5-alpha-reductase-inhibitor). Variation in diagnostics was associated with characteristics of urologists and work setting as well as of patients. For differences in therapy choice, symptomatology, discomfort, sexual activity, peak flow, volume of residual urine, prostate volume, comorbidity, experience of the urologist, and the type of hospital were the most important explanatory variables. CONCLUSION: Variation in both diagnostics and therapy choice is considerable. This variation is associated with characteristics of patients as well as of urologists and work setting.

The symptom questionnaire for benign prostatic hyperplasia: an ambiguous indicator for an ambiguous disease.

OBJECTIVE: To assess the criterion validity of the American Urological Association (AUA) symptom index for benign prostatic hyperplasia (BPH) in urological practice. PATIENTS AND METHODS: The study comprised 1414 consecutive men > or = 50 years of age, newly referred to a urologist in a stratified sample of 12 hospitals throughout the Netherlands, who completed the AUA symptom questionnaire at their first visit. The 39 urologists completed a questionnaire on the diagnosis. The discriminative power of the index for BPH versus other urological diagnoses was calculated by receiver operating characteristic (ROC) analysis. Subsequently, criterion sensibility was studied by assessing the effect of particular variables on the probability of the diagnosis of BPH. RESULTS: ROC areas were low for BPH versus prostate cancer (0.57, SE 0.04), chronic prostatitis/prostatodynia (0.65, SE 0.03), and other diseases of the lower urinary tract (0.57, SE 0.04). Satisfactory to good values were found for BPH versus diseases of the upper urinary tract (0.79, SE 0.03), impotence/infertility (0.79, SE 0.04), penile-scrotal diseases (0.85, SE 0.02), and no abnormalities (0.84, SE 0.03). The diagnosis of BPH, as made by urologists in daily practice, appeared to be a weak criterion. Irrespective of other characteristics, the chance of being diagnosed with BPH was affected by differences in definition and the type of hospital. CONCLUSION: Although the AUA index discriminated fairly well between BPH and diseases of the upper urinary tract, as well as genital diseases, it has no potential for distinguishing BPH from other diseases of the lower urinary tract. In addition, the lack of consensus in defining clinical BPH underscores the weakness of the index as a tool in the diagnostic process of this disease.

Quality of life after treatment of gallstones: results of a randomised study of lithotripsy and open cholecystectomy.

OBJECTIVE: To compare quality of life after extracorporeal shock wave lithotripsy (ESWL) and open cholecystectomy for symptomatic gallstones. DESIGN: Randomised study. SETTING: University hospital, The Netherlands. SUBJECTS: 49 Patients, 23 of whom were randomized to undergo ESWL and 26 to undergo open cholecystectomy. INTERVENTIONS: Health questionnaires were filled out before, and at 3, 6 and 12 months after treatment. MAIN OUTCOME MEASURE: Improvements of quality of life after one year. RESULTS: Both treatments improved quality of life. Open cholecystectomy improved quality of life significantly better than ESWL (median percentage gains in Nottingham Health Profile scores at 1 year 17.1 and 10.5, respectively, p = 0.003). CONCLUSION: Open cholecystectomy is superior to ESWL in improving quality of life, so cholecystectomy remains the treatment of choice for symptomatic gallstones. For patients who are unfit or unwilling to undergo operation, however, ESWL is adequate because most patients have some benefit from it in terms of quality of life.

Methyl tert-butyl ether improves the efficacy of extracorporeal shock wave lithotripsy of human gallstones implanted in pigs.

OBJECTIVE: To investigate the contribution of contact dissolution with methyl tert-butyl ether (MTBE) to the success of extracorporeal shock wave lithotripsy (ESWL) of human gallstones implanted in pigs. DESIGN: Experimental study of matched pairs. SETTING: Laboratory for experimental surgery, The Netherlands. MATERIAL: 30 pigs. INTERVENTIONS: Couples of similar human gallstones were surgically implanted into the gallbladders of 30 pigs. All pigs underwent ESWL with an electromagnetic lithotriptor. Half the animals were given adjuvant treatment with MTBE for 2 hours immediately after the ESWL. All pigs were killed a week after treatment. RESULTS: Adjuvant MTBE dissolution led to superimposed damage of the gallbladder. One pig died of biliary leakage and peritonitis. For all kinds of stones, adjuvant MTBE treatment increased the median (range) percentage of stone dissolved by ESWL from 31 (0-58) to 60 (11-81) (p < 0.01), whereas for pure cholesterol stones the increase was from 23 (0-58) to 61 (11-81) (p < 0.01). CONCLUSIONS: These data warrant clinical evaluation of the applicability of combined ESWL and MTBE dissolution of symptomatic gallstones in selected patients.