Power Doppler Sonography (PDS) and Modified TRUS Systematic Biopsies - Can this Combination Adequately Replace Multiparametric Prostate Magnetic Resonance Imaging (mp-MRI) in Candidates for Re Biopsies Who cannot Undergo mp-MRI.

The MRI targeted biopsy (MRI-TBx) may increase the detection rate of clinically significant cancer (csPCa) in candidates for re-biopsy. However, there will be several patients in whom MRI is contraindicated. In this retrospective study we assessed the ability of combination of PDS guided biopsies (PDS-TBx) and modified SBx to substitute MRI-TBx. 154 men with persistently elevated PSA were referred for re-biopsy. Our protocol included a combination of MRI-TBx, DPS-TBx and modified SBx with additional biopsies from anterior lateral horns and anterior aspects of apex. MRI findings were defined as suspicious lesions (MRI-SL) and highly suspicious lesions (MRI-HL), based on PIRADS scale. In 40 patients csPCa was detected. While, MRI diagnosed csPCa in 36 patients (23%, n-36/154): 25% and 92% of biopsies targeted to the MRI- SL and MRI-HSL confirmed csPCa. Thirty-eight PDS hypervascular areas were found, while csPCa was diagnosed in 84% of these lesions, or in 28 patients (18%, n-28/154). SBx detected csPCa in 34 cores or in 21 patients (13%, n - 21/154). SBx missed cancers in the in the anterior aspect of middle gland. Combination of PDS-TBx + SBx detected csPCa in 35 (88% of csPCa) patients. Strongest predictors for the csPCa presence were MRI-HSL, PDS' lesions and biopsies from anterior aspect that included apex, mid gland and anterior lateral horns (p < 0.001 and p-0.008, respectively). The combination of PDS-TBx + SBx may miss 15% of csPCa detected by MRI. However, it can detect additional 10% of csPCa that were missed by MRI. To improve the accuracy of this combination, the anterior aspect of middle gland should be also included in the modified SBx. These changes in combination can make it helpful in candidates for re-biopsy who cannot undergo MRI.

Multidetector Computed Tomographic Urography (MDCTU): Its Practical Role in Diagnosis of Upper Tract Urothelial Cancer in Patients 50 years and Older with Different Types of Hematuria.

MDCTU is a preferred method for the investigation of malignant lesions in the upper urinary tract. However, to decrease unnecessary radiation exposure the indications for the exam in different groups of patients should be assessed. In this study, we evaluated the role of MDCTU in patients older than 50 years who presented with different types of hematuria. In a retrospective manner, we assessed the radiologic reports of 173 patients ≥50 years who underwent MDCTU as a part of the evaluation for hematuria. To estimate the accuracy of MDCTU in the detection of upper urinary tract urothelial carcinoma (UUTUC) we compared MDCTU findings with the results of ureteroscopy. We also evaluated which factors can predict ureteroscopic confirmation of MDCTU-based diagnosis. In this list we also included diabetes mellitus and anticoagulant medications. As a result, 140 (103 males and 37 females) patients met the inclusion criteria. Mean patients' age was 69.7±16.98. Smokers and passive smokers comprised 38.6% and 26.4% of our patients, while 37.8% of our patients suffered from DM and 45% took anticoagulant medications. MDCTU suspected urothelial carcinoma in 17% (n=24) of our patients: UUTUC in eight and bladder urothelial carcinoma (BUC) in 16patients. Ureteroscopy had diagnosed UUTUC (with/without concurrent urothelial carcinoma of the bladder) in 9 patients: 6 with suspicious lesions in MDCTU and 3 additional patients with CIS/small low grade TCC. MDCTU had a sensitivity of 66.7%, specificity - 98.5%, positive predictive value - 75% and negative predictive value - 97.7%. The logistic regression model revealed five strong predictors for UUTUC: positive/atypical cytology, recurrent hematuria, MDCTU signs, age and Warfarin treatment. Finally a source of hematuria was diagnosed in 57% of patients, while MDCTU individual accuracy reached 42%. We found that MDCTU can effectively identify patients in whom further endoscopy is unnecessary. Otherwise, elder patients with positive/atypical cytology and recurrent microscopic hematuria, who have MDCTU signs and take Warfarin, should undergo endoscopic evaluation.

Utilization of ultrasonography to detect developmental dysplasia of the hip: when reality turns selective screening into universal use.

BACKGROUND: Developmental dysplasia of the hip (DDH) occurs in 3-5 of 1000 live births and is associated with known risk factors. In most countries, formal practice for early detection of DDH entails the combination of risk factor identification and physical examination of the hip, while the golden standard diagnostic instrument is hip ultrasonography (US). This practice is commonly referred to as selective screening. Infants with positive US findings are treated with a Pavlik harness, a dynamic abduction splint. The objective of our study was to evaluate hip US utilization patterns in Maccabi Healthcare Services (MHS), a large health plan. METHODS: Study population: All MHS members, born between June 2011 and October 2014, who underwent at least one US before the age of 15 months. STUDY VARIABLES: Practice specialty and number of enrolled infants. Positive US result was defined as referral to an abduction splint. Cost was based on Ministry of Health price list. Chi square and correlation coefficients were employed in the statistical analysis. RESULTS: Of the 115,918 infants born during the study period, 67,491 underwent at least one hip US. Of these, 60.6% were female, mean age at performance: 2.2 months. Of those who underwent US, 625 (0.93%) were treated with a Pavlik harness: 0.24% of the male infants and 1.60% of the female infants (p < 0.001). Analysis of physician practice characteristics revealed that referral to US was significantly higher among pediatricians as compared with general practitioners (60% and 35%, respectively). Practice volume had no influence on referral rate. Direct medical costs of the 107 hip US examinations performed that led to detection of one positive case (treated by Pavlik): US$10,000. CONCLUSIONS: Current pattern of hip US utilization for early detection of DDH resembles universal screening more closely than selective screening. This can inform policy decisions as to whether a stricter selective screening or a formal move to universal screening is appropriate in Israel.

Improving the quality of primary care by allocating performance-based targets, in a diverse insured population.

BACKGROUND: Primary Care Health organizations, operating under universal coverage and a regulated package of benefits, compete mainly over quality of care. Monitoring, primary care clinical performance, has been repeatedly proven effective in improving the quality of care. In 2004, Maccabi Healthcare Services (MHS), the second largest Israeli HMO, launched its Performance Measurement System (PMS) based on clinical quality indicators. A unique module was built in the PMS to adjust for case mix while tailoring targets to the local units. This article presents the concept and formulas developed to adjust targets to the units' current performance, and analyze change in clinical indicators over a six year period, between sub-population groups. METHODS: Six process and intermediate outcome indicators, representing screening for breast and colorectal cancer and care for patients with diabetes and cardiovascular disease, were selected and analyzed for change over time (2003-2009) in overall performance, as well as the difference between the lowest and the highest socio-economic ranks (SERs) and Arab and non-Arab members. RESULTS: MHS demonstrated a significant improvement in the selected indicators over the years. Performance of members from low SERs and Arabs improved to a greater extent, as compared to members from high ranks and non-Arabs, respectively. CONCLUSION: The performance measurement system, with its module for tailoring of units' targets, served as a managerial vehicle for bridging existing gaps by allocating more resources to lower performing units. This concept was proven effective in improving performance while reducing disparities between diverse population groups.

Parental opinions and level of knowledge regarding influenza immunization for high risk children: follow-up on two reminder methods.

BACKGROUND: The aim of this study was to compare influenza immunization rates in children who were defined as high risk for complications following a letter or a phone reminder, and to survey parental opinions about influenza. METHODS: The 198 families of 930 children were targeted. After the season for immunization, a phone survey was conducted. RESULTS: A letter was sent to the families of 444 children. A telephone reminder was successful with the families of 288 children. The rates of influenza immunization were 15.3% and 13.5%, respectively. In the 86 families that were interviewed, 46.7% of the children in the families who got a reminder letter were immunized compared to 32.1% in those who got a phone reminder (P=0.184). Better knowledge, older parents, and larger families were associated with higher immunization rates. Major reasons for non-immunization were: potential side effects, lack of knowledge, and opposition to influenza vaccine. CONCLUSIONS: A reminder letter or a phone call did not lead to high rates of influenza vaccination in children, nor was there significant difference between the two reminder methods. Parental knowledge, attitude, and barriers for vaccination should be addressed when a reminder method is chosen.

Patients with Persistently Elevated PSA and Negative Results of TRUS-Biopsy: Does 6-Month Treatment with Dutasteride can Indicate Candidates for Re-Biopsy. What is the Best of Saturation Schemes: Transrectal or Transperineal Approach?

To identify patients who actually need a re - biopsy, based on alterations in PSA readings after 6-month treatment with Dutasteride. We also sought to bring out the most beneficial re-biopsy scheme. We have reviewed the records of patients with persistently elevated PSA and at least one set of TRUS biopsies. Patients who were treated with alpha -blockers/Dutasteride combination were considered as the study group, while patients in control received alpha-blockers alone. Patients in both groups underwent re-biopsy 6 months later. The two protocols of re-biopsies were used at that time: 20-24 cores saturation transrectal (ST)) and ≥ 40 cores saturation transperineal template-guided (STT) biopsies. One hundred thirty-three patients were included in this study. In 86.7 % of the patients in the study group mean PSA decreased from 7.4 ± 2.69 to 4.037 ± 1.53 (p-0.001). The overall cancer detection rate was 29 % (n-39: 19 v/s 20, control and study groups, respectively). In the study group PSA decreased to 26.73 ± 11.26 % in patients with cancer, compared with 40.54 ± 13.3 % in patients without. It must be emphasized that STT-biopsies detected significantly more cancers (38.46 v/s 20.59 %, p- 0.005). Mean cores number got to 21 ± 2.45 and 45 ± 5.65 in ST and STT biopsies, respectively. Six-month treatment with Dutasteride decreases PSA readings in 86.7 % of the patients. A PSA decline of less than 40% (cutoff) should be considered as an indicator for re-biopsy. Transperineal template-guided biopsies had a higher cancer detection rate.

The association between improved quality diabetes indicators, health outcomes and costs: towards constructing a "business case" for quality of diabetes care--a time series study.

BACKGROUND: In primary health care systems where member's turnover is relatively low, the question, whether investment in quality of care improvement can make a business case, or is cost effective, has not been fully answered.The objectives of this study were: (1) to investigate the relationship between improvement in selected measures of diabetes (type 2) care and patients' health outcomes; and (2) to estimate the association between improvement in performance and direct medical costs. METHODS: A time series study with three quality indicators - Hemoglobin A1c (HbA1c) testing, HbA1C and LDL- cholesterol (LDL-C) control - which were analyzed in patients with diabetes, insured by a large health fund. Health outcomes measures used: hospitalization days, Emergency Department (ED) visits and mortality. Poisson, GEE and Cox regression models were employed. Covariates: age, gender and socio-economic rank. RESULTS: 96,553 adult (age >18) patients with diabetes were analyzed. The performance of the study indicators, significantly and steadily improved during the study period (2003-2009). Poor HbA1C (>9%) and inappropriate LDL-C control (>100 mg/dl) were significantly associated with number of hospitalization days. ED visits did not achieve statistical significance. Improvement in HbA1C control was associated with an annual average of 2% reduction in hospitalization days, leading to substantial reduction in tertiary costs. The Hazard ratio for mortality, associated with poor HbA1C and LDL-C, control was 1.78 and 1.17, respectively. CONCLUSION: Our study demonstrates the effect of continuous improvement in quality care indicators, on health outcomes and resource utilization, among patients with diabetes. These findings support the business case for quality, especially in healthcare systems with relatively low enrollee turnover, where providers, in the long term, could "harvest" their investments in improving quality.

An intensive family intervention clinic for reducing childhood obesity.

BACKGROUND: Childhood and adolescent obesity constitute a significant public health concern. Family health care settings with multidisciplinary teams provide an opportunity for weight loss treatment. The objective of this study was to examine the effect of intensive treatment designed to reduce weight using a parent-child lifestyle modification intervention in a family health care clinic for obese and overweight children who had failed previous treatment attempts. METHODS: This was a practice-based 6-month intervention at Maccabi Health Care Services, an Israeli health maintenance organization, consisting of parental education, individual child consultation, and physical activity classes. We included in the intervention 100 obese or overweight children aged 5 to 14 years and their parents and 943 comparison children and their parents. Changes in body mass index z-scores, adjusted for socioeconomic status, were analyzed, with a follow-up at 14 months and a delayed follow-up at an average of 46.7 months. RESULTS: The mean z-score after the intervention was lower in the intervention group compared to the comparison group (1.74 and 1.95, respectively; P = .019). The intervention group sustained the reduction in z-score after an average of 46.7 months (P < .001). Of the overweight or obese children, 13% became normal weight after the intervention, compared with 4% of the comparison children. CONCLUSION: This multidisciplinary team treatment of children and their parents in family health care clinics positively affected measures of childhood obesity. Additional randomized trials are required to verify these findings.

Transrectal ultrasonography-guided injection of long-acting steroids in the treatment of recurrent/resistant anastomotic stenosis after radical prostatectomy.

BACKGROUND AND PURPOSE: Different techniques have been used for the treatment of patients with anastomotic stenosis after radical prostatectomy (RP). In this retrospective study, we analyzed our experience with urethral dilation and consecutive transrectal ultrasonography (TRUS)-guided injections of long-acting steroids in the scar area. PATIENTS AND METHODS: We reviewed the records of patients who underwent RP in our department from 2002 to 2010 and presented to the outpatient clinics with symptomatic anastomotic stenosis. Patients were treated with: Urethral dilation, cold knife (CK) urethrotomy, transurethral resection (TUR) of stenosis and dilation/resection of the strictures with consecutive TRUS-guided injection of a long-acting steroid (dilation+TRUS-steroids). Patients remained under follow-up, which included the assessment of voiding and continence patterns, as well as cystourethroscopy. RESULTS: In 32 (10.8%) patients, symptomatic anastomotic stenosis was diagnosed. Initial urethral dilation succeeded in only 3 (10.3%) patients; thus, 29 remained with recurrent/resistant stenosis. Urethral dilation+TRUS-steroids was performed in 14 patients, while 8 patients underwent CK and in 7 TUR was performed. Patients in the dilation+TRUS-steroids group had lower re-treatment rates, and none of these patients became incontinent. Patients in the TUR group needed no re-treatment; however, they had the highest incontinence rate (57.1%). As a result, the highest efficiency quotient was in the dilation+TRUS-steroids with the lowest in the TUR group. CONCLUSION: Urethral dilation with consecutive TRUS-guided injections of steroids has the highest efficiency quotient and can be performed under local anesthesia with a low risk of incontinence.

Reducing the volume of antibiotic prescriptions: a peer group intervention among physicians serving a community with special ethnic characteristics.

BACKGROUND: Antibiotics are a front-line weapon against many infectious diseases. However, antibiotic overuse is the key driver of drug resistance. Previously published studies have suggested benefits of using peer-to-peer education, working with group leaders to build trust and maintain confidentiality within a quality initiative. We hypothesized that working with physicians as a peer group might be beneficial in influencing antibiotic prescribing patterns. OBJECTIVE: To describe and evaluate a peer group model for an intervention to reduce the volume of antibiotic prescriptions among physicians with above average prescribing rates serving an Arab community in northern Israel. METHODS: Primary care physicians in a defined geographic area who served Arab communities and had high antibiotic prescribing rates--defined as above average number of antibiotic prescriptions per office visit compared with regional and organizational averages--were recruited for the intervention. All other physicians from the same region served as a comparison group. The intervention was administered during 2007 and was completed in early 2008. Four structured meetings scheduled 2 months apart, in which the group explored the issues related to antibiotic overuse, included the following topics: adherence to clinical guidelines; the special position physicians serving Arab communities hold and the influence it has on their practices; pressure due to consumer demands; and suggestions for possible strategies to face ethnic sensitivity, mainly because of the special ties the physicians have with their communities. T-tests for independent samples were used to perform between-group comparisons for each quarter and year of observation from 2006 through 2010, and t-tests for paired samples were used to compare pre-intervention with post-intervention antibiotic prescribing rates. RESULTS: In the 2006 pre-intervention period, the antibiotic prescribing rates were 0.17 for the peer group (n = 11 physicians) and 0.15 for the comparison group (n = 72 physicians, P = 0.279). In 2008 following the intervention, rates were 0.12 and 0.14, respectively (P = 0.396). In the paired t-test analysis, rates declined significantly from 2006 to 2008 in the intervention group (P < 0.001) but not in the comparison group (P = 0.138). Antibiotic prescribing rates remained similar in 2009 and 2010. CONCLUSION: In the context of a community with special ethnic and cultural characteristics, an intervention relying on peer group techniques was associated with a modest reduction in the volume of antibiotic prescriptions.

The association between socio-demographic characteristics and adherence to breast and colorectal cancer screening: analysis of large sub populations.

BACKGROUND: Populations having lower socioeconomic status, as well as ethnic minorities, have demonstrated lower utilization of preventive screening, including tests for early detection of breast and colorectal cancer. THE OBJECTIVE: To explore socio-demographic disparities in adherence to screening recommendations for early detection of cancer. METHODS: The study was conducted by Maccabi Healthcare Services, an Israeli HMO (health plan) providing healthcare services to 1.9 million members. Utilization of breast cancer (BC) and colorectal cancer (CC) screening were analyzed by socio-economic ranks (SERs), ethnicity (Arab vs non-Arab), immigration status and ownership of voluntarily supplemental health insurance (VSHI). RESULTS: Data on 157,928 and 303,330 adults, eligible for BC and CC screening, respectively, were analyzed. Those having lower SER, Arabs, immigrants from Former Soviet Union countries and non-owners of VSHI performed fewer cancer screening examinations compared with those having higher SER, non-Arabs, veterans and owners of VSHI (p < 0.001). Logistic regression model for BC Screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab and having a lower SER. The model for CC screening revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. The model estimated for BC and CC screening among females revealed a positive association with age and ownership of VSHI and a negative association with being an Arab, having a lower SER and being an immigrant. CONCLUSION: Patients from low socio-economic backgrounds, Arabs, immigrants and those who do not own supplemental insurance do fewer tests for early detection of cancer. These sub-populations should be considered priority populations for targeted intervention programs and improved resource allocation.

Watchful waiting and active surveillance approach in patients with low risk localized prostatic cancer: an experience of out-patients clinic with 12-year follow-up.

In this study we evaluated the safety of expectant approach in the patients with low risk prostate cancer in the reality of community based out-patients clinics. 48 men were enrolled into the study. The inclusion criteria were age ranged from 60 to 75 years and the Epstein criteria for low risk prostate cancer. Patients were managed expectantly while curative treatment was offered when indicated. Initial and final Charlson comorbidity index (CCI) and BMI were assessed for all men. Patients' median follow-up was 81.1 ± 29.1 years. During this study 41.7% of the patients chose active forms of treatment. Cancer was found in 20.8% (n-10) of our patients. Two first sessions of re-biopsy diagnosed 92% of T1c upgrading. Six men with CCI ≥2 died from concomitant disease and no one died from PCa. Significant correlation was found between BMI and final CCI ≥2 (p-0.001). Expectant approach can be considered as self alternative to active treatment model in selected group of patients with well differentiated PCa, however 20.8% of these patients are still at risk of having aggressive form of cancer. Expectant approach is particular beneficial for the patients with CCI 1-2 and high BMI.

Disparities in diabetes care: role of the patient's socio-demographic characteristics.

BACKGROUND: The commitment to promoting equity in health is derived from the notion that all human beings have the right to the best attainable health. However, disparities in health care are well-documented. The objectives were to explore disparities in diabetes prevalence, care and control among diabetic patients. The study was conducted by Maccabi Healthcare Services (MHS), an Israeli HMO (health care plan). METHODS: Retrospective study. The dependent variables were diabetes prevalence, uptake of follow-up examinations, and disease control. The independent variables were socio-economic rank (SER), ethnicity (Arab vs non Arab), supplementary voluntary health insurance (SVHI), and immigration from Former Soviet Union (FSU) countries. Chi Square and Logistic Regression Models were estimated. RESULTS: We analyzed 74,953 diabetes patients. Diabetes was more prevalent in males, lower SER patients, Arabs, immigrants and owners of SVHI. Optimal follow up was more frequent among females, lower SERs patients, non Arabs, immigrants and SVHI owners. Patients who were female, had higher SERs, non Arabs, immigrants and SVHI owners achieved better control of the disease. The multivariate analysis revealed significant associations between optimal follow up and age, gender (males), SER (Ranks 1-10), Arabs and SVHI (OR 1.02, 0.95, 1.15, 0.85 and 1.31, respectively); poor diabetes control (HbA1C > 9 gr%) was significantly associated with age, gender (males), Arabs, immigrants, SER (Ranks1-10) and SVHI (OR 0.96, 1.26, 1.38, 0.72, 1.37 and 0.57, respectively); significant associations with LDL control (< 100 gr%) were revealed for age, gender (males) and SVHI (OR 1.02, 1.30 and 1.44, respectively). CONCLUSION: Disparities in diabetes prevalence, care and control were revealed according to population sub-group. MHS has recently established a comprehensive strategy and action plan, aimed to reduce disparities among members of low socioeconomic rank and Arab ethnicity, sub-groups identified in our study as being at risk for less favorable health outcomes.

Oral contraceptive use and BRCA penetrance: a case-only study.

BACKGROUND: Women with deleterious mutations in BRCA genes are at increased risk of breast cancer. However, the penetrance of the genetic trait may be regulated through environmental factors. This multinational case-only study tested the interaction between oral contraceptive use and genetic susceptibility in the occurrence of breast cancer. METHODS: We recruited 3,123 patients diagnosed with breast cancer before the age of 45 years. Participants were classified according to their probability of carrying a BRCA mutation on the basis of their family history of breast and ovarian cancer. According to a case-only approach, the frequency of relevant exposures among breast cancer cases with high probability of BRCA mutation ("genetic cases") was compared with the frequency of the same exposures among breast cancer cases with a low probability of BRCA mutation ("sporadic cases"). The interaction odds ratios (OR) and 95% confidence intervals (CI) for oral contraceptive use were estimated by unconditional logistic regression, after controlling for potentially confounding variables. RESULTS: The analysis was carried out comparing 382 "genetic" and 1,333 "sporadic" cases. We found a borderline significant interaction between genetic breast cancer and oral contraceptive use for ever users compared with never users (OR, 1.3; 95% CI, 1.0-1.7). The greatest interaction OR was found for women who started using pill at 18 to 20 years (OR, 1.6; 95% CI, 1.1-2.3). CONCLUSION: These results suggest that BRCA mutation carriers, as well as women with a significant family history of breast and ovarian cancer are more vulnerable to exogenous hormones in oral contraceptives.

7 to 10 years' follow-up of 573 patients with elevated prostate-specific antigen (>4 ng/mL) or/and suspected rectal examination: biopsies protocol and follow-up guides.

PURPOSE: In this study, we tried to design a scheme for performing transrectal ultrasonographic (TRUS)-biopsies that would be accurate and include the optimal number of cores. PATIENTS AND METHODS: We included in this study 600 consecutive patients with suspicious findings on a per-rectum examination and/or an elevated prostate-specific antigen (PSA) (>4 ng/mL) level. Patients were followed for 7 to 10 years. In all patients, we took from 8 to 16 biopsy samples, according to the prostate volume, from the lateral aspects. In the second session, the biopsy samples were taken medially; in the third session, we included the transitional zone, while in consecutive sessions, we increased the number of cores from all areas. RESULTS: Only 573 of the patients remained in follow-up. TRUS-biopsy detected prostate cancer (PCa) in 257 patients (44.85% overall detection rate). The detection rate in the first and second sessions was 32.98% and 14.94%, respectively, reaching 13.2% and 2.17%, in the third and fourth sessions, respectively. Prostate volumes were significantly smaller (52.9 +/- 22.4 cc vs 58.9 +/- 23.8 cc, P < 0.002) and the PSA/adenoma/prostate volumes ratio (ad-pro) ratio was higher (18.3 +/- 9 vs 13.96, P < 0/001) in the patients with PCa. Patients with PCa underwent fewer biopsy procedures and biopsy sessions than patients without a diagnosis of PCa (14.9 +/- 8.9 vs 20.4 +/- 12, P < 0.001;1.3 +/- 0.6 vs 1.7 +/- 0.9, P < 0.001). Biopsy samples obtained from the base were positive for cancer only in larger prostates with a mean volume of 54.3 +/- 15.3 cc. Numbers of biopsy procedures and PSA/ad-pro ratio were the strongest predictive factors for PCa detection (P < 0.001). CONCLUSIONS: In patients with a prostate volume >or=53 cc and PSA/ad-pro ratio >or=18, the optimal biopsy cores should be >or=15. Using this scheme, the discontinuation of biopsy procedures might be considered after three consecutive sessions.

Effect of short-term dutasteride therapy on prostate vascularity in patients with benign prostatic hyperplasia: a pilot study.

OBJECTIVES: In this study we assessed the possible influence of dutasteride (types 1 and 2 isoenzymes of 5-alpha-reductase inhibitors) on prostate tissue vascularity. We also attempted to evaluate whether preoperative treatment with dutasteride could help to avoid excessive bleeding in patients undergoing transurethral resection of prostate (TUR-P). METHODS: This pilot study has 3 phases. All patients enrolled in the study had a prostate-specific antigen < 4 ng/mL and normal digital rectal examination. In the first phase we included 10 patients with benign prostatic hyperplasia treated with alpha-blockers. The end point of this phase was to choose the preset that could exclude noise signals and be reproducible. In the second phase, we included 32 patients in whom color Doppler sonography (CDS) was performed before and 6 weeks after treatment with 0.5 mg dutasteride per day. We counted every discrete color Doppler signal (CD-spot). To compare the CDS data, we used the Student t test, and P < .05 was considered significant. Afterward, 46 patients joined the third phase. Patients were assigned to the control and study groups according to sequentially numbered sealed envelopes. Patients in the study group received 0.5 mg dutasteride 6 weeks before TUR-P. RESULTS: In the first phase: color Doppler preset with pulse repetition frequency of 0.3 kHz was chosen as the most sensible. In the second phase, a significant decline in CD-spots count was detected in 23 (72%) patients (P < .05) and was more distinctive in the periurethral zone. In the third phase, only 43 of the patients continued with TUR-P (in 3 patients, voiding symptoms improved). Operating time and volume of irrigation fluid were significantly different (50.55 minutes/42.65 minutes, P = .014; 8.03/13.10 L, P = .047). CONCLUSIONS: Six weeks of dutasteride treatment may reduce prostate tissue vascularity in the periurethral area proximal to the verumontanum. The third phase of our study confirmed that preoperative treatment with dutasteride could improve operative performance and avoid TUR syndrome.

Healthcare Strategic Planning as Part of National and Regional Development in the Israeli Galilee: A Case Study of the Planning Process.

This article describes a systematic process of geographic and strategic planning for healthcare services as a part of a regional development plan in the Israeli Galilee. The planning process consisted of three stages: (a) assessment of needs, demand and existing resources; (b) prioritisation of initiatives; and (c) scheduling of theoretical priorities. For many years the region has suffered from inequities and inequalities regarding the availability and accessibility of a regional healthcare system, resulting in high mortality and morbidity rates and low quality of life. The aim of the healthcare strategic plan was to suggest initiatives and actions to be taken in order to improve healthcare provision and the health and wellbeing of local residents.

Breast cancer, psychological distress and life events among young women.

UNLABELLED: Since 1983, studies have suggested an interaction between the severe life events, psychological distress and the etiology of Cancer. However, these associations are still under dispute. The aim of the present study was to examine the relationship between life events, psychological distress and Breast Cancer (BC) among young women. METHODS: A case control study. The study population included 622 women, under the age of 45 years. 255 were diagnosed for BC, and 367 were healthy women. A validated Brief Symptom Inventory (BSI) and Life Event Questionnaire were used. RESULTS: The cases presented significantly higher scores of depression compared to the controls and significant lower scores of happiness and optimism. A significant difference was found when comparing the groups according to the cumulative number of life events (two or more events). A multivariate analysis suggest that exposure to more than one life event is positively associated with BC [Odds Ratio(OR) :1.62 95% Confidence Interval (CI): 1.09-2.40], and that a general feeling of happiness and optimism has a "protective effect" on the etiology of BC. (OR-0.75, 95% CI:0.64-0.86). CONCLUSION: Young women who were exposed to a number of life events, should be considered as a risk group for BC and treated accordingly.

Patients with elevated serum PSA and indwelling catheter after acute urinary retention: prospective study of 63 patients with 7-year follow-up.

BACKGROUND AND PURPOSE: Elevated PSA value in the presence of an indwelling catheter is still an enigma. The aims of this prospective study were: to investigate the reliability of elevated PSA levels in patients with normal DRE and indwelling catheter after AUR; to assess the impact of preoperative TRUS-biopsy in detecting prostate cancer in such circumstances; to estimate the crucial duration of follow-up period. PATIENTS AND METHODS: 63 patients were included in the study. PSA was assessed 5 days after catheter insertion. All patients failed to void without catheter and have been scheduled for surgery. TRUS-biopsy was performed before operation. All patients underwent surgery at least two weeks after prostate biopsies. Postoperative follow-up visits continued for at least 7 years. Biopsies were taken when indicated by persistently elevated PSA or an abnormal DRE. RESULTS: Mean PSA before catheter insertion differed significantly from PSA obtained on the 5(th) day after AUR (p = 0.001). Mean prostate volume calculated on TRUS was 80.5 +/- 28 ml. Mean duration of indwelling catheter placement was 37.8 +/- 7.97 days. Mean delay in operative treatment as a result of preoperative evaluation was 23.548 +/- 2.487 days. Carcinoma was detected in 13 patients, while clinically insignificant cancer was present in 31% (4 patients). It must be also emphasized that 38% of patients with carcinoma were >70 year-old. Preoperative TRUS-biopsy and postoperative pathologic exam diagnosed carcinoma in 5 patients (2 and 3 respectively). During 42 months of 7-year follow-up cancer was revealed in 8 patients. Mean PSA value in the follow-up period was significantly elevated in patients with carcinoma: 5.99 +/- 3.34 v/s 2.34 +/- 1.68 ng/ml (p = 0.007) and was the strongest predictor for cancer detection (p = 0.001). CONCLUSIONS: The detection rate of clinically significant cancer on preoperative biopsies postoperative pathologic exam in patients with AUR and indwelling catheter is low. These patients could be safely operated on without any delay. However, in order to detect clinically important cancer in the peripheral zone a postoperative monitoring period of should be recommended: starting 6 months after operation and continuing subsequently for at least 4 years. Postoperative PSA level is the strongest predictor of cancer detection and could be usefully employed in these patients. AUR and in the patients with large prostate cause elevated PSA. Cancer detection rate on preoperative biopsies is low in these patients. Long postoperative monitoring period should be strongly recommended.

The influence of smoking cessation on hemodynamics and arterial compliance.

Cigarette smoking is associated with consistent changes in small arteries and arterioles. Recently, arterial compliance was determined in smokers; however, the effect of smoking cessation on arterial compliance has not yet been investigated. The objective of the study was to assess how smoking cessation, achieved with use of behavioral and pharmacologic therapy, influences vascular compliance and arterial stiffness in smokers. In an open-label study, 60 habitual smokers were treated for 2 months with buproprion 300 mg per day and personal and group conversations in order to facilitate smoking cessation. Hemodynamic variables, including vascular compliance and augmentation index (AI), were measured twice, at the beginning of the study and after 6 months. Of the 60 smokers, 35 stopped smoking and 25 failed at the end of the 2-month treatment period. Of the 35 who were initially successful, 12 went back to smoking, and thus only 23 remained nonsmokers at the end of 6 months. Smoking cessation was accompanied by significantly lower arterial pressure and heart rate but by weight gain. Among the 23 subjects who stopped smoking for 6 months capacitive compliance (C(1)) did not change but oscillatory compliance (C(2)) rose significantly (from 5.1 +/-2.3 to 6.3 +/-3.0 p<0.01), and AI decreased significantly (from 63.1 +/-22 to 50.6 +/-17 p<0.05), whereas in smokers who still smoked after this period, both C(1) and C(2) and augmentation index did not change significantly from their basal values. The authors conclude that smoking cessation improves arterial stiffness as assessed by the augmentation index, owing mainly to increasing the small artery compliance, which is known to be an early index of endothelial damage.