Patient's experience with comorbidity management in primary care: a qualitative study of comorbid pain and obesity.

AIM: The aim of this research is to examine perceptions of those with comorbid chronic pain and obesity regarding their experience of comorbidity management in primary care settings. BACKGROUND: Chronic pain and obesity are common comorbidities frequently managed in primary care settings. Evidence suggests individuals with this comorbidity may be at risk for suboptimal clinical interactions; however, treatment experiences and preferences of those with comorbid chronic pain and obesity have received little attention. METHODS: Semi-structured interviews conducted with 30 primary care patients with mean body mass index=36.8 and comorbid persistent pain. The constant comparative method was used to analyze data. FINDINGS: Participants discussed frustration with a perceived lack of information tailored to their needs and a desire for a personalized treatment experience. Participants found available medical approaches unsatisfying and sought a more holistic approach to management. Discussions also focused around the need for providers to initiate efforts at education and motivation enhancement and to show concern for and understanding of the unique difficulties associated with comorbidity. Findings suggest providers should engage in integrated communication regarding weight and pain, targeting this multimorbidity using methods aligned with priorities discussed by patients.

A randomized clinical trial of an integrated behavioral self-management intervention Simultaneously Targeting Obesity and Pain: the STOP trial.

BACKGROUND: Obesity often occurs co-morbid with chronic, non-cancer pain. While behavioral treatments have proved effective for pain management and weight loss independently, integrated interventions are lacking. The study Simultaneously Targeting Obesity and Pain (STOP) is a prospective, pragmatic, randomized controlled trial that aims to determine whether overweight/obese individuals with chronic pain who are randomized to receive an integrated treatment Simultaneously Targeting Obesity and Pain (STOP) will show more weight loss and greater reduction in pain intensity over a 6-month period and greater maintenance at 12 months than those who receive standard care behavioral weight loss or standard care behavioral pain management. We hypothesize that individuals randomized to receive the STOP treatment will demonstrate improved weight loss, pain reduction, and maintenance compared to standard care treatment approaches. METHODS/DESIGN: Adults aged ≥ 18 with a body mass index ≥ 25 and who report persistent pain (≥4 out of 0-10 for > 6 months) will be recruited for treatment at the Health Behavior Research Lab at the University of the Sciences. After baseline assessments and goal setting, participants will be randomized to receive one of three treatments. Participants will receive eleven treatment sessions delivered during 1 hour, weekly individual meetings with a clinic therapist. Follow-up will occur at 3, 6 and 12-month time points; assessments will include measures of weight and pain intensity (primary outcomes). A mixed-method approach to evaluating study outcomes will include individual interviews with participants about their treatment experience. These interviews will be led by a research staffer who was not involved in study intervention or assessment using a semi-structured discussion guide. DISCUSSION: This study fills an important gap in intervention research, evaluating best-practices for behavioral management of a highly prevalent co-morbidity that has sub-optimal outcomes with currently-implemented approaches. STOP's pragmatic focus builds upon treatments already in use in clinical practice. Should STOP be found efficacious in achieving the dual outcomes of pain management and weight loss, such an approach could be integrated into practice with minimal additional cost or training. TRIAL REGISTRATION: Clinical Trials.gov NCT02100995 Date of Registration: March 2014.

The role of surveillance in the treatment of patients with muscle-invasive bladder cancer after chemotherapy.

OBJECTIVE: To determine the survival of patients at our institution who were clinically tumour-free (cT0) on re-staging transurethral resection (TUR) after treatment with chemotherapy for muscle-invasive bladder cancer. PATIENTS AND METHODS: In all, 55 patients with muscle-invasive, organ-confined transitional cell carcinoma of the bladder were treated with TUR followed by systemic chemotherapy, over a 10-year period. Patients were separated into two groups, those who were clinically T0 and those who showed persistent disease (>cT0) on re-biopsy after chemotherapy. Overall and disease-specific survival rates were calculated for the two groups. The cT0 group was further followed for tumour recurrence and clinical outcomes. RESULTS: Thirty-one patients (56%) were clinically T0 on TUR after chemotherapy; of these patients, 22 (71%) either died from other causes (with no disease recurrence) or are alive and with no evidence of disease at a mean follow-up of 53 months. Twenty of the 31 patients (65%) have retained their bladder with no evidence of cancer recurrence at a mean follow-up of 46 months. Disease-free status (cT0) at the time of TUR after chemotherapy was associated with significantly higher overall and cancer-specific survival (hazard ratio 3.40, P = 0.003; and 8.63, P = 0.001, respectively). CONCLUSION: Previous studies suggest that surveillance can be a reasonable option for patients with muscle-invasive transitional cell carcinoma of the bladder who show no evidence of disease on TUR after chemotherapy. Patients with persistent bladder cancer on re-biopsy after chemotherapy tend to fare poorly even with immediate cystectomy.

Trends in pelvic lymphadenectomy at the time of radical cystectomy: 1988 to 2004.

PURPOSE: Studies suggest that patients who undergo thorough lymphadenectomy for bladder cancer benefit from improved survival. We evaluated the incidence of and trends in lymphadenectomy in conjunction with radical cystectomy for bladder cancer. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Results registry we identified 8,072 eligible patients with bladder cancer who underwent radical cystectomy with or without lymphadenectomy from 1988 to 2004. After stratification by age group, race, stage, grade and year of diagnosis we performed logistic and linear regression to correlate variables to the mean number of lymph nodes sampled and the likelihood of undergoing lymphadenectomy (classified as 1 or more, 5 or more and 10 or more nodes removed). RESULTS: In the final cohort 1,660 patients (21%) did not have any lymph nodes sampled at radical cystectomy. This number decreased from 37% in 1988 to 16% in 2004. During this period the mean number of lymph nodes removed increased by 2.6 nodes over all definitions of lymphadenectomy and the percentage of patients undergoing any form of lymph node dissection increased by an average of 19%. Year of diagnosis was most strongly predictive of the likelihood of undergoing lymphadenectomy and most correlative with the mean number of nodes sampled. CONCLUSIONS: Over time there has been improvement in terms of the performance of lymphadenectomy and node counts obtained during radical cystectomy. If these trends continue the incidence and quality of lymphadenectomy should continue to increase, ultimately to the benefit of the patients being treated.

Sociodemographic factors associated with nephrectomy in patients with metastatic renal cell carcinoma.

PURPOSE: Studies suggest that radical nephrectomy imparts a survival benefit in select patients with metastatic renal cell carcinoma. We determined the roles of patient age, gender, race and in particular marital status in the decision to pursue nephrectomy and the ensuing effect on overall survival. MATERIALS AND METHODS: Using the Surveillance, Epidemiology and End Results database we identified 11,182 patients between 1988 and 2004 who were diagnosed with metastatic renal cell carcinoma. Patients were separated into 2 groups, including those who underwent nephrectomy and those who did not, and they were stratified by the mentioned variables. Logistic regression and Kaplan-Meier analyses were used to determine the likelihood of undergoing nephrectomy and of overall survival in the cohorts. RESULTS: In the final cohort 3,443 patients (31%) underwent radical nephrectomy. These patients experienced longer median survival than those who did not undergo surgery (11 vs 4 months, p <0.001). The survival benefit was statistically similar regardless of age group, race, gender and marital status. However, nephrectomy was more commonly performed in younger age groups, and in white and married patients. While age group and race were statistically significant predictors of undergoing nephrectomy (OR 0.64, 95% CI 0.61-0.66 and OR 0.79, 95% CI 0.70-0.89, respectively), marital status was the most important predictor (OR 1.52, 95% CI 1.39-1.66). CONCLUSIONS: Patients with metastatic renal cell carcinoma who undergo radical nephrectomy experience a survival advantage over those who do not undergo surgery. Married patients are more likely to undergo nephrectomy than their unmarried counterparts. Physicians must be aware of this bias when selecting patients for nephrectomy.

Manuscript publication by urology residents and predictive factors.

PURPOSE: Many academic institutions have set expectations for peer reviewed publications, yet there is no objective guideline to gauge the performance of a urology resident or program. We quantified and determined predictive factors for resident manuscript production. MATERIALS AND METHODS: Electronic surveys were sent to 255 chief residents and recent graduates of 83 accredited urological training programs in the United States and Canada. Survey questions pertained to manuscript submission and acceptance before and during residency, months of research incorporated into residency, PhD degree status and the pursuit of fellowship training. RESULTS: Surveys were completed by 127 residents from 83 programs. The median number of manuscripts submitted and accepted during residency was 3 (range 0 to 32) and 2 (range 0 to 25), respectively. Months of protected research time and the number of publications before residency were significantly predictive of the number of manuscripts submitted during residency (p <0.001 and p <0.001, respectively). The number of manuscripts submitted during residency was significantly associated with entering fellowship training (p <0.05). CONCLUSIONS: Manuscript preparation and publication are important aspects of the training process at a number of urological surgery residency programs. While the majority of residents are not involved in publication before residency, most submit and publish at least 1 manuscript as first author in a peer reviewed journal during residency. The number of prior publications and months of allotted research time are significantly predictive of resident manuscript productivity. In turn, manuscript submission is indicative of the decision to pursue fellowship training.

Current applications for prostate-specific antigen doubling time.

OBJECTIVE: To review the current status of prostate-specific antigen doubling time (PSADT) as it pertains to the evolution of prostate cancer (PCa), specifically assessing its role in the following four stages: before diagnosis, prior to definitive treatment, following treatment including salvage therapy after recurrence, and lastly, after onset of androgen-insensitive PCa. METHODS: We searched PubMed literature for current articles on PSADT using the key words listed for this review and, where possible, selected those with significant levels of evidence that were deemed relevant, seminal, or controversial. We summarized the data regarding PSADT as a marker for diagnosis and disease characterization, as well as a predictor of progression, response to treatment, and mortality. RESULTS: PSADT may offer an advantage in providing a more dynamic picture of tumor behavior, providing clues regarding the relative aggressiveness of the underlying pathology. Evidence points toward a role for PSADT in the management of PCa, specifically in active surveillance, disease recurrence after treatment, and in androgen-independent PCa. PSADT is an important prognostic factor that may serve as an auxiliary end point for cancer-specific survival; however, optimal cut-off points denoting risk remain debatable. CONCLUSIONS: PCa management requires risk stratification with a combination of variables, PSADT being one of the most reliable predictors. It is now a parameter included in many predictive nomograms and in treatment guidelines for expectant management and salvage therapy.

Medical and surgical management male infertility.

Male infertility is the result of a variety of highly treatable conditions. The critical step in treating male infertility is to evaluate properly every male partner of an infertile couple and to generate the proper treatment strategy. There are many medical and surgical options that can help most couples overcome male factor infertility. Male infertility can most easily be broken down into problems of sperm production (testicular dysfunction) and problems of sperm transport (obstruction). When applicable, medical therapies are used as an initial strategy to improve sperm production or as a preliminary therapy to boost production transiently in anticipation of a surgical sperm retrieval attempt. A range of surgical options is available to correct varicoceles, reconstruct the obstructed system, or retrieve sperm for assisted reproduction.

Managing prostate cancer: the role of hormone therapy.

Androgen deprivation therapy has been the mainstay of treatment for men with metastatic prostate cancer and now plays a more active role in the management of less advanced cancers as neoadjuvant and adjuvant treatment. Investigative uses include primary therapy for patients unsuitable for definitive therapy and as a complement to ablative procedures, brachytherapy, and chemotherapy. Intermittent androgen deprivation therapy is being considered as an alternative to continuous therapy and further evaluated as triple androgen blockade in conjunction with finasteride. Many accepted and potential management schemes incorporating hormonal therapy are increasingly employed despite indeterminate indications for use. Here, we review currently available data on the efficacy of hormonal therapy with regard to complete androgen ablation, primary, neoadjuvant, and adjuvant therapy. Additionally, we examine the usefulness of delayed versus immediate administration, intermittent androgen deprivation, and other prospective applications for hormonal therapy.

Current management of small renal masses.

The incidence of small renal masses (< 4 cm) is increasing due to the widespread use of imaging studies. Many of these incidental lesions may remain asymptomatic or in fact be benign, and recent insight into their natural course has contributed to modifications in management. With improvements in biopsy technique and minimally invasive technologies, appropriate diagnosis and treatment of these masses are further being evaluated. Other contemporary approaches, including surveillance, laparoscopic partial nephrectomy, enucleation, ablative procedures, and high-intensity focused ultrasound, are weighed against open nephron-sparing surgery, the current gold standard for treatment. Here, we review currently available data on the efficacy of these treatment options. Additionally, we examine the natural history of small renal masses, the role of diagnostic biopsy, and follow-up strategies for proper management.