June 21, 2014

We need more clinical time outs

A few months ago, the father of a primary care physician came into the emergency department with syncope.   He was 102 years old.  His age was more than double his heart rate.  That may or may not be bad but it certainly is often a reason for more testing.  The senior resident seeing the patient ordered an EKG, a battery of labs, a head scan,  and anticipated admitting the patient as he had been taught to do: old person, syncope, bunch of tests, admit — pretty bread and butter case.  Or was it?

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

A new buzz around primary care

I recently described the loathsome “relative value unit” (RVU) and its role in the decline in prestige and pay in primary care.  The RVU is maintained and updated by a small panel of 31 physicians called the Specialty Society Relative Value Scale Update Committee (RUC).  Twenty-seven of the 31 physicians are specialists, which is not at all representative of the physician workforce, given that primary care doctors comprise over one third of it.

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Your patients are rating you online: How to respond. Manage your online reputation: A social media guide. Find out how.

June 20, 2014

Type 2 MI: addressing and resolving the confusion

A review article addressing this topic is available as free full text from the American Journal of Medicine.The classification of MI into types 1-5 is linked here.Confusion may exist between type 2 MI and elevated troponin due to non ischemic myocardial necrosis occurring in a variety of severe illnesses. Perhaps the most familiar example of the latter condition is the troponin elevation that

Want to know why performance measures fail?

Here's a big reason: Objectives The aim of this study was to examine the prescribing patterns of medications quantified by the performance measures for acute myocardial infarction (AMI). Background Current performance measures for AMI are designed to improve quality by quantifying the use of evidence-based treatments. However, these measures only assess medication prescription. Whether

Exercise – the most difficult prescription to fill

Perhaps this post represents my current obsessions, but the literature suggests very strongly that exercise has great preventive benefits.  Our challenge as physicians comes in trying to convince patients to exercise.

Our medical students seem to understand.  The great majority of our students exercise.  The same goes for our residents.

Back in the 70s when I was a student, it was rapidly becoming clear that very few students smoked.  I have not known a medical student smoker in the past several years.

Physicians and aspiring physicians generally are early adopters of healthy behaviors.  Our challenge is translating our understanding and positive habits to our patients.

The exercise prescription, quite similar to the smoking cessation prescription, requires hard work from the patient.  How do we help our patients adopt a healthy lifestyle?  What are the magic words?

I would love to read comments from readers who have had success in helping patients enter the world of regular exercise.

Exercise does not have to be strenuous.  Regular walking brings great benefits.

Exercise does so much positive, yet too many Americans eschew movement.  We should continue making exercise the norm rather than special.

June 18, 2014

Constipation - Mayo Clinic patient education video series

Constipation: Causes and Symptoms - Mayo Clinic - YouTube http://buff.ly/1pUrfdV

Constipation: Dietary and Behavior Modifications - Mayo Clinic - YouTube http://buff.ly/Sq8lNv

Constipation: Lifestyle Modifications - Mayo Clinic - YouTube http://buff.ly/1pUrsO9

Constipation and the Colon - Mayo Clinic - YouTube http://buff.ly/Sq8pg8

June 15, 2014

On becoming a runner – many lessons learned – Part 2 – clothing

Running works better when you have the proper gear.  Clothes are important.  If you are starting, you will probably put on some shorts, a cotton tee shirt and socks.  If you are going to run regularly, you should look into modern clothing.

Most “serious” runners wear technical shirts.  Technical shirts wick – they do get wet, but not as heavy or as wet as cotton. They also lead to less chafing.  My experience suggests that you do not want the shirt to be too tight.  Technical shirts are more expensive, but most runners will tell you that they are worth it once you are running long enough to have significant sweating.

Each runner will need to find their favorite running shorts.  I have tried several, and particularly like the Nike Dri-fit, but each runner will find their own favorites.

Socks are most important to prevent blisters.  I recommend going to a running store and buying socks that wick.  Socks are very important to protect your feet.  I am wearing Swiftwick socks currently, but there are several excellent brands to choose from.



June 13, 2014

Does the concept of "value based payments" make any sense at all?

Greg Scandlen at the Health Policy Blog comments on the term "value based" quoting from a worth- reading article by David Carr writing on the site Information Week. Here is link to Scandlen 's thoughts.

Scandlen deftly takes apart a widely quoted article by Michael Porter that appeared in the NEJM in 2010 .

The concepts  of professor Porter are widely quoted and for him value is defined as "health outcome per dollar spent" but he spends considerable effort in explicating how elusive and difficult that is to put into meaningful operational use.

A number of the concepts that Porter has made popular ,after a little thought, seem more to be catchy platitudes than useful,reality based insights.For example the notion of improving performance and accountability by "having a shared goal that unites the interests and activities of all stakeholder.s"Is there any real sense in which the patient has a shared goal with the third party payer?

quoting Scandlen:

" ..I would argue that the whole idea that “value to the patient” can be defined objectively is misguided. Even with precisely the same cost and the same medical outcome, the “value” of a service will be different for every patient. Dick Cheney seems to be very happy with his heart transplant and thrilled to extend his life by several more years. Someone else might think that the ordeal of the surgery and medical attention isn’t worth it. Or they might think that their life is pretty crappy and not worth extending."

In other words, value is subjective and in the eyes of the beholder which should be the patient and  not the cost effectiveness practitioners who can "determine" the value with numbers and regressions, even though at the end of the analysis someone has to make a value judgment call.

I have ranted about this near naked emperor before.  See here.

 The " value based payments" meme seems more and more to be  just another phony-baloney justification for third party payers to limit expenditures for medical care and dress it up with platitudes.

June 12, 2014

Board Exam Studying Tips by Mayo Clinic Cardiologist (video)

From Mayo Clinic: Dr. Jeffrey Geske, a Cardiology fellow, interviews Dr. Joseph Murphy, a Cardiologist and Mayo Clinic Professor of Medicine, regarding how to prepare for the cardiovascular board exam. As a speaker of the board review course and also the co-author of the Fourth Edition of the Mayo Clinic Cardiology Concise Textbook, he has experience in preparation for the exam.

June 06, 2014

Is the underlying problem with the VA hospitals scandals greed?

Perhaps self-interest in a better word to describe what is going here.

There is a wide spread and naive notion that for-profit institutions,  aka business, are driven by greed and that dishonesty and bad motives dominate their existence and that non-profit organizations are the opposite in every regard; But folks who populate non-profit organizations are cut from the same cloth as the rest of humanity and for them as for everyone incentives matter.

This commentary by Glen Reynolds gets it right.

I quote from  his  comments from USA Today:

"In other words, they cooked the books. And what's more, they did it to ensure bigger "performance bonuses." The performance may have been fake, but the bonuses were real. (One whistle-blower compared the operation to a "crime syndicate.")
And that captures an important point. People sometimes think that government or "nonprofit" operations will be run more honestly than for-profit businesses because the businesses operate on the basis of "greed." But, in fact, greed is a human characteristic that is present in any organization made up of humans. It's all about incentives." ....And, ironically, a for-profit medical system might actually offer employees less room for greed than a government system. That's because VA patients were stuck with the VA. If wait times were long, they just had to wait, or do without care. In a free-market system, a provider whose wait times were too long would lose business, and even if the employees faked up the wait-time numbers, that loss of business would show up on the bottom line. That would lead top managers to act, or lose their jobs."

If you look at the history of the VA system you will see greed and corruption boiling over the top at the very beginning..The historian  Burt Folsom gives a brief review of the origin of the VA system and the corruption and mismanagement that characterized its early days under the administration of President  Warren Harding.

The point is that people act in their self interest ( when their actions rub up against our moral priors we call it greed) and that markets impose the discipline of profit and loss that are lacking in  monopolies such as the socialized medicine of the VA system and often -but not always- direct that greed to the benefit of others.

As Milton Friedman said the question is: under what system will
greed lead to the  least harm,his answer was capitalism.Here is his priceless reply to Phil Donahue .

June 03, 2014

Diseases Everywhere

When people want a diagnosis there is always one to give and eager medical enterprises to treat them. If medical care was that good and cures that assured, it would be a blessing. Otherwise.....

May 28, 2014

Prevention Of Harm To Oneself

Should people be prevented from doing harm to themselves? When that involves immediate and drastic harm the answer is yes. Suicide for example. When the harm is more gradual and less obviously acknowledged the response is more debatable. Smoking and junk food for example. Over time the linkage between cause and effect becomes more obvious and society chooses to act. Even then regulations are less effective than social norms. The wrinkle comes with the large commercial enterprises built upon bad habits. It is a long and arduous path to a healthy society and the future belongs to the children. When people make better choices, no one will sell the bad choices. If I'm not mistaken the sales of soda in the U.S. is declining. Most people want to look good and feel good and sooner or later they learn what it takes to accomplish that goal. In that regard a free market society is the best option. Business enterprises follow their customers or they go out of business. Just don't forget those children  

May 09, 2014

Anti-Vaccine Myths and Misinformation

Of course, the great majority of parents vaccinate their kids and get them fully protected against vaccine-preventable diseases. And with the rise in these diseases, including mumps, measles, and pertussis, ...

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April 16, 2014

Mumps Outbreak in Ohio

In addition to the ongoing measles outbreaks across the country, there is currently a large mumps outbreak in central Ohio.

Although not getting as much attention, the mumps outbreak, which began ...

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More Car Seat Recalls

TrendZ Fastback Car Seat Recall - Photo courtesy of the NHTSABaby Trend, Inc., in collaboration and cooperation with the National Highway Traffic Safety Association, is recalling about 16,655 of their  3-in-1 child restraints because, because like a recent Graco car seat recall, "it may be difficult to remove the child from the restraint, increasing the risk of injury in the event of an emergency in which a prompt exit from the vehicle is required."

Included in this car seat recall, are the 2011 and 2012 TrendZ Fastback 3-in-1 child restraints, including:


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April 09, 2014

Do Not Track Kids Act of 2013

The Do Not Track Kids Act of 2013 (S. 1700) was introduced in the United States Senate and in the House as HR. 3481 last November.

The bill "amends the Children's Online Privacy Protection Act of 1998 to extend, enhance, and revise the provisions relating to collection, use, and disclosure of personal information of children, to establish certain other protections for personal information of children and minors, and for other purposes."


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April 07, 2014

World Health Day 2014

World Health Day - Photo courtesy of the WHOIt's World Health Day and the focus this year is on vector-borne diseases, or diseases that can be transmitted by the bite of mosquitoes, ticks, fleas, and water snails.

Unfortunately, while the CDC states that "vector-borne diseases account for 17% of the estimated global burden of all infectious diseases," it is important to remember that there are no vaccines to help prevent most of them. These diseases include dengue, schistosomiasis, leishmaniasis, Lyme disease, West Nile virus, Rocky Mountain spotted fever, Chagas disease, and malaria, which remains "one of the most severe public health problems worldwide."


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Update on New Meningitis Vaccines

While there are more than a few meningitis vaccines already available, some recent outbreaks of meningococcal meningitis and meningococcemia highlight the fact that at least one is sorely missing.

In addition to many sporadic cases, last year, eight students and one prospective student at Princeton University developed meningococcal disease in an outbreak that began in March 2013. At University of California, Santa Barbara, there were four confirmed cases in November 2013, including one student who became so sick that he had to have both of his feet amputated. Both outbreaks were caused by different strains of the serogroup B meningococcal bacteria, which isn't included in our current meningococcal vaccines (Menactra and Menveo).


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Walking to School Safely

Walking to School - Photo by Getty ImagesPeople often bemoan the fact that it doesn't seem like as many kids walk to school like they used to in the 'good old days.'

It would certainly be good if they did. Most kids need more physical activity, especially those who aren't involved in youth sports.


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April 06, 2014

Autism Group Awareness

Autism Speaks kids off World Autism Awareness Day on the NYSE - Photo by Astrid Stawiarz/Getty ImagesThis year, for Autism Awareness Month, how about being a little more aware of the differences in all of the autism organizations out there.

The very recent Chili's public relations blunder, in which they were planning to donate 10% of sales on April 7 to the National Autism Association, an anti-vaccine autism organization, highlights how important it is to know the organization you are supporting and or visiting information and advice.


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April 03, 2014

Measles Count Up To 108 Cases

A measles alert posted on a home of a child with measles by the health department. - Photo by Buyenlarge/Getty ImagesThe CDC has released the latest measles case count for the United States.

We are now up to 108 cases.

While that still may not seem like a lot to some people, ...

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April 02, 2014

Update on the Measles Outbreaks of 2014

A measles alert posted on a home of a child with measles by the health department. - Photo by Buyenlarge/Getty ImagesNot expectantly, the measles outbreaks of 2014 continue to grow larger.

We now have at least 89 cases in the United States, including:

  • at least 25 cases of measles in New York City, including 13 adults and 12 children, with 6 requiring hospitalization.
  • ...

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March 19, 2014

2014 Alzheimer's Disease Facts and Figures Report from the Alzheimer's Association

The "2014 Alzheimer's Disease Facts and Figures" report from the Alzheimer's Association has been released. It is available as a .pdf document at Facts and Figures and has an accompanying YouTube video.

March 04, 2014

Neuropsychology Abstract of the Day

Robinson, G. & Ceslis, A. (2014). An unusual presentation of probable dementia: Rhyming, associations, and verbal disinhibition. J Neuropsychol. doi: 10.1111/jnp.12041. [Epub ahead of print]

We report a case of probable Alzheimer's disease who presented with the unusual feature of disinhibited rhyming. Core language skills were largely intact but generative language was characterized by semantic-based associations, evident in tangential and associative content, and phonology-based associations, evident in rhyming, in the context of prominent executive dysfunction. We suggest this pattern is underpinned by a failure to terminate or inhibit verbal associations resulting in a 'loosening' of associations at the level of conceptual preparation for spoken language.
© 2014 The British Psychological Society.

PMID: 24581283 [PubMed - as supplied by publisher]

September 29, 2011

Out of the hospital...

Beautiful fall days call for beautiful fall activities. This weekend, SWIMBO and I headed to Williams Canyon outside of Manitou Springs. Day one --- HIKE IT!

Looks like some bozo doesn't know how to read.

And for the next day's activities --- BIKE IT!


April 25, 2011

Gambling with Matches

"Match Day" came and went this year on March 17th; I find it interesting to look at the raw data from the residency match, as it gives one an idea of what the next generation of physicians are thinking about the future, and my chosen specialty in particular. It is also instructive to see what is put out as PR for the match and compare it to the match results themselves:
For Second Year, More U.S. Medical School Seniors Match to Primary Care Residencies
For the second year in a row, more U.S. medical school seniors will train as family medicine residents, according to new data released today by the National Resident Matching Program (NRMP). The number of U.S. seniors matched to family medicine positions rose by 11 percent over 2010. In Match Day ceremonies across the country today, these individuals will be among more than 16,000 U.S. medical school seniors who will learn where they are going to spend the next three to seven years of residency training.

I'd like to focus on three residencies --- Family Medicine, Internal Medicine, and General Surgery. For Family Medicine, 48% of the 2,708 slots this year went to US medical school graduates, compared with 44.8%, 42.2%, 43.9%, and 42.1% in the previous four years. For Internal Medicine, the numbers were somewhat higher, with 57.4% of the 5,121 positions being filled by US graduates, in comparison to 54.5%, 53.5%, 54.8%, and 55.9%. Both are a bit of a bump up, but the 11% rise noted for Family Medicine in the press release is a bit misleading, as the number of slots increased by 100 over 2010 as well.

General surgery numbers were a bit mixed, as there were more slots available this year (1,108 versus 1,077 in 2010), 81% of which were filled by US graduates; in comparison, the percentages were 83.1%, 77.4%, 83.1%, and 78.1% going back to 2007. Pediatrics and OB-GYN numbers are hanging in the low-to-mid 70% range for the same time period.

What does all of this mean? I'm not really sure. Not being a statistician, I can't say for sure but none of these numbers suggest a statistically significant change in the percentage of US medical school graduates going into these residencies, all political and PR posturing aside. One thing that many tend to forget is that subspecialty care will draw off many of these primary care physicians with time --- into cardiology, GI, neonatology, high-risk OB, plastic surgery, cardiothoracic surgery, etc.

If I was a betting man, I would bet that the minor increase in FP and IM numbers this year will not be sustained; there are too many financial forces working against the physicians in those specialties. And general surgery is not terribly different in the long run.

March 25, 2010

A Brief Anthropology of the Nigerian Healthcare Tier System and Her Primary Healthcare Exigency: comments

Tun left the following comments on an earlier post. Please read the original post first. I thank Tun for the comments.

Good (if slightly inaccurate) reading of Nigeria's medical history. Just wish to point out that the Colonial Medical Service started way before the Second World War. Indeed, the first set of medical officers were sent out in 1898. You are of course correct that primary attention was given to European personnel; but because part of the mandate of the service was to gather medical and scientific data, doctors had to be interested in treating locals.
You may wish to correct these in your blog so that some unknowing visitor may not be so misinformed.
Best wishes.

November 13, 2009

Lessons from my trip

I am in Monrovia for a scientific meeting. I have been here for about a week. I have learnt quite a lot during this short stay. I itemise my musings below:
1. The destruction caused by the Liberian war is of no small dimension
2. The attendant national retrogression is not quantifiable
3. The human spirit is resilient
4. The efforts of the government here to return a similitude of normal life has reached a fevered pitch
5. The favourable disposition of the average Liberian towards Madam Ellen Johnson Sirleaf is contagious
6. The plea of Liberia for assistance with capacity building is urgent and cogent
7. There is a marked presence of the international community here helping with national revamping
8. The dearth of quality translational research in the West African sub-region is alarming
9. Feeble efforts are being made by stakeholders to correct this dearth
These are some of my thoughts.

October 03, 2009

UroToday - Prospective evaluation of prostate cancer risk in candidates for inguinal hernia repair - Abstract


We found the incidence of concurrent prostate cancer with hernia to be low, but 51% of men had PSA values that suggested an increased relative risk of future development of prostate cancer. Men at increased risk of prostate cancer should be made aware of the impact that mesh might have on subsequent treatment options before mesh placement.

Many years ago it was thought that a prior laparoscopic hernia repair would be a major problem for a patient who had prostate cancer wanted a robotic prostatectomy.

Since 2003 the majority of robotic surgeons have performed robotic surgery through the abdominal cavity. With this approach, the bladder and blood vessels can safely be separated from the mesh with direct visualization.

I do not consider a prior hernia repair with mesh to be a significant concern prior to robotic surgery. The surgery should take a little longer, but removing the prostate is not a significant problem.

The only concern in patients that will undergo hernia repair is to make sure they do not have cancer at the present time. If they do and want surgery for prostate cancer, then a robotic hernia repair and robotic prostatectomy shoudl be done at the same time, avoiding 2 surgeries. I have performed over 100 of these combination hernia repairs and davinci prostatectomies.

May 18, 2009

Risk of prostate cancer unaffected by antibiotic treatment

Source: MedWire News

The average age of the patients was 62.9 years. Average total PSA before and after treatment was 6.05 ng/ml and 5.55 ng/ml, respectively. On biopsy, 23% of patients had histologically proven prostate cancer. There were no significant differences between men with and without prostate cancer in age, pretreatment PSA, free PSA, percent free PSA, and PSA density.

Average total PSA, free PSA, and PSA density decreased after treatment in men with and without prostate cancer. But the reductions in total PSA and PSA density were not significant in prostate cancer patients and the reduction in free PSA in cancer-free patients was not significant.

This paper looked at treating patients with an elevated PSA and a normal rectal exam with antibiotics. The reason why this is important is that many urologists prescribe antibiotics for men with elevated PSA values and only biopsy them if the PSA is still elevated.

This study did not show a significant difference for men with and without prostate cancer for PSA changes. Both groups had a decline in PSA values.

This is not a conclusive study and the use of antibiotics is still an option in treating men with a high PSA. I personally like to start with a biopsy and not antibiotics in men that have never had a prostate biopsy.

UroToday - Nephroureteral Stent on Suction for Urethrovesical Anastomotic Leak After Robot-Assisted Laparoscopic Radical Prostatectomy

Source Urotoday.com

I foudn an abstract about a way to manage urinary ascites that can rarely happen after dvP.

Conventional measures, including catheter traction, passive drainage, and needle vented Foley catheter suction, failed. On postoperative day 6 a unilateral nephroureteral stent was placed on intermittent suction.

Placement of one nephroureteral stent on suction device immediately stopped the urinary anastomotic leakage into the peritoneal cavity.

In case of a persistent urinary leak after RALP that fails conservative management, a nephroureteral stent on suction may aid to stop the anastomotic leak.

I have seen this problem a few times in the past 5 years. The best way to manage it, in my opinion, is to place a drain laparoscopically by the surgeon if one does not exist. I found that interventional radiology does not place as large a drain or in as good a place.

While I am placing the drain laparascopically, I also perform a cystoscopy to attempt to place 5 fr ureteral catheters for urinary diversion. I think the most important thing is to push the foleyin away from the bladder neck. I think foley traction on the anastamosis is what keeps the opening open.

February 05, 2009

Is the Complication Rate of Radical Cystectomy Predictive of the Complication Rate of Other Urological Procedures?

Source: UroToday

A higher hospital radical cystectomy volume appears to lead to a lower risk of complications only after other common urological oncological procedures, namely radical prostatectomy and nephrectomy, but not after nononcological urology procedures.

This abstract found that hospitals that performed radical cystectomy (removal of the bladder and surrounding tissue for bladder cancer) had less complcations for kidney and prostate cancer surgery as well.

I have been perfoming radical cystecomies my whole career and started perfoming these robotically 3 1/2 years ago. Although I thought performing the more complex surgery helpe me in other surgeries, I didnt realize that a study would show less complications for these other procedures.

December 21, 2008

Impact of Accessory Pudendal Arteries on Potency Following Robot-Assisted Prostatectomy

Source: UroToday from 2008 Wold Congress of Endourology

  • After multivariate analysis there was no significance with sacrificing an APA and time of potency recovery. There was no correlation with sacrificing an APA and postoperative quality of erections (94% vs 90% p=0.30) or mean IIEF-5 (22.4 vs 20.7 p=0.11).

  • As one of the few reports regarding anomalous venous anatomy during robotic prostatectomy, this study found no correlation between APAs and preoperative potency. Additionally the authors found no correlation between sacrificing APAs and 24-month potency return. The authors concluded that they found no effect on the time to return of potency, quality of erections or mean IIEF-5 scores at 24 months.

This is the first study that I have seen that addresses return of sexual function in men with accessory pudendal arteries. This is an extra artery that brings blood to the genital area that travels very close to the prostate and through the DVC (vein that brings blood back from the penis).

I usually try saving these arteries and usually I am successful, but it is good to know it is not a big deal to transect it if necessary.

The Prognostic Impact of Seminal Vesicle Involvement Found at Prostatectomy and the Effects of Adjuvant Radiation

Source: Urotoday

Patients with seminal vesicle positive disease who received adjuvant radiation compared to observation realized an improvement in 10-year biochemical failure-free survival from 12% to 36% (p = 0.001), in 10-year overall survival from 51% to 71% (p = 0.08) and in metastasis-free survival from 47% to 66% (p = 0.09), respectively.

Although seminal vesicle involvement is a negative prognostic factor, long-term control is possible especially if patients are given adjuvant radiation therapy. This therapy appears to be effective in patients with seminal vesicle involvement.

This one study showed an advantage of giving patients radiation if they had cancer in the seminal vesicles at the time of radical prostatectomy. Many factors need to be addressed in determining if radiation is necessary after surgery.

Robotic prostatectomy findings in patients with a single microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy

A Single Microfocus (5% or Less) of Gleason 6 Prostate Cancer at Biopsy-Can We Predict Adverse Pathological Outcomes?

Source: Urotoday

While a microfocus of Gleason score 6 prostate cancer on biopsy is commonly considered low risk disease, there was a greater than 1/5 risk of pathological upgrading and/or up staging. Patients with Gleason score 6 microfocal prostate cancer should be counseled that they may harbor more aggressive disease, especially when pretreatment clinical risk factors are present, such as advanced age or high clinical prostate specific antigen density.

The team at the University of Chicago looked at patients with only 1 small focus of cancer that was the lower grade (6) on biopsy. Overall 42 patients (22%) had adverse pathological outcomes, including upgrading in 35 [higher gleason score] (18%) and upstaging [cancer outside the prostate] in 16 (8%). I performed a similar study almost 2 years ago that also found the amount and type of cancer is underestimated on biopsy.

Robotic Inguinal Hernia Surgery at the time of Robotic Prostatectomy

Source: Journal of Robotic Surgery, Volume 1, Number 4 / February, 2008


Urological surgeons should be encouraged to perform a thorough inguinal exam during preoperative evaluation and intraoperatively to detect subclinical hernias. Inguinal herniorrhaphy done concurrently at the time of RALP is safe, with no added morbidity and should be routinely performed.

This is a paper Dr. Ahlering and I wrote which is a review of our results and techniques of fixing hernias during dvP.

Since conferring with Dr Ahlering on this paper, I have changed my technique to resemble his more.

The main point of the article is that hernias are common and it is beneficial for patients to have them fixed.

Robotic Partial Nephrectomy Study

Journal of Robotic Surgery, Volume 2, Number 3 / September, 2008


We report a large, multi-institutional series of RPN for renal tumors, confirming safety and feasibility reported in previous small, single-institution studies. Although we report the initial experience in RPN at each center, immediate oncologic results and perioperative outcomes approached those of more mature laparoscopic series. Robotic assistance may facilitate the technical challenges of precise tumor resection and renal reconstruction within acceptable warm ischemia times. Long-term outcomes are needed to establish the role of RPN in nephron-sparing surgery.

This was a large multi-institutional study that I was part of. This was the largest robotic partial nephrectomy study reported.

December 20, 2008

MedWire News - Prostate Cancer - Endocrine and radiotherapy 'standard care' for locally advanced prostate cancer

Source Medwire News

Adding local radiotherapy to endocrine treatment halves the 10-year prostate cancer-specific mortality in patients with locally advanced or high-risk local prostate cancer compared with endocrine treatment alone, researchers report.

"In the light of these data, endocrine treatment plus radiotherapy should be the new standard," Anders Widmark (Umeå University, Sweden) and team write in The Lancet.

This study looked at 875 patients with locally advanced prostate cancer (T3; 78%; PSA70; N0; M0) without evidence of distant spread. These men were from multiple centers in Norway, Sweden, and Denmark. In this set of patients, adding radiation helped men live longer compared to hormonal therapy alone.

The only difference in my practice, and in many centers in the US is that we sometimes perform surgery for these patients as well. The other difference is that these patients were given continuous endocrine treatment using flutamide, which is not as effective as other hormonal therapy regimens that we usually use (gonadotropin-releasing hormone ( GnRH) agonists).

December 18, 2008

Dr Moyad on Vitamin E- Do not take over 400 IU daily

Source: Dr. Moyad on December 2008 Newsletter

"It is now 100% official, high-doses (400 IU or more per day) of vitamin E supplements should not be taken by anyone, especially men trying to prevent, those diagnosed, or even treated for prostate cancer (in other words all men on planet earth)!!!"

Dr. Moyad is in my opinion, the most respected and knowledgeable authority on nutritional support and supplements for prostate cancer. He comments on how the use of high dose Vitamin E is not only beneficial, but likely harmful.

December 17, 2008

Robotic Partial Nephrectomy Versus Laparoscopic Partial Nephrectomy for Renal Cell Carcinoma: Single-Surgeon Analysis of >100 Consecutive Procedures

Source: UroToday

The mean total operative time (140 vs 156 minutes, P = .04), warm ischemia time (19 vs 25 minutes, P = .03), and length of stay (2.5 vs 2.9 days, P = .03) were significantly shorter for RPN than for LPN, respectively.

RPN can produce results comparable to LPN but has disadvantages, such as cost and assistant control of the renal hilum. Additional randomized trials are needed.

A friend and expert robotic renal surgeon, Dr Bhayani, discusses his results with robotic partial nephrectomy.

The most important finding is the improvement in warm ischemia time, the amount of time the kidney is not receiving blood supply.

Another important finding is that the operation can be done quicker robotically, which can translate into a cost savings that will partially offset the increased cost of the robotic equipment.

November 15, 2008

SELECT: Selenium, vitamin E show no benefit in prostate cancer prevention - - UrologyTimes

Source: Urology Times

Selenium and vitamin E supplements, taken either alone or together, do not appear to prevent prostate cancer, according to an initial, independent review of study data from the Selenium and Vitamin E Cancer Prevention Trial (SELECT).

The data also showed two concerning trends: a small but not statistically significant increase in the number of prostate cancer cases among the more than 35,000 men age 50 years and older in the trial taking only vitamin E; and a small, but not statistically significant increase in the number of cases of adult-onset diabetes in men taking only selenium.

Because this is an early analysis of the data from the study, neither of these findings proves an increased risk from the supplements, and both may be due to chance, according to the authors.

This was a well recruited study that started many years ago when I was at Indiana. We were one of the sites that were recruiting patients. This is the first analysis I have seen from this, so we will need to wait for more data to come out. According to early findings, neither Vitamin E nor selenium help prevent prostate cancer.

November 02, 2008

Medical News: ASTRO: Proton Radiation Fails to Impress in Prostate Cancer Study - in Meeting Coverage, ASTRO

Source: Med page today

Proton radiation for early prostate cancer had an acceptable tolerability profile but produced little evidence of a "gee whiz" impact to support its cost, according to preliminary results from a phase I/II clinical trial.

Two-thirds of patients had acute genitourinary or gastrointestinal toxicity, and a third had late GU/GI toxicity, Anthony Zietman, M.D., of Harvard and Massachusetts General Hospital, reported at the American Society for Therapeutic Radiology and Oncology meeting.

Although most of the toxicity was grade 2 in severity, the overall profile provided little reason for enthusiasm.

"The bottom line is that the treatment was safe, it was reasonably well tolerated, but probably no better tolerated than any other form of radiation that we give," Dr. Zietman said.

According to this study, the less available and much more expensive proton radiation therapy for prostate cancer is not much different than traditional radiation.

September 21, 2008

UroToday - Trial Evaluation of Erectile Function after Attempted Unilateral Cavernous Nerve-Sparing Retropubic Radical Prostatectomy With Versus Without Unilateral Sural Nerve Grafting for Clinically Localized Prostate Cancer - Abstract

Source Urotoday

The trial planned to enroll 200 patients, but an interim analysis at 107 patients met criteria for futility and the trial was closed. For patients completing the protocol to 2 yr, potency was recovered in 32 of 45 (71%) of SNG and 14 of 21 (67%) of controls (p=0.777). By intent-to-treat analysis, potency recovered in 32 of 66 (48.5%) of SNG and 14 of 41 (34%) of controls (p=0.271). No differences were seen in time to potency or quality of life scores for ED and urinary function. Limitations included slower-than-expected accrual and poor compliance with ED therapy: 65% for VED and 40% for injections.

The addition of SNG to a UNS RP did not improve potency at 2 yr following surgery.

This study was comparing men who were going nerve sparing prostatectomy on one side and adding a nerve graft on the other side. Nerve grafting takes more time and has some side effects depending on which nerve you use. This study, like many before it, did not find a benefit in performing a nerve graft.

I've always felt that this wwould be the case since the neurovascualr bundle is a series of small microscopic nerves, not a large nerve that you can see.