Alvah R. Cass

Preferences of Husbands and Wives for Outcomes of Prostate Cancer Screening and Treatment

OBJECTIVE: To explore the preferences of male primary care patients and their spouses for the outcomes of prostate cancer screening and treatment, and quality of life with metastatic prostate cancer.DESIGN: Cross-sectional design.SETTING: Primary care clinics in Galveston County, Texas.PATIENTS: One hundred sixty-eight couples in which the husband was a primary care patient and a candidate for prostate cancer screening.MEASUREMENTS AND MAIN RESULTS: Preferences were measured as utilities for treatment outcomes and quality of life with metastatic disease by the time trade-off method for the husband and the wife individually and then conjointly for the couple. For each health state considered, husbands associated lower utilities for the health states than did their wives. Couples’ utilities fell between those of husbands and wives (all comparisons were significant at P<.01). For partial and complete impotence and mild-to-moderate incontinence, the median utility value for the wives was 1.0, indicating that most wives did not associate disutility with their husbands having to experience these treatment complications.CONCLUSIONS: Male primary care patients who are candidates for prostate cancer screening evaluate the outcomes of prostate cancer treatment and life with advanced prostate cancer as being far worse than do their wives. Because the choice between quantity and quality of life is a highly individualistic one, both the patient and his partner should be involved in making decisions about prostate cancer screening.

Psychological benefits of prostate cancer screening: the role of reassurance.

Objectives  The role of reassurance in decision‐making about screening for health problems is largely unknown. We examined the reassurance value of prostate cancer screening in primary care patients.

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

PURPOSE We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA). METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture. RESULTS The MORES included 3 variables—age, weight, and history of chronic obstructive pulmonary disease—and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85–0.97), a specificity of 0.59 (95% CI, 0.56–0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807–0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population. CONCLUSIONS Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Yellow fever 17D vaccine virus isolated from healthy vaccinees accumulates very few mutations

The live attenuated yellow fever (YF) vaccine strain 17D is one of the safest vaccines in use today with only 22 cases of reversion to virulence documented from over 300 million doses administered. We have isolated virus in cell culture from sera of six volunteers who received 17D vaccine and found that very few nucleotide mutations were detected in the consensus sequence of the entire genome of each of the serum viruses. Moreover, most of these mutations accumulated in the non-structural protein genes, especially the NS5 protein gene. Although no nucleotide change was identified in the structural protein genes of any of these six serum viruses, minor sequence heterogeneity existed in the serum virus population. Our results indicate that 17D vaccine virus accumulates mutations at a very low frequency and may explain in part the excellent safety record of 17D vaccine.

Health-Related Quality of Life in Primary Care Patients with Recognized and Unrecognized Mood and Anxiety Disorders

Objective: Primary care providers have been criticized for underrecognizing and undertreating mental health disorders. This criticism assumes patients with recognized disorders and those with unrecognized disorders suffer the same burden of illness. This study describes differences in health-related quality of life (HRQOL) in patients with recognized and unrecognized mood and anxiety disorders in a primary care setting. Methods: A probability sample of 500 adult ambulatory patients from a university-based, family practice clinic, completed the PRIME-MD mood and anxiety disorder modules and the SF-36 Health Survey. Computerized patient records were reviewed retrospectively to determine recognition of mood and anxiety disorders. The Mental Health (MCS) and Physical Health (PCS) Component Summary scales of the SF-36 served as the primary outcome measures. Results: Sub-threshold mood and anxiety disorders were less likely to be recognized by physicians than disorders meeting DSM-III-R criteria. Recognized mood disorders were associated with a significant decrement in MCS scores (poorer HRQOL) compared with unrecognized disorders. In contrast, recognized mood disorders demonstrated slightly higher PCS scores. Recognized and unrecognized mood disorders differed significantly in physical functioning, vitality, social functioning, role functioning related to emotional state, and mental health. Recognition of anxiety disorders was not related to HRQOL. Conclusions: Patients with mental health disorders that have been recognized by their health providers appear to suffer from poorer HRQOL than patients whose disorders have not been recognized. This relationship, though, is only apparent for mood disorders. Poorer physical functioning may mask less severe emotional symptoms in mood disorders; profound emotional symptoms make recognition easier.

Osteoporosis Risk Assessment and Ethnicity: Validation and Comparison of 2 Clinical Risk Stratification Instruments

BACKGROUND: Dual energy x-ray absorptiometry (DXA), coupled with early treatment, may reduce morbidity and mortality associated with osteoporosis. Clinical tools to enhance selection of women for DXA screening have not been developed or validated in an ethnically diverse population.OBJECTIVE: To compare the performance of the osteoporosis risk assessment instrument (ORAI) and the simple calculated osteoporosis risk estimation (SCORE) instrument across 3 racial/ethnic groups to identify women who would benefit from DXA scans.DESIGN: Blinded comparison of the instruments in a cross-sectional sample.PARTICIPANTS: Two-hundred twenty-six postmenopausal women were recruited from a university-based family medicine clinic. Women with a prior diagnosis of osteoporosis or those taking bone active medications were excluded.MEASUREMENTS: Participants completed a questionnaire that contained the ORAI and the SCORE questions; 203 completed a DXA scan.RESULTS: The sensitivity and specificity for the ORAI (0.68, [0.49 to 0.88, 95% CI]; 0.66, [0.59 to 0.73, 95% CI]) and the SCORE instrument (0.54, [0.34 to 0.75, 95% CI]; 0.72, [0.65 to 0.78, 95% CI]) differed significantly from previous reports. Overall, the accuracy of the ORAI (66.5%) and SCORE instrument (70.0%) were similar (McNemar’s test P value=37). The accuracy between instruments differed significantly in African-American women (McNemar’s test, P value <.001). In African Americans, the SCORE instrument correctly identified more women without osteoporosis, but missed 70% of those with osteoporosis.CONCLUSIONS: The performance of the ORAI and SCORE instrument differed significantly from previous reports. Although both can reduce the use of DXA scans for screening for osteoporosis, lower sensitivities resulted in underrecognition of osteoporosis and may limit their clinical usefulness in an ethnically diverse population.

Validation of the Male Osteoporosis Risk Estimation Score (MORES) in a Primary Care Setting

Background: Primary care physicians are positioned to promote early recognition and treatment of men at risk for osteoporosis-related fractures; however, efficient screening strategies are needed. This study was designed to validate the Male Osteoporosis Risk Estimation Score (MORES) for identifying men at increased risk of osteoporosis. Methods: This was a blinded analysis of the MORES, administered prospectively in a cross-sectional sample of men aged 60 years or older. Participants completed a research questionnaire at an outpatient visit and had a dual-energy X-ray absorptiometry (DXA) scan to assess bone density. Sensitivity, specificity, and area under-the-curve (AUC) were estimated for the MORES. Effectiveness was assessed by the number needed-to-screen (NNS) to prevent one additional major osteoporotic fracture. Results: A total of 346 men completed the study. The mean age was 70.2 ± 6.9 years; 76% were non-Hispanic white. Fifteen men (4.3%) had osteoporosis of the hip. The operating characteristics were sensitivity 0.80 (95% confidence interval [CI], 0.52–0.96); specificity 0.70 (95% CI, 0.64–0.74), and AUC of 0.82 (95% CI, 0.71–0.92). Screening with the MORES yielded a NNS to prevent one additional major osteoporotic fracture over 10 years with 259 (95% CI, 192–449) compared to 636 for universal screening with a DXA. Conclusion: This study validated the MORES as an effective and efficient approach to identifying men at increased risk of osteoporosis who may benefit from a diagnostic DXA scan.

Determining risk of vertebral osteoporosis in men: validation of the male osteoporosis risk estimation score.

Background: Vertebral fracture, one of the most frequent osteoporotic fractures in both sexes, is a powerful indicator of future osteoporotic fractures. Vertebral fractures are associated with increased mortality and decreased quality of life. Osteoporosis is a major predictor of low-trauma fracture. The Male Osteoporosis Risk Estimation Score (MORES), a clinical prediction tool that uses age, weight, and a history of chronic obstructive pulmonary disorder, was developed and validated previously to identify men at risk for hip osteoporosis who might benefit from bone densitometry. This study evaluated the effectiveness of the MORES to identify men at risk of lumbar osteoporosis. Methods: US population data from the National Health and Nutrition Examination Survey (NHANES, 1999–2004) were used to test the validity of the MORES to identify men at risk of lumbar osteoporosis. Results: The MORES value was compared with vertebral done densitometry (DXA) scores for men 50 years of age and older. The sensitivity was 0.582 (95% CI, 0.460–0.694) and specificity was 0.652 (95% CI, 0.627–0.676). Comparing universal DXA screening in 50-year-old men, the number needed to screen (NNS) to prevent one case of vertebral fracture would be reduced from 9418 to 3641 by prescreening with the MORES. In 70-year-old men, the MORES reduced the NNS from 4987 with universal screening to 3583. Conclusion: This analysis validated the MORES as a clinical tool to identify men at risk for lumbar osteoporosis. Compared with universal screening, the MORES was able to reduce the NNS to prevent one additional vertebral fracture across all age groups except in men 85 to 89 years of age. The magnitude of the NNS to prevent one additional vertebral fracture does not support using the MORES to screen solely for osteoporosis of the lumbar spine.

Concordance of Couples' Prostate Cancer Screening Recommendations from a Decision Analysis

AbstractObjective: To determine whether different utilities for prostate cancer screening outcomes for couples, and husbands and wives separately, lead to incongruent screening recommendations. Methods: We evaluated survey results of 168 married couples from three family practice centers in Texas, USA. Utilities for eight adverse outcomes of prostate cancer screening and treatment were assessed using the time trade-off method. We assessed utilities separately for each partner and jointly for each couple. Using a previously published decision-analytic model of prostate cancer screening, we input the husband’s age (starting point) and utilities for outcomes from the husband’s, wife’s, and couple’s perspectives (to adjust for quality of life). Both group-level and individualized models were run. We also asked husbands (and wives) if they intended to be screened (or have their husbands screened) for prostate cancer in the future. Results: Husbands’ lower tolerance for adverse outcomes (lower utilities) was associated with lower quality-adjusted life expectancy (than their wives) for the choice of screening versus not screening. Depending on the perspective, 48 husbands (28.6%), 89 wives (53.0%), and 58 couples (34.5%) preferred screening in the individual decision-analytic models. Comparing the three perspectives, agreement in model recommendations was greatest between the husbands and the couples (82.1%), intermediate between the wives and couples (63.7%), and lowest between the husbands and wives (55.4%). Using group-aggregated utilities in the decision-analytic model tended to mask the variation in recommended strategies amongst individuals. There was no relationship between screening preferences from the model and the husbands’ and wives’ reported desire for screening, as the majority of subjects wanted screening. Conclusions: Discordant health preferences may yield conflicting recommendations for prostate cancer screening. The results have broad implications for informed healthcare decision making for couples.

Comparison of the Male Osteoporosis Risk Estimation Score (MORES) With FRAX in Identifying Men at Risk for Osteoporosis

PURPOSE We wanted to compare the male osteoporosis risk estimation score (MORES) with the fracture risk assessment tool (FRAX) in screening men for osteoporosis. METHODS This study reports analysis of data from the Third National Health and Nutrition Examination Survey (NHANES III), a nationally representative sample of the US population, comparing the operating characteristics of FRAX and MORES to identify men at risk for osteoporosis using a subset of 1,498 men, aged 50 years and older, with a valid dual-energy x-ray absorptiometry (DXA) scan. DXA-derived bone mineral density using a T score of −2.5 or lower at either the femoral neck or total hip defined the diagnosis of osteoporosis. Outcomes included the operating characteristics, area under the receiver-operator characteristic curve, and agreement of the FRAX and MORES. RESULTS Sixty-seven (4.5%) of the 1,498 men had osteoporosis of the hip. The sensitivity, specificity, and area under the curve (AUC) for the MORES were 0.96 (95% CI, 0.87–0.99), 0.61 (95% CI, 0.58–0.63), and 0.87 (95% CI, 0.84–0.91), respectively. The sensitivity, specificity, and AUC for the FRAX were 0.39 (95% CI, 0.27–0.51), 0.89 (95% CI, 0.88–0.91), and 0.79 (95% CI, 0.75–0.84) respectively. Agreement was poor. CONCLUSIONS Compared with the MORES, the FRAX underperformed as a screening strategy for osteoporosis using the threshold score suggested by the US Preventive Services Task Force (USPSTF). An integrated approach that uses the MORES to determine which men should have a DXA scan and the FRAX to guide treatment decisions, based on the risk of a future fracture, identified 82% of men who were candidates for treatments based on National Osteoporosis Foundation guidelines.