Douglas E. Mager

Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies.

PURPOSE We update results in a series of consecutive patients treated with anatomic radical retropubic prostatectomy regarding recovery of erections, urinary continence and postoperative complications. MATERIALS AND METHODS One surgeon performed anatomic radical retropubic prostatectomy on 1,870 men, using the nerve sparing modification when feasible. We evaluated recovery of erections and urinary continence in men followed for a minimum of 18 months. Patients who were not reliably potent before surgery, did not undergo a nerve sparing procedure, or received hormonal therapy or postoperative adjuvant radiotherapy were excluded from the analysis of potency rates but not of continence rates. Other postoperative complications were evaluated for the entire patient population. RESULTS Recovery of erections occurred in 68% of preoperatively potent men treated with bilateral (543 of 798) and 47% treated with unilateral (28 of 60) nerve sparing surgery. Recovery of erections was more likely with bilateral than with unilateral nerve sparing surgery in patients less than 70 years old (71 versus 48%, p<0.001) compared with patients with age 70 years old or older (48 versus 40%, p = 0.6). Recovery of urinary continence occurred in 92% (1,223 of 1,325 men) and was associated with younger age (p<0.0001) but not with tumor stage (p = 0.2) or nerve sparing surgery (p = 0.3). Postoperative complications occurred in 10% of patients overall and were associated with older age (p<0.002) but the incidence declined significantly with increasing experience of the surgeon (p<0.0001). There was no operative mortality. CONCLUSIONS Anatomic radical retropubic prostatectomy with the nerve sparing modification can be performed with favorable results in preserving potency and urinary continence. Better results are achieved in young men with organ confined cancer. Other complications can be reduced with increasing surgeon experience.

WHO Study on the reliability and validity of the alcohol and drug use disorder instruments: overview of methods and results

The WHO Study on the reliability and validity of the alcohol and drug use disorder instruments in an international study which has taken place in centres in ten countries, aiming to test the reliability and validity of three diagnostic instruments for alcohol and drug use disorders: the Composite International Diagnostic Interview (CIDI), the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) and a special version of the Alcohol Use Disorder and Associated Disabilities Interview schedule-alcohol/drug-revised (AUDADIS-ADR). The purpose of the reliability and validity (R&V) study is to further develop the alcohol and drug sections of these instruments so that a range of substance-related diagnoses can be made in a systematic, consistent, and reliable way. The study focuses on new criteria proposed in the tenth revision of the International Classification of Diseases (ICD-10) and the fourth revision of the diagnostic and statistical manual of mental disorders (DSM-IV) for dependence, harmful use and abuse categories for alcohol and psychoactive substance use disorders. A systematic study including a scientifically rigorous measure of reliability (i.e. 1 week test-retest reliability) and validity (i.e. comparison between clinical and non-clinical measures) has been undertaken. Results have yielded useful information on reliability and validity of these instruments at diagnosis, criteria and question level. Overall the diagnostic concordance coefficients (kappa, kappa) were very good for dependence disorders (0.7-0.9), but were somewhat lower for the abuse and harmful use categories. The comparisons among instruments and independent clinical evaluations and debriefing interviews gave important information about possible sources of unreliability, and provided useful clues on the applicability and consistency of nosological concepts across cultures.

A PROSPECTIVE RANDOMIZED TRIAL COMPARING 6 VERSUS 12 PROSTATE BIOPSY CORES: IMPACT ON CANCER DETECTION

PURPOSE Several studies suggest that sextant transrectal ultrasound guided biopsy of the prostate provides insufficient material to detect all clinically important prostate cancer, and obtaining more biopsy cores may improve the cancer detection rate. We performed a prospective randomized trial comparing 6 to 12 prostate biopsy cores to determine the impact on the cancer detection rate. MATERIALS AND METHODS We prospectively randomized 244 men, including 71 (29%) black men, with a mean age plus or minus standard deviation of 65 +/- 8 years to undergo biopsy with 6 or 12 peripheral zone tissue cores. In our study subjects serum total prostate specific antigen (PSA) was between 2.5 and 20 ng./ml., and/or digital rectal examination was suspicious for cancer. All men completed a self-administered pre-biopsy and 2 post-biopsy questionnaires at 2 and 4 weeks. Cancer detection rates were compared in the groups and correlated with race, biopsy history, digital rectal examination findings, total PSA, transrectal ultrasound volume and PSA density, as determined by the formula, total PSA/transrectal ultrasound volume. RESULTS The cancer detection rate in the 6 and 12 core groups was almost identical (26% and 27%, p = 0.9). There was no significant difference in cancer detection in the 2 trial arms with respect to subject race, biopsy history, digital rectal examination findings, total PSA, transrectal ultrasound volume or PSA density. However, our study did not have the statistical power to rule out small differences. CONCLUSIONS The overall cancer detection rate is not materially increased by 12 core, peripheral zone biopsy in men in whom prostate cancer was mainly detected by screening.

Concordance between ICD-10 alcohol and drug use disorder criteria and diagnoses as measured by the AUDADIS-ADR, CIDI and SCAN: results of a cross-national study

Agreement between the AUDADIS-ADR, CIDI and SCAN in case identification for ICD-10 alcohol and drug use disorders and diagnostic criteria was investigated in three countries, Luxembourg, Greece and the US. Overall, agreement for ICD-10 dependence diagnoses between the three instruments was fair to good for alcohol, opioids and cocaine, but generally lower for dependence diagnoses for other substance. In contrast, concordance between instruments for harmful use diagnoses was extremely poor for all substances. Implications of these major findings are discussed in terms of the relationship between prevalence, reliability and concordance and indications and cautions regarding cross-instrument comparisons.

Digital rectal examination for detecting prostate cancer at prostate specific antigen levels of 4 ng./ml. or less

PURPOSE We evaluated the detection rate of prostate cancer in men with suspicious digital rectal examination findings and serum prostate specific antigen (PSA) 4 ng./ml. or less. We also evaluated the stage and grade of cancers detected. MATERIALS AND METHODS We screened 22,513 community volunteers by PSA testing and digital rectal examination at 6-month intervals. Biopsy was recommended when either test was suspicious for cancer. In the subset of 2,703 white and black men in whom PSA was 4 ng./ml. or less and digital rectal examination was suspicious for prostate cancer we compared compliance with biopsy recommendations, cancer detection rates, and stage and grade of cancers detected. We then correlated these results with patient age, race and serum PSA concentration. We performed multivariate logistic regression analysis to predict cancer based on clinical characteristics, and evaluated the positive predictive value of digital rectal examination for detecting cancer as stratified by race and PSA. RESULTS Of the men 70% underwent biopsy with no difference in compliance according to age, race or PSA level. The 13% cancer detection rate correlated with age, race and PSA (p <0.003). The positive predictive value of a suspicious digital rectal examination was 5, 14 and 30% in men with PSA 0 to 1.0, 1.1 to 2.5 and 2.6 to 4.0 ng./ml., respectively. All cancers were clinically localized. Of the 72% of cases that were surgically staged 82% were organ confined and 78% were moderately differentiated. CONCLUSIONS The positive predictive value of suspicious digital rectal examination was appreciable in men with low serum PSA. The majority of cancer cases detected by digital rectal examination had features of clinically important and potentially curable disease.

USE OF LOWER PROSTATE SPECIFIC ANTIGEN CUTOFFS FOR PROSTATE CANCER SCREENING IN BLACK AND WHITE MEN

PURPOSE We evaluated differences in the prostate cancer detection rate among black and white men with serum prostate specific antigen (PSA) levels between 2.6 and 4.0 ng./ml., and benign findings on digital rectal examination. MATERIALS AND METHODS From May 1995 through June 1997 we screened 14,209 white and 1,004 black men 50 years old or older with serum PSA and rectal examinations at 6-month intervals. If PSA was greater than 2.5 ng./ml. or the rectal examination was suspicious for cancer, we recommended an ultrasound guided sextant biopsy of the prostate. We compared differences in clinical characteristics, compliance with the recommendation for biopsy, cancer detection rate, and stage and grade of tumors detected for 924 white and 57 black men. RESULTS Black men were younger (60 versus 63 years old, p = 0.005) and presented with slightly higher PSA levels (3.3 versus 3.1 ng./ml., p = 0.03) than white men. Overall cancer detection rate was 27% (106 of 391 patients), with cancer detection 2-fold higher among black (13 of 29, 45%) than among white (93 of 362, 26%) men (p = 0.03, odds ratio 2.4, 95% confidence interval 1.1 to 5.1). Controlling for age, total PSA, PSA density, percent free PSA and number of prior screening visits, race remained a significant predictor of cancer (adjusted odds ratio 3.4, confidence interval 1.4 to 8.4). We found trends for worse pathological stage and grade among black men but these differences did not reach statistical significance. CONCLUSIONS Black race was an independent predictor of prostate cancer even at lower PSA cutoffs (2.6 to 4.0 ng./ml.). Although the positive predictive value for cancer detection was relatively high in black men, long-term outcomes studies are necessary to determine whether the use of lower PSA cutoffs would result in favorable shifts in cancer stage and grade, and a reduction in racial differences in prostate cancer mortality rates.

CLINICAL AND PATHOLOGICAL CHARACTERISTICS, AND RECURRENCE RATES OF STAGE T1C VERSUS T2A OR T2B PROSTATE CANCER

PURPOSE We compare clinicopathological features, and cancer recurrence and survival rates in men with stage T1c versus T2a or T2b prostate cancer. MATERIALS AND METHODS From 1988 through 1998, 1 surgeon (W. J. C.) performed radical retropubic prostatectomy in 1,620 men with a mean age plus or minus standard deviation of 62.3 +/- 7 years. Clinical stage was T1c in 39%, T2a in 22% and T2b in 39% of patients. Patients were followed with semiannual prostate specific antigen (PSA) measurement and annual digital rectal examination. Serum total PSA greater than 0.3 ng./ml., histologically confirmed local tumor recurrence or distant metastases were considered evidence of cancer recurrence. Simple univariate statistics were used to compare clinical and pathological features by clinical stage, and multivariate Cox models were used to compare 5-year recurrence-free probabilities . The 5-year all cause and disease specific survival rates were calculated using Kaplan-Meier product limit estimates. RESULTS Mean patient age was younger for the clinical stage T1c group (61 years) than for the T2a (62 years) or T2b (64 years) group. Mean preoperative PSA and the percentage of patients with biopsy Gleason score 8 to 10 were more favorable for the T1c (8 ng./ml., 3%) and T2a (7, 5%) groups than for the T2b group (11, 6%). Cancerous surgical margins, seminal vesicle invasion and lymph node metastases were also less frequent in the T1c (20, 5 and 0.8%, respectively) and T2a (23, 5 and 0.3%) groups than in the T2b group (29, 11 and 1.8%). The 5-year recurrence-free survival rate was 85% for T1c, 83% for T2a and 72% for T2b cases. Multivariate analysis indicated a decreased risk of recurrence for the T1c group compared to the T2a and T2b groups. The 5-year disease specific survival rate was 100% for the T1c and T2a groups, and 97% for the T2b group. CONCLUSIONS Clinical and pathological features were similar for stages T1c and T2a, and different from stage T2b cancers. The 5-year recurrence-free survival was similar for T1c and T2a (log rank 0.89, p = 0.34), and higher than that for T2b (log rank 34.5, p <0.0001) cancers. However, controlling for all other prognostic factors on a Cox multivariate model, the risk of cancer recurrence was decreased for T1c compared to T2a and T2b disease. The detection of nonpalpable prostate cancer appears to be advantageous for intermediate-term cancer control.

Subtypes of adult antisocial behavior among drug abusers

Recent work has shown that a substantial proportion of injecting drug users would have met criteria for antisocial personality disorder (ASPD) if the childhood trajectory of conduct disorder (CD) were ignored. From among 545 St. Louis, Missouri, drug users interviewed in person, we evaluated the clinical homogeneity of the 405 men and women with adult antisocial behaviors who did and did not have conduct disorder. The fully diagnosed ASPD group (those with CD) was distinguishable from the adult antisocial behavior only group without CD on all childhood behaviors, adult impulsive and aggressive behaviors, and measures of severe drug abuse, including earlier age of onset of drug use and drug treatment utilization. Clinical homogeneity of the groups was reflected by the groups similarity on indices such as types of adult antisocial behaviors, consequences of drug use, injection drug use history, and comorbid psychiatric disorders. Implications for a modification in the concept of ASPD are addressed.

RETROSPECTIVE COMPARISON OF RADICAL RETROPUBIC PROSTATECTOMY AND125 IODINE BRACHYTHERAPY FOR LOCALIZED PROSTATE CANCER

PURPOSE Favorable results with 125iodine (I) brachytherapy have been reported in select patients with localized prostate cancer. We evaluate the results of radical prostatectomy in patients matched for similar pretreatment clinicopathological characteristics. MATERIALS AND METHODS From May 1983 to April 1998, 1 surgeon (W. J. C.) performed radical retropubic prostatectomy in 1,952 men (mean age plus or minus standard deviation 63+/-7 years), of whom 1,364 had Gleason score 6 or less on preoperative needle biopsy, a preoperative serum prostate specific antigen (PSA) value available and clinical stage T1 or T2 disease. We categorized all patients by preoperative Gleason score, preoperative PSA and clinical stage. For each Gleason score-by-PSA stratum we randomly selected by computer the number of men necessary to achieve the same overall distribution of clinical characteristics as in a series of patients treated with brachytherapy. All men were followed with semiannual PSA measurements and annual digital rectal examinations. Serum PSA greater than 0.3 ng/ml was considered evidence of cancer recurrence. Simple univariate statistics were used to compare clinical characteristics between series, and 7-year recurrence-free survival was estimated using Kaplan-Meier product limit estimates. To avoid a possible chance extreme result from 1 random sample we estimated 7-year recurrence-free survival in 5 computer selected random samples of our population. RESULTS Mean 7-year recurrence-free survival was 84% (95% confidence intervals 78 to 89) for the radical prostatectomy series compared to 79% (confidence intervals not provided) for the 125I brachytherapy series. CONCLUSIONS Radical prostatectomy yielded a proportionately but not statistically significant higher 7-year probability of nonprogression than 125I brachytherapy in patients with favorable clinicopathological characteristics. Comparisons are confounded by residual differences in clinicopathological features of tumors between groups and different treatment end points to determine outcomes. Further prospective, randomized clinical trials are required for valid comparisons.

Subjective reports of withdrawal among cocaine users: recommendations for DSM-IV

The proposed DSM-IV criteria for substance use disorders have included, as an option, a subtyping for physiologic dependence, characterized by either tolerance or withdrawal. Even if this option is not chosen at this stage of system revision, this weighting scheme justifies wider surveillance of these symptoms, especially for the more newly described cocaine dependence disorder. Wider surveillance of withdrawal is possible with the CIDI Substance Abuse Module (SAM), a WHO/ADAMHA diagnostic interview which covers criteria of substance use disorders according to the DSM-III, III-R, ICD-10 and proposed DSM-IV systems. To aid in this effort, we used the SAM, which includes a master list of all symptoms (n = 16) in the DSM manuals related to withdrawal from any substance to assess withdrawal symptoms from all substances. In this study, we hypothesized that the persons who used opiates with cocaine might misattribute their symptoms to cocaine; thus, we compared the responses of persons who used cocaine and opiates (opiate users) with the responses of persons who used cocaine without opiates (non-opiate users). Data from two St. Louis studies were combined for these analyses, users not in treatment or newly enrolled to drug-free or methadone treatment from a NIDA demonstration project and users selected for the St. Louis DSM-IV Field Trial. Of the 196 persons included from the field trial, 80% reported lifetime cocaine use compared with 91% of the 412 persons from the demonstration project. The symptoms mentioned in the diagnostic manuals were among the most frequently endorsed by both cocaine use groups.(ABSTRACT TRUNCATED AT 250 WORDS)