Viraj A. Master

Absolute Preoperative C-Reactive Protein Predicts Metastasis and Mortality in the First Year Following Potentially Curative Nephrectomy for Clear Cell Renal Cell Carcinoma

PURPOSEnC-reactive protein is an inflammatory biomarker associated with tumor burden and metastasis in renal cell carcinoma. Recent studies suggest that preoperative C-reactive protein predicts metastasis and mortality after nephrectomy for localized renal cell carcinoma. However, these studies dichotomized C-reactive protein (typically 10 mg/l or greater vs less than 10 mg/l). Considering the continuous range of C-reactive protein (less than 1 mg/l to greater than 100 mg/l) we assessed the ability of absolute preoperative C-reactive protein to predict metastases and mortality as a continuous variable.nnnMATERIALS AND METHODSnPatients with clinically localized (T1-T3N0M0) clear cell renal cell carcinoma were followed for 1 year postoperatively. Metastases were identified radiologically and mortality was determined by death certificate. Univariate and multivariate binary logistic regression analyses examined 1-year relapse-free survival and overall relative survival across patient and disease characteristics.nnnRESULTSnOf the 130 patients in this study metastases developed in 24.6% and 10.8% of the patients died. Mean (SD) preoperative C-reactive protein for patients in whom metastases did and did not develop was 89.17 (74.17) and 9.16 (30.62) mg/l, respectively. Mean preoperative C-reactive protein for patients who did and did not die was 102.61 (77.32) and 19.52 (46.10) mg/l, respectively. On multivariate analysis SSIGN score (p <0.001) and preoperative C-reactive protein (B 0.027, SE 0.003, p <0.001) were significant predictors of relapse-free survival, and preoperative platelets (p = 0.009) and preoperative C-reactive protein (B 0.011, SE 0.008, p <0.001) were significant predictors of overall relative survival.nnnCONCLUSIONSnAbsolute preoperative C-reactive protein is a robust predictor of metastasis and mortality after nephrectomy for localized renal cell carcinoma. Clinicians should consider absolute preoperative C-reactive protein to identify high risk patients for closer surveillance or additional therapy. In addition, predictive algorithms and models of metastasis should consider incorporating C-reactive protein as a continuous variable to maximize predictive ability.

Postoperative Better Than Preoperative C-reactive Protein at Predicting Outcome After Potentially Curative Nephrectomy for Renal Cell Carcinoma

OBJECTIVESnPreoperative C-reactive protein (CRP) predicts metastasis and mortality in localized renal cell carcinoma (RCC). However, the predictive potential of after resection of localized RCC remains unclear. Therefore, we assessed the absolute ability of postoperative CRP to predict metastases and mortality as a continuous variable.nnnMETHODSnPatients with clinically localized (T1-T3N0M0) clear-cell RCC were followed for 1 year postoperatively. Metastases were identified radiologically and mortality by death certificate. Univariate and multivariate binary logistic regression analyses examined 1 year relapse-free survival (RFS) and overall survival (OS) across patient and disease characteristics.nnnRESULTSnOf the 110 patients in this study, 16.4% developed metastases and 6.4% died. Mean (SD) postoperative CRP for patients who did and did not develop metastases were 69.06 (73.55) mg/L and 5.27 (7.80), respectively. Mean (SD) postoperative CRP for patients who did and did not die were 89.31 (69.51) mg/L and 10.88 (30.32), respectively. In multivariate analysis, T-stage (OR: 12.452, 95% CI: 2.889-53.660) and postoperative CRP ((B: .080, SE: .025; P < .001) were significant predictors of RFS. T-Stage (OR: 11.715; 95% CI: 1.102-124.519) and postoperative CRP (B: .017; SE: .007; P < .001) were also significant predictors of OS. After adjusting for postoperative CRP, preoperative CRP was not predictive of these outcomes.nnnCONCLUSIONSnPostoperative, not preoperative, CRP is the better predictor of metastasis and mortality following nephrectomy for localized RCC. Clinicians should consider absolute postoperative CRP to identify high-risk patients for closer surveillance or additional therapy. Predictive algorithms should consider incorporating postoperative CRP as a continuous variable to maximize predictive ability.

Patient misunderstanding of the individual questions of the American Urological Association symptom score.

PURPOSEnLower urinary tract symptoms are often assessed using the American Urological Association symptom score. However, some patients may experience difficulty completing the AUA questionnaire. We hypothesized that certain individual questions may generate more misunderstanding than others.nnnMATERIALS AND METHODSnThis study involved patients at 2 hospitals who completed the American Urological Association symptom score twice, that is 1) self-administered and 2) physician assisted. Analyses compared self-reported and physician obtained responses to each individual question. One-way ANOVA with the Tukey HSD post hoc test was done to assess whether mean disagreements between self-reported and physician administered American Urological Association symptom scores differed significantly by patient education level.nnnRESULTSnThe study group consisted of 998 patients. For each symptom score question we found an inverse relationship between education level and symptom misrepresentation. This discrepancy was the largest for questions on frequency (question 2) and urgency (question 4), which are related to irritative symptoms. Mean misrepresentation of the total American Urological Association symptom score was 2.42 and 5.33 for patients with greater than 12 and fewer than 9 years of education, respectively (p <0.001). Of patients with more than 12 years of education 28% misreported their symptoms by 4 points or greater and 1% misreported them by 10 points or greater, while 58% with fewer than 9 years of education misreported their total score by 4 points or greater and 21% misreported it by greater than 10 points.nnnCONCLUSIONSnWhile the American Urological Association symptom score is a useful tool for the rapid diagnosis of benign prostatic hyperplasia, patients with low education misrepresent their scores more often and to a higher degree, possibly predisposing them to inappropriate care.

Systematic Review of the Evidence of a Relationship Between Chronic Psychosocial Stress and C-Reactive Protein

IntroductionC-reactive protein (CRP) is an acute-phase reactant with an increasing number of clinical functions. Studies in recent years have identified several social, economic, demographic, and psychological factors that contribute to baseline inflammation. Psychosocial stress represents a significant contributor to baseline inflammation. Given the importance of understanding background drivers of CRP levels, we conducted this review to assess the impact of chronic psychosocial stress on CRP levels.MethodsMedline was searched through February 2013 for human studies examining CRP levels with respect to chronic psychosocial stress.ResultsThe initial search identified 587 articles from which 129 potentially appropriate articles were reviewed. Of these 129 articles, 41 articles were included in the review. These studies were published between 2003 and 2013. Of these studies, 6 analyzed employment stress, 2 analyzed unemployment stress, 6 analyzed burnout and vital exhaustion, 6 analyzed caregiver stress, 3 analyzed interpersonal stress, 17 analyzed socioeconomic position, and 2 analyzed discrimination.ConclusionWe conclude that psychosocial stress significantly impacts CRP and should be considered when interpreting the meaning of CRP elevations.

Nocturia Associated With Depressive Symptoms

OBJECTIVESnTo assess the relationship between nocturia and depression, two inflammatory conditions that affect a significant number of men worldwide.nnnMETHODSnWe asked 547 male patients to self-administer the American Urological Association Symptom Score (AUA-SS) and the Geriatric Depression Scale (GDS), a validated screening tool for depression. Univariate analysis identified significant differences in patient characteristics between depressed and nondepressed patients, and binary logistic regression was used to assess the potential relationship between nocturia and depression while controlling for patient demographics and quality of life.nnnRESULTSnOf the cohort, 17.0% screened positive for depression. Depressed and nondepressed patients reported a mean (SD) of 2.7 (1.4) and 1.9 (1.4) episodes of nocturia per night, respectively (P <.001). After controlling for demographic variables and overall quality of life, patients with 5 or more episodes of nocturia per night experienced a 6.5-fold increased risk of depression compared with patients without nocturia (OR, 6.530; 95% CI, 2.107-20.239, P <.001).nnnCONCLUSIONSnA significant correlation exists between nocturia and depression. Consequently, clinicians might use nocturia as a predictor of depression. Patients with increased frequency of nocturia may be considered for referral for further mental health evaluation.

Assessment of the Performance of the American Urological Association Symptom Score in 2 Distinct Patient Populations

PURPOSEnRecent research suggests that low education and illiteracy may drive misunderstanding of the American Urological Association Symptom Score, a key tool in the American Urological Association benign prostatic hyperplasia guidelines. It is unclear whether misunderstanding is confined to patients of low socioeconomic status. Therefore, we reevaluated the prevalence and impact of this misunderstanding in a county vs university hospital population.nnnMATERIALS AND METHODSnThis prospective study involved 407 patients from a county hospital and a university hospital who completed the American Urological Association Symptom Score as self-administered and then as interviewer administered. Responses were compared by calculating correlation coefficients and weighted kappa statistics to assess patient understanding of the American Urological Association Symptom Score. Multivariate logistic regression analyses were used to examine the association between patient characteristics and poor understanding of the American Urological Association Symptom Score.nnnRESULTSnOf the patients 72% understood all 7 American Urological Association Symptom Score questions. Of the measured demographic variables only education level significantly affected this understanding. Compared to patients with more than 12 years of education county hospital patients with less than 9 years of education were 57.06 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 14.32-329.34) while university hospital patients with less than 9 years of education were 38.27 times more likely to misunderstand the American Urological Association Symptom Score (95% CI 1.69-867.83). Of county hospital patients 31% and of university hospital patients 21% significantly misrepresented their symptom severity according to current guidelines.nnnCONCLUSIONSnPatients with low education regardless of location are more likely to misunderstand the American Urological Association Symptom Score, misrepresent their symptoms and, therefore, receive inappropriate treatment.

Ice Packs Reduce Postoperative Midline Incision Pain and Narcotic Use: A Randomized Controlled Trial

BACKGROUNDnPostoperative pain is an unavoidable consequence of open abdominal surgery. Although cryotherapy, the application of ice to a surgical wound site, has been shown to be effective in reducing postoperative pain in orthopaedic, gynecologic, and hernia operations, it has not been assessed in patients who undergo major open abdominal operations. We hypothesized that patients who receive cryotherapy would report lower pain scores as a primary outcomes measure.nnnSTUDY DESIGNnPatients undergoing abdominal operations with midline incisions were randomized to receive cryotherapy for a minimum of 24 hours in time intervals dictated by patient preference vs no cryotherapy. The primary outcome of pain relief was assessed with visual analog pain scores (VAS). The study was powered to detect a clinically significant difference in VAS between the control and cryotherapy group. Comparisons between groups were measured by Students t-test or Mann-Whitney U test for parametric and nonparametric data, respectively.nnnRESULTSnThere were 55 patients randomized: 28 to the control group and 27 to the cryotherapy group. For the primary measure, mean postoperative pain score on postoperative days (PODs) 1 and 3 after surgery was significantly lower between the control and cryotherapy groups on the visual analog pain scale (p < 0.005). Narcotic use was decreased in the cryotherapy group on POD 1 by 3.9 morphine equivalents (pxa0= 0.008). No statistically significant difference was found between the 2 treatment groups with respect to length of hospital stay, pulmonary complications, and wound infection rate in terms of secondary measures.nnnCONCLUSIONSnIce packs are a simple, cost-effective adjuvant for decreasing postoperative pain and narcotic use in patients undergoing major abdominal operations.

Intratumor C-Reactive Protein as a Biomarker of Prognosis in Localized Renal Cell Carcinoma

PURPOSEnSerum C-reactive protein has been shown to have prognostic value in localized and metastatic renal cell carcinoma. However, the prognostic value of intratumor C-reactive protein remains unknown.nnnMATERIALS AND METHODSnA total of 95 patients with resected, clinically localized (T1-T4N0M0) clear cell renal cell carcinoma were followed postoperatively. Intratumor C-reactive protein expression was assessed in surgical specimens using immunohistochemical analysis. Patients were categorized by staining intensity into low risk (staining 0 to 1), intermediate risk (staining 2) and high risk (staining 3) groups. Kaplan-Meier and multivariate Cox regression analyses were used to examine overall survival across patient and disease characteristics. Variables examined in multivariate Cox regression analysis included T stage, Fuhrman nuclear grade, tumor size, preoperative serum C-reactive protein and intratumor C-reactive protein staining.nnnRESULTSnFollowup extended up to 46 months with a mean (SD) of 29.8 (11.0) months. Twelve patients (12.6%) died during followup. Of all tumors 49.5%, 25.3% and 25.3% were graded by intratumor C-reactive protein staining as low risk (0 to 1), intermediate risk (2) and high risk (3), respectively. After controlling for variables significant on univariate analysis, patients in the high risk (3) group experienced a 27-fold increased risk of overall mortality compared to those in the low risk (0-1) group (HR 27.767, 95% CI 1.488-518.182). After adjusting for tumor staining, preoperative serum C-reactive protein was not a significant predictor of overall survival (p = 0.741).nnnCONCLUSIONSnIntratumor C-reactive protein may be a robust biomarker of prognosis in patients with localized renal cell carcinoma.

Poorly Numerate Patients in an Inner City Hospital Misunderstand the American Urological Association Symptom Score

OBJECTIVESnTo hypothesize that numeracy may also predict patient misunderstanding of the American Urological Association symptom score (AUA-SS). Health literacy consists of document and prose literacy, both considered traditional literacy. But, health literacy also comprises quantitative literacy or numeracy. We previously reported that document literacy independently predicts misunderstanding of the AUA-SS. However, the AUA-SS consists of written and numeric information.nnnMETHODSnProspective cohort study of male patients who completed a validated, 3-question numeracy test once and the AUA-SS twice, which were self-administered and then interviewer-assisted. These 2 responses were compared with assessed patient understanding of the AUA-SS. Multivariate logistic regression analyses examined the association between patient characteristics and poor understanding of the symptom score, defined as understanding fewer than half of the questions, by calculating the odds ratios and corresponding 95% confidence intervals.nnnRESULTSnA total of 571 patients completed the study, with an average age and education level of 58 and 13.5 years, respectively. On the numeracy test, 16%, 18%, 35%, and 31% correctly answered 3, 2, 1, and 0 questions, respectively. After adjusting for the highest educational level completed, written literacy, and demographics, completely innumerate respondents (score = 0 points) were more than 3 times as likely (odds ratio = 3.55; 95% confidence interval: 1.58-7.99; P = .002) to misrepresent their AUA-SS compared with those who had some numeracy (1-3 points).nnnCONCLUSIONSnRegardless of educational or literacy status, a significant number of patients self-report AUA-SS scores that are different from interviewer-assisted scores, which may severely limit their access to appropriate care.

Major Depression Drives Severity of American Urological Association Symptom Index

OBJECTIVESnTo evaluate the unclear relationship between depression and benign prostatic hyperplasia (BPH) by assessing depressions effect on the American Urological Association Symptom Index (AUA-SI) scores. Depression is a common illness associated with chronic inflammatory disease states. Data have suggested a significant role of inflammation in the progression of BPH.nnnMETHODSnThe present prospective study involved 547 male patients who completed the Geriatric Depression Scale and the AUA-SI. We evaluated whether the mean AUA-SI score and the severity categories differed by the state of depression. We then conducted binary logistic regression analysis with forward stepwise regression to assess the relationship between depression and the severity symptoms as determined by the AUA-SI score.nnnRESULTSnOf the cohort, 22% screened positive for depressive symptoms. The depressed patients (Geriatric Depression Scale score >5) reported significantly more severe symptoms (mean AUA-SI score 16.61 ± 9.89) compared with the nondepressed patients (Geriatric Depression Scale score of ≤5 and mean AUA-SI score 10.65 ± 7.29; F = 40.19, P <.001). After controlling for socioeconomic and demographic variables, depressed patients were 3 times more likely to present with severe symptoms (odds ratio 3.079, 95% confidence interval 1.129-8.402, P = .028).nnnCONCLUSIONSnA significant association was found between depression and BPH. However, it remains unclear whether this relationship represents unidirectional or bidirectional causality. Additional research is imperative to assess the nature of this correlation, either to address comorbid depression in patients with BPH or to ensure that depressed patients do not report falsely elevated symptoms.