Can the Use of Serial Multiparametric Magnetic Resonance Imaging During Active Surveillance of Prostate Cancer Avoid the Need for Prostate Biopsies?-A Systematic Diagnostic Test Accuracy Review.

CONTEXT: The role of multiparametric magnetic resonance imaging (mp-MRI) during active surveillance (AS) of prostate cancer needs evaluation. It remains unclear whether mp-MRI can replace prostate biopsies completely during AS. OBJECTIVE: To evaluate the diagnostic performance of mp-MRI for disease progression in men on AS for prostate cancer. EVIDENCE ACQUISITION: This systematic review was performed in accordance with the Cochrane Handbook and the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). Cross-sectional studies that evaluate the diagnostic performance of mp-MRI (index test) for disease progression compared with systematic and targeted prostate/template biopsies or a composite of this (reference standard) were included. A meta-analysis was performed using STATA with "metandi" and "midas" commands. EVIDENCE SYNTHESIS: Seven studies with 800 patients were included in this systematic review. The pooled pathological progression rate was 27%. The pooled sensitivity and specificity of mp-MRI for disease progression were 0.61 (95% confidence interval [CI]: 0.46-0.74) and 0.78 (95% CI: 0.54-0.91), respectively. Adjusting for a prevalence of disease progression of 30% results in a positive predictive value of 0.43 (95% CI: 0.39-0.46) and a negative predictive value of 0.81 (95% CI: 0.78-0.84). Significant heterogeneity was observed. The meta-regression analysis did not demonstrate any significant outliers. CONCLUSIONS: It is not possible to supplant prostate biopsies with mp-MRI in AS protocols with the current level of evidence. There is significant institutional variation in the diagnostic performance of mp-MRI during AS. Institutions must internally audit the diagnostic performance of mp-MRI in the AS setting. AS protocols must be based on local diagnostic performance, rather than on international AS protocols that may have limited applicability at individual settings. PATIENT SUMMARY: In this review, we explored the accuracy of multiparametric magnetic resonance imaging in diagnosing disease progression for patients who were enrolled in active surveillance programmes for prostate cancer.

Careful assessment key in managing prostatitis.

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with acute onset pelvic pain which may or may not be related to voiding, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors. A documented history of recurrent urinary tract infections is the key feature of chronic bacterial prostatitis. Duration of symptoms > 3 months defines chronicity. The key symptom of chronic pelvic pain syndrome is pain. Patients may describe pain during or after ejaculation as their predominant symptom. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules. In acute bacterial prostatitis the MSU is the only laboratory investigation required. Chronic pelvic pain syndrome may be multifactorial and part of a more generalised pain disorder. Pelvic floor muscle abnormalities, altered neuroendocrine pathways, chemically induced inflammation, bacterial infection, autoimmune processes, dysfunctional voiding as well intraprostatic ductal reflux mechanisms have all been identified in men with chronic pelvic pain syndrome.

Continuous subglottic suction is effective for prevention of ventilator associated pneumonia.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether subglottic suction is an effective preventative measure for ventilator associated pneumonia (VAP) after cardiac surgery. Altogether 457 papers were found using the reported search, of which 13 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude Subglottic suction significantly reduces the incidence of VAP in high risk patients (NNT of 8 if ventilated over 3 days), although the benefit is lower in elective cardiac patients. Subglottic suction is currently not commonly used, but even with marginal benefits, its use is likely to be highly cost effective.