Continuing Medical Education and Continuing Professional Development: a credit system for monitoring and promoting excellence.

Probably the most important demand on the career of a medical specialist is that of having to keep up-to-date both scientifically and professionally. But the onus does not fall only on the practitioner. The institutions involved in medical teaching and professional development also have a crucial role to play by providing opportunities for continuing education and assuring that the specialist carries out enough relevant, experience-enhancing tasks to ensure continuous professional growth. As upgrading medical knowledge and developing professionally is a life-long task, both the need and the obligation to learn and improve apply to doctors of all ages and at all hierarchical levels.

The responsiveness of the ICSmale questionnaire to outcome: evidence from the ICS-'BPH' study.

OBJECTIVE: To evaluate the responsiveness of the ICSmale questionnaire to the outcome of treatments for lower urinary tract symptoms (LUTS). PATIENTS AND METHODS: Consecutive men aged >45 years attending 23 urology centres in 12 countries, with symptoms suggestive of bladder outlet obstruction secondary to benign prostatic hyperplasia (BPH), were recruited to Phase I of the International Continence Society (ICS)-'BPH' study. In Phase II of the ICS-'BPH' study, 355 men in 15 centres in nine countries were followed up, having proceeded to treatment according to clinical practice. All men completed the ICS-'BPH' study questionnaire at baseline and follow-up, including the ICSmale which concerns LUTS and related problems. RESULTS: Patients included in Phase II were similar to those in Phase I according to age and levels of baseline symptoms. Patients received a range of treatments: 32% TURP, 29% drug therapies, 20% watchful waiting, 9% minimally invasive therapies and 10% 'others' (including open prostatectomy). For patients who underwent TURP, most LUTS, including voiding and filling symptoms, were highly statistically significantly better at follow-up than at baseline (P<0.0001). For drug, minimally invasive and 'other' treatments, fewer LUTS were highly statistically significantly better. For those undergoing watchful waiting, no symptoms were significantly different between baseline and follow-up. CONCLUSION: The ICSmale questionnaire, in addition to being psychometrically valid and reliable, is responsive to change in outcome.

Improvement of pressure flow parameters with finasteride is greater in men with large prostates. Finasteride Urodynamics Study Group.

PURPOSE: We assess the effect of finasteride, a 5alpha-reductase inhibitor, on objective voiding parameters in men with lower urinary tract symptoms and benign prostatic enlargement on digital rectal examination (known as clinical benign prostatic enlargement) in a double-blind placebo controlled multicenter study using strict standard pressure flow study techniques. MATERIALS AND METHODS: A modification of the Abrams-Griffiths nomogram was used by 1 reader to ensure that all patients met objective criteria for bladder outlet obstruction at baseline. After performing a pressure flow study patients with obstruction were randomized 2:1 to receive 5 mg. finasteride (81) or placebo (40) daily. A second pressure flow study was performed at month 12. At baseline and month 12 free urinary flow studies and transrectal ultrasound were performed, and International Prostate Symptom Score questionnaires were completed. Patients were treated between May 1994 and July 1996. RESULTS: Finasteride caused a significant decrease (-8.1 cm. water) in detrusor pressure at maximum flow (p <0.05 versus placebo p = 0.02), increase (+1.1 ml. per second) in maximum flow rate (p <0.05 versus placebo p = 0.02) and decrease (-22.8%) in prostate volume (p <0.05 versus placebo p <0.001). Men with prostates larger than 40 cc had greater improvement in detrusor pressure at maximum flow (between group difference -14.5 cm. water, 95% confidence interval -26.2 to -2.6, p = 0.02) and maximum flow rate (mean treatment effect +1.6 ml. per second, 95% confidence interval -0.2 to 3.0, p = 0.02) compared to those with prostates 40 cc or less (between group differences not significant). CONCLUSIONS: Finasteride treatment resulted in improvements in urodynamic parameters, which were greater in men with large prostates.

Repeated pressure-flow studies in the evaluation of bladder outlet obstruction due to benign prostatic enlargement. Finasteride Urodynamics Study Group.

Test-retest reliability of repeated voids in pressure-flow studies and the influence on maximum flow rate (Q(max)pQ), detrusor pressure at maximum flow rate (p(det)Qmax), voided volume, and residual urine were studied. Also the agreement in interpretation of pressure-flow tracings between investigators and a single blinded central reader acting as a quality control center (QCC) were assessed. In addition, correlations between p(det)Qmax and patient age, International Prostate Symptom Score (IPSS), free maximum flow rate (Qmax), and prostate volume were calculated. Using suprapubic pressure recording, 216 men with lower urinary tract symptoms (LUTS) due to benign prostatic enlargement (BPE) were investigated in 11 centers. In each pressure-flow study, three sequential voids were performed, and quality controlled recordings were analyzed for Q(max)pQ and p(det)Qmax by the QCC. Trans rectal ultrasound was used to measure the prostate volume. Mean Q(max)pQ did not change, but p(det)Qmax decreased significantly in the second and third sequential voids. Using the Abrams-Griffiths nomogram definition of obstruction, 125 patients (67%) were classified as obstructed from the first void, but only 111 patients (59%) from the third void. The agreement between the investigator assessment and that of a single blinded reader was good. There was no significant correlation between p(det)Qmax and patient age, IPSS, and Qmax, whereas a modest correlation was found between p(det)Qmax and prostate volume. In summary, there was no significant change in Q(max)pQ, but p(det)Qmax decreased for the three consecutive voids, which can be explained by a decrease in outlet resistance. The agreement between the investigator and QCC interpretations shows the value of a standardized technique, supporting the feasibility of multicenter urodynamic studies. There is a modest, but statistically significant, correlation between detrusor pressure and prostate size, supporting the hypothesis that prostate size is a contributing factor in symptomatic BPH.

Using the ICSOoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-'BPH' Study. International Continence Society--Benign Prostatic Hyperplasia.

OBJECTIVE: To present and describe the validity and reliability of the International Continence Society-Benign Prostatic Hyperplasia study quality-of-life (ICSQoL) instrument, a new set of questions to assess the impact of lower urinary tract symptoms (LUTS) on quality of life (QoL) in middle-aged and elderly men. PATIENTS AND METHODS: The study comprised 1271 consecutive men over the age of 45 years, attending urology departments in 12 countries, with LUTS and possible benign prostatic obstruction who were recruited to the ICS-'BPH' study (the clinic group); 423 ambulant men were recruited from a general practice in the UK to provide a community group. Each individual completed the ICS-'BPH' study questionnaire which includes six items addressing general and specific aspects of QoL (the ICSQoL). Content and construct validity were assessed by interviews with patients and by testing hypotheses within the study groups, e.g. the relationships with age, individual LUTS (as measured on the ICSmale questionnaire) and generic health status, as measured by the Short Form (SF-36) and EuroQol instruments. Reliability was assessed by measures of internal consistency and a test-retest analysis. RESULTS: The ICSQoL items were easily understood by patients, were completed with low levels of missing data, and address some (but not all) concerns about the impact of LUTS on QoL. The ICSQoL items have good construct validity, showing expected differences between community and clinic samples, and expected relationships with each other and individual LUTS. Items had good test-retest reliability, but their internal consistency was poor, confirming that ICSQoL questions should not be combined into a score. General ICSQoL items were closely related with most domains of the SF-36 and the EuroQol. CONCLUSION: ICSQoL items may be used individually or as a group in research studies or in clinical practice.

Electrovaporization of the prostate in patients with benign prostatic enlargement.

OBJECTIVE: To determine the effectiveness and safety of transurethral electrovaporization in the treatment of benign prostatic enlargement (BPE). PATIENTS AND METHODS: The study comprised 91 patients (median age 65 years) with BPE (median prostate volume 61 mL). Patients were assessed with a general and urological history, the International prostate symptom score (IPSS), urinary tract and prostatic ultrasonography, uroflowmetry and biopsy of the prostate. An electrosurgical generator (cutting at 200 W and coagulating at 70 W) with grooved electrodes was used to vaporize the prostate. The variables assessed before and after treatment were the IPSS, quality-of-life score, uroflowmetry, complications, and the duration of hospitalization. RESULTS: The mean operative duration was 45 min, blood loss was negligible and the mean duration of catheterization was 24 h. Recatheterization was necessary in 5.5% of patients. The median values before and after treatment were: IPSS, 19 and 5; QOL score, 4 and 2; and maximum urinary flow rate 8.3 and 22.1 mL/s (all P < 0.001). In nearly all cases, the Siroky nomogram showed that patients became unobstructed. CONCLUSIONS: Electrovaporization of the prostate has many advantages over other techniques used in the treatment of BPE, including transurethral resection (TURP). It is cheaper than laser-assisted prostatectomy in particular and is also simpler to perform. Higher-risk patients can be treated, it uses existing electrosurgical equipment with minor modifications and only the electrodes, which are inexpensive, differ from TUR loops; the TURP resectoscope can be used and there is almost no need for blood transfusion. Intra- and post-operative morbidity is very low, recatheterization rare, the hospital stay brief and the results equal to or better than those obtained with TURP. Convalescence is generally uneventful and rapid because haematuria is rare and, when present, mild. Patients can return to work earlier than after TURP. Although a promising technique, only a longer follow-up will allow firm conclusions about its suitability.

Lignans and isoflavonoids in plasma and prostatic fluid in men: samples from Portugal, Hong Kong, and the United Kingdom.

BACKGROUND: Chinese men have lower incidences of prostate cancer compared to men from Europe and North America. Asians consume large quantities of soya, a rich source of isoflavanoids phyto-oestrogens and have high plasma and urinary levels of these compounds. The mammalian lignans, enterolactone and enterodiol, are another group of weak plant oestrogens and are derived from seeds, cereals and grains. Vegetarians have high plasma and urinary concentrations of lignans. METHODS: The concentrations lignans and isoflavonic phyto-oestrogens were determined by gas chromatography-mass spectrometry (GC-MS) in plasma and prostatic fluid from Portuguese, Chinese and British men consuming their traditional diets. RESULTS: In prostatic fluid the mean concentrations of enterolactone were 31, 162 and 20.3 ng/ml for Hong Kong, Portugal and Britain respectively. Very high levels of enterolactone (> 600 ng/ml) were observed in the prostatic fluid of some of the men from Portugal. High concentrations of equol (3270 ng/ml) and daidzein (532 ng/ml) were found in a sample of prostatic fluid from Hong Kong. Higher mean levels of daidzein were observed in prostatic fluid from Hong Kong at 70 ng/ml, compared to 4.6 and 11.3 ng/ml in samples from Portugal and Britain respectively. Mean levels of daidzein were higher in the plasma samples from Hong Kong (31.3 ng/ml) compared to those from Portugal (1.3 ng/ml) and Britain (8.2 ng/ml). In general, the mean plasma concentrations of enterolactone from the three centres were similar, at 6.2, 3.9 and 3.9 ng/ml in samples from Hong Kong Portugal and Britain respectively. CONCLUSIONS: Higher concentrations of the isoflavanoid phyto-oestrogens, daidzein and equol, were found in the plasma and prostatic fluid of men from Hong Kong compared to those from Britain and Portugal. However, the levels of the lignan, enterolactone, were very much higher in prostatic fluid of Portuguese men. Isoflavanoids and lignans have many interesting properties and may, in part, be responsible for lower incidences of prostate cancer in men from Asia and also some Mediterranean countries. The isoflavanoids from soya, which are present in high concentrations in the prostatic fluid of Asian men, may be protective against prostate disease.

Measurement and metabolism of isoflavonoids and lignans in the human male.

Asian men, who consume a low fat/high fibre soya-based diet, have very much lower incidence of prostate cancer than men from North America and Europe. The soya bean is a rich source of the isoflavonic phyto-oestrogens, daidzein, genistein and equol, compounds which may be cancer-protective in Asian populations. The lignans, enterolactone and enterodiol, plant oestrogens derived from cereals and vegetables, may act in a similar manner in vegetarian men. We report here on the measurement of isoflavonoids and lignans, by gas chromatography-mass spectrometry, in prostatic fluid of men from Asia and Europe and also on the metabolism of these compounds in Western men following dietary supplementation.

[New review of radical prostatectomy]. / Nueva revisión de la prostatectomía radical.

The author raises some doubts regarding arguments that have been used to justify the increase in the number of radical prostatectomies in localized prostate cancer. In well or moderately differentiated localized prostate cancer who undergo radical prostatectomy do not show marked differences in mortality in relation to patients subjected only to watchful waiting. Results between the two groups are similar even though their being slanted by significant differences between the two groups in the definition of tumour staging. Characterization is much more accurate in cases undergoing radical prostatectomy, where tumours not confined to the prostate are excluded from the operation by histological examination of regional lymph-nodes. This fact is clearly unfavourable in cases where conservative therapy is used and in which, frequently carcinomas apparently confined to the prostate are included, even though they are not really localized. The author concentrates on patients with undifferentiated, highly aggressive, tumours that seem to call for equally aggressive therapy. Radical prostatectomy has exhibited a cure rate in these patients which, though not very high, bears substantial significance since, without treatment, this type of aggressive carcinomas kills nearly one hundred percent of the patients.

The effect of bromocriptine in benign prostatic hypertrophy and vesicosphincteric dynamics.

Four studies were carried out on 66 patients in order to examine the effect of bromocriptine in benign prostatic hypertrophy (BPH) and to clarify its mechanism of action. Two studies were clinical: the first was a double-blind, controlled trial (lasting 6 months) in which bromocriptine 5 mg/day was compared with placebo, and the second was an open study to evaluate the effect of bromocriptine 5 mg on patients with acute retention due to BPH. The other two studies were designed to investigate the action of the drug on vesicosphincteric dynamics. These were double-blind, controlled, parallel trials, one comparing bromocriptine at dosages of 2.5 and 5 mg with placebo 90 min after administration, and the other comparing bromocriptine 5 mg/day with placebo after 15 days' administration in post-prostatectomy patients. Bromocriptine had a favourable effect on patients with BPH but no effect on cases of acute retention. The urodynamic studies suggested that the drug affected urethral sphincteric mechanisms specifically. The weight and volume of the prostate remained unchanged after administration of the drug, so that any clinical response was not due to a direct effect on the gland itself.

An open trial of ceftazidime in the treatment of complicated urinary tract infections.

In an open prospective trial, twenty-two patients (twenty-one males and one female) with complicated urinary tract infections were treated with 2 g of ceftazidime every 12 hours (nineteen patients were treated intramuscularly and three intravenously for 7 or 10 days). The weight, age and underlying disorders of the urinary tract are indicated for each patient, as well as infecting pathogens and corresponding MICs. Clinical cure, as defined by complete resolution of symptoms and signs was obtained in all the patients. The over all bacteriological clearance rate was 93.3%. Four out of five Pseudomonas aeruginosa infections were cleared. There were no adverse events during ceftazidime treatment except for slight pain around the site of intramuscular injection. No changes in laboratory parameters attributable to ceftazidime therapy were noted. Ceftazidime is a safe and effective drug in the treatment of complicated urinary tract infections.

Influence of indomethacin and aspirin on the vesicosphincteric dynamics of prostatectomized patients.

The urodynamic and clinical effects of two known prostaglandin synthetase inhibitors--indomethacin and aspirin--were analysed using 59 prostatectomized patients as experimental subjects. We obtained clinical and urodynamic results within each group by comparing the situation before and after medication. A placebo group of 12 patients was used to get an idea of the natural evolution of the situation. A urodynamic workup was done 1 h and 30 min after the administration of the drugs and placebo and the clinical results were analysed on the 8th day of treatment, at which time a few patients were again studied urodynamically. The clinical results were again evaluated a short time after the treatment had been terminated. Marked clinical and urodynamic changes showed that bladder and urethral structures had been affected. Urodynamic modifications, were statistically analysed. We concluded that changes noted were at least partially due to prostaglandin synthesis inhibition and the resulting inhibition of prostaglandin action.

Hydatid cyst of the kidney: 8 cases.

The clinical features, investigations and treatment of 8 patients with renal hydatid diseases are presented. It is stressed that this condition is a rare differential diagnosis of space-occupying kidney lesions and diagnosis depends mainly upon radiological evaluation. Of the laboratory tests that suggested infestation eosinophilia was the most reliable. When partial nephrectomy was carried out or when there was the danger of rupture of the cyst during the operation, preliminary instillation of 2% formalin into the cyst was always done.