Labels improve emergency medicine physician comfort and ability to use a slit lamp.

Slit-lamp (SL) biomicroscopy is an important skill for emergency medicine (EM) clinicians. However, residents and faculty have varying levels of comfort and skill with this procedure. While some of the discomfort may be from a knowledge gap, we hypothesized that at least some difficulty came from infrequent use and forgetting which of the many knobs, levers, buttons, and switches of the SL create the desired effects. We strategically labeled a SL and tested the impact of this on the ability of 39 EM faculty and residents to identify a target on a maladjusted SL. Time to target identification was significantly lower with the labeled SL compared to the unlabeled SL, with median (IQR) time decreasing from 93 (31.5-154.5) seconds to 47 (0-141) seconds (p < 0.0001). Comfort level, as measured by a written survey and a graphic rating scale, also increased significantly with the labeled SL compared to the unlabeled SL.

Targeted focal therapy for the management of organ confined prostate cancer.

PURPOSE: Patients currently diagnosed with low risk prostate cancer are often overtreated and experience complications, resulting in detriment to quality of life. Targeted focal therapy is a minimally invasive procedure designed to ablate tumor foci while minimizing collateral damage to maintain quality of life. MATERIALS AND METHODS: This institutional review board approved, prospective study was done to assess the safety and efficacy of targeted focal therapy using cryotherapy in men 40 to 85 years old diagnosed with low risk, organ confined prostate cancer at our institution between 2006 and 2009. Low risk, organ confined prostate cancer was defined as Gleason score 7 or less (3 + 4) on transrectal ultrasound biopsy, tumor burden 50% or less and prostate specific antigen less than 10 ng/dl. Patients were evaluated for eligibility after undergoing 3-dimensional mapping biopsy. Median followup was 28 months (IQR 26-31). RESULTS: A total of 62 men with low risk disease met study inclusion criteria. At 1 year biopsy was negative in 50 of 62 patients (81%). All 12 men who tested positive on repeat biopsy had a Gleason score of 3 + 3 = 6 with 1 or 2 positive cores. The median prostate specific antigen change was a 3.0 ng/dl decrease (p <0.01). The median American Urological Association symptom score change was a 1.5-point decrease (p <0.01). No significant change was observed in Sexual Health Inventory for Men score (p = 0.6). No urinary incontinence episodes and no severe side effects were noted. CONCLUSIONS: Targeted focal therapy in carefully selected patients provides a feasible, practical option for treating low risk prostate cancer with minimal impact on quality of life.

Validation of the Urgency, Weak stream, Incomplete emptying, and Nocturia (UWIN) score compared with the American Urological Association Symptoms Score in assessing lower urinary tract symptoms in the clinical setting.

OBJECTIVE: To validate the Urgency, Weak stream, Incomplete emptying, and Nocturia (UWIN) survey for patients with lower urinary tract symptoms (LUTS) by comparison with the American Urological Association Symptoms Score (AUA-SS). The hypothesis is that the UWIN will perform as well as the AUA-SS in assessing LUTS symptoms and quality of life. The AUA-SS is complex for many patients and can be misunderstood. The UWIN questionnaire was developed to serve as a simpler and shorter version of the AUA-SS, with the intent of improving accuracy and minimizing error in assessing LUTS. The UWIN consists of 4 questions scored 0-3 to give a maximum score of 12. METHODS: We screened 700 patients in the urology clinic between 2011 and 2012. We enrolled 593 patients who completed the AUA-SS survey and UWIN in the same clinic visit. The AUA-SS and UWIN responses were evaluated using Spearman correlation coefficients and Bland-Altman graphs. RESULTS: Correlation coefficients were calculated between the corresponding AUA-SS and UWIN items on 593 matched surveys, demonstrating a strong correlation coefficient of 0.81 or greater for each question, which was statistically significant (P <.0001). The correlation coefficient between the total scores of the AUA and UWIN was 0.89 (P <.01). A second analysis was performed using Bland-Altman plots between AUA-SS and UWIN including total score, quality of life, and categories, which showed a good agreement. CONCLUSION: The UWIN appears to provide results comparable to the AUA-SS, while using a simpler format and taking less time to complete.

The accuracy of prostate cancer localization diagnosed on transrectal ultrasound-guided biopsy compared to 3-dimensional transperineal approach.

Background. Prostate cancer is often understaged following 12-core transrectal ultrasound- (TRUS-) guided biopsies. Our goal is to understand where cancers are typically missed by this method. Methods. Transperineal 3-dimensional mapping biopsy (3DMB) provides a more accurate depiction of disease status than transrectal ultrasound- (TRUS-) guided biopsy. We compared 3DMB findings in men with prior TRUS-guided biopsies to determine grade and location of missed cancer. Results were evaluated for 161 men with low-risk organ confined prostate cancer. Results. The number of cancer-positive biopsy zones per patient with TRUS was 1.38 ± 1.21 compared to 3.33 ± 4.06 with 3DMB, with most newly discovered cancers originating from the middle lobe and apex. Approximately half of all newly discovered cancerous zones resulted from anterior 3DMB sampling. Gleason upgrade was recognized in 56 patients using 3DMB. When both biopsy methods found positive cores in a given zone, Gleason upgrades occurred most frequently in the middle left and right zones. TRUS cancer-positive zones not confirmed by 3DMB were most often the basal zones. Conclusion. Most cancer upgrades and cancers missed from TRUS biopsy originated in the middle left zone of the prostate, specifically in anterior regions. Anterior sampling may lead to more accurate diagnosis and appropriate followup.

The role of targeted focal therapy in the management of low-risk prostate cancer: update on current challenges.

Prostate cancer is one of the most prevalent cancers among men in the United States, second only to nonmelanomatous skin cancer. Since prostate-specific antigen (PSA) testing came into widespread use in the late 1980s, there has been a sharp increase in annual prostate cancer incidence. Cancer-specific mortality, though, is relatively low. The majority of these cancers will not progress to mortal disease, yet most men who are diagnosed opt for treatment as opposed to observation or active surveillance (AS). These men are thus burdened with the morbidities associated with aggressive treatments, commonly incontinence and erectile dysfunction, without receiving a mortality benefit. It is therefore necessary to both continue investigating outcomes associated with AS and to develop less invasive techniques for those who desire treatment but without the significant potential for quality-of-life side effects seen with aggressive modalities. The goals of this paper are to discuss the problems of overdiagnosis and overtreatment since the advent of PSA screening as well as the potential for targeted focal therapy (TFT) to bridge the gap between AS and definitive therapies. Furthermore, patient selection criteria for TFT, costs, side effects, and brachytherapy template-guided three-dimensional mapping biopsies (3DMB) for tumor localization will also be explored.