External validation of nomograms including MRI features for the prediction of side-specific extraprostatic extension.

BACKGROUND: Prediction of side-specific extraprostatic extension (EPE) is crucial in selecting patients for nerve-sparing radical prostatectomy (RP). Multiple nomograms, which include magnetic resonance imaging (MRI) information, are available predict side-specific EPE. It is crucial that the accuracy of these nomograms is assessed with external validation to ensure they can be used in clinical practice to support medical decision-making. METHODS: Data of prostate cancer (PCa) patients that underwent robot-assisted RP (RARP) from 2017 to 2021 at four European tertiary referral centers were collected retrospectively. Four previously developed nomograms for the prediction of side-specific EPE were identified and externally validated. Discrimination (area under the curve [AUC]), calibration and net benefit of four nomograms were assessed. To assess the strongest predictor among the MRI features included in all nomograms, we evaluated their association with side-specific EPE using multivariate regression analysis and Akaike Information Criterion (AIC). RESULTS: This study involved 773 patients with a total of 1546 prostate lobes. EPE was found in 338 (22%) lobes. The AUCs of the models predicting EPE ranged from 72.2% (95% CI 69.1-72.3%) (Wibmer) to 75.5% (95% CI 72.5-78.5%) (Nyarangi-Dix). The nomogram with the highest AUC varied across the cohorts. The Soeterik, Nyarangi-Dix, and Martini nomograms demonstrated fair to good calibration for clinically most relevant thresholds between 5 and 30%. In contrast, the Wibmer nomogram showed substantial overestimation of EPE risk for thresholds above 25%. The Nyarangi-Dix nomogram demonstrated a higher net benefit for risk thresholds between 20 and 30% when compared to the other three nomograms. Of all MRI features, the European Society of Urogenital Radiology score and tumor capsule contact length showed the highest AUCs and lowest AIC. CONCLUSION: The Nyarangi-Dix, Martini and Soeterik nomograms resulted in accurate EPE prediction and are therefore suitable to support medical decision-making.

Is cribriform pattern in prostate biopsy a risk factor for metastatic disease on 68Ga-PSMA-11 PET/CT?

INTRODUCTION: Cribriform growth pattern (CP) in prostate cancer (PCa) has been associated with different unfavourable oncological outcomes. This study addresses if CP in prostate biopsies is an independent risk factor for metastatic disease on PSMA PET/CT. METHODS: Treatment-naive patients with ISUP GG ≥ 2 staged with 68Ga-PSMA-11 PET/CT diagnosed from 2020 to 2021 were retrospectively enrolled. To test if CP in biopsies was an independent risk factor for metastatic disease on 68Ga-PSMA PET/CT, regression analyses were performed. Secondary analyses were performed in different subgroups. RESULTS: A total of 401 patients were included. CP was reported in 252 (63%) patients. CP in biopsies was not an independent risk factor for metastatic disease on the 68Ga-PSMA PET/CT (p = 0.14). ISUP grade group (GG) 4 (p = 0.006), GG 5 (p = 0.003), higher PSA level groups per 10 ng/ml until > 50 (p-value between 0.02 and > 0.001) and clinical EPE (p > 0.001) were all independent risk factors. In the subgroups with GG 2 (n = 99), GG 3 (n = 110), intermediate-risk group (n = 129) or the high-risk group (n = 272), CP in biopsies was also not an independent risk factor for metastatic disease on 68Ga-PSMA PET/CT. If the EAU guideline recommendation for performing metastatic screening was applied as threshold for PSMA PET/CT imaging, in 9(2%) patients, metastatic disease was missed, and 18% fewer PSMA PET/CT would have been performed. CONCLUSION: This retrospective study found that CP in biopsies was not an independent risk factor for metastatic disease on 68Ga-PSMA PET/CT.

IDEAL study: magnetic resonance imaging for suspected deep endometriosis assessment prior to laparoscopy is as reliable as radiological imaging as a complement to transvaginal ultrasonography.

OBJECTIVE: To compare the value of using one-stop magnetic resonance imaging (MRI) vs standard radiological imaging as a supplement to transvaginal ultrasonography (TVS) for the preoperative assessment of patients with endometriosis referred for surgery in a tertiary care academic center. METHODS: This prospective observational study compared the diagnostic value of the standard preoperative imaging practice of our center, which involves expert TVS complemented by intravenous urography (IVU) for the evaluation of the ureters and double-contrast barium enema (DCBE) for the evaluation of the rectum, sigmoid and cecum, with that of expert TVS complemented by a 'one-stop' MRI examination evaluating the upper abdomen, pelvis, kidneys and ureters as well as rectum and sigmoid on the same day, for the preoperative triaging of 74 women with clinically suspected deep endometriosis. The findings at laparoscopy were considered the reference standard. Patients were stratified according to their need for monodisciplinary surgical approach, carried out by gynecologists only, or multidisciplinary surgical approach, involving abdominal surgeons and/or urologists, based on the extent to which endometriosis affected the reproductive organs, bowel, ureters, bladder or other abdominal organs. RESULTS: Our standard preoperative imaging approach and the combined findings of TVS and MRI had similar diagnostic performance, resulting in correct stratification for a monodisciplinary or a multidisciplinary surgical approach of 67/74 (90.5%) patients. However, there were differences between the estimation of the severity of disease by DCBE and MRI. The severity of rectal involvement was underestimated in 2.7% of the patients by both TVS and DCBE, whereas it was overestimated in 6.8% of the patients by TVS and/or DCBE. CONCLUSIONS: Complementary to expert TVS, 'one-stop' MRI can predict intraoperative findings equally well as standard radiological imaging (IVU and DCBE) in patients referred for endometriosis surgery in a tertiary care academic center. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Sperm motility after laparoscopic inguinal hernia repair with lightweight meshes: 3-year follow-up of a randomised clinical trial.

PURPOSE: To analyse the effects of lightweight meshes in laparoscopic inguinal hernia repair on male fertility aspects, chronic pain development and recurrence at 3-year follow-up. METHODS: Fifty-nine male patients with a primary, unilateral or bilateral inguinal hernia were randomised to laparoscopic inguinal hernia repair using a standard polypropylene (Marlex(®)) or lightweight mesh (VyproII(®), TiMesh(®)). Patients attended clinical follow-up 3 years postoperatively, at which male fertility aspects, by semen analysis and scrotal ultrasound, chronic pain status (McGill Pain Questionnaire), quality of life (SF-36) and recurrence were assessed, or completed quality of life, pain and hernia-specific questionnaires at home. RESULTS: In total, 49 patients (83.1 %) completed follow-up (median follow-up = 39.1 months), by questionnaire and/or clinical follow-up. As other semen parameters and scrotal ultrasound results, sperm motility was unchanged compared to 1 year postoperatively, but not significantly different between VyproII(®) and TiMesh(®) versus Marlex(®) patients (-8.5 % and -8 % vs. -2.8 %; P = 0.23). Pain perception and quality of life were comparable between the heavyweight and lightweight groups, and no change was noted in comparison with 1 year postoperatively. Chronic pain incidence was 6.1 % (3 patients), without occurrence of disabling pain. Three patients were clinically diagnosed with a recurrent hernia (5.9 %). CONCLUSIONS: The decrease in sperm motility in patients operated on with a lightweight mesh compared to patients operated on with a heavyweight mesh 1 year after laparoscopic inguinal hernia repair could not be confirmed at 3 years follow-up. Furthermore, heavyweight and lightweight groups were comparable regarding quality of life, chronic pain and recurrence rate.

Fluoroquinolone-resistant E. coli in intestinal flora of patients undergoing transrectal ultrasound-guided prostate biopsy--should we reassess our practices for antibiotic prophylaxis?

Although the estimate of the incidence of sepsis following transrectal ultrasound-guided prostate biopsy (TRUSPB) is low, fluoroquinolone-resistant infections after prostate biopsy are being increasingly noted. This study was aimed at determining the prevalence of faecal carriage of fluoroquinolone-resistant Escherichia coli strains before TRUSPB and at evaluating potential predisposing risk factors. The incidence of sepsis after prostate biopsy was determined, and our routine practice for antibiotic prophylaxis for TRUSPB was evaluated. A prospective study was conducted in 342 consecutive patients undergoing prostate biopsy between December 2009 and July 2010. Before TRUSPB, a rectal swab was cultured. The correlation between the presence of fluoroquinolone-resistant strains and plausible risk factors was investigated by the use of a questionnaire. Of the 236 patients included, 22.0% (52/236) harboured ciprofloxacin-resistant E. coli strains. The use of fluoroquinolones in the 6 months before biopsy was associated with an increased risk of faecal carriage of fluoroquinolone-resistant E. coli strains (p <0.01). Faecal carriage of fluoroquinolone-resistant E. coli strains was an important risk factor for infectious complications after TRUSPB (p <0.01). In conclusion, a significant number of patients have faecal carriage of fluoroquinolone-resistant E. coli strains (22.0%) before TRUSPB. The use of fluoroquinolones in the previous 6 months before biopsy is a risk factor for faecal carriage of fluoroquinolone-resistant E. coli strains and for infectious complications after TRUSPB. Hence, the universal administration of fluoroquinolones should be reconsidered.

Evaluación de las lesiones quísticas del páncreas por ultrasonido endoscópico y hallazgos citológicos a través de la punción aspiración con aguja fina: reporte preliminar / Evaluation of cystic lesions of the pancreas by endoscopic ultrasound and cytological findings through fine needle aspiration: preliminary report

Las lesiones quísticas y las colecciones del páncreas presentan un reto diagnóstico y terapéutico; su patología varía desde pseudoquistes y necrosis pancreáticas hasta neoplasias benignas y malignas. El ultrasonido endoscópico más la punción aspiración con aguja fina es una modalidad útil y exacta para evaluar y obtener muestras de dichas lesiones, y puede ayudar a identificar aquellos pacientes con lesiones potencialmente malignas que pudiesen beneficiarse de una resección quirúrgica. Describir las características ecoendoscópicas y los hallazgos citológicos en las lesiones quísticas del páncreas. Estudio retrospectivo, descriptivo de 9 pacientes durante el periodo comprendido entre junio 2008 hasta mayo 2009. Ocho presentaron lesiones quísticas del páncreas, 6 eran femeninas (75%) y 2 masculinos (25%) con una edad media de 56 años. Se reportaron 2 cistoadenoma mucinosos (25%), 1 tumor pseudopapilar sólido (12,5%), 2 neoplasias intraductales productoras de mucinas (25%), 1 pseudoquiste pancreático (12,5%), y en 2 lesiones quísticas (25%) no se obtuvo acceso al resultado. El ultrasonido endoscópico más los hallazgos citológicos obtenidos por la punción con aguja fina nos ofrecen diagnóstico de las lesiones quísticas pancreáticas en un alto porcentaje de los pacientes...

Cystic lesions and collections of the pancreas present a diagnostic and therapeutic challenge; its pathology varies from pseudocysts and pancreatic necrosis to benign and malignant neoplasms. Endoscopic ultrasound plus fine-needle aspiration is a useful and accurate method to assess and collect samples of these lesions and may help identify patients with potentially malignant lesions that could benefit from surgical resection. To describe the endoscopic ultrasonography cytological findings in pancreatic cystic lesions. Retrospective, descriptive study of 9 patients between June 2008 to May 2009. Eight cystic pancreatic lesions, 6 were female (75%) and 2 men (25%) with a mean age of 56 years. Two (2) of the lesions were reported mucinous cystadenoma (25%), one (1) solid pseudopapillary tumor (12.5%), two (2) mucin-producing intraductal neoplasms (25%), 1 pancreatic pseudocyst (12.5%), and in two (2) cystic lesions (25%) there was no access to the result. Endoscopic ultrasound plus cytological findings obtained by fine needle aspiration provides the diagnosis of pancreatic cystic lesions in a high percentage of patients...

Patrones sonográficos y ubicación topográfica de la esteatosis pancreática por ecoendoscopia

Introducción: El reemplazo graso del páncreas se conoce que ocurre bajo ciertas condiciones pero esta patogénesis no está bien establecida. El diagnóstico requiere la demostración del reemplazo graso y a pesar del desarrollo reciente de imágenes diagnósticas, es difícil distinguir de otras anormalidades. Objetivo: evaluar por ecoendoscopia los patrones sonográficos de la glándula pancreática y establecer un diagnóstico de Esteatosis Pancreática. Materiales y Pacientes: Estudio retrospectivo cuyos datos fueron obtenidos de 1764 historias de pacientes referidos al Centro de Investigaciones Tecnológicas Ecoendoscópicas (CITE), para realizarse una EE superior, en el período comprendido entre abril del 2000 y junio del 2004. El estudio dinámico del páncreas evaluó dos elementos: primero se realizaron comparaciones del patrón ecográfico de la glándula en estudio con evaluaciones de páncreas normales por ecoendoscopia y segundo se utilizaron las características sonográficas del hígado. Los diferentes patrones fueron descritos desde el punto de vista topográfico ubicándose según la anatomía de la glándula pancreática en: proceso uncinado, cabeza, istmo, cuerpo y cola. Los patrones sonográficos fueros evaluados por separados dependiendo de su distribución en la glándula Resultados: Un total de 45 pacientes fueron estudiados, 28 mujeres y 17 hombres, con una media de 55 +/- 11 años. Las alteraciones del páncreas fueron divididas en esteatosis difusa n=43: leve, moderada y severa, y esteatosis heterogénea n=2. El estado general de acuerdo al grado de esteatosis pancreática fue: leve en 24 casos, moderado 17 casos y severo en 4 casos. Se observo un patrón en parches leve y otro moteado moderado, ambos ubicados en el istmo, el cuerpo y la cola. Las zonas más afectadas fueron cuerpo y cola 98% y 96% respectivamente. Las zonas menos afectadas fueron cabeza y proceso uncinado con 58% y 47% respectivamente. En las diferentes topografías se muestran tres patrones predominantes. Fueron más evidentes los siguientes tres patrones: afectación igual en todo el páncreas 42%, en cuerpo y cola 22% y cuerpo, cola e istmo con eventual aparición de afectación en proceso uncinado y cabeza 33%. Conclusiones: la ecoendoscopia permite evaluar en forma rigurosa los cambios de ecogenicidad del páncreas al igual que la topografía de este, siendo más compleja de lo antes expuesto en la literatura requiriendo de trabajos prospectivos que enfoquen el tema de la esteatosis pancreática y la ecoendoscopia.

Introduction: The fatty replacement of the pancreas occurs under certain conditions but the pancreatic pathogenesis is not well understood. Even though, there are new imaging techniques available fatty pancreas replacement is difficult to differentiate from other pancreatic abnormalities. Aim of the study: assessment of the different sonographic patterns of the pancreatic gland using endoscopic ultrasound in other to diagnose pancreatic steatosis. Patients and Methods: Between April 2000 an June 2004 1764 endoscopic ultrasound were review at the Centro de Investigaciones Tecnológicas Ecoendoscópicas (CITE). The dynamic sonography of the pancreas assess two elements, first it made a relation between normal pancreatic sonographic parenchyma and the evaluated gland, and second the sonographic features of the liver were used. All patterns where described topographically and divided according to the different anatomic parts of the pancreas: uncinated process, head, neck, body and tail. Separated analysis of the pancreatic patterns was performed according to the pancreatic distribution. Results: 45 patients were evaluated, 28 females and 17 males, with a mean of 55 +/- 11 years. Pancreatic patterns were divided in diffused steatosis n=43 mild, moderated and severe, and heterogeneous steatosis n=2. According to severity we found 24 mild, 17 moderated and 4 severs. One pattern was mild patch in and the other one was moderated spots both located at the neck, body and tail. The body and tail were the most affected location with a 98% and 96% respectively; the less affected locations were the head and the uncinated process with 58% and 47% respectively. Three patterns were the most frequents: 42% had global steatosis, 22% had the body and tail and 33% had body, tail and neck with sporadic changes in head and uncinated process. Conclusions: pancreatic echogenecity is well defined by endoscopic ultrasound. Pancreatic steatosis should be address in future prospective protocols due to a complexity of his topography in the pancreas.

Conocimiento de las indicaciones de la ecoendoscopia en ciertos médicos Venezolanos

Antecedentes: La Ecoendoscopia es una tecnología en desarrollo y que cada día abarca un mayor terreno, requiere de un amplio conocimiento por parte de los médicos gastroenterólogos y no gastroenterólogos, ya que muchos de esos pacientes son manejados por médicos que no son especialistas en el área incluyendo Internistas, Cirujanos, Neumonólogos por citar algunos, siendo la gran mayoría referidos por Gastroenterólogos, sin embargo estudios previos han demostrado que incluso algunos Gastroenterólogos, tienen un conocimiento moderado de las indicaciones y de la utilidad de la ecoendoscopia. Este conocimiento acerca de las indicaciones de la Ecoendoscopia en médicos gastroenterólogos y no gastroenterólogos venezolanos no ha sido estudiado por eso basamos este estudio como un preliminar para tener acceso sobre las indicaciones y las utilidades de la ecoendoscopia en ciertos médicos especialistas. Objetivos: Evaluar el conocimiento que tienen ciertos médicos venezolanos acerca de las indicaciones de la Ecoendoscopia. Métodos: Se distribuyo una encuesta vía mail y personalmente a médicos gastroenterólogos y no gastroenterólogos, en la cual se preguntaba acerca de las indicaciones de la Ecoendoscopia en 4 órganos principales o sistemas de las vías digestiva: (esófago, estomago-duodeno, hepato-pancreato-biliar y colorecto) con un punto aparte sobre vías respiratorias para neumonólogos. Resultados: La encuesta fue distribuida 91 médicos de los cuales 81 respondieron: gastroenterólogos (38), internistas (21), cirujanos generales (11) y de otras especialidades (11). Globalmente fueron significativamente mayores los puntajes promedios de los médicos gastroenterólogos (75,4%) seguidos por los cirujanos y los internistas (ambos 65,5%) y las otras especialidades (61,5%) (p-valor < 0,05). Las indicaciones para EE de estómago y colorecto son las mejor conocidas (p-valor<0,05) por los médicos encuestados, seguidas de las indicaciones para esófago y hepato-pancreato-biliar. El resultado global es que los médicos encuestados acertaron el 67,2% de las indicaciones de ecoendoscopia en las diferentes categorías específicas de órganos. Conclusiones: el conocimiento de los gastroenterólogos en cuanto a las indicaciones de la ecoendoscopia es mayor al del resto de las especialidades cuando se evalúa globalmente. Las distribuciones de puntajes en las indicaciones específicas de estomago-duodeno y colorecto no son significativamente diferentes o dominadas por una especialidad médica, mas las indicaciones para esófago son mejor conocidas por otras especialidades y las de indicaciones en hepato-pancreato-biliar, por los gastroenterólogos.

Background: endoscopic ultrasound is a developing technology that is growing in different fields, a Wide knowledge is require among gastroenterologist and non gastroenterologist because many patients are evaluated by physicians that are estrange to this field, including, internist, surgeons and pneumonologist among them. Most of the patients are referred by gastroenterologist; however they have shown a moderated knowledge in endoscopic ultrasound indications and utilities. The knowledge of endoscopic ultrasound indications among Venezuelan physicians specialized in gastroenterology or not have no been evaluated, therefore we decide to evaluate endoscopic ultrasound knowledge regarding its indications and utilities. Aim of the study: assessment of the different knowledge among Venezuelan physicians regarding endoscopic ultrasound indications. Methods and Patients : a survey form with endoscopic ultrasound indications and utilities was distributed by mail or personally to different Venezuelan physicians. Each form had the same questions regarding endoscopic ultrasound indications with 4 principal organs of the digestive tract (esophagus, stomach-duodenum, hepato-biliary-pancreatic and colorectal) with a separated item about respiratory air ways concerning pneumonologist. Results: 91 physicians had sent the survey, 81 answered correctly and were analyzed: 38 gastroenterologist, 21 internist, 11 surgeons and 11 from other specialities. Global scores were significantly higher among gastroenterologist (75%) fallowed by the surgeons and internists both with same score (66%) and other specialties obtained 62% (p < 0, 05). Endoscopic ultrasound indication regarding the stomach-duodenum and colorectal were more known, fallowed by esophagus and finally hepato-pancreatic-biliary. 67% of the physicians had correct answers in their surveys. Conclusions: Its seems that gastroenterologist have a better knowledge than other specialties concerning endoscopic ultrasound indications, gastroenterologist have a better understanding in hepatic-pancreatic-biliary organs however other specialties are better in the esophagus indications.

Evaluación de los tumores benignos y malignos, superficiales y profundos de la ampolla de vater con endoscopia digestiva / Evaluation of the superficial and deep benign and wicked tumors of the vater bladder with digestive endoscopic

Los tumores benignos de la ampolla de Vater son un diagnóstico poco común para muchos gastroenterólogos. Las opciones terapéuticas incluyen la resección quirúrgica tipo resección local transduodenal o la opción no quirúrgica tipo ampulectomía endoscópica seguida o no de una ablación térmica (1)(2). El carcinoma de ampolla de Vater es relativamente raro y se dificulta la evaluación del grado de extensión usando técnicas de imágenes convencionales. La ecoendoscopia ha demostrado ser útil en la evaluación de la profundidad de las lesiones del tracto digestivo. El objetivo de nuestro trabajo fue evaluar el uso de la ecoendoscopia en las lesiones superficiales y profundas, malignas y benignas de la ampolla de Vater. Los datos fueron obtenidos de los pacientes referidos a CITE para una ecoendoscopia, en el período comprendido entre abril de 2000 a junio 2004. A todos los pacientes se les llenó una hoja de registros y los datos retrospectivos fueron obtenidos mediante llamadas telefónicas realizadas por un gastroenterólogo.Un total de 43 pacientes fueron estudiados, 24 mujeres y 19 hombres, la edad mínima 27 años, la máxima de 83 años con una media de 55 años. La indicación del estudio fue sospecha de tumor de ampolla en 20 (47 por ciento) casos, certeza de tumor de ampolla por comprobación histológica en 10 (23 por ciento) casos, ictericia en 19 (44 por ciento) casos, litiasis coledociana en 2 casos, colédoco dilatado en 10 casos, sólo colestasis extrahepática en 3 casos. En el 80 por ciento de los pacientes existieron al menos tres indicaciones. Se clasificaron un total de 43 lesiones de la ampolla de Vater, de estas: 9 presentaron por histología lesiones benignas, 23 fueron reportadas como lesiones malignas de diferentes grados de diferenciación y 11 (25 por ciento) lesiones fueron no concluyentes por histología ya que presentaron lesiones tumorales sin un diagnóstico histológico preciso. 25 lesiones fueron T1, 9 lesiones T2 , 6 lesiones T3, 1 T4 y 2 otros. 25 pa...

Role of health-related quality of life in palliative chemotherapy treatment decisions.

PURPOSE: To determine the frequency with which health-related quality-of-life (HRQL) considerations lead to modification or discontinuation of palliative chemotherapy, and the association between physicians' ratings of patients' HRQL and such treatment decisions. METHODS: Four consecutive medical consultations of 203 patients receiving outpatient palliative chemotherapy were tape-recorded and the content was analyzed to determine the frequency of and reasons for treatment alterations. Physicians rated their patients' HRQL by using the COOP/WONCA health assessment charts. Data on tumor response and treatment toxicity were obtained from the audiotapes and, when necessary, were confirmed by medical chart audits. RESULTS: Treatment was modified in 54 cases (26%) and discontinued in 40 (20%). The primary reasons for modifying treatment were toxicity (n = 22), HRQL considerations (n = 18), and tumor progression (n = 14). The primary reasons for discontinuation of treatment were tumor progression (n = 23), HRQL considerations (n = 6), and toxicity (n = 3). For eight patients, a combination of tumor progression and HRQL issues resulted in discontinuation of treatment. Treatment decisions were associated significantly with physicians' global ratings of patients' HRQL but not with more specific HRQL domains. In the presence of tumor progression or serious toxicity, HRQL considerations played little or no role in treatment decisions. Furthermore, approximately 70% of patients without evidence of tumor progression or toxicity, but with seriously impaired HRQL, continued to receive their treatment as planned. CONCLUSION: Contrary to previous findings based on physicians' self-report data, HRQL considerations seem to play a relatively minor role in decisions regarding modification or discontinuation of palliative chemotherapy.

The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: an observational study.

CONTEXT: Improving health-related quality of life (HRQL) is an important goal of palliative treatment, but little is known about actual patient-physician communication regarding HRQL topics during palliative treatment. OBJECTIVES: To investigate the content of routine communication regarding 4 specific HRQL issues between oncologists and their patients and to identify patient-, physician-, and visit-specific factors significantly associated with discussion of such issues. DESIGN: Observational study conducted between June 1996 and January 1998. SETTING: Outpatient palliative chemotherapy clinic of a cancer hospital in the Netherlands. PARTICIPANTS: Ten oncologists and 240 of their patients (72% female; mean age, 55 years) who had incurable cancer and were receiving outpatient palliative chemotherapy. MAIN OUTCOME MEASURES: Patient and physician questionnaires and audiotape analysis of communication regarding daily activities, emotional functioning, pain, and fatigue during an outpatient consultation using the Roter Interaction Analysis System. RESULTS: Physicians devoted 64% of their conversation to medical/technical issues and 23% to HRQL issues. Patients' communication behavior was divided more equally between medical/technical issues (41%) and HRQL topics (48%). Of the independent variables investigated, patients' self-reported HRQL was the most powerful predictor of discussing HRQL issues. Nevertheless, in 20% to 54% of the consultations in which patients were experiencing serious HRQL problems, no time was devoted to discussion of those problems. In particular, these patients' emotional functioning and fatigue were unaddressed 54% and 48% of the time, respectively. Discussion of HRQL issues was not more frequent in consultations in which tumor response was evaluated. CONCLUSION: Despite increasing recognition of the importance of maintaining patients' HRQL as a goal of palliative treatment, the amount of patient-physician communication devoted to such issues remains limited and appears to make only a modest contribution, at least in an explicit sense, to the evaluation of treatment efficacy in daily clinical practice.

How are you feeling? Who wants to know? Patients' and oncologists' preferences for discussing health-related quality-of-life issues.

PURPOSE: This study investigated (1) the attitudes of cancer patients toward discussing health-related quality-of-life (HRQL) issues; (2) the association between such attitudes and patients' characteristics; and (3) oncologists' attitudes and self-reported behavior regarding these same issues. PATIENTS AND METHODS: Two hundred seventy-three patients receiving palliative chemotherapy and ten physicians were asked to complete a series of questionnaires. RESULTS: Almost all patients wanted to discuss their physical symptoms and physical functioning and were also willing to address their emotional functioning and daily activities. However, 25% of the patients were only willing to discuss these latter two issues at the initiative of their physician. Patients varied most in their willingness to discuss their family and social life, with 20% reporting no interest in discussing these issues at all. Female patients were more reluctant to discuss various HRQL issues than male patients. Older and less well-educated patients were more likely to prefer that their physician initiate discussion of HRQL issues. All physicians considered it to be primarily their task to discuss the physical aspects of their patients' health, whereas four physicians indicated that discussion of psychosocial issues was a task to be shared with other health care providers. All physicians indicated that they generally defer to their patients in initiating discussion of psychosocial issues. CONCLUSION: Although both patients and oncologists seem willing to discuss a wide range of HRQL issues, communication regarding psychosocial issues may be hampered by competing expectations as to who should take the lead in initiating such discussions.

Revealing response shift in longitudinal research on fatigue--the use of the thentest approach.

In this study we examined whether response shift resulting from changes in internal standards occurs in cancer patients undergoing radiotherapy. Ninety-nine newly diagnosed patients undergoing radiotherapy were administered two standardized self-report measures of fatigue prior to receiving radiotherapy. After completion of radiotherapy, patients filled out these questionnaires as a conventional posttest and in reference to how they perceived themselves as they were prior to radiotherapy (a so-called 'thentest'). A transition (direct change) score on fatigue was used as a stratification measure. Patients were subsequently interviewed about their responses. The pattern of mean scores indicative of response-shift effects was found in two distinct subgroups: patients experiencing diminishing levels of fatigue and patients facing early stages of adaptation to increased levels of fatigue. Since response shift may adversely affect the results of self-reported outcomes in clinical trials or other longitudinal research, further research is very much needed.

Evaluating the quality of life of cancer patients: assessments by patients, significant others, physicians and nurses.

This study examined the usefulness of caregiver ratings of cancer patients' quality of life (QOL), an issue of relevance to both adequate patient care and to the possible use of proxy QOL raters in clinical studies. We compared QOL ratings of 90 cancer patients receiving inpatient chemotherapy with those provided by their significant others (most often the spouse), physicians and nurses. During patients' scheduled appointment for receiving chemotherapy on a clinical ward, all raters completed independently the Dartmouth COOP Functional Health Assessment charts/WONCA, an instrument developed by a cooperative group of primary care physicians to briefly assess a core set of seven QOL domains (physical fitness, feelings, daily and social activities, overall health, pain and quality of life) by single items with five response options. With few exceptions, mean scores of the proxy raters were equivalent or similar to those of the patients. Most patient-proxy correlations varied between 0.40 and 0.60, indicating a moderate level of agreement at the individual level. Of all comparisons made, 41% were in exact agreement and 43% agreed within one response category, leaving 17% more profound patient-proxy discrepancies. Disagreement was not dependent on the type of proxy rater, or on raters' background characteristics, but was influenced by the QOL dimension under consideration and the clinical status of the patient. Better patient-proxy agreement was observed for more concrete questions (daily activities, pain) and for patients with either a very good (ECOG 0) or poor (ECOG 3) performance status. The results indicate that both significant others and health care providers can be useful sources of information about cancer patients' QOL.

Rearing stable fly larvae (Diptera: Muscidae) on an egg yolk medium.

The growth and survival of Stomoxys calcitrans (L.) larvae on egg yolk medium inoculated with bacteria isolated from a colony of stable flies was evaluated. Five species of bacteria--Acinetobacter sp., Aeromonas sp., Empedobacter breve (Holmes & Owen), Flavobacterium odoratum Stutzer, and Serratia marcescens Bizio--were identified according to fatty acid profiles using a microbial identification system. Larvae failed to develop on uninoculated plates, confirming that bacteria are required to complete development. Larvae also failed to complete development on plates inoculated with Aeromonas sp. and S. marcescens, and died during the 1st instar. Larvae completed development on the remaining 3 bacterial species as well as on Escherichia coli (Migula). Survival was generally higher when larvae were reared on Acinetobacter sp. and F. odoratum compared with E. coli and E. breve. Egg density did not influence larval survival, although the variability in survival was lowest using 20 and 40 eggs per plate. Larval survival in mixed cultures of Acinetobacter and Flavobacterium averaged 22.7% lower than survival in the pure cultures, and averaged 21.6% higher in mixed cultures of Empedobacter and Flavobacterium compared with pure cultures. Larval survival in mixed cultures did not differ significantly from mean survival in pure cultures for combinations of Acinetobacter and E. coli, Acinetobacter and Empedobacter, E. coli and Empedobacter, and E. coli and Flavobacterium. Larval developmental time was faster on all mixed bacterial cultures compared with developmental time on pure bacterial cultures. Optimal sample sizes and egg numbers are presented for detecting specified differences in larval survival. This rearing procedure will be useful for studying insect-microbe interactions and evaluating mortality using bacterial agents.

Comparison of patient and proxy EORTC QLQ-C30 ratings in assessing the quality of life of cancer patients.

The aim of this study was to examine whether significant others can provide useful proxy information on the health-related quality of life (QL) of cancer patients. We examined the level and pattern of agreement between patient and proxy ratings of the EORTC QLQ-C30, the reliability and validity of both types of information, and the influence of several factors on the extent of agreement. QL ratings were obtained for 307 and 224 patient-proxy pairs (at baseline and follow-up, respectively). Agreement was moderate to good (ICC = 0.42 to 0.79). Multitrait-multimethod analysis showed good convergence and discrimination of specific QL domains. Comparison of mean scores revealed a small but systematic bias between patient and proxy ratings. The maximum level of disagreement was found at intermediate levels of QL, with smaller discrepancies noted for patients with either a relatively poor or good QL. Both patient and proxy QL ratings were reliable and responsive to changes over time. Several characteristics of the patients and their significant others were found to be associated with the level of agreement, but explained less than 15% of the variance in patient-proxy differences. In conclusion, the present findings lend support to the viability of employing significant others as proxy respondents of cancer patients' quality of life where this is necessary.

Value of caregiver ratings in evaluating the quality of life of patients with cancer.

PURPOSE: To evaluate the usefulness of caregiver ratings of cancer patients' quality of life (QL), we examined the following: (1) the comparability of responses to a brief standardized QL questionnaire provided by patients, physicians, and informal caregivers; and (2) the relative validity of these ratings. METHODS: The study sample included cancer patients receiving chemotherapy, their treating physicians, and significant others involved closely in the (informal) care of the patients. During an early phase of treatment and 3 months later, patients and caregivers completed independently the COOP/WONCA charts, covering seven QL domains. At baseline, all sources of information were available for 295 of 320 participating patients (92%). Complete follow-up data were obtained for 189 patient-caregiver triads. RESULTS: Comparison of mean scores on the COOP/WONCA charts revealed close agreement between patient and caregiver ratings. At the individual patient level, exact or global agreement was observed in the majority of cases (73% to 91%). Corrected for chance agreement, moderate intraclass correlations (ICC) were noted (0.32 to 0.72). Patient, physician, and informal caregiver COOP/WONCA scores were all responsive to changes over time in specific QL domains, but differed in their relative performance. Relative to the patients, the physicians were more efficient in detecting changes over time in physical fitness and overall health, but less so in relation to social function and pain. CONCLUSION: For studies among patient populations at risk of deteriorating self-report capabilities, physicians and informal caregivers can be useful as alternative or complementary sources of information on cancer patients' QL.