Prostate-specific antigen test in diagnostic evaluation of chronic prostatitis/chronic pelvic pain syndrome.

OBJECTIVES: To determine whether prostate-specific antigen (PSA), the percent free PSA, or free PSA isoforms may be used as diagnostic markers for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS; National Institutes of Health category IIIa and IIIb). METHODS: We evaluated 421 patients enrolled in the Chronic Prostatitis Cohort Study and 112 age-matched controls. Subjects were stratified by the number of white blood cells (WBCs) in their expressed prostatic secretions and pain as determined by the National Institutes of Health Chronic Prostatitis Symptom Index. RESULTS: Total PSA, free PSA, and [-2]proPSA ([-2]pPSA) were significantly elevated in those with CP/CPPS compared with controls (mean PSA 1.97 ng/mL versus 1.72 ng/mL, P = 0.03; mean free PSA 0.76 ng/mL versus 0.70 ng/mL, P = 0.01; and [-2]pPSA 2.38 ng/mL versus 1.80 ng/mL, P = 0.04). The percent free PSA was not significantly different between the patients and controls. For those with CP/CPPS, the percent free PSA was significantly lower as the WBC count rose in the expressed prostatic secretions (0 WBCs = 43.29 versus more than 25 WBCs = 26.52; P < .0001). A PSA level of 4.0 ng/mL or greater was found in 10% of patients and 7% of controls (P = 0.03). CONCLUSIONS: Men with elevated PSA values and CP/CPPS should be treated as one would any other patient screened for prostate cancer with an elevated PSA level. Although PSA, free PSA, and [-2]pPSA were slightly elevated in men with CP/CPPS, the low sensitivity and specificity do not warrant using them as biomarkers for CP/CPPS.

A case-control study of risk factors in men with chronic pelvic pain syndrome.

OBJECTIVE: To compare the demographic, behavioural, clinical and medical history characteristics of men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and asymptomatic controls, to identify characteristics that might be associated with this syndrome. PATIENTS AND METHODS: Self-administered epidemiological questionnaires were completed by 463 men with CP/CPPS and 121 asymptomatic age-matched controls. We compared the prevalence of possible risk factors between men with CP/CPPS and controls, using generalized Mantel-Haenszel tests, and developed multivariate predictive models using logistic regression methods, adjusting for clustering by clinical centre within both methods. RESULTS: Compared to controls, men with CP/CPPS reported a significantly greater lifetime prevalence of nonspecific urethritis (12% vs 4%, P = 0.008), cardiovascular disease (11% vs 2%, P = 0.004), neurological disease (41% vs 14%, P < 0.001), psychiatric conditions (29% vs 11%, P < 0.001), and haematopoietic, lymphatic or infectious disease (41% vs 20%, P < 0.001). CONCLUSION: A wide range of self-reported medical conditions was associated with CP/CPPS. Further studies are necessary to determine whether they play a role in the pathogenesis of CP/CPPS.

Impact of the 1998 World Health Organization/International Society of Urological Pathology classification system for urothelial neoplasms of the kidney.

The classification of urothelial neoplasms of the kidney traditionally has been similar to that of urinary bladder tumors. Several years ago, the classification of papillary urothelial neoplasms was revised. The current study focuses on the application of the 1998 World Health Organization (WHO)/International Society of Urological Pathology classification system to 102 renal pelvic urothelial neoplasms and compares it to the 1973 WHO classification scheme. In this study, all tumors were classified as urothelial carcinomas, and the majority (85%) were papillary. Most patients with papillary tumors presented with 'superficial' disease (< or = pT1). With the 1998 system, most papillary carcinomas were high grade, and were more often invasive as compared to low-grade tumors. Only 34% were low-grade papillary tumors and, of these, most (93%) were noninvasive. With the 1973 system, most papillary tumors were grade 2 or 3, with invasion more common in grade 3 tumors. By 1973 criteria, grade 2 tumors were a heterogeneous group; with 1998 criteria, nearly one-half were high grade and the other half low grade. The grade of papillary urothelial carcinomas with both the 1973 and 1998 grading methods was associated with stage (P=0.001). Our study reveals that papillomas and papillary urothelial neoplasms of low malignant potential are uncommon tumors in the kidney. Renal pelvic papillary urothelial neoplasms are most often carcinomas and are more commonly high grade than low grade. Although both the 1973 and 1998 systems showed a significant association with tumor stage, grade 2 papillary carcinomas are a heterogeneous group by 1973 criteria. The 1998 system provides useful information in that it more clearly defines a papillary tumor's grade and selects for a group of tumors, namely low-grade papillary urothelial carcinomas, for which a low likelihood of invasion can be predicted.

Predictors of quality of life and pain in chronic prostatitis/chronic pelvic pain syndrome: findings from the National Institutes of Health Chronic Prostatitis Cohort Study.

OBJECTIVES: To examine the cross-sectional relationship of age, urinary and depressive symptoms and partner status on pain intensity and quality of life (QoL) in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). PATIENTS AND METHODS: In all, 463 men enrolled in the National Institutes of Health (NIH) Chronic Prostatitis Cohort Study from seven clinical centres (six in the USA and one in Canada) reported baseline screening symptoms using the NIH Chronic Prostatitis Symptom Index (CPSI). The CPSI provides scores for pain, urinary symptoms and QoL. In addition, a demographic profile, including age and partner (living with another) status, and a depressive symptom score were obtained. Regression modelling of QoL, adjusting for between-centre variability, examined the unique effects of age, partner status, urological symptoms, depressive symptoms and pain. RESULTS: Urinary scores, depressive symptoms and pain intensity scores significantly predicted QoL for patients with CP/CPPS (higher CPSI QoL scores indicated more impairment; median 8.0, range 0-12). On average, for every 1-point increase in urinary scores, there was a corresponding increase in QoL score of 0.118 points (P = 0.001); for every 1-point increase in pain intensity score, there was a corresponding increase in QoL score of 0.722 points (P < 0.001); and for every 1-point decrease in depressive symptoms (lower scores equal poorer mood), the QoL score increased (poorer quality of life) by 0.381 points (P < 0.001). Age and partner status did not significantly contribute to poorer QoL. Urinary scores and depressive symptoms were significant predictors (P < 0.001) of pain in patients with CP/CPPS. CONCLUSIONS: These data show that depressive symptoms and pain intensity significantly predict a poorer QoL in patients with CP/CPPS, and that these effects are independent of partner status, age and urinary status. In particular, pain intensity was the most robust predictor of a poorer QoL. Further data relating pain and psychological factors to CP/CPPS are highly recommended, to aid in determining specific factors for pain and its impact on QoL. These data are essential if empirically guided efforts to manage pain are to progress.

Ciprofloxacin or tamsulosin in men with chronic prostatitis/chronic pelvic pain syndrome: a randomized, double-blind trial.

BACKGROUND: Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) in men is principally defined by pain in the pelvic region lasting more than 3 months. No cause of the disease has been established, and therapies are empirical and mostly untested. Antimicrobial agents and alpha-adrenergic receptor blockers are frequently used. OBJECTIVE: To determine whether 6-week therapy with ciprofloxacin or tamsulosin is more effective than placebo at improving symptoms in men with refractory, long-standing CP/CPPS. DESIGN: Randomized, double-blind trial with a 2 x 2 factorial design comparing 6 weeks of therapy with ciprofloxacin, tamsulosin, both drugs, or placebo. SETTING: Urology outpatient clinics at 10 tertiary care medical centers in North America. PATIENTS: Patients were identified from referral-based practices of urologists. One hundred ninety-six men with a National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) score of at least 15 and a mean of 6.2 years of symptoms were enrolled. Patients had received substantial previous treatment. MEASUREMENTS: The authors evaluated NIH-CPSI total score and subscores, patient-reported global response assessment, a generic measure of quality of life, and adverse events. INTERVENTIONS: Ciprofloxacin, 500 mg twice daily; tamsulosin, 0.4 mg once daily; a combination of the 2 drugs; or placebo. RESULTS: The NIH-CPSI total score decreased modestly in all treatment groups. No statistically significant difference in the primary outcome was seen for ciprofloxacin versus no ciprofloxacin (P = 0.15) or tamsulosin versus no tamsulosin (P > 0.2). Treatments also did not differ significantly for any of the secondary outcomes. LIMITATIONS: Treatment lasting longer than 6 weeks was not tested. Patients who had received less pretreatment may have responded differently. CONCLUSION: Ciprofloxacin and tamsulosin did not substantially reduce symptoms in men with long-standing CP/CPPS who had at least moderate symptoms.

Comparative cardiac safety of low-dose thioridazine and low-dose haloperidol.

AIM: To compare the rate of ventricular arrhythmia, sudden death and unexplained or unattended death among users of thioridazine and haloperidol. METHODS: Observational cohort study of thioridazine and haloperidol users in the UK General Practice Research Database (GPRD) using data from 1987 through 29 June 2000. Patients were followed for 30 days following each study prescription. The event of interest was a diagnosis of ventricular arrhythmia, sudden death, or unexplained or unattended death. Cox regression was used to calculate rate ratios (RRs) and 95% confidence intervals (CIs), to examine potential confounding factors, and to examine dose-response relationships. RESULTS: Use of thioridazine and haloperidol in the GPRD was primarily in older patients, at low dose (median daily dose 31 mg thioridazine, 1.8 mg haloperidol). There was no association between thioridazine use and the rate of ventricular arrhythmia, sudden death, and unexplained or unattended death (adjusted RR 0.9, 95% CI 0.7, 1.1). The rate did not appear to increase with dose for either drug over the range observed. CONCLUSIONS: These results suggest that low-dose thioridazine and haloperidol have similar cardiac safety.

Administration of parenteral iron and mortality among hemodialysis patients.

The objective of this study was to evaluate whether the apparent relationship demonstrated in prior studies between iron dosing and mortality in hemodialysis (HD) patients was confounded by incomplete representation of iron dosing and morbidity over time. A cohort study was conducted among 32,566 patients who received at least 1 yr of HD at the Fresenius Medical Corporation dialysis centers during 1996 to 1997. The outcome measure was all-cause mortality through mid-1998. A total of 19 demographic, comorbidity, and laboratory characteristics were available. By proportional hazards analysis, no adverse effect on 2-year survival was found for baseline iron dose over 6 mo of < or = 1000 mg, but statistically significant elevated mortality was demonstrated for iron doses >1000 mg to 1800 mg (adjusted hazards ratio [HR] = 1.09; 95% confidence interval [CI], 1.01 to 1.17) and >1800 mg (adjusted HR = 1.18; 95% CI, 1.09 to 1.27). However, fitting multivariable models that appropriately account for time-varying measures of iron administration as well as other fixed and time-varying measures of morbidity, the authors found no statistically significant association between any level of iron administration and mortality. This study suggests that previously observed associations between iron administration and higher mortality may have been confounded, and it provides cautious support for the safety of the judicious administration of cumulative iron doses >1000 mg over 6 mo if needed to maintain target hemoglobin levels among patients treated with maintenance HD.

Predictors of successful arteriovenous fistula maturation.

BACKGROUND: Understanding the factors associated with successful arteriovenous fistula (AVF) maturation may provide an opportunity to improve vascular access outcomes. METHODS: This prospective cohort study enrolled 348 hemodialysis patients receiving an AVF and followed them until ascertainment of successful AVF maturation. Multivariable logistic regression was used to develop (1) explanatory models of factors associated with AVF success and (2) models for predicting success based on sociodemographic and comorbidity profiles. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the discriminative ability of our predictive model. Predictive probabilities of AVF maturation under the assumption of optimal surgical technique defined by explanatory models were calculated. RESULTS: A total of 55.5% of AVFs successfully matured. A history of stroke or transient ischemic attack, increasing age, and dependence on dialysis at the time of access placement were associated with lower probabilities of maturation. Of potentially modifiable variables, maturation was associated with greater intraoperative doses of heparin, use of large-diameter veins, and mean arterial pressure of 85 mm Hg or greater. Using optimal surgical technique, the probability of successful AVF maturation would have been as high as 84%. A predictive logistic regression model had moderate ability to predict AVF maturation under optimal surgical therapy with an area under the ROC curve of 0.69. CONCLUSION: Surgical technique potentially may be modified to yield a greater probability of successful AVF maturation. Predictive probabilities of successful AVF maturation under optimal surgical technique reinforce the view that functioning AVFs can be achieved in a large proportion of hemodialysis patients, consistent with experience in selected regions of the United States and abroad.

Compliance with oral HRT in postmenopausal women in clinical trials--meta analysis.

OBJECTIVE: To assess compliance with oral hormone replacement therapy (HRT) over time in postmenopausal women in clinical trials and to examine aspects of study conduct (e.g. randomized vs. nonrandomized design) that might be associated with observed compliance rates. METHODS: Aggregation of data from the available published studies using meta-analysis. Eligible studies had to be clinical trials reporting compliance with oral HRT among postmenopausal women and have a sample size of at least 20. MEDLINE and EMBASE databases were used through January 1998 to find studies that assessed compliance with oral HRT in postmenopausal women in clinical trials. Summary estimates of compliance, and of associations between compliance and features of study conduct, were computed allowing for clustering of data within studies. RESULTS: Thirty reports met the inclusion criteria. Overall compliance at about 1 year on average was 83.4%. In a multivariable model, one variable, whether compliance was the primary objective of the study or not, remained statistically significant, even after adjustment for clustering (odds ratio=0.47, 95% confidence interval: 0.22-1.00, P=0.05). CONCLUSIONS: This study supports the importance of using appropriate methods for measuring compliance, if valid estimates of compliance are a serious objective of an investigation. There has been much discussion about the need for increased medication compliance, particularly for those medications used for prevention, but the means and methods to improve compliance remain elusive.

Leukocytes and bacteria in men with chronic prostatitis/chronic pelvic pain syndrome compared to asymptomatic controls.

PURPOSE: Chronic prostatitis has been traditionally characterized by inflammation and/or infection of the prostate gland, objectively categorized by white blood cells and cultured bacteria in prostate specific specimens. We compared leukocyte counts and localization rates for bacterial cultures of segmented urine samples (VB1, VB2, VB3), expressed prostatic secretion (EPS) and semen in men diagnosed with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) to men without pelvic pain (controls). MATERIALS AND METHODS: A total of 463 men enrolled in the National Institutes of Health Chronic Prostatitis Cohort study and 121 age matched men without urinary symptoms had leukocyte counts performed and 5-day bacterial cultures on specimens obtained from a standard 4-glass test (VB1, VB2, EPS, VB3) and semen. All risk factor comparisons between case and control analyses were tested using generalized Mantel-Haenszel methods, and multivariable models were developed using logistic regression methods, adjusting for clustering by clinical center within both methods. RESULTS: Men with CP/CPPS had statistically higher leukocyte counts in all segmented urine samples and EPS, but not in semen compared to asymptomatic control men. However, the control population also had a high prevalence of leukocytes. Of the men with CP/CPPS 50% and 32% had 5 or more, or 10 or more white blood cells (WBCs) per high power field, respectively, in EPS compared to 40% and 20% of the control population. Similarly, 32% and 14% of the patients with CP/CPPS had 5 or more, or 10 or more WBCs per high power field in VB3 compared to 19% and 11% in the control population. Localization of uropathogenic bacteria in EPS, VB3 and/or semen was similar in men with CP/CPPS (8.0%) and asymptomatic men (8.3%). CONCLUSIONS: Men with CP/CPPS have significantly higher leukocyte counts in all segmented urine samples and EPS but not in semen as compared to controls. There is no difference in rates of localization of bacterial cultures for men with CP/CPPS compared to control men. The high prevalence of WBCs and positive bacterial cultures in the asymptomatic control population raises questions about the clinical usefulness of the standard 4-glass test as a diagnostic tool in men with CP/CPPS.

Medical conditions as risk factors for pressure ulcers in an outpatient setting.

OBJECTIVES: the purpose of this study was to evaluate the likelihood that the presence of certain medical conditions in older ambulatory patients are associated with the risk of developing a new pressure ulcer. DESIGN: a cohort study. SETTING AND SUBJECTS: a large outpatient record database from the United Kingdom called the General Practice Research Database. METHODS: the frequency of disease was reported as simple percentages and the associations between the medical conditions and the development of a pressure ulcer as instantaneous rate ratios. RESULTS: we studied 75,168 older individuals. Pressure ulcers occurred in 1,211 individuals. The medical conditions that were significantly associated with the development of a pressure ulcer after adjustment were: Alzheimer's disease, congestive heart failure, chronic obstructive pulmonary disease, cerebral vascular accident, diabetes mellitus, deep venous thrombosis, hip fracture, hip surgery, limb paralysis, lower limb oedema, malignancy, malnutrition, osteoporosis, Parkinson's disease, rheumatoid arthritis, and urinary tract infections. Angina, hypertension, and pneumonia were inversely associated with the development of a pressure ulcer. CONCLUSIONS: it is important that physicians recognise that patients with many medical conditions may be at higher risk for pressure ulcers so that even in the ambulatory care environment appropriate prevention and detection strategies can be directed towards the patients who are most likely to benefit.

Determinants of successful synthetic hemodialysis vascular access graft placement.

OBJECTIVE: Synthetic vascular grafts, the most common type of permanent dialysis graft used in the United States, are associated with great morbidity and expense. In this cohort study of patients undergoing hemodialysis and receiving a new synthetic vascular graft, detailed intraoperative procedural data were examined as predictors of graft dysfunction and failure. METHODS: A prospective cohort study of patients receiving hemodialysis who had undergone synthetic (polytetrafluoroethylene) graft placement over 4(1/2) years were followed up until either the graft was no longer usable, kidney transplantation was performed, the patient died, or the study ended. The principal methods of analysis used were the Kaplan-Meier method, to compute survival function for primary and secondary graft patency, and Cox proportional hazards regression, to model associations between predictor variables and graft failure. RESULTS: Of 284 patients enrolled in the study, 172 patients (61%) had at least one graft-related event, ie, temporary graft dysfunction or graft failure, during follow-up. Three-year cumulative graft survival was 54% (95% confidence interval, 45%-62%). Using proportional hazards analysis, history of claudication (rate ratio [RR], 2.14 [range, 0.97-4.73]; P =.06), number of previous permanent grafts (1 graft: RR, 1.49 [range, 0.88-2.51]; 2 or more grafts: RR, 2.85 [range, 1.43-5.69]; P =.01), dialysis dependency at surgery (RR, 2.96 [range, 1.23-7.12]; P =.02), and use of arterial clamps in construction of the graft (RR, 2.32 [range, 1.14-4.73]; P =.02) were associated with lower survival, even after accounting for medical history. Type of graft material, ie, Gore-Tex versus other material (RR, 0.28 [range, 0.16-0.50]; P <.01) and use of the axillary vein (RR, 0.61 [range, 0.36- 1.02]; P =.06) for the access site were associated with a lower rate of graft failure. Similar results were found with Poisson analysis of all graft-related events. In addition, acute arterial anastomosis, ie, arterial angle less than 90 degrees (RR, 0.63 [range, 0.45-0.91]; P =.01) and use of the brachial artery versus the radial artery (RR, 0.54 [range, 0.33-0.54]; P =.01) were associated with a lower rate of graft-related events. CONCLUSION: These findings suggest possible areas for intervention to improve synthetic vascular graft outcome.

Cardiac arrest and ventricular arrhythmia in patients taking antipsychotic drugs: cohort study using administrative data.

OBJECTIVE: To examine the rates of cardiac arrest and ventricular arrhythmia in patients with treated schizophrenia and in non-schizophrenic controls. DESIGN: Cohort study of outpatients using administrative data. SETTING: 3 US Medicaid programmes. PARTICIPANTS: Patients with schizophrenia treated with clozapine, haloperidol, risperidone, or thioridazine; a control group of patients with glaucoma; and a control group of patients with psoriasis. MAIN OUTCOME MEASURE: Diagnosis of cardiac arrest or ventricular arrhythmia. RESULTS: Patients with treated schizophrenia had higher rates of cardiac arrest and ventricular arrhythmia than controls, with rate ratios ranging from 1.7 to 3.2. Overall, thioridazine was not associated with an increased risk compared with haloperidol (rate ratio 0.9, 95% confidence interval 0.7 to 1.2). However, thioridazine showed an increased risk of events at doses > or =600 mg (2.6, 1.0 to 6.6; P=0.049) and a linear dose-response relation (P=0.038). CONCLUSIONS: The increased risk of cardiac arrest and ventricular arrhythmia in patients with treated schizophrenia could be due to the disease or its treatment. Overall, the risk with thioridazine was no worse than that with haloperidol. Thioridazine may, however, have a higher risk at high doses, although this finding could be due to chance. To reduce cardiac risk, thioridazine should be prescribed at the lowest dose needed to obtain an optimal therapeutic effect.

Leukocyte and bacterial counts do not correlate with severity of symptoms in men with chronic prostatitis: the National Institutes of Health Chronic Prostatitis Cohort Study.

PURPOSE: We examine whether leukocytes and bacteria correlate with symptom severity in men with chronic prostatitis/chronic pelvic pain syndrome. MATERIALS AND METHODS: All 488 men screened into the National Institutes of Health Chronic Prostatitis Cohort Study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, were used to measure symptoms. Urethral inflammation was defined as white blood cell (WBC) counts of 1 or more (1+) in the first voided urine. Participants were classified as category IIIa based on WBC counts of 5 or more, or 10 or more (5+, 10+) in the expressed prostatic secretion, or 1+ or 5+ either in the post-expressed prostatic secretion urine (voided urine 3) or semen. Uropathogens were classified as localizing if the designated bacterial species were absent in voided urine 1 and voided urine 2 but present in expressed prostatic secretion, voided urine 3 or semen, or present in expressed prostatic secretion, voided urine 3 or semen at 2 log concentrations higher than at voided urine 1 or 2. Associations between symptoms, and inflammation and infection were investigated using generalized Mantel-Haenszel methods. RESULTS: Of all participants 50% had urethral leukocytes and of 397 with expressed prostatic secretion samples 194 (49%) and 122 (31%) had 5+ or 10+ WBCs in expressed prostatic secretion, respectively. The prevalence of category IIIa ranged from 90% to 54%, depending on the composite set of cut points. None of the index measures were statistically different (p >0.10) for selected leukocytosis subgroups. Based on prostate and semen cultures, 37 of 488 men (8%) had at least 1 localizing uropathogen. None of the index measures were statistically different (p >0.10) for selected bacterial culture subgroups. CONCLUSIONS: Although men with chronic prostatitis routinely receive anti-inflammatory and antimicrobial therapy, we found that leukocytes and bacterial counts as we defined them do not correlate with severity of symptoms. These findings suggest that factors other than leukocytes and bacteria also contribute to symptoms associated with chronic pelvic pain syndrome.

Demographic and clinical characteristics of men with chronic prostatitis: the national institutes of health chronic prostatitis cohort study.

PURPOSE: We describe the study design of the National Institutes of Health Chronic Prostatitis Cohort (CPC) study characterizing men with chronic prostatitis/the chronic pelvic pain syndrome. MATERIALS AND METHODS: All 488 men screened into the CPC study before close of recruitment on August 22, 2001 were selected for analysis. The National Institutes of Health Chronic Prostatitis Symptom Index, including subscores, was used to measure symptoms. A comprehensive history, physical examination and demographic profile were obtained from each participant. Generalized Mantel-Haenszel procedures were used to investigate baseline associations between selected factors and symptoms. RESULTS: Chronic prostatitis/chronic pelvic pain syndrome is a chronic syndrome affecting men over a wide age range. The majority of CPC study participants are white, well educated and affluent. However, lower education, lower income and unemployment were associated with more severe symptoms. Patients most frequently reported pain in the perineum and tenderness in the prostate. The highest self-reported diseases were genitourinary (55%), allergies (53%), neurological (40%) and hematopoietic, lymphatic or infectious (40%). This disease has a significant negative impact on mental and physical domains of quality of life. Almost all patients (95%) reported antimicrobial drug use. Of these 488 participants 280 (57%) reported the previous or current use of 5 or more categories of prostatitis related treatments. CONCLUSIONS: Chronic prostatitis/chronic pelvic pain syndrome is a multifactorial problem affecting men of all ages and demographics. Patients with the chronic pelvic pain syndrome have dismal quality of life and many have benefited only minimally from empirical, goal directed therapy. Long-term followup of this cohort may answer important questions on the natural treated history of this syndrome.

The incidence and prevalence of pressure ulcers among elderly patients in general medical practice.

PURPOSE: The objective of this study was to estimate the period prevalence and incidence of pressure ulcer among those 65 years of age and older. METHODS: We used a patient-record database called the General Practice Research Database (GPRD). Subjects were 65 years of age and older and cases were ascertained based on strict inclusion and exclusion criteria. The accuracy of the ascertainment strategy was estimated using mailed physician-answered questionnaires. Annual period prevalence and age-specific incidence were estimated per 100 person-years with exact 95% confidence intervals (CI). RESULTS: The accuracy of our ascertainment strategy was excellent, with a positive predictive value of 100% (95% CI: 92%,100%) and negative predictive value of 95% (85%, 95%). Over 200,000 person-years of data were analyzed. The annual period prevalence of pressure ulcer among those 65 years of age and older varied from 0.31% to 0.70%. The incidence varied significantly with advancing patient age from 0.18 to 3.36 per 100-person years (p < 0.001) but was not associated with gender (p = 0.95). CONCLUSIONS: Pressure ulcers are seen in the general practice setting. They are most likely to occur in those over 85 years of age. Preventative strategies within the general practice setting should concentrate on the oldest of the elderly.

Hormone replacement therapy and prevention of pressure ulcers and venous leg ulcers.

Pressure ulcers and venous leg ulcers are common chronic wounds. Oestrogens in the form of hormone replacement therapy (HRT) might have an effect on wound healing, but this possibility has not been studied in detail. Using a case-cohort study including elderly patients in the UK General Practice Research Database, we showed that patients who received HRT were less likely to develop a venous leg ulcer (age-adjusted relative risk 0.65 [95% CI 0.61-0.69]) or a pressure ulcer (0.68 [0.62-0.76]) than those who did not use HRT. Therefore, we believe that HRT could be beneficial for the prevention of these wounds.