PubMed Health⌕ Search

Biomedical subjects

Mark Emberton

Publications and source records attributed to Mark Emberton.

At least 37 records · Page 2Linked to original sources
PubMed2006

Visually directed high-intensity focused ultrasound for organ-confined prostate cancer: A proposed standard for the conduct of therapy.

OBJECTIVE: To propose a standard for the conduct of visually directed transrectal high-intensity focused ultrasound (HIFU) and to offer a formal description of the changes observed on B-mode ultrasonography (US) during this procedure. We describe our early experience of using two different treatment methods; algorithm-based HIFU and visually directed HIFU for the treatment of organ-confined prostate cancer. PATIENTS AND METHODS: Between November 2004 and October 2005, 34 men were treated using the Sonablate-500 (Focus Surgery, Indianapolis, IN, USA) as primary therapy for T1 or T2 prostate cancer. None had had previous hormone therapy and all had > or = 3-month PSA nadirs recorded at the follow-up. Nine men were treated using an algorithm-based protocol (group 1) and 25 using visually directed therapy (group 2). The conduct of visually directed treatment was described and changes seen using B-mode US were categorized using three 'Uchida' grades. RESULTS The mean PSA nadir achieved in group 2 was 0.15 ng/mL, vs 1.51 ng/mL in group 1 (P < 0.005). In group 2, 21 of 25 men achieved PSA nadirs of < or = 0.2 ng/mL 3 months after treatment. Seven men achieved undetectable PSA values. The occurrence rate of treatment-related toxicity was similar in both groups. CONCLUSION: Visually directed, transrectal HIFU enables clinically important and statistically significantly lower PSA nadirs to be achieved than algorithm-based HIFU. This is the first reported experience of visually directed HIFU for the treatment of organ-confined prostate cancer. We think that this is the first attempt to standardize the conduct of therapy; such standardization facilitates teaching it, and makes it possible to derive quality standards. The standardization of the conduct of therapy is a key step in the process of health technology assessment.

Aged↗
PubMed2005

An analysis of the Research Fellowship Scheme of the Royal College of Surgeons of England.

BACKGROUND: The Research Fellowship Scheme of the Royal College of Surgeons of England commenced in 1993 with the aim of exposing selected surgical trainees to research techniques and methodology, with the hope of having an impact on surgical research and increasing the cadre of young surgeons who might decide to pursue an academic career in surgery. Over 11 million pounds sterling (approximately US 20 million dollars) has been invested in 264 fellowships. The College wished to evaluate the impact of the Scheme on the careers of research fellows, surgical research, and patient care. As the 10th anniversary of the Scheme approached. STUDY DESIGN: Two-hundred and sixty research fellows whose current addresses were available were sent a questionnaire. Two-hundred and thirty-eight (91.5%) responded. RESULTS: Three-quarters of the research fellows conducted laboratory-based research, with most of the remainder conducting patient-based clinical research. One-third of the fellows who have reached consultant status have an academic component to their post. The total number of publications based on fellowship projects was 531, with a median impact factor of 3.5. Almost all fellows had been awarded a higher degree or were working toward this. Half of the fellows received subsequent funding for research, mostly awarded by national or international funding bodies. CONCLUSIONS: The Research Fellowship Scheme of the Royal College of Surgeons of England has successfully supported many trainee surgeons in the initial phase of their research career. It has helped surgical research by increasing the pool of surgeons willing to embark on an academic career. Indirectly, patient care has benefited by promoting an evidence-based culture among young surgeons. Such schemes are relevant to surgical training programs elsewhere if more young surgeons are to be attracted into academic surgery.

Biomedical Research↗
PubMed2005

Symptom deterioration during treatment and history of AUR are the strongest predictors for AUR and BPH-related surgery in men with LUTS treated with alfuzosin 10 mg once daily.

OBJECTIVES: To assess the predictors of acute urinary retention (AUR) and/or surgery related to benign prostatic hyperplasia (BPH) in 3514 men complaining of lower urinary tract symptoms and treated for 6 months with the selective alpha1-blocker alfuzosin at 10 mg once daily. METHODS: The impact of baseline (age, prior AUR, prostate-specific antigen tertiles, lower urinary tract symptoms severity, and bother score) and dynamic (International Prostate Symptom Score [IPSS] worsening of 4 points or greater and bother greater than 3 during treatment) variables on the risk of AUR/BPH-related surgery was assessed using Kaplan-Meier curves and log-rank tests. Associated hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazard models. RESULTS: Of the 3514 men analyzed, 140 (4%) experienced a first episode of conservatively managed AUR before inclusion. Of those 140 men, 5 (3.6%) had AUR relapse during alfuzosin treatment and 6 (4.3%) underwent BPH-related surgery. Of those 3374 men without prior AUR, 19 (0.6%) experienced AUR during treatment and 41 (1.2%) underwent BPH-related surgery. During treatment, the most important predictors of AUR were prior AUR (HR 6.35, 95% CI 2.31 to 17.40; P < 0.01), IPSS worsening of 4 or greater (HR 3.34, 95% CI 1.11 to 9.99; P = 0.03), and bother score greater than 3 (HR 3.32, 95% CI 1.29 to 8.53; P < 0.01) at endpoint. Other variables (age, PSA, baseline IPSS, and bother) had much less predictive value. Similar results were observed regarding the risk of AUR and/or BPH-related surgery. CONCLUSIONS: The results of this 6-month real life practice study suggest that prior AUR and symptom deterioration during treatment with alfuzosin 10 mg once-daily (IPSS worsening of 4 or more points, bother score greater than 3) were the strongest predictors of AUR and AUR/BPH-related surgery in men with lower urinary tract symptoms.

Acute Disease↗
PubMed2005

Changes in patient characteristics and outcomes for radical cystectomy in England.

OBJECTIVES: To describe temporal changes in patient characteristics and outcomes for radical cystectomy (RC) in England between 1995 and 2002, using routinely collected administrative data. PATIENTS AND METHODS: Data were extracted from the Hospital Episode Statistics database of the Department of Health in England, describing all patients recorded as having undergone RC between 1995/1996 and 2001/2002; 8228 patients were included. RESULTS: Of the patients who had undergone RC, two-thirds were > or = 65 years old and 75.6% were men. From 1995/1996 to 2001/2002 the annual number of RCs increased from 1013 to 1254, the proportion of patients admitted as an emergency decreased from 6.5% to 4.9%, the mean length of hospital stay decreased from 20.7 days to 18.7 days, and in-hospital mortality rates fell from 5.3% to 3.6%. The length of hospital stay and in-hospital mortality rates were higher in older patients, in female patients, and in those admitted as an emergency. CONCLUSIONS: There was no sign of centralization of RCs over the study period, as the 25% increase in annual hospital volume was accompanied by a similar increase in the annual number of RCs. Length of hospital stay and in-hospital mortality rates have decreased.

Adult↗
PubMed2005

Alfuzosin 10 mg once daily improves sexual function in men with lower urinary tract symptoms and concomitant sexual dysfunction.

OBJECTIVE: To assess the effect on sexual function of alfuzosin 10 mg once daily, a uroselective alpha(1)-blocker, in men with lower urinary tract symptoms (LUTS) suggestive of bladder outlet obstruction. PATIENTS AND METHODS: In all, 3076 men (mean age 65.9 years) were treated for 1 year with alfuzosin 10 mg in 'real life' practice. They were asked to complete the International Prostatic Symptom Score (IPSS), its appended eighth question (bother score) and the Danish Prostatic Symptom Score questionnaire for sexual dysfunction (DAN-PSSsex). The results were analysed at the endpoint in the intent-to-treat population. RESULTS: At baseline, 2434 (79.1%) men were sexually active and answered correctly at least one item of the DAN-PSSsex. Sexual dysfunction was highly prevalent (reduced stiffness of erection, 65.3%; reduced volume of ejaculate, 63.2%; pain/discomfort on ejaculation, 20.2%), and was strongly related to the severity of LUTS and impairment of quality of life. At the endpoint, alfuzosin significantly improved the total IPSS (-6.1, - 32%) and bother score (-1.4, - 33.2%, both P < 0.001) over baseline. In those men with sexual dysfunction there were significant improvements in weighted scores related to reduced rigidity of erection (-0.5), reduced amount of ejaculate (-0.4) and pain/discomfort on ejaculation (-1.2, all P < 0.001) over baseline. The perceived improvements were more marked in men with severe LUTS or a severe bother score at baseline. CONCLUSIONS: Sexual dysfunction is highly prevalent in men with LUTS and related to the baseline IPSS and bother score. Alfuzosin 10 mg once daily for 1 year is effective in improving LUTS and quality of life, and is well tolerated. It may even improve sexual function in those men with concomitant erectile and/or ejaculatory dysfunction.

Adrenergic alpha-Antagonists↗
PubMed2005

A description of radical nephrectomy practice and outcomes in England: 1995-2002.

OBJECTIVES: To describe national trends in the practice of radical nephrectomy (RN) in England between 1995 and 2002. METHODS: Data were extracted from the Hospital Episode Statistics database of the Department of Health in England between 1995/1996 and 2001/2002. Patients were included in the study if an International Classification of Diseases diagnosis code (ICD-10) for malignant neoplasm of the kidney, renal pelvis or ureter, and an operative procedure code (OPCS-4) describing total or partial excision of the kidney by either a laparoscopic or open approach, were present in any of the diagnosis or operative procedure fields. Overall, 17 308 patients were included. RESULTS: Patient age and the proportion who were men did not change over the study period. The proportion of patients admitted as an emergency decreased from 14.0% to 7.5% over this period (P < 0.001). The mean waiting duration increased by almost 6 days (P < 0.001) and length of stay by approximately 1 day, from 11.7 days in 1995 to 10.8 days in 2001 (P < 0.001). In-hospital mortality decreased from 2% to 1.5% (P = 0.134). In-hospital mortality and length of stay were higher in older patients and in those admitted as an emergency. Women had a longer stay than men (11.5 vs 11.1 days), but in-hospital mortality was higher in men (2.3% vs 1.6%). The national number of RNs per year increased by approximately 20%, from 2254 in 1995 to 2671 in 2001. Over the same period the mean annual hospital volume of RN increased by approximately 40%, from 17 in 1995 to 24 in 2001. The annual number of laparoscopic RNs nationally increased from seven in 1995 to 84 in 2002. CONCLUSIONS: The annual number of RNs in England increased by almost a fifth and this was accompanied by an increase in annual hospital volume of about two-fifths. There was a large proportional increase in the number of laparoscopic RNs. Emergency admission rates and length of stay decreased but this was not accompanied by a significant change in in-hospital mortality rate.

Adult↗
PubMed2005

Lower urinary tract symptoms in men: self-perceptions and the concept of bother.

OBJECTIVE: To explore the meaning that men attach to their experiences of having lower urinary tract symptoms (LUTS) and to understand 'bother' in the context of those meanings. PATIENTS AND METHODS: Sixteen men with symptoms suggestive of LUTS and/or an enlarged prostate were recruited from the outpatient urology clinic of a London teaching hospital. They were assessed before or shortly after their first appointment, during which demographic information, including age, occupation, marital status and ethnicity, was obtained and an individualized repertory grid was completed. Each man also completed the International Prostate Symptom Score, which included an item measuring overall bother, and the Hospital Anxiety and Depression Scale. RESULTS: Most participants held very negative views about what it meant to have prostate problems and viewed them as being associated with old age. Nevertheless, they also had reasonably high levels of self-esteem. However, there was evidence that these had been higher before they had prostate problems, and that self-esteem might decline over time. Bother was related to symptom scores and to anxiety. Also, a perception that other people, particularly their partner, saw them in a more negative light because of their symptoms was associated with higher levels of bother. CONCLUSIONS: The findings suggest that men attempt to preserve a sense of a relatively youthful and intact 'self' in the face of advancing years and a progressive disease that was viewed as being associated with old age. Overall, these men had a reasonably secure self-image and they deployed a range of cognitive strategies to maintain this. Bother appears to be a combination of symptom severity, psychological distress, negative evaluations of the condition and beliefs about the reactions of others. Reducing anxiety and challenging negative stereotypes and expectations that others would view them negatively if their problems were known might reduce bother. Attending to these factors could enable watchful waiting to be optimized by reducing bother. Trials to evaluate interventions drawing on these principles would be valuable.

Aged↗
PubMed2004

Patients' preferences for the management of non-metastatic prostate cancer: discrete choice experiment.

OBJECTIVE: To establish which attributes of conservative treatments for prostate cancer are most important to men. DESIGN: Discrete choice experiment. SETTING: Two London hospitals. PARTICIPANTS: 129 men with non-metastatic prostate cancer, mean age 70 years; 69 of 118 (58%) with T stage 1 or 2 cancer at diagnosis. MAIN OUTCOME MEASURES: Men's preferences for, and trade-offs between, the attributes of diarrhoea, hot flushes, ability to maintain an erection, breast swelling or tenderness, physical energy, sex drive, life expectancy, and out of pocket expenses. RESULTS: The men's responses to changes in attributes were all statistically significant. When asked to assume a starting life expectancy of five years, the men were willing to make trade-offs between life expectancy and side effects. On average, they were most willing to give up life expectancy to avoid limitations in physical energy (mean three months) and least willing to trade life expectancy to avoid hot flushes (mean 0.6 months to move from a moderate to mild level or from mild to none). CONCLUSIONS: Men with prostate cancer are willing to participate in a relatively complex exercise that weighs up the advantages and disadvantages of various conservative treatments for their condition. They were willing to trade off some life expectancy to be relieved of the burden of troublesome side effects such as limitations in physical energy.

Aged↗
PubMed2004

Defining the components of a self-management programme for men with uncomplicated lower urinary tract symptoms: a consensus approach.

OBJECTIVE: To define the components of a self-management programme of lifestyle and behavioural interventions for symptom control in men with uncomplicated LUTS. The use of lifestyle and behavioural interventions for symptom control in men with uncomplicated LUTS is widespread in the UK, however the effectiveness of these interventions has never been formally evaluated. Defining the components of a self-management programme will allow effectiveness studies to take place. MATERIALS AND METHODS: An eight member multidisciplinary panel rated 94 items for their appropriateness to be incorporated into the self-management programme using The Research and Development Appropriateness Method--RAM (UCLA). The item list was developed using semi-structured interviews with health care professionals and a national UK practice survey. RAM is a formal consensus process where an expert panel rate items over two rounds. The first round is conducted by post and in the second round the panel meets to discuss their initial ratings chaired by an independent moderator, then a second and final vote is made. RESULTS: The panel agreed that 57 of the original 94 items were appropriate to be incorporated in the self-management programme. These interventions were contained within the following categories: patient assessment prior to starting a self-management programme (6), education and reassurance (4), fluid management (6), caffeine (4), alcohol (2), concurrent medication (2), types of toileting (2), bladder re-training (15), miscellaneous (1), and implementation of a self-management programme (15). CONCLUSIONS: The components of a self-management programme of lifestyle and behavioural interventions for men with uncomplicated LUTS has been defined using the RAM consensus process. Now this problem of definition has been overcome, the effectiveness of self-management can be formally explored.

Consensus↗
PubMed2004

EAU 2004 guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms suggestive of benign prostatic obstruction (BPH guidelines).

OBJECTIVE: To provide the first update of the EAU guidelines on assessment, therapy and follow-up of men with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO). METHODS: A systematic literature review was conducted based on the results of a MEDLINE search concentrating on the years 1999-2003. In combination with expert opinions recommendations were made on the usefulness of diagnostic tests, therapeutic options and follow-up. RESULTS: During initial assessment the following tests are recommended: medical history, physical examination including digital-rectal examination, International Prostate Symptom Score, urinalysis, serum creatinine and prostate specific antigen measurement, uroflowmetry and post-void residual volume. All other tests are optional or not recommended. Aim of treatment is to improve LUTS and quality of life and to prevent severe BPE-related complications. Development of a 5alpha-reductase type I and II inhibitor and the data of the MTOPS trial providing scientific evidence for a combination therapy were the most significant innovations since the first version. Finally a more detailed knowledge on the natural history with identification of several risk factors for progression is the basis for a risk-profile orientated (preventive) therapy. CONCLUSIONS: Updated recommendations for assessment, treatment, and follow-up of patients with LUTS due to BPO are presented.

Europe↗
PubMed2004

Could self-management challenge pharmacotherapy as a long-term treatment for uncomplicated lower urinary tract symptoms?

PURPOSE OF REVIEW: This review highlights the lifestyle and behavioural management strategies (self-management) available to men with lower urinary tract symptoms. RECENT FINDINGS: Pharmacotherapy has evolved considerably over the last decade and now most men with lower urinary tract symptoms are treated at some point with either single or combined therapy. However, recent studies reporting the longer term usage of pharmacotherapy have shown significantly high rates of discontinuation due to patient compliance, treatment ineffectiveness, side effects and patient choice. Not all these men will require or desire surgery. For those with bothersome symptoms self-management may be an effective strategy. Self-management interventions include education, reassurance, fluid management, caffeine avoidance, rescheduling concurrent medications and bladder retraining. As in other chronic disease areas such as diabetes and arthritis for which self-management is well established, lifestyle and behavioural interventions for men with lower urinary tract symptoms aim to allow the patient some day-to-day control over their symptoms. These interventions have been shown to be in wide use in the UK without good quality supporting evidence, suggesting that they are thought to be safe and effective. SUMMARY: Self-management (lifestyle and behavioural) interventions provide men with some control over their symptoms, their role as either a primary treatment strategy or to augment pharmacotherapy has yet to be defined.

Aged↗
PubMed2004

A systematic review and critique of the literature relating hospital or surgeon volume to health outcomes for 3 urological cancer procedures.

PURPOSE: We performed a systematic review and critique of the literature of the relationship between hospital or surgeon volume and health outcomes in patients undergoing radical surgery for cancer of the bladder, kidney or prostate. MATERIALS AND METHODS: Four electronic databases were searched to identify studies that describe the relationship between hospital or surgeon volume and health outcomes. RESULTS: All included studies were performed in North America. A total of 12 studies were found that related hospital volume to outcomes. For radical prostatectomy and cystectomy all 8 included studies showed improvement in at least 1 outcome measure with increasing volume and never deterioration. For nephrectomy the 4 included studies produced conflicting results. Four studies were found that related surgeon volume to outcomes. All radical prostatectomy and cystectomy studies showed that some outcomes were better with higher surgeon volume and never deterioration. We did not find any studies of the effect of surgeon volume on outcomes after nephrectomy. The 3 studies of the combined effect of hospital and surgeon volume on outcomes after radical prostatectomy or cystectomy suggest that high volume hospitals have better outcomes, in part because of the effect of surgeon volume and vice versa. CONCLUSIONS: Outcomes after radical prostatectomy and cystectomy are on average likely to be better if these procedures are performed by and at high volume providers. For radical nephrectomy the evidence is unclear. The impact of volume based policies (increasing volume to improve outcomes) depends on the extent to which "practice makes perfect" explains the observed results. Further studies should explicitly address selective referral and confounding as alternative explanations. Longitudinal studies should be performed to evaluate the impact of volume based policies.

Cystectomy↗