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PubMed1997

Correlation of prostate needle biopsy and radical prostatectomy Gleason grade in academic and community settings.

Prior studies have not analyzed grading patterns and accuracy in nonacademic sites and have not analyzed reasons for discrepant grades. We analyzed 499 radical prostatectomy (RP) specimens at The Johns Hopkins Hospital (JHH) from 1994 and compared them with the corresponding JHH needle biopsy Gleason grade and, when available (n = 390), to the outside institution (non-JHH) Gleason biopsy grade. For JHH, there was exact agreement between biopsy and RP in 58% and agreement to within one digit in 93% of cases, compared with 34% and 67%, respectively, for non-JHH. Combining cases into more meaningful groups (Gleason 2-4, 5-6, 7, and 8-10), there was 66% exact correlation between the biopsy and RP for JHH as compared with 45% for non-JHH. Non-JHH undergraded biopsy results more than JHH, with 22.3% and 1.2% Gleason score 2-4, respectively. None of the cases with a Gleason score of 2-4 on biopsy from JHH or non-JHH were Gleason score 2-4 on RP. Fifty-five percent of the tumors with non-JHH needle biopsy results graded Gleason 2-4 had either capsular penetration, seminal vesicle, or lymph node involvement. All of the tumors with needle Gleason score 2-4 at JHH were organ confined. The JHH needle biopsy grade correlated better with pathologic stage than did non-JHH (R = 0.27 JHH vs. R = 0.12 non-JHH). Extent of cancer in the biopsy sample was not a factor in the accuracy of predicting RP grade or stage. Eighty-two cases evaluated at JHH were signed out by a genitourinary pathologist; the grading of the biopsy samples by other JHH pathologists was just as accurate. Gleason score of > or = 7 on the biopsy sample predicted a Gleason score of > or = 7 in the RP 87.5% of the time. A Gleason score of < 7 predicted a Gleason score of < 7 only 63.9% of the time. Discordant grades in some cases reflected patterns of cancer on needle biopsy that were borderline between two different Gleason scores. Sampling was the major source of discrepancy and was often due to the high-grade component in the RP not being present in the biopsy results or due to a component of cancer on the needle reflecting such a small percentage of the pattern seen on RP that this pattern was not included in the final RP Gleason score.

Academic Medical Centers↗
PubMed2006

Comparison of ureteral washing and biopsy specimens in the community setting.

BACKGROUND: Ureteral lesions can be difficult to diagnose. The value of ureteral biopsy in addition to ureteral washings has not been defined clearly. METHODS: All ureteral washings and biopsies with follow-up that were performed at a single institution were reviewed. RESULTS: In total, 39 patients underwent ureteral washing, ureteral biopsy, or both and had follow-up: Eighteen patients had urothelial tumors at follow-up (14 high-grade carcinomas, 3 low-grade carcinomas, and 1 papillary urothelial neoplasm of low malignant potential). The sensitivity was 79% for washings and 71% for biopsies (P = 1.0), for a combined sensitivity of 100%. Biopsies often were scant, and cell blocks from biopsies and washings often were of value. CONCLUSIONS: Ureteral washings and biopsies had similar sensitivity and appeared to be complementary. Cell blocks often are useful for both specimen types.

Biopsy↗
PubMed2003

Carotid artery stenting in a community setting: experience outside of a clinical trial.

Carotid artery angioplasty and stenting (CAS) currently represents a less invasive percutaneous alternative to conventional endarterectomy for the treatment of carotid occlusive disease. We report here the results and complication rates of CAS performed by a team of interventionalists at a non-clinical trial center utilizing a standardized CAS protocol. CAS was attempted in 51 arteries in 48 patients (mean age 71 +/- 9 years, range 53-90). Fifteen (29%) of 48 patients were symptomatic. Indications for CAS were previous ipsilateral endarterectomy (15/51, 29%), previous neck radiation therapy (1/51, 2%), or significant coronary artery disease (30/51, 59%). SMART((R)) stents were deployed via percutaneous femoral artery access, with anticoagulation (heparin, abciximab, aspirin, clopidogrel) and temporary transvenous cardiac pacemakers employed in all patients. Neuroprotection was not used. Neurological examination and duplex scans were performed in follow-up. CAS was successfully performed in 96% of cases (49 lesions/46 patients) with angiographic stenoses of 88 +/- 8%. Neurological complications included one (2%) minor stroke that occurred 12 hr after CAS. There were no periprocedural mortalities. Clinically significant bradycardia or asystole occurred in 11/49 (22%) procedures, necessitating short-term ventricular pacing. All stented vessels remained patent during 12.2 +/- 10.1 (range 1-37) months follow-up period. One asymptomatic restenosis (>70%) occurred at 3 months, which was successfully reangioplastied; we thus had 1-year angiographic restenosis rate of 2%. Patients selected for CAS may represent a subset of patients with carotid disease who have considerable comorbidities or unfavorable anatomy compared to those undergoing conventional endarterectomy. CAS may be performed safely outside of a clinical trial with results similar to those of published series from trial centers using a standardized protocol.

Aged↗
PubMed1992

Meta-analysis of intervention trials on case-management of pneumonia in community settings.

To appraise the effectiveness of the pneumonia case-management strategy in improving child survival, we have done a meta-analysis of six published intervention trials. The results of a seventh published study and two unpublished studies were also reviewed. The six published studies satisfied our criteria for methodological soundness. The reduction in mortality rate (control group minus intervention group) was estimated for each study, and for all the studies together. For total infant mortality, the overall reduction was 15.9 (95% confidence interval 10.6-21.1) deaths per 1000 livebirths; infant mortality due to acute lower respiratory infection was reduced by 10.7 (4.8-16.7) deaths/1000 livebirths. Mortality among children under 5 years was decreased by 36 deaths/1000 livebirths. The pooled estimates of relative risk are consistent with a 20% reduction in infant mortality and a 25% reduction in under-5 mortality. There was no clear association across the studies between the effect of the pneumonia case-management and extent of co-interventions such as immunisation and oral rehydration therapy. The consistency of findings of all the studies, despite differences in design and methods, shows that the case-management strategy has a substantial effect on infant and under-5 mortality, at least in settings with infant mortality rates of 90/1000 livebirths or more. It is important to find out the most efficient ways of implementing this strategy and integrating it into primary health care.

Child, Preschool↗
PubMed2004

Executive dysfunction and visuospatial ability among depressed elders in a community setting.

Visuospatial ability is frequently compromised among elderly depressed patients, but it is unclear whether the impairment is a consequence of a visuospatial memory deficit or of an executive dysfunction that impacts visuospatial ability. The Boston Qualitative Scoring System is a method of scoring the Rey-Osterrieth Complex Figure (ROCF) that assesses the process used to draw the figure, the executive aspect of the task, as well as the accuracy and location of the completed elements. The hypotheses that executive scores as measured by the BQSS would separate diagnostic groups and that executive function would mediate the relationship between depression and nonverbal recall were tested using a between groups design with elderly depressed volunteers (N = 31) and healthy controls (N = 31). Participants were screened for other Axis I disorders with the Structured Clinical Interview for DSM-IV Diagnosis, diagnosed for major depression per DSM-IV criteria, and administered the ROCF. The copy and recall drawings were scored using BQSS criteria, and scores were grouped into executive and drawing scores from both copy and recall phases. Executive scores during the copy phase and drawing scores from the recall phase separated the diagnostic groups [F(1,59), = 4.14, P = .05] and [F(1,59) = 6.88, P = .01], respectively. Follow-up ANCOVAS showed that copy Planning, the score that quantified the process by which the figure was drawn, separated the diagnostic groups. Planning also mediated the association between depression and the percent of the figure recalled after the short delay (Z = 1.84, P < .05). The significance of the depression-to-recall pathway was eliminated when Planning was controlled for, but Planning remained related to percent recalled [B = -6.90, P < .007]. A dimension of executive dysfunction, represented here by Planning, may be one underlying source of the observed decline in nonverbal recall among elderly depressed patients. This result is consistent with the theory that dysfunction of the prefrontal cortex is a critical feature of late-life depression.

Aged↗
PubMed2000

Prognostic value of exercise echocardiography in women in the community setting.

Treadmill stress echocardiography was performed in 1,136 women with known or suspected coronary artery disease whose clinical course was then evaluated a mean of 33 months later (range 12 to 60). The strongest predictor of an adverse outcome was the presence of a resting or an exercise-induced wall motion abnormality.

Adolescent↗
PubMed1997

Intraoperative brain mapping in a community setting--technical considerations.

Intraoperative brain mapping is a surgical adjunct used during lesionectomy or epilepsy surgery in functional cortex. This procedure is typically performed at academic institutions by fellowship trained neurosurgeons. However, most of the technology is straightforward and adaptable to the private practice setting. This paper outlines our intraoperative methodology for brain mapping during lesion resection in eloquent cortex.

Brain Mapping↗
PubMedDate not supplied

A model of nurse-midwife and family physician collaborative care in a combined academic and community setting.

Certified nurse-midwives and family physicians share a philosophy of family-centered maternity care. Collaboration between the two disciplines, however, has not been common. Collaboration can enhance the primary care and maternity care options available to clients of such collaborative practices. Advantages and barriers to collaboration for both types of practitioners, as well as suggestions for successful collaboration, are discussed.

Family Practice↗
PubMed1990

Setting community health goals: one District Health Councils experience.

The Niagara District Health Council has embarked on a strategic planning exercise to develop health goals, objectives and preliminary targets for action. This process was approached in three phases: establishment of a Health Goals Task Force and adoption of the five goals developed by the Premier's Council on Health Strategy; planning and implementation of a Health Goals Consultation Day to involve community members in the identification and priority ranking of objectives; and development of measurable and realistic preliminary targets through consultations with expert groups and individuals. This process is a practical planning tool applicable across sectors and communities.

Goals↗
PubMed1999

Docetaxel in the community setting: an analysis of 377 breast cancer patients treated with docetaxel (Taxotere) in the UK. UK Study Group.

BACKGROUND: Given as first- or second-line chemotherapy docetaxel appears to have great potential in advanced breast cancer. PATIENTS AND METHODS: Three hundred and seventy-seven locally advanced or metastatic breast cancer patients received docetaxel (Taxotere) as part of a named patient programme under the care of 108 oncologists from 61 cancer units across the UK. The recommended starting dose was 100 mg/m2, but patients at higher risk of toxicity started at 75 mg/m2. All patients received corticosteroid premedication. The modal number of prior chemotherapy regimens was 2 (range 1-7). 342 patients (91%) had at least one prior anthracycline-based regimen. RESULTS: Response was graded according to the managing clinician's best judgement without formal criteria. The overall response rate (ORR) was 46% among the 331 evaluable patients. 46% among the 299 patients who were anthracycline resistant and 35% among the 82 patients who were anthracycline refractory (progressive disease being the best response obtained to the most recent anthracycline containing regimen). One hundred and ninety-three patients started at the full dose of 100 mg/m2 with an ORR of 55% and 129 started at 75 mg m2 with an ORR of 33%. In October 1997, some two years after the programme had started, 26 of 377 patients were still alive, although no complete remissions have lasted to this date. Kaplan-Meier survival analysis yielded a median survival of 194 days (95% CI: 178-218 days). Haematological parameters were checked before each course of docetaxel and additionally as clinically indicated. The safety data confirmed that docetaxel has a manageable, predictable side effect profile; 29 of 377 (7.7%) patients were hospitalised as a result of neutropenic sepsis. CONCLUSIONS: The results of this named patient programme over a two year timespan confirm that docetaxel is an effective chemotherapy option in patients with locally advanced and/or metastatic breast cancer, including an 'anthracycline refractory' population.

Adult↗
PubMed2006

The cognitive effects of electroconvulsive therapy in community settings.

Despite ongoing controversy, there has never been a large-scale, prospective study of the cognitive effects of electroconvulsive therapy (ECT). We conducted a prospective, naturalistic, longitudinal study of clinical and cognitive outcomes in patients with major depression treated at seven facilities in the New York City metropolitan area. Of 751 patients referred for ECT with a provisional diagnosis of a depressive disorder, 347 patients were eligible and participated in at least one post-ECT outcome evaluation. The primary outcome measures, Modified Mini-Mental State exam scores, delayed recall scores from the Buschke Selective Reminding Test, and retrograde amnesia scores from the Columbia University Autobiographical Memory Interview-SF (AMI-SF), were evaluated shortly following the ECT course and 6 months later. A substantial number of secondary cognitive measures were also administered. The seven sites differed significantly in cognitive outcomes both immediately and 6 months following ECT, even when controlling for patient characteristics. Electrical waveform and electrode placement had marked cognitive effects. Sine wave stimulation resulted in pronounced slowing of reaction time, both immediately and 6 months following ECT. Bilateral (BL) ECT resulted in more severe and persisting retrograde amnesia than right unilateral ECT. Advancing age, lower premorbid intellectual function, and female gender were associated with greater cognitive deficits. Thus, adverse cognitive effects were detected 6 months following the acute treatment course. Cognitive outcomes varied across treatment facilities and differences in ECT technique largely accounted for these differences. Sine wave stimulation and BL electrode placement resulted in more severe and persistent deficits.

Adult↗
PubMed2001

The relationships between health beliefs and utilization of free health examinations in older people living in a community setting in Taiwan.

OBJECTIVE: To examine the influence of demographics and the health beliefs of older people on uptake of a free annual health examination administered by the Twu-Tyan Bureau of Sanitation (TTBS), Pingtung, Taiwan. BACKGROUND: The free health examination is a preventive intervention with potential to detect illness. This programme for older people aged 65 years and over, has been available free in some areas since 1980. METHOD: A stratified random systematic sample of 200 men and women over 65 years was selected and consisted of 100 individuals who had undertaken the free health examination and 100 who had not. A 17-item Health Belief Scale (HBS) was used to glean information on their health beliefs and uptake of a free health examination. FINDINGS: It was found that those with higher education and higher economic status had a greater uptake. Family support was also found to influence take-up. A statistically significant difference was found between the health beliefs of users and nonusers. Users perceived a higher level of seriousness and susceptibility to ill health than nonusers. CONCLUSIONS: A number of practical pointers are given that might help clinicians increase uptake rates in such health promotion programmes. These encompass understanding the influence of key demographical and social factors, perceived susceptibility, severity and benefits of the intervention, barriers to attendance and self-efficacy.

Aged↗
PubMed2003

Obstacles to implementing research outcomes in community settings.

PURPOSE: In contrast to controlled laboratory- or clinic-based research that can fail to capture the real-world behaviors of older adults, field research offers the best opportunity for ecological validity. However, the tradeoff inherent in field studies is the potential sacrifice of scientific rigor. Applied research presents a unique set of challenges that vary with context. This article discusses these challenges along with possible solutions. DESIGN: Examples are drawn from an ongoing, longitudinal Roybal Center study of driving competence that is being conducted in Department of Motor Vehicles field sites. The challenges faced at each stage of the project are discussed. METHOD: Methodological issues include identifying field collaborators, approaching administrators with the research proposal, producing a battery that is manageable and acceptable while maintaining scientific merit, training indigenous personnel to administer this battery, introducing the research and consenting potential participants, and managing large data sets offsite. Additional issues include quality control, the importance of distinguishing between individuals who consent and those who decline participation, and the collection of follow-up data via telephone. IMPLICATIONS: The use of field research in changing public perceptions, medical practice, and public policy is discussed.

Aged↗
PubMed1999

Baseline HIV drug resistance profile predicts response to ritonavir-saquinavir protease inhibitor therapy in a community setting.

OBJECTIVE: To determine whether baseline drug resistance assays could help to predict treatment failure with the protease inhibitor combination ritonavir-saquinavir. METHODS: Baseline HIV-1 drug resistance was determined for 76 consecutive patients who started treatment with the dual protease inhibitor combination ritonavir-saquinavir between September 1996 and June 1997 either alone or in combination with other antiviral agents. Resistance to 10 different antiviral agents was assessed by both phenotype (Virco Antivirogram) and genotype (Vircogen). RESULTS: Resistance inferred from viral genotype was similar to measured phenotypic resistance for both ritonavir and saquinavir (P<0.01). Baseline drug resistance phenotype was predictive of poor virological response to this dual protease inhibitor combination, despite the confounding effects of other antivirals. Patients were at least four times less likely to achieve a 0.5 log10 decrease in plasma HIV RNA viral load if their viral isolates were resistant to ritonavir or saquinavir. Patients classified as resistant to either drug using either method had median decreases in plasma viral load of 0.05 log10 HIV RNA copies/ml or less, compared to >0.8 log10 for those with sensitive virus. Patients resistant to both drugs never achieved plasma viral loads <100000 copies/ml. As little as fourfold increases in baseline resistance appeared to be sufficient to compromise even dual protease inhibitor therapy. CONCLUSION: Baseline resistance to ritonavir or saquinavir or both was associated with a poor antiviral response. Our data suggest that the measurement of drug resistance may assist in optimizing antiretroviral therapy in the clinic.

Anti-HIV Agents↗