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M Emberton

Publications and source records attributed to M Emberton.

At least 19 recordsLinked to original sources
PubMed2006

Self-management in lower urinary tract symptoms: the next major therapeutic revolution.

The standard treatments for men with lower urinary tract symptoms (LUTS) range from watchful waiting to medical and finally surgical intervention. However, the role of self-management interventions such as education and reassurance, lifestyle modification and behavioural changes has not been formally investigated, although they are widely advocated and utilised for LUTS. Self-management interventions are well established in other chronic diseases such as diabetes, arthritis and asthma. These interventions, if successfully organised within a structured program for LUTS, could improve patient outcomes as well as reduce the economic burden of LUTS treatment, by replacing or augmenting other treatments. Recent studies showing that long-term urodynamic and symptomatic deterioration of LUTS is minimal suggest that this is a safe and valid treatment option. This is supported by a recent pilot study of a LUTS self-management program which showed significant improvements in I-PSS and frequency-volume parameters. The results of a recently completed randomised controlled trial are awaited.

Humans↗
PubMed2006

Trends in paediatric circumcision and its complications in England between 1997 and 2003.

BACKGROUND: It has been suggested that too many English boys undergo circumcision. This report describes how circumcision rates have changed in England between 1997 and 2003, including data on complication rates and on how age, medical indication and surgical specialty affect postoperative haemorrhage rates. METHODS: Data were extracted from the Hospital Episode Statistics database of admissions to National Health Service hospitals in England. Patients were included in the study if an Office of Population Censuses and Surveys version 4 code for circumcision was present in any of the operative procedure fields of the database; 75 868 boys below 15 years of age were included in the study. RESULTS: Circumcision rates declined by about 20 per cent, from 2.6 per 1000 boys per year in 1997 to 2.1 in 2003. Between 2000 and 2003, circumcision rates remained static at 2.1 per 1000 boys per year. Circumcision rates fell by 31.2 per cent for boys aged 0-4 years, 9.3 per cent for boys aged 5-9 years and increased by 7.7 per cent in boys aged 10-14 years; 90.2 per cent of circumcisions were done for phimosis and 1.2 per cent of boys experienced a complication. CONCLUSION: Circumcision rates in England continued to fall up until 2000, particularly in those aged under 5 years, in whom pathological phimosis is rare. The circumcision rate remains five times higher than the reported incidence of Phimosis.

Adolescent↗
PubMed2006

Photodynamic therapy using meso tetra hydroxy phenyl chlorin (mTHPC) in early prostate cancer.

BACKGROUND AND OBJECTIVES: Prostate cancer is increasing in incidence, but current treatments including surgery and radiotherapy have significant side effects. This pilot study was designed to assess the potential of photodynamic therapy (PDT) using meso tetra hydroxy phenyl chlorin (mTHPC) for organ confined prostate cancer. STUDY DESIGN/PATIENTS AND METHODS: Six men with organ confined prostate cancer were photosensitised with mTHPC (0.15 mg/kg). Between 2 and 5 days later, red light (652 nm) was delivered to areas of biopsy proven cancer via fibres inserted through transperineal needles (50-100 J per site). RESULTS: After 8 of 10 PDT sessions, the prostate specific antigen (PSA) fell by up to 67%. Early MRI scans showed oedema and patchy necrosis, which resolved over 2 months. Biopsies of treated areas revealed necrosis and fibrosis at 1-2 months. CONCLUSIONS: PDT for primary prostate cancer appears safe and can reduce PSA levels. As this was a phase I study, no attempt was made to treat the whole prostate; this or targeted tumour ablation could be attempted in a phase II study with an increased number of fibres. This technique merits further investigation in early prostate cancer.

Aged↗
PubMed2006

Age, comorbidity and hypertensive co-medication do not affect cardiovascular tolerability of 10 mg alfuzosin once daily.

PURPOSE: We assessed in real-life practice the impact of age, cardiovascular comorbidity and co-medication on the tolerability and efficacy of 10 mg alfuzosin OD in men with lower urinary tract symptoms suggestive of benign prostatic obstruction. MATERIALS AND METHODS: A total of 6,523 men with a mean age of 64.7 years were enrolled in a 6-month open label study of 10 mg alfuzosin OD. They were stratified by age quartile (younger than 60, 60 to 64, 65 to 70 and older than 70 years), comorbidity (hypertension, ischemic heart disease and diabetes) and antihypertensive co-medication (diuretics, beta-blockers, angiotensin converting enzyme inhibitors, angiotensin II inhibitors and calcium channel antagonists). RESULTS: Alfuzosin was effective and well tolerated. Despite an increased prevalence of cardiovascular comorbidity and antihypertensive co-medication with age changes in blood pressure did not significantly differ among age groups. In controls, ie those with no cardiovascular comorbidity or co-medication, alfuzosin produced minimal decreases in sitting systolic (mean -2.6 to -2.8 mm Hg) and diastolic (mean -1.7 to -1.8 mm Hg) blood pressure. In men with cardiovascular comorbidity mean decreases in systolic (-3.5 to 5.8 mm Hg) and diastolic (-2.0 to -3.3 mm Hg) blood pressure remained marginal. Of the 6,523 exposed patients 19.3% withdrew from the study, mainly for adverse events (6.4%) or a lack of efficacy (5.3%), while 229 (3.5%) experienced serious adverse events and 1,558 (23.9%) reported at least 1 treatment emergent adverse event. The most commonly reported adverse event was dizziness/postural dizziness (4.8%). Hypotension/postural hypotension was uncommon (0.7%). Age, cardiovascular comorbidity and antihypertensive co-medication had no impact on the safety profile of 10 mg alfuzosin OD. CONCLUSIONS: Alfuzosin (10 mg) OD is effective and well tolerated, and it has marginal effects on blood pressure, including in elderly patients and those with hypertension, ischemic heart disease or diabetes and those receiving antihypertensive agents.

Adrenergic alpha-Antagonists↗
PubMed2005

The use of a structured form during urology out-patient consultations -- a randomised controlled trial.

OBJECTIVES: To compare the completeness of documentation in the medical record using a structured form (SF) versus a traditional medical record (TMR). METHODS: Randomised controlled trial comparing the use of SF and TMR in urology out-patient clinics for documentation of 15 items of clinical information, time taken to complete and acceptability to clinicians assessed by a self-completion questionnaire.in a teaching and district general hospitals. RESULTS: Four hundred new urology patient consultations, 11 clinicians. Completeness of information was compared between groups based on the medical record alone (SF vs. TMR), medical record plus letter to GP and letter alone. SFs were significantly (p<0.0001) more complete than TMRs for the majority of the items in all three groups. There was no significant difference in the time taken to document information using either type of record. The clinicians generally found the SF acceptable for routine use. CONCLUSIONS: Structured forms significantly improved the completeness of documentation for new out-patient consultations in urology.

Ambulatory Care↗
PubMed2004

5-Alpha reductase inhibition provides superior benefits to alpha blockade by preventing AUR and BPH-related surgery.

OBJECTIVES: This analysis examines the relative effectiveness of current medical therapies for BPH in preventing AUR, AUR-related catheterisation and surgery in real-life clinical practice. METHODS: This is a retrospective analysis of observational data from the General Practice Research Database (UK) (GPRD). The cohort contains 4500 patients experiencing BPH or lower urinary tract symptoms strongly suggestive of BPH, aged over 50 years, who were prescribed a 5ARI (finasteride) or an alpha-blocker (alfuzosin, doxazosin, indoramin, prazosin, tamsulosin, terazosin) as their first BPH treatment between 1996 and 1999 inclusive. Cox regression and competing risks analyses, adjusted for age and year of first treatment, followed patients from the start of their first BPH treatment to AUR, catheterisation or surgery, or censoring. RESULTS: Patients prescribed an alpha-blocker were significantly more likely to experience AUR (hazard ratio 2.32, 95%CI 1.37, 3.94) or surgery (hazard ratio 1.78, 95%CI 1.30, 2.44) than patients prescribed a 5ARI. These differences were sustained with sensitivity analyses. CONCLUSION: Real-life clinical practice shows that significantly fewer BPH patients prescribed a 5ARI experienced serious complications associated with the progression of BPH compared with those prescribed an alpha-blocker.

5-alpha Reductase Inhibitors↗
PubMed2004

Antibiotics on urethral catheter withdrawal: a hit and miss affair.

Globally, millions of patients undergo urethral catheterization every year. Our objective was to study the current use of prophylactic antibiotics on urinary catheter withdrawal. A questionnaire (N = 300) was sent to healthcare professionals involved in the management of patients with urinary catheters (consultant microbiologists, infection control nurses, consultant urologists, specialist nurses in urology, continence advisers and consultants in the care of older people). The questionnaire asked about their use of prophylactic antibiotics on the withdrawal of a urethral catheter. Sixty percent of healthcare professionals advocated the use of antibiotics for either all or selected groups of patients. The remainder did not. The use of prophylactic antibiotics varied among different groups. Of the healthcare professionals who used antibiotics, the majority cited more than one reason for their use (prevent bacteraemia, avoid an infection in a prosthesis or urinary tract infection). The course and type of antibiotic used varied. Our study has shown diversity in practice that is of concern. At present, just over one-half of patients with urinary catheters are being given antibiotics, although there is no evidence to suggest that such an intervention confers any benefit. If benefits do not exist, these patients are being exposed to the harm of antibiotics and providers are incurring costs unnecessarily. A formal trial to address this issue is urgently needed.

Aged↗
PubMed2004

Eliciting preferences for drug treatment of lower urinary tract symptoms associated with benign prostatic hyperplasia.

PURPOSE: There are 2 main medical preparations available for lower urinary tract symptoms resulting from benign prostatic hyperplasia (BPH). Choosing between an alpha-blocker and a 5alpha-reductase inhibitor requires trade-offs between their attributes or characteristics. We investigated the relative importance of and trade-offs between the attributes of the 5alpha-reductase inhibitor dutasteride and alpha-blockers in community dwelling men using a validated technique. MATERIALS AND METHODS: A discrete choice experiment was administered to 211 men older than 40 years who were randomly selected from the general United Kingdom population. Attributes investigated in the discrete choice experiment were time to symptom improvement, sexual and nonsexual side effects, the risks of acute urinary retention (AUR) and surgery, cost and prostate size decrease. Using regression analysis the relative importance of these attributes, the trade-offs that men are willing to make between these attributes and the willingness to pay for each attribute were estimated. RESULTS: All attributes were important to respondents. The most important attribute was side effects. The least preferred side effects was impotence, followed by decreased libido and dizziness. Respondents were willing to wait 13, 2 and 8 months longer for symptom improvement in exchange for decreased prostate size, and the risks of AUR and surgery, respectively. Men reporting moderate symptoms were less concerned about sexual side effects, time to symptom improvement and the risk of AUR compared with men reporting mild symptoms. CONCLUSIONS: Given the attribute levels of BPH medical treatment, overall community dwelling men preferred the 5alpha-reductase inhibitor over alpha-blockers. In the interests of shared decision making it is important to consider the importance of eliciting the preferences of patients with BPH.

Adrenergic alpha-Antagonists↗
PubMed2003

Classic papers in Urology.

OBJECTIVE: Most clinicians are aware of the importance of using "evidence based medicine" to support their clinical practice, but where does the evidence come from? The aim of this study was to examine the concordance between papers deemed "important" by urologists compared with those selected by the more objective criteria of the citation index. METHOD: To achieve this, two approaches were used; firstly "experts" in various fields of urology were asked to select what they felt were classic papers and secondly urology journals were searched to find the 100 most cited papers for 1982-1997 and 1935-1997. The results of both of these "league tables" were then combined. RESULTS: The most cited papers varied depending on the time period studied. When the experts' selections were combined with those obtained via citation index it was found that the experts had chosen papers with a high citation index from non-urological as well as urological journals. CONCLUSION: It is possible to collate the classic papers within urology and the most effective means of doing so is to combine objective selection with expert choice. This is an exercise that can be repeated within any specialty.

Bibliometrics↗
PubMed2003

The fear of prostate cancer in men with lower urinary tract symptoms: should symptomatic men be screened?

OBJECTIVE: To explore the concerns and worries in men with uncomplicated lower urinary tract symptoms (LUTS, but no evidence of prostate cancer) relating to their symptoms. PATIENTS AND METHODS: There is no current prostate cancer screening programme in the UK. Evidence suggests that men with LUTS have the same risk of prostate cancer as aged-matched asymptomatic men. However, most men with LUTS are 'screened' with a digital rectal examination (DRE) and prostate specific antigen (PSA) testing as part of routine assessment. Whether this screening offers any benefit to patients and whether national screening for prostate cancer and subsequent early treatment offer any long-term survival or quality of life benefit is uncertain. Thus 30 men with uncomplicated LUTS were qualitatively interviewed to explore their concerns and worries about their symptoms. Interviews were transcribed verbatim and subjected to content analysis using validated techniques. RESULTS: Of the 30 men, 22 (73%) expressed a fear of prostate cancer at the time of their initial presentation. This fear was independent of race, social class and symptom severity; older men were less worried. Of the 22, 15 (68%) stated that after reassurance their symptoms were less bothersome and easier to cope with. CONCLUSIONS: These findings suggest there is a considerable gain in health by explicitly addressing the concerns of prostate cancer in men with uncomplicated LUTS. Informing these men of their true risk of prostate cancer (before or after a DRE and PSA estimate) may alleviate much of the bother associated with their symptoms. Despite no evidence of any greater risk of prostate cancer than in asymptomatic men, symptomatic men should continue to be screened after appropriate counselling.

Decision Making↗
PubMed2003

Catheter-associated urinary tract infections: prevalence of uropathogens and pattern of antimicrobial resistance in a UK hospital (1996-2001).

OBJECTIVE: To assess the change in the bacterial profile and pattern of antibiotic resistance of catheter-associated urinary tract infections (CAUTIs, the most prevalent form of nosocomial infections) between 1996 and 2001. MATERIALS AND METHODS: Catheter samples of urine (CSUs) submitted in 1996, 1998 and 2001 (2451, 2460 and 3349 specimens, respectively) were analysed. The distribution of different uropathogens in bacterial CAUTIs and their in vitro antimicrobial resistance was evaluated over the study interval. The likelihood ratio test was used to assess whether there was a linear trend according to calendar year. RESULTS: Escherichia coli was the most frequently isolated pathogen in all years, but its frequency declined over time (35.6%, 32.5% and 26.6%, respectively). Enterococcus was the second most frequent overall, with a significant increase in frequency with time (11.8%, 15.3% and 22.0%, respectively). There was also a considerable change in resistance patterns to antibiotics. As a result, in 1996, CAUTIs were least often resistant to ciprofloxacin (8.0%) followed by co-amoxiclav (18.5%) and cephalexin (25.4%). In 2001, CAUTIs were least often resistant to co-amoxiclav (22.5%), followed by ciprofloxacin (27.2%) and nitrofurantoin (28.8%). CONCLUSION: The types of organisms associated with CAUTI have changed over the last 5 years in a UK institution, as have the patterns of antibiotic resistance. Currently, the most appropriate agents for the empirical management of CAUTIs seem to be co-amoxiclav, ciprofloxacin and nitrofurantoin.

Anti-Bacterial Agents↗
PubMed2003

Lifestyle and behavioural interventions for men on watchful waiting with uncomplicated lower urinary tract symptoms: a national multidisciplinary survey.

OBJECTIVE: To determine the use of lifestyle and behavioural interventions in the UK for symptom control in men with uncomplicated lower urinary tract symptoms (LUTS) on watchful waiting (WW). METHOD: Semi-structured interviews with urologists, nurse practitioners and continence advisors were used to obtain a list of lifestyle and behavioural interventions used in men with LUTS. From the 18 interventions identified, a survey was constructed asking how often these interventions were used in routine practice. The survey was sent to 100 consultant urologists (British Association of Urological Surgeons), 100 nurse practitioners (British Association of Urological Nurses), and 100 continence advisors (International Continence Society) with an interest in male urology, all randomly selected. RESULTS: Of 248 (83%) responses, 236 were suitable for analysis; 193 (82%) of the respondents reported using lifestyle or behavioural interventions in men on WW with uncomplicated LUTS. The most frequently used interventions were education about the prostate and bladder, avoiding caffeine, urethral milking and reassuring men that they do not have prostate cancer. The use of lifestyle and behavioural interventions showed an 'all-or-none' pattern. Respondents used either few or many of the 18 interventions identified. There was considerable variation in the extent to which these interventions were used among the survey groups (P < 0.01); urologists used these interventions the least and continence advisors the most. CONCLUSIONS: Lifestyle and behavioural interventions are advised by many medical professionals to men on WW with uncomplicated LUTS. However, the use varies considerably, with some medical professionals advising many of these interventions and some a few or none at all. Further research is required to define and test the effectiveness of these interventions in reducing LUTS.

Aged↗
PubMed2003

The patient's dilemma: prostate cancer treatment choices.

PURPOSE: We summarize the literature addressing factors that influence treatment decisions made by men with prostate cancer. MATERIALS AND METHODS: A MEDLINE search of the English language literature published between 1969 and 2000, using the combined MESH key words "prostatic neoplasms," "patient participation," "Internet" and "decision making," generated 181 abstracts. Only 23 of these publications addressed factors influencing treatment decisions made by men with prostate cancer. Nine additional relevant studies were identified from references in the original 23 articles. Subsequently a search for the term "prostate cancer" using several popular Internet search engines yielded more than 1 million hits. A further search was performed using the key words "prostate cancer" and "prostate" within on-line archives of the United Kingdom television channels BBC, ITV, and channels 4 and 5, and newspapers The Sun, The Daily Mail, The Observer, The Guardian and The Times. RESULTS: When there is poor quality evidence or little professional consensus to support a particular treatment over another, no clinical guidelines regarding treatment are possible. Patients are faced with a series of options, and the data reveal that the process of choosing between these options is based on input from a large number of sources. These sources differ in the way that benefits of treatment are emphasized over harms and vice versa. We identified little evidence regarding which type of input exerts the greatest influence on patients. It may be that the sources associated with the most bias have the greatest influence. CONCLUSIONS: There is a paucity of information on how patients with prostate cancer use different types of input in the treatment decision making process. The physician, as principal caregiver, still appears to have the most direct influence on patient choice. Just how long this status will continue is uncertain.

Compact Disks↗
PubMed2003

A review of guidelines on benign prostatic hyperplasia and lower urinary tract symptoms: are all guidelines the same?

OBJECTIVE: To compare overall and methodological quality with content in national and supra-national Clinical Practice Guidelines (CPGs) on benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS), as the purpose of CPGs is to reduce unwanted variation in practice and improve patient care by setting agreed standards based on the best available evidence. METHODS: An electronic search was used to identify Internet-based national and supra-national CPGs on BPH and LUTS available in 2001. Two independent assessors analysed the content and appraised the methodological quality of the CPGs using an existing and validated instrument (St. George's Hospital Medical School Health Care Evaluation Unit Appraisal Instrument) comprising 37 items grouped into three broad areas, i.e. rigour of development, context and content, and clinical application. RESULTS: Eight CPGs were suitable for appraisal; there was much variation in overall and methodological quality. There was agreement that a patient history and physical examination (including a digital rectal examination) should be used in all symptomatic men. In addition, patients' symptoms should be assessed using a validated symptom score, e.g. the International Prostate Symptom Score. There was considerable variation in the number and type of diagnostic tests recommended for routine assessment. CPGs scoring low on the appraisal instrument (indicating poor overall and methodological quality) were more likely to recommend more diagnostic tests than those scoring high. There was general agreement between the guidelines on the treatment of BPH/LUTS and the importance of the patient's involvement in making management decisions. Guideline quality was independent of local health resources and publication year. CONCLUSION: The overall and methodological quality of CPGs on BPH/LUTS varies considerably. There appears to be an inverse relationship between guideline quality and the number of diagnostic tests recommended for routine assessment. Using CPGs of high quality may prevent men with BPH/LUTS being exposed to tests of doubtful utility. Although this may reduce both resource use and exposure to potential harm, moving to a more minimalist approach to diagnosis may itself be potentially harmful to patients.

Decision Making↗
PubMed2003

Diagnostic accuracy of flow rate testing in urology.

OBJECTIVE: To highlight the importance of methodological standards in diagnostic testing in urology, by reviewing the extent of compliance with these standards in reports of published evaluations. METHODS: Sixteen papers evaluating the diagnostic accuracy of urinary flow-rate testing were independently assessed by two reviewers for compliance with the following methodological standards: specification of study population, analysis of pertinent subgroups, avoidance of evaluation (verification) bias, avoidance of review bias, reporting of precision of estimates of test accuracy, indeterminate test results, and test reproducibility. Compliance with each standard was expressed as a percentage with a 95% confidence interval. RESULTS: Compliance ranged from just 12.5 (1.5-38)% for reporting of test reproducibility to 87.5 (62-98)% for specification of the study population. Only nine of the 16 evaluations complied with four or more of the methodological standards; one paper did not comply with any. CONCLUSIONS: This evaluation of urological flow-rate testing show poor compliance with accepted methodological standards. The study design, reporting and evaluation of new diagnostic tests can be improved by adhering to these standards. Policy-makers, purchasers and providers would be less likely to adopt new diagnostic tests inappropriately if they were to appraise published evaluations against the standards. A reduction in the inappropriate use of tests would in turn lead to more cost-effective use of healthcare resources.

Diagnostic Techniques and Procedures↗
PubMed2002

The 'top 10' urological procedures: a study of hospital episodes statistics 1998-99.

OBJECTIVE: To summarize the urological procedures recorded in Hospital Episodes Statistics (HES, 1998-99) and to examine the accuracy of coding and HES. MATERIALS AND METHODS: Data on the 10 commonest urological procedures from the Department of Health website (www.doh.gov.uk/hes) were extracted, summarized and presented. RESULTS: Urethral catheterization, endoscopic procedures on the bladder, prostate, urethra and ureter (excluding ureteric stone extraction), minor open procedures on the foreskin and the vas, bladder instillation, extracorporeal shockwave lithotripsy and prostatic biopsy are the 10 commonest procedures, according to finished consultant episodes. There is published evidence that the data from coding and HES are not completely accurate. CONCLUSION: This study highlights shortfalls in the HES data (1998-99) which may directly affect the funding of urological services.

Cystoscopy↗