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Our treatment strategies for benign prostatic hyperplasia (BPH) have changed, with new insights into the pathophysiology of the disease, new clinical trials, and surgical advances. We present an update on treatment options and a diagnostic and treatment algorithm for this condition.
OBJECTIVE: To describe spontaneous bacterial peritonitis (SBP) in the context of currently accepted criteria for diagnosis, treatment, and prevention. DESIGN: A review of SBP and its associated etiopathogenic factors is presented. MATERIAL AND METHODS: Numerous studies on mechanisms of disease, diagnosis, treatment, and prevention are discussed. Diagnostic and therapeutic algorithms are presented. RESULTS: Peritonitis in patients with ascites in the absence of secondary causes, such as peforation of a viscus, occurs primarily in patients with end-stage liver disease. Enteric organisms, mainly gram-negative bacilli, probably translocate to regional lymph nodes to produce bacteremia and seeding of ascitic fluid. Signs and symptoms of peritonitis are usually subtle. The ascitic fluid polymorphonuclear leukocyte count is the best determinant for early diagnosis and treatment of SBP. Third-generation cephalosporins such as cefotaxime are considered the drugs of choice for treatment, whereas quinolones such as norfloxacin are used to decrease recurrence. CONCLUSION: Despite increased awareness, early diagnosis, and prompt and effective antimicrobial therapy, SBP recurs frequently and is associated with a high mortality rate. Patients with SBP should be assessed for candidacy for liver transplantation.
BACKGROUND: To comprehend the results of diagnostic accuracy studies, readers must understand the design, conduct, analysis, and results of such studies. That goal can be achieved only through complete transparency from authors. OBJECTIVE: To improve the accuracy and completeness of reporting of studies of diagnostic accuracy in order to allow readers to assess the potential for bias in the study and to evaluate its generalizability. METHODS: The Standards for Reporting of Diagnostic Accuracy (STARD) steering committee searched the literature to identify publications on the appropriate conduct and reporting of diagnostic studies and extracted potential items into an extensive list. Researchers, editors, methodologists and statisticians, and members of professional organizations shortened this list during a 2-day consensus meeting with the goal of developing a checklist and a generic flow diagram for studies of diagnostic accuracy. RESULTS: The search for published guidelines on diagnostic research yielded 33 previously published checklists, from which we extracted a list of 75 potential items. The consensus meeting shortened the list to 25 items, using evidence on bias whenever available. A prototypical flow diagram provides information about the method of patient recruitment, the order of test execution, and the numbers of patients undergoing the test under evaluation, the reference standard, or both. CONCLUSIONS: Evaluation of research depends on complete and accurate reporting. If medical journals adopt the checklist and the flow diagram, the quality of reporting of studies of diagnostic accuracy should improve to the advantage of the clinicians, researchers, reviewers, journals, and the public.
The quality of reporting of studies of diagnostic accuracy is less than optimal. Complete and accurate reporting is necessary to enable readers to assess the potential for bias in the study and to evaluate the generalizability of the results. A group of scientists and editors has developed the STARD (Standards for Reporting of Diagnostic Accuracy) statement to improve the reporting the quality of reporting of studies of diagnostic accuracy. The statement consists of a checklist of 25 items and flow diagram that authors can use to ensure that all relevant information is present. This explanatory document aims to facilitate the use, understanding, and dissemination of the checklist. The document contains a clarification of the meaning, rationale, and optimal use of each item on the checklist, as well as a short summary of the available evidence on bias and applicability. The STARD statement, checklist, flowchart, and this explanation and elaboration document should be useful resources to improve reporting of diagnostic accuracy studies. Complete and informative reporting can only lead to better decisions in health care.
In 1995, the National Comprehensive Cancer Network (NCCN) embarked on an ambitious project to develop comprehensive diagnostic and treatment algorithms for the broad spectrum of oncologic diseases and support modalities. To date, 28 NCCN guideline panels have developed guidelines covering an estimated 93% of tumors, and an additional 9 panels have guidelines under development. This article reviews the NCCN guideline infrastructure and development process. The process relies on the expertise of the 17 NCCN member institutions and follows a formal procedure for guideline development to ensure that the recommendations offer the cancer patient the best chance for a successful outcome.
AIMS: The objective of this guideline is to provide evidence-based recommendations for the management of regular heavy menstrual bleeding in women with no detectable pathology. METHODS: A multidisciplinary working party was formed which met on four occasions over a 12 month period. The evidence from randomised controlled trials was summarised into evidence tables and guidelines were developed. A draft report was circulated in November 1997 prior to the final report which was published in July 1998. RESULTS: A diagnostic and treatment algorithm was produced (Figure 1) as well as a full text report. The cost of implementing the guideline was considered and overall net savings of $6 million were likely. CONCLUSIONS: An explicit evidence-based guideline on the management of heavy menstrual bleeding was produced. Both the Royal New Zealand College of Obstetricians and Gynaecologists and the Royal New Zealand College of General Practitioners endorsed this guideline.
The authors herein show their own experience in the treatment of acute biliary pancreatitis. Aim of this study is to evaluate the effectiveness and the safety of the "early" laparoscopic approach to the mild to moderate acute biliary pancreatitis. The authors studied sixty cases of laparoscopic cholecystectomy with intraoperative colangiography for acute biliary pancreatitis (M/F 1:1.2; mean age 59.6 yrs, range 29.79). The patients were divided in two groups on the basis of the severity of the pancreatitis, defined through Ranson's score and Balthazar classification. The mortality rate was nil. Intraoperative morbidity rate was 6.6% in the group I (3/45), and 13.3% in the group II (2/15). Postoperative morbidity rate was 6.7% (3/45) in the group I and 40% in the group II (6/15). The authors show an original diagnostic and therapeutic algorithm for the treatment of acute biliary pancreatitis. Early laparoscopic cholecystectomy with I.O.C. is proposed as the gold standard treatment for mild to moderate acute biliary pancreatitis. This approach appears to be effective and safe in their experience. In case of severe acute biliary pancreatitis, further investigations are mandatory to evaluate the role of laparoscopic approach.
UNLABELLED: The CASS (Clinical Assessment of Schizophrenic Syndromes) is a new multi-purpose and multi-level clinical diagnostic instrument consisting of a diagnostic questionnaire (CASS-D) allowing for analysis of a diagnosis of schizophrenia according to DSM-IV and ICD-10 criteria, as well as of three rating scales designed for description and intensity evaluation of schizophrenic syndromes on the global (CASS-G), dimensional (CASS-P, a profile of 13 basic dimensions) or symptomatological (CASS-S, a set of 31 symptoms) level. AIM: The paper presents a rationale and construction principles of the tool followed by a study of its reliability and sensitivity as well as by preliminary attempt to normalize its results. SUBJECTS: Twelve trained diagnosticians assessed twice (at the start and end of their hospitalization) 194 inpatients admitted consecutively, within approximately 6 months, to the Department. METHOD: Results of the CASS were compared with results of the SANS/SAPS, BPRS, and PANSS assessments playing the role of standard, reference instruments. FINDINGS: High agreement coefficients (kappa) were calculated between a diagnosis of schizophrenia based on unoperationalized (clinical) criteria and operationalized diagnoses based on the CASS diagnostic questionnaire including ICD-10 and DSM-IV diagnostic criteria and algorithms. In the case of both complex (many-item) CASS scales (CASS-P, CASS-S) high reliability measures (internal consistency according to Cronbach's alpha) were found. Characteristics of frequency, intensity and dynamics of the CASS individual symptoms, dimensions and of syndrome as a whole were consistent with expectations based on clinical experience. Direct indices of clinical improvement calculated from CASS-G, CASS-P or CASS-S scores obtained at two time-points (admission, discharge) correlated fairly highly with more direct measures based on diagnosticians' clinical global impressions made when summing the results of treatment at discharge from the hospital. This finding suggests that CASS scores may sensitively register changes in patients' mental state during hospital stay and treatment. On the base of empirical distributions of CASS scales, a normalization (sten-scales) was proposed which may be useful for comparison of results obtained in differing groups of patients. Analysis of percentile and sten distributions of the CASS-P and CASS-S pointed out that patients with a diagnosis of schizophrenia had higher mean scores than patients with other diagnoses. This observation as well as above mentioned reasonableness (consistency with clinical experience) of a picture and dynamics of schizophrenic syndromes revealed in CASS assessments may be treated as preliminary assumptions of its content validity. CONCLUSIONS: Results of the study suggest that CASS has satisfactory measures of reliability and sensitiveness. They allow for a preliminary normalization of its scales and prompt to study its validity.
The estimated risk of development of complications of atherosclerosis (coronary or cerebral ischaemia) is one of the activities every physician should include in the diagnostic and therapeutic algorithm. Treatment with hypolipidaemic agents is indicated according to the European consensus if the danger of a coronary or cerebral event is 20%/10 years. The objective of preventive provisions should be reduction of this risk to < 5%/10 years in younger subjects (< 45 years in men and < 50 years in women) and < 10%/10 years in elderly subjects. These recommendations obviously do not apply to secondary prevention (in case of complications of atherosclerosis) where treatment with hypolipidaemic agents is indicated already when the LDL-cholesterol level is 2.3 mmol/l or when triacylglycerols are 2.3 mmol/l, combined with a drop of HDL-cholesterol to < 0.9 mmol/l.
An overview of the key concepts about detection of thrombophilic states, establishment of risk factors for thrombosis, the current strategies on diagnosis of thrombophilia, as well as an analysis of the current experience with the use of fractionated and unfractionated heparins, is presented. It is well known that thrombotic disease is multifactorial and that its treatment must be interdisciplinary and multidisciplinary in order to perform an opportune diagnosis and to establish an adequate prophylaxis and anti-thrombotic therapy. Even though several advantages are observed when low molecular weight heparins are used, unfractionated heparins still have some specific indications. Furthermore, under specific conditions, they can work synergistically to achieve a maximal effect on the thromboembolic states. We propose that every medical unit should establish its own criteria and diagnostic and therapeutic algorithms that allow to detect, to diagnose, and to treat the thrombotic events in the best way thus diminishing the morbidity and mortality associated with these thrombotic events.
A radical change of epidemiological structure of thyroid cancer incidence in Poland has been reported for few years. The total incidence of thyroid cancer is successively increasing, mostly in form of well differentiated thyroid cancer, especially papillary cancer. The diagnostic and therapeutic approach to thyroid cancer have also changed. Ultrasound guided fine needle aspiration has become the first choice procedure in diagnostics of thyroid cancer. Careful assessment of prognostic factors is no longer helpful in choice of selective surgical procedure in thyroid cancer as elective total thyroidectomy is widely recommended. In well differentiated thyroid cancer a complementary treatment with radioiodine is mandatory in most cases. Own experience in treatment of thyroid cancer presented in the paper is based on over 520 consecutive patients with thyroid cancer treated in a single department specialised in endocrine surgery during last 20 years. Successive changes in epidemiological structure of thyroid cancer incidence as well as the evolution of diagnostic and therapeutic algorithm in thyroid cancer are presented in details. Radical surgical treatment of thyroid cancer is still a fundamental part of a complex treatment of thyroid cancer.
OBJECTIVE: To assess the standard diagnostic and therapeutic algorithm of erectile dysfunction (ED) after radical operations on account of rectosigmoid tumours. MATERIAL AND METHODS: At the Faculty Hospital in Plzen from Jan. 1995 till Oct. 1999 the mentioned operation was implemented in 167 men, incl. 98 who were sent a questionnaire concerning postoperative sexual complaints. 39 replied. Those interested were examined further and treatment of ED was started. RESULTS: Four men, mean age 75.3 +/- 1.0 years were before surgery sexually inactive. In the remaining 35 ED developed in 68.6% (24/35)--mean age 58.2 +/- 9.8 years (in men without ED it was 61.7 +/- 11.1 years), in 37.1% (13/35) ED was complete, in 31.4% (11/35) partial. A postoperative decline of libido was in recorded in 37.1% (13/35) and impaired ejaculation in 65.7% (23/35). In men with postoperative ED 66.7% (16/24) suffered also from another disease causing ED, in men without ED this ratio was only 18.1%. In the group of men with ED, on account of ED 40% were examined and treated (14/35) incl. 10 who were examined for the first time in conjunction with the questionnaire project. Sildenafil was administered to 10 men, an effect sufficient for intercourse was described by two (both with partial ED), a partial effect however inadequate for intercourse was described by four and four recorded no response. Only four men tried intracavernous PGE1 injections and in all instances with a favourable effect. CONCLUSION: ED which affects about two thirds of patients is not treated as a rule. For examination a rule anamnestic data and physical examination are sufficient. Oral sildenafil treatment is effective only in a small percentage of patients. Intracavernous injections are more effective but are usually refused.
The result of the more wide spread use of abdominal imaging procedures has lead to reveal more incidentally discovered adrenal masses. In this review we evaluated the different biological an radiologic procedures to explore such tumors. We finally, presented a proposal of diagnostic and therapeutic algorithm for patients with incidental adrenal mass.
Results of treatment of 164 patients with combined abdominal trauma were analyzed. It makes sense to evaluate severity of trauma and severity of the patient condition by scales VPKh-MT and VPKh-SP. These scales permit to standardize severity of damages and choose optimum diagnostic and curative algorithm. The emphasis is on early ultrasonic examination of the abdomen in combined trauma. In obscure ultrasonic diagnosis laparoscopy is recommended, in severe or extremely severe condition of patients (over 31 points by scale VPKh-SP)--laparocentesis. Choice and time of surgical interventions must be determined by priority of severity of damage.
Increasing incidence of bladder tumors necessitates development of new techniques of early diagnosis. A total clinical system including application of ultrasonoangiography proved superior to examination under the gray scale mode. The diagnostic and monitoring algorithm makes the system highly effective.
In 1996, the estimated costs in Sweden, owing to urinary incontinence, increased to $0.5 billion or 2-3% of the health budget. In Denmark, the cost of urinary incontinence is unknown, but probably much the same as that in Sweden. Growth of the elderly population, a rise in the costs of routine incontinence care (mostly pads), and an increasing ability to cure incontinence challenge the existing economic priorities. Economic analysis in this field is sparse. Treatment of urinary incontinence imposes a significant financial burden on society. Based on a review of the literature, the authors recommend increased focus on health economy and preventive possibilities, as well as a change in the diagnostic and treatment algorithm of urinary incontinence.
There were 21,850 cases of newly diagnosed lung cancers in France in 1995. This figure corresponds to an incidence rate (standardized to the population of Europe) of 66.5 per 100,000 men and 8.9 per 100,000 women. The incidence is age-related and reaches a peak between 70 and 74 years of age for men and between 75 and 79 years of age for women. The incidence also varies by region and the highest rates were observed in east of France. Non-small-cell lung cancers represent 80% of all lung cancers. Between 1985 and 1995, as a result of changes in tobacco consumption, the incidence rates increased by 56% in women and by 5% in men under the age of 65. The incidence rates in France are close to the average rates observed in Europe. In 1995, lung cancers led to 23,900 deaths in France (mortality rate standardized to Europe: 36.6 per 100,000). 85% of deaths due to lung cancer occurred among men. Prognosis of lung cancer remains poor and has not improved appreciably over the last two decades. 58% of all patients died during the first year and 82% during the three years following lung cancer diagnosis. Survival rates appear to be better for patients with non small cell lung cancer than for patients with small cell lung cancer. Few studies have addressed the economics of lung cancer in France. Cost-of-illness studies of lung cancer were published mainly in Canada, the Netherlands and Australia. These analyses have included descriptive works as well as economic models based on theoretical diagnostic and treatment algorithms.
The surgical management of frontal sinus fractures is controversial in cranio-maxillofacial trauma, due to the complexity of the anatomy surrounding the frontal sinus and the potential for devastating complications if these fractures are improperly treated. The critical factor in the evaluation of the frontal sinus is the status of the nasofrontal duct, which must be patent if a decision is made to preserve the sinus. Compromise of the nasofrontal duct warrants the removal of the frontal sinus as a functional unit by either obliteration or cranialization. The authors present a diagnostic and therapeutic algorithm for the operative management of frontal sinus fracture and discuss the complications that have been encountered in the authors' experience with frontal sinus fractures.