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Prostate cancer screening with prostate-specific antigen (PSA) test: A clinical practice guideline
Get PDFWhat is the role of prostate-specific antigen (PSA) screening in prostate cancer? An expert panel produced these
recommendations based on a linked systematic review.1
The review was triggered by a large scale, cluster randomised trial on PSA screening in men without a previous
diagnosis of prostate cancer published in 2018 (box 1).2
It
found no difference between one-time PSA screening and
standard practice in prostate cancer mortality but found
an increase in the detection of low risk prostate cancer
after a median follow-up of 10 years.
Although the results of this study suggest screening
is not worthwhile, several guidelines advocate offering
screening in some cases. The study was much larger than
previous studies, and existing trials had published more
extended follow-up results, and the BMJ Rapid Recommendations team felt these merited a new appraisal of
the body of evidence. This guideline aims to promptly
and transparently translate potentially practice-changing
evidence to usable recommendations for clinicians and
patients, based on the GRADE framework and following
standards for trustworthy guidelines.
The panel suggests against systematic PSA screening
(weak recommendation). The panel members judged that
most men will decline screening because the benefit is
small and uncertain and there are clear harms. However,
there is likely considerable variation in values and preferences. Men with family history of prostate cancer, African
descent or of lower socioeconomic status, having higher
baseline risk of prostate cancer death, may be more likely
to choose PSA screening. Shared decision-making is
needed for men considering screening.
Box 2 shows all of the articles and evidence linked in
this Rapid Recommendation package. The main infographic provides an overview of the absolute benefits
and harms of PSA screening. The table at the end of the
article shows any evidence that has emerged since the
publication of this guideline.publishedVersio
Cognitive impairment in Zambians with HIV infection and pulmonary tuberculosis
Get PDFBACKGROUND:
HIV infection may result in neurocognitive deficits, but the effects of pulmonary tuberculosis (TB+), a common comorbid condition in HIV infection, on cognition in HIV infections are unknown. Accordingly, we examined the effects of TB+, on neurocognitive functioning in HIV-infected (HIV+) Zambian adults.
SETTING:
All participants were drawn from HIV clinics in and around Lusaka, the capital of Zambia.
METHODS:
Participants were 275 HIV+, of whom 237 were HIV+ and TB-negative (HIV+/TB-), and 38 also had pulmonary TB+ (HIV+/TB+). Controls were 324 HIV- and TB-uninfected (HIV-) healthy controls. All HIV+ participants were prescribed combination antiretroviral treatment (cART). Published, demographically corrected Zambian neuropsychological norms were used to correct for effects of age, education, sex, and urban/rural residence.
RESULTS:
Neuropsychological deficits, assessed by global deficit scores, were more prevalent in this order: 14% (46 of 324) of HIV- controls, 34% (80 of 237) of HIV+/TB-, and 55% (21 of 38) of HIV+/TB+ group. Thus, both HIV-infected groups evidenced more impairment than HIV- controls, and the HIV+/TB+ group had a higher rate of neurocognitive impairment than the HIV+/TB- group. HIV+/TB+ patients were more likely to be male, younger, less-educated, and have lower CD4 counts and detectable HIV RNA in blood compared with the HIV+/TB- patients.
CONCLUSIONS:
In HIV infection, TB may contribute to cognitive impairment, even after controlling for lower CD4 counts and viral load. Thus, systemic inflammation from HIV and TB and more advanced immune deficiency at diagnosis of HIV may contribute to impaired cognition in HIV+/TB+ patients.This study was supported by the NORAD’s master program (NOMA) NOMAPRO-2007/10046 and The
Inland Norway University of Applied Sciences (to Knut A. Hestad). Additional support was provided by the
National Institutes of Health grant 5P30MH062512–15 (to Robert Heaton).acceptedVersio
The Association Between Heart Rate Variability and Neurocognitive and Socio-Emotional Development in Nepalese Infants
Get PDFBackground:
Many young children in developing countries do not reach their developmental potential. Traditional methods for assessing developmental outcome are time consuming, thus, physiological measures that can contribute to the prediction of developmental outcomes in high risk groups have been suggested. Vagally mediated heart rate variability (vmHRV) is considered a neurophysiological or peripheral proxy for prefrontal and executive functioning and might serve as a supplement for traditional measurements of developmental status and as a potential useful risk indicator.
Aim:
In the present study, we wanted to describe the vmHRV in Nepalese infants and relate it to the Bayley Scales of infant and toddler development, 3. edition (Bayley-III) subscales.
Methods:
600 Nepalese infants were included in the study. At 6-11 and 17-24 months, we measured neurodevelopmental and socio-emotional outcomes by the Bayley-III. Inter-beat intervals were recorded at two measurement points when the children were 17-24 months.
Results:
There was a high intraclass correlation between HRV indices generated from the two measurement points. No significant associations between vmHRV and Bayley-III sub scales were found at any time.
Conclusion:
This study is the first to describe vmHRV in healthy infants and the relationship between Bayley-III scores. Our results suggest that vmHRV is not associated with measures of general development in infancy.publishedVersio
The association between executive functioning and parental stress and psychological distress is mediated by parental reflective functioning in mothers with substance use disorder
Get PDFMothers with a substance use disorder (SUD) have been found to exhibit heightened experience of stress and deficits in executive functioning (EF) and in parental reflective functioning (PRF). Although experiences of stress, EF and PRF are important for caregiving capacities; no studies have explored associations between the phenomena in mothers with SUD. This study aimed to examine the association between EF (working memory, inhibition, and cognitive flexibility) and different forms of stress (parental stress, general life stress, and psychological distress) in 43 mothers with SUD with infants. We further aimed to investigate whether PRF had a mediating function between EF and the experience of stress. The mothers completed self-report questionnaires regarding experiences of different types of stress, and we also used neuropsychological tests to assess EF and a semistructured interview to assess PRF. Results identified problems in EF were associated with higher parental stress and psychological distress but not with general life stress. Cognitive flexibility contributed uniquely to variance in parental stress, whereas working memory was a unique contributor to variance in psychological distress. PRF had a mediating function between EF and parental stress and between EF and psychological distress. Findings highlight the importance of considering individual differences in PRF when targeting EF in interventions trying to reduce the experience of parental stress and psychological distress in mothers with SUD.Innlandet Hospital Trust; The Research Council of Norway (NFR), Grant/Award Number: 213079/H10publishedVersio
TIME to reduce agitation in persons with dementia in nursing homes. A process evaluation of a complex intervention
Get PDFBACKGROUND:
The Targeted Intervention Interdisciplinary Model for Evaluation and Treatment of Neuropsychiatric Symptoms (TIME) has recently in a three-month cluster randomised controlled trial demonstrated reduction in agitation in nursing home residents with dementia. To ease replication and future implementation, and to clarify possible causal mechanisms, we performed a process evaluation of the intervention based on the RE-AIM framework (Reach, Effectiveness, Adoption, Implementation, Maintenance).
METHODS:
An exploratory and a quasi-experimental design with mixed methods were used. The RE-AIM dimensions were explored by questionnaires to 807 staff members and 46 leading ward nurses in both the intervention nursing homes (INH) and the control nursing homes (CNH), before the start of the trial (baseline), and six and 12 months later. These questionnaires assessed data regarding the reach, effectiveness (staff level) and adoption dimensions. To assess implementation, we used a checklist for performance of the main components in TIME and analysed the minutes from 84 case conferences in the INH. To explore adoption and maintenance, five focus group interviews with 32 participants from the staff in the INH were conducted three to 6 months after the end of the trial.
RESULTS:
Reach: On average 61% (SD 22) of the staff in each ward in the INH attended the training sessions. Effectiveness at staff level: There were no between-group differences throughout the study period for attitudes towards dementia, perceived competence or perception of mastery and social interaction. Adoption: 16 of the 17 INH completed the intervention.
IMPLEMENTATION:
75% or more of the components of TIME were performed for 91% of the included residents. Maintenance: Most of the nursing homes used TIME three to 6 months after the end of the trial. An easy to grasp model and an engaged leadership facilitated the intervention and maintenance.
CONCLUSIONS:
A high degree of reach, adoption, implementation and maintenance contributed to the effectiveness of TIME at resident level. One other causal assumption of the effectiveness of TIME is the development in the staff of a new, shared and situated knowledge about each individual resident, not reflected by measurements in general knowledge and attitudes.The study is funded by a grant from the Innlandet Hospital Trust (Grant Number 150 333). The funding body did not take part in the design of the study, data collection, analysis, interpretation of data or in writing of the manuscript.publishedVersio
Adaptation and implementation of a mobile phone-based remote symptom monitoring system for people with cancer in Europe
Get PDFBACKGROUND:
There has been an international shift in health care, which has seen an increasing focus and development of technological and personalized at-home interventions that aim to improve health outcomes and patient-clinician communication. However, there is a notable lack of empirical evidence describing the preparatory steps of adapting and implementing technology of this kind across multiple countries and clinical settings.
OBJECTIVE:
This study aimed to describe the steps undertaken in the preparation of a multinational, multicenter randomized controlled trial (RCT) to test a mobile phone-based remote symptom monitoring system, that is, Advanced Symptom Management System (ASyMS), designed to enhance management of chemotherapy toxicities among people with cancer receiving adjuvant chemotherapy versus standard cancer center care.
METHODS:
There were 13 cancer centers across 5 European countries (Austria, Greece, Ireland, Norway, and the United Kingdom). Multiple steps were undertaken, including a scoping review of empirical literature and clinical guidelines, translation and linguistic validation of study materials, development of standardized international care procedures, and the integration and evaluation of the technology within each cancer center.
RESULTS:
The ASyMS was successfully implemented and deployed in clinical practices across 5 European countries. The rigorous and simultaneous steps undertaken by the research team highlighted the strengths of the system in clinical practice, as well as the clinical and technical changes required to meet the diverse needs of its intended users within each country, before the commencement of the RCT.
CONCLUSIONS:
Adapting and implementing this multinational, multicenter system required close attention to diverse considerations and unique challenges primarily related to communication and clinical and technical issues. Success was dependent on collaborative and transparent communication among academics, the technology industry, translation partners, patients, and clinicians as well as a simultaneous and rigorous methodological approach within the 5 relevant countries.This project received funding from the European Union’s Seventh Framework Programme for research, technological development, and demonstration under grant agreement number 602289.publishedVersio
Mortality in older adults with frequent alcohol consumption and use of drugs with addiction potential – The Nord Trøndelag Health Study 2006-2008 (HUNT3), Norway, a population-based study
Get PDFBACKGROUND:
The aim of this study was to investigate whether frequent drinking, use of drugs with addiction potential and the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older adults.
METHODS:
We used data from the Nord-Trøndelag Health Study (HUNT3 2006-08), a population-based study in Norway. A total of 11,545 (6,084 women) individuals 65 years and older at baseline participated. We assessed frequent drinking (≥ 4 days a week), occasional drinking (i.e. a few times a year), never drinking and non-drinking in the last year. Drugs with addiction potential were defined as at least one prescription of benzodiazepines, z-hypnotics or opioids during one year for a minimum of two consecutive years between 2005 and 2009. This information was drawn from the Norwegian Prescription Database. The main outcome was all-cause mortality with information drawn from the Norwegian Cause of Death Registry. Follow-up continued until death or latest at 31 December 2013. Logistic regression analyses were used to investigate all-cause mortality since date of study entry and exact age at time of death was unknown.
RESULTS:
The adjusted logistic regression analyses showed that frequent drinking was not associated with all-cause mortality compared to occasional drinking. Men who reported to be never drinkers and non-drinkers in the last year had higher odds of mortality compared to those who drank occasionally. Use of prescribed drugs with addiction potential was associated with increased mortality in men, but not in women. No association was found between the possible combination of frequent drinking and use of prescribed drugs with addiction potential and mortality.
CONCLUSION:
Neither frequent drinking nor the possible combination of frequent drinking and use of prescribed drugs with addiction potential were associated with all-cause mortality in older women and men. Use of prescribed drugs with addiction potential was associated with higher odds of mortality in men. This finding should lead to more caution in prescribing drugs with addiction potential to this group.This project has been made possible by the Norwegian Extra Foundation for Health and Rehabilitation (https://www.extrastiftelsen.no/) through The Norwegian Council for Mental Health (http://www.psykiskhelse.no/) (2015/FO5044 to KT). In addition, the project has been funded partly by the Norwegian National Advisory Unit on Ageing and Health, Vestfold Hospital Trust (http://www. aldringoghelse.no/) (185106 to KT). The funders had no role in study design, data collection and analyses, decision to publish, or preparation of the manuscript.publishedVersio
Changes in C-reactive protein, neopterin and lactoferrin differ after conservative and surgical weight loss in individuals with morbid obesity
Get PDFAbstract
C-reactive protein, neopterin and lactoferrin are biomarkers of atherosclerotic disease. We aimed to assess changes in these biomarkers after conservative and surgical weight loss interventions in individuals with morbid obesity, to evaluate associations between biomarker changes and changes in body mass index and HbA1c, and to study associations between changes in the biomarkers. C-reactive protein, neopterin and lactoferrin were measured before and after conservative weight loss intervention and bariatric surgery. Data were analysed with mixed models. 137 individuals (mean age 43 years) were included. Body mass index decreased from 42.1 kg/m2 to 38.9 kg/m2 after the conservative intervention, and further to 30.5 kg/m2 after bariatric surgery. All biomarkers decreased after the conservative weight loss intervention. C-reactive protein and lactoferrin continued to decrease following bariatric surgery whereas neopterin remained stable. After adjustments for change in body mass index and HbA1c, all biomarkers decreased significantly after the conservative weight loss intervention, whereas none changed after bariatric surgery. There were no consistent correlations between changes in C-reactive protein, neopterin and lactoferrin. In conclusion, biomarkers of atherosclerosis decreased after weight loss interventions but had different trajectories. Neopterin, a marker related to atherosclerotic plaque stability, decreased after conservative weight loss but not following bariatric surgery.The project was funded by Innlandet Hospital Trust, Brumunddal, NorwayacceptedVersio
Quality of life of family carers of persons with young-onset compared to late-onset dementia
Get PDFAbstract
OBJECTIVES:
To compare quality of life (QOL) of family carers of persons with young- (YOD) to late-onset dementia (LOD).
METHODS:
This was a cross-sectional comparison of 88 carers of persons with YOD and 100 carers of persons with LOD. The Quality of Life - Alzheimer's Disease questionnaire (QOL-AD) was used to measure QOL of both carers and persons with dementia. Depressive symptoms were measured by the Geriatric Depression Scale (GDS) for carers and the Cornell Scale for Depression in Dementia for persons with dementia. Care burden was measured by the Relatives' Stress Scale. Activities of Daily Living (ADL) of the persons with dementia were assessed using the total score from the Lawton & Brody Instrumental-ADL scale and the Physical Self-Maintenance Scale. Multiple linear regression models with interactions between covariates and group (YOD versus LOD) were estimated.
RESULTS:
The QOL-AD scores of YOD-carers were significantly poorer compared to LOD-carers (mean difference 2.5 (95% CI 0.7; 4.3), p = 0.006). Poorer QOL of carers was associated with more depressive symptoms (mean QOL-AD change -0.5 (-0.6; -0.3), p < 0.001), but with no difference between the two groups. In contrast to LOD, QOL of carers of people with YOD was also significantly associated with symptom duration (p = 0.002), depressive symptoms of the persons with dementia (p = 0.030), ADL (p = 0.001), and carer burden (p = 0.002).
CONCLUSION:
YOD-carers reported significantly poorer QOL compared to LOD-carers. QOL was significantly associated with depressive symptoms in carers of both groups.This work was supported by The Research Council of Norway under Grant 229002 and registered in the WHO International Clinical Trials Registry Platform (ICTRP), NCT02055092.submittedVersio
Determinants of Cognitive Development in the Early Life of Children in Bhaktapur, Nepal
Get PDFBackground: Children in low and middle income countries may have many risk factors for poor cognitive development, and are accordingly at a high risk of not reaching their developmental potential. Determinants for cognitive development in early life can be found among biological and socioeconomic factors, as well as in stimulation and learning opportunities. Objective: The present study aimed to identify determinants of cognitive, language and motor development in 6-11 months old Nepalese infants. Methods: Six hundred infants with a length-for-age z-score <-1 were assessed with the Bayley Scales of Infant and Toddler development, 3rd edition (Bayley-III). Information on socioeconomic factors, child and maternal demographics, clinical and biological factors, and the home environment were collected. In a manual stepwise variable selection procedure, we examined the association between selected biological, socioeconomic and stimulation and learning opportunity variables and the Bayley-III cognitive, language and motor development subscale scores in multiple linear regression models. Results: The length-for-age z-scores was positively associated with the cognitive composite score [standardized beta (ß): 0.22, p < 0.001] and the motor composite score [(ß): 0.14, p = 0.001]. Children born with low birth weight (<2500 g) scored significantly lower on all subscale scores. Diarrheal history was associated with poor language composite scores, and females had higher language composite scores than boys [(ß): 0.11, p = 0.015]. Children who had been hospitalized during the first month of life had also lower cognitive and motor composite scores than those who had not been hospitalized. Parental reports of physical punishment and lack of spontaneous vocalization were associated with poor cognitive and language composite scores, respectively. The statistical models with the various subscale scores as dependent variables explained between 8 to 16 percent of the variability in the cognitive developmental outcomes. Conclusion: Our findings reveal important determinants for developmental scores in infancy, and underline the role of biological risk factors faced by marginalized children in low and middle income countries such as in Nepal. Copyright © 2019 Ranjitkar, Hysing, Kvestad, Shrestha, Ulak, Shilpakar, Sintakala, Chandyo, Shrestha and Strand.This work was supported by the Thrasher Research Fund (award
11512) and GC Rieber Fund