Prostate

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This site is extensive and patient orientated - set up by someone with cancer I think. You'll hear from doctors and patients. Bundles of articles and links. Great place to start. To get to site click on image above.

A pile of guidelines from NZGG

NZGG


Population Screening for Colorectal Cancer


Prostate Cancer Screening in New Zealand


A Guideline for the Management of Heart Failure: health professionals guide


Assessment and Management of Cardiovascular Risk


New Zealand Cardiovascular Guidelines Handbook: Developed for Primary Care Practitioners


The Management of People with Atrial Fibrillation and Flutter


Management of Type 2 Diabetes



Guidelines for the Management of Heavy Menstrual Bleeding


Management of Dyspepsia and Heartburn


Depression: information for health practitioners


Guidelines for Medical Practitioners Using Sections 110 and 110A of the Mental Health (Compulsory Assessment and Treatment) Act 1992


Guidelines for the Use of Acetylcholinesterase Inhibitor Drugs in the Treatment of People with Alzheimer's Disease


Diagnosis and Management of Soft Tissue Knee Injuries: Internal Derangements


Diagnosis and Management of Soft Tissue Shoulder Injuries and Related Disorders


New Zealand Acute Low Back Pain Guide, incorporating the Guide to Assessing Psychosocial Yellow Flags in Acute Low Back Pain

Analysis of Chronic Fatigue Syndrome Guidelines

Traumatic Brain Injury: Diagnosis, Acute Management and Rehabilitation

Diagnosis and Treatment of Adult Asthma

Management of Asthma in Children aged 1-15 years

The COPD-X Plan: Australian and New Zealand Guidelines for the management of Chronic Obstructive Pulmonary Disease 2006

Guidelines for the Management of Genital Herpes in New Zealand

Hormone Replacement Therapy

How come these have come out black

From the lancet

Findings

Against the predictions of the linear logistic model, neither all-cause nor cardiovascular deaths depended on systolic blood pressure in a strictly increasing manner. The linear logistic model was rejected by the Framingham data. Instead, risk was independent of systolic blood pressure for all pressures lower than a threshold at the 70th percentile for a person of a given age and sex. Risk sharply increased with pressure higher than the 80th percentile. Since systolic blood pressure steadily increases with age, the threshold increases with age, but more rapidly in women than in men.

Intrepretation

The Framingham data contradict the concept that lower pressures imply lower risk and the idea that 140 mm Hg is a useful cut-off value for hypertension for all adults. There is an age-dependent and sex-dependent threshold for hypertension. A substantial proportion of the population who would currently be thought to be at increased risk are, therefore, at no increased risk.

overactive bladder

Treatments for

• Oxybutynin and tolterodine (all forms) have not been tested in randomized controlled trials (RCTs) beyond 12 weeks nor in elderly patients or those with serious co-morbidities.

• Oral anticholinergic formulations and regimens are equivalent in benefit; evidence for transdermal oxybutynin is less clear.

• Symptomatic benefit occurs in 60% of people with OAB treated with an anticholinergic drug versus 45% of people treated with placebo, ARR 15%, NNT 6 to 7.

• Anticholinergic side effects, particularly dry mouth, are frequent: ARI 22%, NNH 4 to 5.

• The benefit of anticholinergic drugs (0.6 less leakage episodes per day) must be weighed against the harm (3% of patients treated for 12 weeks experienced a serious adverse event).

Prostate enlarged

Benign Prostatic htpertrophy

• Alpha blockers improve symptoms on average by 2-3 points more than placebo (35 point AUAscale), a difference patients perceive as 'slight benefit'. Alpha blockers do not reduce complications, but increase dizziness, postural hypotension and asthenia (ARI 3-8%, NNH 13-33).

• 5-a-reductase inhibitors reduce acute urinary retention (ARR 2%, NNT 50), and BPH surgery (ARR 2-3%, NNT 33-50), but impair sexual function (ARI 3%, NNH 33).

• There is insufficient evidence that combining the two drug classes provides additional benefit.

• Most BPH trials do not report total serious adverse events and mortality. This prevents an assessment of the overall clinical impact of drug treatment.

Prostate cancer

Listen to a lecture downloaded from McGill by a urologist. First he declared that he was involved with various drug companies. Later he talk about a particular biphosphonate by name - alarm bells for me. How can they possibly think they aren't influenced by these payments. I belive they don't have to declare unless the sum is above 40 odd grand. How would they feel if a judge was receiving money from their in a court case?

Anyway he talked of the a contolled trial which he said had methodological problems but did show a reduction in deaths from prostate cancer. Then he mentioned rather briefly that there was no over all mortality benefit. Then he told us that there was also a reduction in bony metastases. Then he launched into pretty much promoting aggressive treatments for most prostate cancer - the younger the more aggressive of course.

Then I came across this

Symptoms Worsen After Surgery
Now for the question of quality of life. It's certainly possible that a prostatectomycould improve a man's life without prolonging it. Consequently, the Swedish research team sent questionnaires to the 326 men who had symptoms at the start of the study to see how they fared four years later. The percentage of men suffering the following symptoms was consistently higher among the surgically treated, as compared to the untreated: impotence (80% vs 45%), "distress from compromised sexuality" (55% vs 40%), urinary leakage (49% vs 21%), "distress from all urinary symptoms"(27% vs 18%).

He was very keen on the PSA. There will be some double blind trials coming out that may tell us the goods - they will probably make the grey a little clearer. Even though he acknowledges the problems with PSA he is into it - big time.

Does anyone remember radical mastectomies and how long it took to stop surgeons doing them even when the evidence was in that they did major harm with no benefit.

I met a friend of a friend the other day. He has an enlarge prostate and a PSA of 4. What would you do? It may be coming my way this problem as my dad died of it. What will I do?

Here in the BMJ is an impressive review with some interesting rapid response.

Can not put url in for some some reason - go to BMJ and search for

Clinically localised prostate cancer

Prostate Cancer - a detailed guide.

Go here

and here

and here

Blood Pressure

Click on table to enlarge. These figures help to put relative risk, absolute risk and percentage chance in perspective. 20% reduction sounds a lot. 96.8 % chance of surviving as opposed to a 96% chance doesn't sound like very much. 4S was a trial of statins on folk that had already had a CVD event ie secondary prevention. The WOSCOPS was a trial of statins for primary prevention in high risk patients. That BP result is interesting!! Click here to see where this came from.

while hypertension is an established risk factor for coronary heart disease at all ages and in both sexes, most high blood pressure-lowering trials have shown no reduction in coronary or total mortality in women and younger individuals (2) Uffe Ravnskov and in many studies, no effect has been demonstrated on male mortality either (3). This clearly indicates that hypertension is not a causa vera of coronary heart disease and "risk marker" would be a more appropriate description.

Here are three facts that currently co-exist in the world of medical research. Starting in the early nineteen eighties when the Medical Research Council (MRC) UK carried out the first ever long-term study into the effect of blood pressure lowering on mortality and morbidity. The drugs used were a diuretic and a beta-blocker.

Up to this point, you may be surprised to hear, this issue had never been studied. It was sort of assumed that a high blood pressure caused CHD, so if you lowered the blood pressure, you would prevent CHD.

The primary finding of the MRC trial was that blood pressure lowering had no impact on the rate of death from CHD. (There was some reduction in stroke and renal failure.)

Jumping to the present day, the ALLHAT study recently showed that there was no difference in CHD prevention between diuretics, beta-blockers, ACE-inhibitors and Calcium Channel blockers.

However, a recent meta-analysis in the NEJM shows that ACE inhibitors do provide protection against CHD.

From second article

From the European Heart Journal Issue 20, October 2000.

‘No randomized trial has ever demonstrated any reduction of the risk of either overall or cardiovascular death by reducing systolic blood pressure from our thresholds to below 140mmHg.’

‘Most importantly, the current paradigm considerably over-estimates the risk in the mid-range of pressure (roughly 125 — 180mmHg). .......... Consequently, a large proportion of the population considered at increased risk with the current cut-point are in fact at no increased risk.’

Developers of guidelines, ourselves included, have been overburdened by evidence which gives undue emphasis to the relative risks........ We think it is time to consider basing guidelines explicitly on clinically more useful absolute measures of the effects of treatment. Indeed, we suggest that the clinical credibility and success of the guidelines process depends on it.

Yup! Convince me, as a GP, that the benefits out weigh the harms - present it in a black and white manner. Be brutally straight forward about harms. What about harms that might take 20 years to show up!! Talk about these too! Present guidelines in ways that lay people can understand. I like percentage chance with and without intervention.

Find visual ways like this prostate risk roulette wheels