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Men who are being monitored may be more open to interventions for improving their general health and quality of life
Prostate cancer is the most frequently registered cancer in Australian men, with an estimated 17 729 new diagnoses in 2018.1 For the 25% who are diagnosed with low risk disease, active surveillance (AS) is now the recommended management strategy, as their cancer may never progress.2 Avoiding or at least postponing radical treatment reduces the quality of life risks associated with surgery or radiation therapy. However, there is no evidence-based consensus about the optimal approach to surveillance, and practices differ between countries with regard to the type, frequency, and sequence of follow-up.3 AS differs from “watchful waiting” in that it has a curative intent; watchful waiting involves less intense routine monitoring, intervening only when symptoms appear. One standard approach to AS recommends prostate-specific antigen (PSA) assessment every 3–6 months, a digital rectal examination at least once a year, and at least one biopsy within 12 months of diagnosis, followed by serial biopsy every 2–5 years.
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David Smith and Gary Wittert are collaborators on an NHMRC Centre for Research Excellence in Prostate Cancer Survivorship (CRE-PCS) (1116334). David Smith was supported by a grant from Cancer Institute NSW (15/CDF/1‑10).
David Smith is a member of the Prostate Cancer Outcomes Registry Australia and New Zealand (PCOR-ANZ) steering committee. Gary Wittert is Independent Chair of the Weight Management Council of Australia and has received research support from Weight Watchers.
Better biomarkers are needed to ensure early and accurate detection and prognosis of prostate cancer
Prostate cancer is now the most common cancer diagnosed in men in Australia,1 and Australia has one of the highest incidence rates of prostate cancer in the world, with an estimated age-standardised rate of 119.2 per 100 000 men.2 Before 1960, the primary diagnostic test for prostate cancer was the prostatic acid phosphatase test. This was eventually replaced in the 1980s by the prostate-specific antigen (PSA) test.
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Doug Brooks is developing cancer biomarkers for commercialisation with Envision Sciences Pty Ltd.
Objective: To characterise the practice of active surveillance (AS) for men with low risk prostate cancer by examining the characteristics of those who commence AS, the rate of adherence to accepted AS follow-up protocols over 2 years, and factors associated with good adherence.
Design, setting: Retrospective cohort study; analysis of data collected from 38 sites participating in the Prostate Cancer Outcomes Registry–Victoria.
Participants: Men diagnosed with prostate cancer between August 2008 and December 2014 aged 75 years or less at diagnosis, managed by AS for at least 2 years, and with an ISUP grade group of 3 or less (Gleason score no worse than 4 + 3 = 7).
Main outcome measures: Adherence to an AS schedule consisting of at least three PSA measurements and at least one biopsy in the 2 years following diagnosis.
Results: Of 1635 men eligible for inclusion in the analysis, 433 (26.5%) adhered to the AS protocol. The significant predictor of adherence in the multivariate model was being diagnosed in a private hospital (v public hospital: adjusted odds ratio [aOR], 1.83; 95% CI, 1.42–2.37; P < 0.001). Significant predictors of non-adherence included being diagnosed by transurethral resection of the prostate (v transrectal ultrasound biopsy [TRUS]: OR, 0.54; 95% CI, 0.39–0.77; P < 0.001) or transperineal biopsy (v TRUS: OR, 0.32; 95% CI, 0.19–0.52; P < 0.001), and being 66 years of age or more at diagnosis (v < 55 years: OR, 0.65; 95% CI, 0.45–0.92; P = 0.015).
Conclusion: Almost three-quarters of men who had prostate cancer with low risk of disease progression did not have follow-up investigations consistent with standard AS protocols. The clinical consequences of this shortcoming are unknown.
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Funding for this project has been provided by the Movember Foundation. Ian Davis is supported by a National Health and Medical Research Council Practitioner Fellowship (APP1102604). Sue Evans is supported by a Monash Partners Academic Health Science Centre Fellowship.
No relevant disclosures.
Virtual reality is thought to create an immersive distraction that restricts the mind from processing pain
Not so far in the future, doctors might prescribe a virtual beach vacation to calm aches and pains, in lieu of pharmacotherapy. Insurance companies might offer scenic tours of Icelandic fjords to lower blood pressure, instead of doubling up on drugs. Psychiatrists might treat social phobia by inviting patients to a virtual dinner party. Hospitals may immerse children in a fantastical playland while they receive chemotherapy.
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Support for this work is provided by the Marc and Sheri Rapaport Fund for Digital Health Sciences and Precision Health.
I have received a research grant, administered by Cedars-Sinai Health Services, from appliedVR (Los Angeles, CA). I have no equity, royalty, board positions or other relevant financial relationships to disclose with appliedVR or any other company with a product or service mentioned in this article.
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We acknowledge the support of the Movement Disorder Society Non-Motor PD Study Group and the Non-Motor PD Early Career Subgroup, and of the National Institute for Health Research (NIHR) London South Clinical Research Network and the NIHR Biomedical Research Centre. Anna Sauerbier has received funding from Parkinson’s UK and the Kirby Laing Foundation. This article represents independent collaborative research part funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King’s College London.
No relevant disclosures.
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We thank the National Institute of Health Research Biomedical Research Centre and the Institute of Psychiatry, Psychology and Neuroscience at Kings College London for supporting research cited in this article, and the MDS Non-Motor Parkinson’s Disease Study Group.
No relevant disclosures.
Individualised psychosocial interventions are needed as alternatives to pharmacological sedation
Sedating psychotropic drugs, including antipsychotics and benzodiazepines, are commonly prescribed in residential aged care facilities (RACFs), despite extensive evidence of their limited efficacy for treating behavioural and psychological symptoms in older people and of their potential for eliciting serious adverse effects, including death.1 As a consequence, efforts are afoot in many countries to minimise the use of these medications in RACFs. In this issue of the MJA, Westbury and colleagues2 report findings from the RedUSe study of a multi-component intervention designed to reduce the prescribing of sedative medications in Australian RACFs. This uncontrolled investigation employed four complementary interventions in 150 nursing homes: psychotropic medication audits by a local champion nurse; RACF staff education sessions conducted by a pharmacist using benchmarked local data and incorporating training in non-pharmacological interventions; interdisciplinary prescribing reviews for each RACF resident; and academic detailing for prescribers. This intervention sequence was repeated twice, 3 months apart. Data for 12 157 RACF residents collected at baseline, 3 months and 6 months indicated that prescribing of antipsychotics and benzodiazepine had decreased significantly following the intervention: the prevalence of antipsychotic use dropped from 21.6% of residents at baseline to 18.9% at 6 months, and that of benzodiazepines from 22.2% to 17.6%. For 39% of RACF residents taking antipsychotics or benzodiazepines at baseline, medication was ceased or the dosage reduced at 6 months.
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No relevant disclosures.
Tremor is the most common movement disorder encountered in clinical practice.1-3 It is defined as an involuntary, rhythmic and oscillatory movement of a body part. Tremors tend to be relatively constant in frequency but variable in amplitude,1 which may happen due to exaggeration of the physiological tremor or due to a tremor disorder. If significant enough, it may lead to medical presentation.
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Series Editors
Balakrishnan (Kichu) R Nair
Simon O'Connor
No relevant disclosures.
Recent studies are expanding our understanding of the genetic basis of Parkinson disease
Parkinson disease (PD) is a common neurodegenerative disorder which manifests as bradykinesia, movement rigidity and tremors in affected individuals. Our understanding of the genetic basis of PD has been steadily increasing since the initial report of α-synuclein mutations two decades ago.1 Mutations implicated in familial PD fully account for monogenic inheritance and point to potential functional mechanisms underlying PD.2,3 However, most sporadic PD cannot be accounted for by known familial PD genes, with the late-onset nature of PD making further linkage studies challenging. Genome-wide association and whole exome sequencing studies have implicated a growing list of mutations and genes in PD, which are expected to provide new insights into potential pathways involved in PD pathogenicity.
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Eng-King Tan acknowledges funding from the National Medical Research Council Singapore under the Singapore Translational Research Investigator Award and the Translational and Clinical Research Flagship Programme (NMRC/TCR/013-NNI/2014); Duke–NUS Medical School; and the Singapore Millennium Foundation. Jia Nee Foo is a Singapore National Research Foundation Fellow (NRF-NRFF2016-03).
No relevant disclosures.
Abstract
Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care.
Design: Cross-sectional retrospective analysis of linked health service data, January 2015 – February 2016.
Setting: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care.
Participants: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent).
Main outcome measures: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs.
Results: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028–0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13–0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14–0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092–14 831) per person per year in residential care costs.
Conclusions: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.