feature query posts
array(4) {
[0]=>
object(WP_Post)#11362 (24) {
["ID"]=>
int(132152)
["post_author"]=>
string(4) "3682"
["post_date"]=>
string(19) "2024-04-12 09:05:00"
["post_date_gmt"]=>
string(19) "2024-04-12 13:05:00"
["post_content"]=>
string(5843) "
Clinically significant prostate cancer is found in a “non-negligible” number of men who have screening PSA levels of 1.8 or higher but less than 3.0 ng/mL, according to recent study findings. It remains unclear, however, if a delay in the diagnosis of these cancers until PSA levels rise to 3.0 ng/mL would lower the likelihood of cure.
The findings are from the population-based Göteborg-2 screening study. Among 17,974 participants, 6006 men with a median age of 55.9 years were included in the current analysis. Of these, 82% had a PSA level less than 1.8 ng/mL, 11% had a PSA level of 1.8 or higher but less than 3 ng/mL (low-PSA group; median PSA 2.1 ng/mL), and 6.3% had a PSA level of 3 or higher but less than 10 ng/mL (high-PSA group; median PSA 3.9 ng/mL). Another 0.5% had a PSA level of 10 ng/mL or higher. Patients in the low-PSA group were recommended to undergo magnetic resonance imaging (MRI). Men with positive MRI findings had 4 targeted biopsies from each MRI-visible lesion.
Prostate cancer was found in 64 patients (41%) with positive MRI findings in the low-PSA group, the investigators reported in European Urology. Of these, 33 (21%) had Gleason 6 tumors (insignificant cancer) and 31 (20%) had Gleason 7 or higher tumors (significant cancer). In the high-PSA group, prostate cancer was detected in 61 patients (56%), including 26 (24%) with Gleason 6 tumors and 35 (32%) with Gleason 7 or higher tumors.
“These results are in-line with previous knowledge of prostate cancer incidence at low PSA levels” said study corresponding author Fredrik Möller, MD, of Skövde Hospital in Skövde, Sweden.
He added, “Our study indicates that MRI could be used as a selection tool to reduce prostate cancer overdiagnosis at lower PSA values, but would lead to a large increase in MRI [use]. We hope our future planned study comparing PSA cutoff of 3 ng/mL to a PSA cutoff of 1.8 ng/mL will show robust evidence regarding the benefits and harms of a lower PSA cutoff as an indication for MRI.”
Due to the limited sensitivity and specificity of PSA screening, it has been proposed that MRI be part of first-line screening for prostate cancer. However, the high costs, limited availability, and large inter-reader variability are significant barriers.
The main strength of the current study is its large, population-based design with a relatively high participation rate. “The results should therefore be generalizable to a screening situation,” Dr Möller said. “The main limitations are the relatively young age group and results that are based on a single screening round and lack follow-up so far.”
Despite the strengths of the study, an important question remains as to whether the lead time in diagnosing these cancers (PSA 1.8 or higher versus PSA 3-10 ng/mL) has a major impact on outcomes, said Aly-Khan Lalani, MD, an assistant professor in the department of oncology at McMaster University in Hamilton, Ontario, Canada, who was not involved with the study.
“The larger point is that population-based screening, with rational guidance of when to leverage adjunctive tests and thereby risk stratify patients, will help ensure the most patients who warrant treatment are caught early,” Dr Lalani said. “By balancing this concept and also limiting overdiagnosis or excessive invasive testing, we can seek to provide survival benefits for our patients.”
Michael Whalen, MD, an associate professor of urology and chief of urologic oncology at George Washington University in Washington DC, noted that the number of positive MRI findings in the low-PSA group (25%) was surprisingly quite similar to the rate of positivity in the high PSA (3-10 ng/mL) group (31%). “However, significant cancer detection rates in the low-PSA group were about half of that in the high PSA group,” Dr Whalen said.
He pointed out that 37,887 men were invited to participate in the study, but only 17,806 opted to do so and 6006 were included in the current analysis. “Compared to other screening trials, this number is actually very low. The European Randomized Study of Screening for Prostate Cancer (ERSPC) trial included about 182,000 men, and the Prostate, Lung, Colorectal, and Ovarian (PLCO) trial in the United States included about 76,000 men. “Thus, the generalizability of the findings may be limited,” Dr Whalen said.
The study had a high biopsy compliance rate, so disease detection rates should be accurate, Dr Whalen said. Also, there was pathologic consensus from 3 different experienced uropathologists. “Although racial demographics were unpublished, it is likely predominately a Caucasian population,” he said. “How the lower PSA threshold of 1.8 ng/mL applies to a population with a higher proportion of African American men is unclear. Also, the influence of family history on acceptable PSA threshold was not explored.”
"
["post_title"]=>
string(61) "Clinically Significant Prostate Cancers Found Despite Low PSA"
["post_excerpt"]=>
string(82) "Recent study raises questions about the use of MRI as a first-line screening test."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(61) "clinically-significant-prostate-cancers-found-despite-low-psa"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-09 18:11:33"
["post_modified_gmt"]=>
string(19) "2024-04-09 22:11:33"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(45) "https://www.renalandurologynews.com/?p=132152"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[1]=>
object(WP_Post)#11372 (24) {
["ID"]=>
int(130127)
["post_author"]=>
string(4) "3682"
["post_date"]=>
string(19) "2024-04-05 09:05:00"
["post_date_gmt"]=>
string(19) "2024-04-05 13:05:00"
["post_content"]=>
string(5198) "
It is well known that chronic kidney disease (CKD) has an impact on many body systems. Perhaps underappreciated is the link between the kidney and the thyroid. Increasing understanding of the relationship between the kidney and thyroid offers a largely unexplored opportunity to improve management of patients with CKD, in whom thyroid problems are frequently under-recognized.
An estimated 20 million Americans have some type of thyroid disease. Disconcertingly, it is also estimated that 60% of those with a thyroid condition are unaware of it.1 With regard to CKD, subclinical hypothyroidism has been found to increase from 7% to 17% in people whose glomerular filtration rate (GFR) drops to 60 mL/min/1.73 m2 from 90 mL/min/1.73 m2 or higher.2 Recent research indicates that subclinical hypothyroidism can be considered an independent predictor of CKD in the general population, even when adjusting for other common risk factors such as age, hypertension, and obestiy.3
What is this relationship between the kidney and the thyroid? The effects of poor thyroid function on the kidney are widespread, including reduced renin-angiotensin-aldosterone system (RAAS) activity, reduced GFR, and decreased heart rate and cardiac output that leads to diminished renal blood flow and ischemic kidney injury.4 CKD is thought to negatively impact thyroid function through multiple pathways. One such pathway is reduced expression of 1 5’-deiodinase that leads to decreased conversion of T4 to T3. Indeed, the most common finding is not an elevated TSH, but low T3.2 However, TSH is the most common and typically only laboratory measure used to assess thyroid function, which can result in underdiagnosis of thyroid disease. This is significant because it is estimated that GFR is reversibly reduced by about 40% in more than half of adults with hypothyroidism.4
Providers can improve CKD care by:
- Regularly screening for thyroid issues by ordering a full thyroid panel. Because TSH is not a reliable marker of thyroid issues in patients with CKD, a full thyroid panel including TSH, free T3, Free T4 and TPO antibodies would be more informative. It is important to recheck thyroid function as GFR changes as well.2
- Considering patient symptoms. Subclinical hypothyroidism is common in those with CKD, which may mean laboratory values look normal but patients present with common hypothyroidism symptoms like cold intolerance, fatigue, brain fog, hair loss, joint and muscle pain, increased cholesterol and triglycerides, unintentional weight gain or difficulty sleeping.5 These symptoms can be common in CKD due to anemia or other common coexisting conditions, so testing is important to properly identify the root cause.
- Ensuring adequate micronutrients and amino acids. T4 to T3 conversion and thyroid function require several micronutrients, such as zinc, iodine, selenium, choline, iron, folate, and essential amino acids. This is an important consideration if the patient is on a T4-only thyroid medication or on a low-protein or plant-based diet.6 A dietitian can play an important role in assessing nutrient need, guiding diet changes and recommending appropriate supplements.
- Managing stress. Cortisol can inhibit conversion of T4 to T3 and actually increase conversion of T4 to reverse T3.7 While stress management support is not a typical responsibility of nephrology providers, providing tools or referrals to support patients is appropriate. Measures that can reduce stress include meditation, counseling, and vagus nerve stimulation.8
Thyroid disease is under-recognized in many individuals. Because thyroid disease can affect kidney health (and vice versa), nephrology providers are uniquely poised to investigate and identify thyroid issues. As with many connected issues in CKD, nephrology providers need not shoulder the responsibility of treating thyroid disease, but refer out to dietitians, endocrinologists, and other appropriate providers to ensure the patient is getting the best care possible. It is not fully understood how much of an impact supporting thyroid health can have for those with CKD, but with a few simple proactive steps providers can begin to see possibilities.
Lindsey Zirker MS, RD, is a renal dietitian and Director of Clinical Services for the Kidney Nutrition Institute in Titusville, Florida. She specializes in autoimmune kidney disease and advanced practice medical nutrition therapy for people with kidney disease.
"
["post_title"]=>
string(38) "Chronic Kidney Disease and the Thyroid"
["post_excerpt"]=>
string(120) "Poor thyroid function can lead to reduced GFR and decreased renal blood flow that can result in ischemic kidney injury. "
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(57) "chronic-kidney-disease-and-thyroid-disease-hypothyroidism"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-01 17:50:17"
["post_modified_gmt"]=>
string(19) "2024-04-01 21:50:17"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(45) "https://www.renalandurologynews.com/?p=130127"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[2]=>
object(WP_Post)#11373 (24) {
["ID"]=>
int(131476)
["post_author"]=>
string(4) "3682"
["post_date"]=>
string(19) "2024-04-03 09:05:00"
["post_date_gmt"]=>
string(19) "2024-04-03 13:05:00"
["post_content"]=>
string(7068) "
“Don’t ever arrive empty-handed,” my older sister advised me about the etiquette of gift-giving after I graduated college. Beyond the more obvious expectations with birthday parties, she recommended that whenever invited to a barbecue or a dinner party, I should bring a small token of my appreciation of the host’s generosity of the invitation. Although to my young brain she made it sound like a rule, she was describing existing norms that guide social behavior. These norms are not necessarily uniform by culture or country, and they have their exceptions, but they serve a useful role in maintaining social cohesiveness. Given this, it is not unusual that gift-giving from patients may sometimes confound both patients and their physicians.
There are ethical considerations that help inform the potential challenges of gift-giving in a professional setting. (In some states and hospital systems, there may be laws that relate to accepting gifts from patients.) First, the relationship between patient and physician is bound by norms of professional behavior in part because it is ethically distinct from other social relationships. Physicians have an ethical and professional obligation to put patient’s interests above their own. This concept of patient primacy animates the entirety of how physicians care for patients and helps to promote care that is guided not by the physician’s personal interests (e.g., financial, moral, etc.) but by what is primarily in the patient’s best interest.
This so called “frame” of the physician-patient relationship helps create boundaries that advance the goals of medical care by promoting the patient’s interests and avoiding patient exploitation. The most recognizable and easily appreciated boundary is the violation that occurs when a physician has a sexual relationship with a current patient. This violation is so problematic that in some states, for some types of physicians, it has legal consequences for licensure. From an ethics perspective, the prohibition on sexual relationships with patients is based on the inherent power differential and potential for exploitation that exists in the physician-patient relationship. Physicians must not exploit the vulnerability of being a patient to serve their own personal interests.
Second, the physician-patient relationship is not simply transactional. Although there is insurance and potentially co-pays for services rendered, the basis for the relationship is fiduciary. Patients trust that their physician will care for them without regard to who they are, what illness they have, or whether they give gifts. Therefore, the physician should be mindful of the patient’s motivation behind the gift-giving to evaluate when it appears to be primarily transactional. Does this patient believe that unless they provide the physician with a gift, the physician will not give them the time, attention, or individualized are they need? In this case, it is the physician’s responsibility to assure the patient of the fiduciary nature of their relationship and remind them that their care is never contingent on the provision of gifts.
Gift-giving is not likely to violate the same boundaries as a sexual relationship, but the ethical considerations in maintaining appropriate boundaries still applies. Furthermore, there are situations when gift-giving from a patient would be completely appropriate. From a patient’s perspective, gift-giving is often an entirely normal part of social interaction when showing appreciation. So how should clinicians approach this problem when confronted with a gift from a patient?
Questions to Consider
First, clinicians should consider the ethics principles previously described and how they apply to a particular situation. Would accepting the gift be in the patient’s best interests? Does accepting the gift promote the physician’s interests far beyond the patients? Would accepting this gift contribute to or give the impression of exploitation? What are the patient’s potential motivations in giving this gift? The answers to these questions in specific scenarios may depend significantly on the context, suggesting that gift-giving would be ethically justifiable in some cases but not in others.
For example, it is unlikely to be ethically problematic for a physician to accept a patient’s gift of baked goods during the holiday season as a token of the patient’s appreciation. Accepting a relatively inexpensive gift is not likely to exploit the patient and can promote the patient’s best interests by showing appreciation for the thoughtfulness of the gesture. In other words, rejecting a modest gift provided when gifts might normally be exchanged is more likely to harm the physician-patient relationship.
Size of the Gift Matters
Alternatively, a patient who wishes to bequeath their physician with a sizable fortune after their death is likely to be ethically (and potentially legally) problematic. The size of the gift is far beyond a customary show of appreciation for the physician’s care and services. Accepting such a gift would overwhelmingly promote the physician’s interest and would raise concerns that it is exploitative. The motivation behind such a gift would be important to more fully understand. When an appreciative patient wishes to support a physician’s clinical care or research with an estate gift, the donation should be negotiated and managed through an institutional development office which minimizes the potential ethical conflict with the individual physician.
The more challenging cases may be somewhere in the middle of these extremes. Perhaps a patient wishes to gift their physician with expensive tickets to a sporting event or the arts. Again, physicians should discuss with the patient the principles above, trying to understand the patient’s motivation, assuring patient primacy, being mindful of potential exploitation, and assessing what the effect will be on the treatment relationship of accepting the gift. Depending on the answers to those questions, declining a gift might be as simple as saying, “I appreciate this lovely and thoughtful gesture. I can’t accept such large gifts from my patients.” Accepting the gift might be as simple as saying, “Thank you for such a special gift,” and then remaining mindful of maintaining professional boundaries going forward.
"
["post_title"]=>
string(59) "When Is It OK for Physicians to Accept Gifts From Patients?"
["post_excerpt"]=>
string(125) "From a patient’s perspective, gift-giving is often an entirely normal part of social interaction when showing appreciation."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(58) "when-is-it-ok-for-physicians-to-accept-gifts-from-patients"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-04-03 09:28:23"
["post_modified_gmt"]=>
string(19) "2024-04-03 13:28:23"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(45) "https://www.renalandurologynews.com/?p=131476"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
[3]=>
object(WP_Post)#11315 (24) {
["ID"]=>
int(130138)
["post_author"]=>
string(4) "3682"
["post_date"]=>
string(19) "2024-03-29 09:05:00"
["post_date_gmt"]=>
string(19) "2024-03-29 13:05:00"
["post_content"]=>
string(3197) "
Patient-reported outcomes (PROs) among patients with advanced urothelial carcinoma (UC) show that treatment with enfortumab vedotin with or without pembrolizumab is associated with preserved or improved quality of life (QOL), according to a recent study.
The finding is from a phase 1b/2 trial (ClinicalTrials.gov Identifier: NCT03288545) in which investigators evaluated the impact of first-line enfortumab vedotin (EV) alone or with pembrolizumab on patient QOL, emotional functioning, and symptoms in cisplatin-ineligible patients with locally advanced or metastatic UC. They randomly assigned patients 1:1 to receive enfortumab monotherapy intravenously (1.25 mg/kg once daily) on days 1 and 8 or enfortumab plus pembrolizumab intravenously (200 mg once daily) on day 1 of 3-week cycles. A total of 149 patients received treatment: 73 in the monotherapy arm and 76 in the combination arm.
“Patient-reported outcomes demonstrated preservation or improvement in quality of life. In particular, pain improvement was seen with both the combination and EV monotherapy,” said lead investigator Matthew I. Milowsky, MD, of the University of North Carolina at Chapel Hill.
Worst pain, average pain, pain interference, and pain severity remained stable over time, with small-to-moderate improvements observed at weeks 8, 12, and 24 compared with baseline.
In the combination and monotherapy arms, 76.7% and 65.4% of patients experienced a sustained improvement in pain, respectively, with a median time to improvement of 1.2 and 1.0 months, respectively. In the combination and monotherapy arms, 73.9% and 47.7% of patients experienced an improvement in worst pain, respectively, with a median time to improvement of 1.1 months and 1.4 months, respectively.
Gary D. Steinberg, MD, professor of urology at RUSH University in Chicago, Illinois, said this QOL study is important for physicians treating patients with advanced bladder cancer because it provides reassurance that patients find EV plus pembrolizumab tolerable and acceptable. “This new combination of enfortumab vedotin plus pembrolizumab has significantly changed the disease-free and cancer-specific survival rates for patients with locally advanced and metastatic bladder cancer,” Dr. Steinberg said. “In both the cisplatin eligible and ineligible population, the increase in survival is truly remarkable and completely changes the treatment paradigm for this traditionally difficult-to-treat population.”
"
["post_title"]=>
string(79) "PROs Support First-Line Use of Enfortumab Vedotin+Pembrolizumab for Advanced UC"
["post_excerpt"]=>
string(94) "Investigators reported preserved or improved quality of life, especially with respect to pain."
["post_status"]=>
string(7) "publish"
["comment_status"]=>
string(6) "closed"
["ping_status"]=>
string(6) "closed"
["post_password"]=>
string(0) ""
["post_name"]=>
string(78) "pros-support-first-line-use-of-enfortumab-vedotinpembrolizumab-for-advanced-uc"
["to_ping"]=>
string(0) ""
["pinged"]=>
string(0) ""
["post_modified"]=>
string(19) "2024-03-15 10:57:07"
["post_modified_gmt"]=>
string(19) "2024-03-15 14:57:07"
["post_content_filtered"]=>
string(0) ""
["post_parent"]=>
int(0)
["guid"]=>
string(45) "https://www.renalandurologynews.com/?p=130138"
["menu_order"]=>
int(0)
["post_type"]=>
string(4) "post"
["post_mime_type"]=>
string(0) ""
["comment_count"]=>
string(1) "0"
["filter"]=>
string(3) "raw"
}
}
