September 12, 2002
Radical Prostatectomy versus Watchful Waiting for Early Prostate Cancer
A total of 695 men with early prostate cancer were randomly assigned to radical prostatectomy or watchful waiting. After a median follow-up of more than six years, more deaths due to prostate cancer had occurred in the watchful-waiting group, but overall survival in the two groups was essentially the same. This randomized trial offers physicians information that should be valuable to patients with newly diagnosed prostate cancer. The accompanying paper by Steineck et al. provides complementary data on the quality of life in the two groups of men enrolled in this study.
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Quality of Life after Radical Prostatectomy or Watchful Waiting
In this companion to the report by Holmberg et al. on survival in a randomized comparison of radical prostatectomy with watchful waiting among men with localized prostate cancer, sexual dysfunction and urinary leakage were more common in the radical-prostatectomy group, but the subjective quality of life in the two groups was similar. This study underscores the uncertainties men with prostate cancer face in choosing between radical prostatectomy and watchful waiting. The differences might have been less ambiguous if all patients in the radical-prostatectomy group had undergone surgery in which preservation of the erectile nerves was routine. Nevertheless, the authors point out that "erectile function is not the only determinant of an active sex life."
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Nocturnal Blood Pressure and Microalbuminuria in Type 1 Diabetes
Although microalbuminuria presages diabetic nephropathy, it may be a relatively late sign. Nocturnal hypertension may be an early indicator of diabetic nephropathy. In this study, investigators used 24-hour ambulatory blood-pressure monitoring in a prospective study of 75 subjects with type 1 diabetes mellitus who had normal blood pressure and urinary albumin excretion at enrollment. Over time, microalbuminuria developed in 14 subjects. An increase in nocturnal blood pressure preceded the development of microalbuminuria. The normal nocturnal dip in blood pressure had a negative predictive value of 91 percent for the development of microalbuminuria and was associated with a 70 percent reduction in risk. Ambulatory blood-pressure monitoring may provide a means of identifying patients with type 1 diabetes who are at risk for the development of microalbuminuria and subsequent nephropathy.
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Cough and Bronchial Responsiveness in Firefighters at the World Trade Center Site
The collapse of and fires at the World Trade Center in New York on September 11, 2001, resulted in large quantities of airborne material. The authors report on a syndrome characterized by severe cough, reductions in forced vital capacity and forced expiratory volume in one second, and bronchial hyperresponsiveness in 332 firefighters who worked at the site. In most, the cough lasted more than six weeks but resolved spontaneously or with treatment. Computed tomographic scans showed air trapping and bronchial-wall thickening. Workers involved in the rescue operations at the World Trade Center site had clinical, physiological, and radiographic changes consistent with the presence of airway dysfunction. Protection of the respiratory tract is essential in such settings.
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Clinical Practice: Office-Based Treatment of Opioid-Dependent Patients
A 30-year-old man reports a two-year history of heroin use. For the past year, he has been using intranasal heroin every day. He has undergone detoxification twice at a local opioid-abuse treatment program but began using heroin within two days after discharge each time. He has heard of methadone but fears that he will lose his business if he is recognized attending the local program. How should this patient be treated?
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Current Concepts: Respiratory Protection
Respiratory protection is important in many occupations involving exposure to gases, vapors, or particles, including biologic agents. This article reviews the types of respiratory protection and the necessity for the proper selection and use of these devices. Respirators have predictable physiological effects, and under conditions of low oxygen levels, improper use of a respirator increases the risk of asphyxiation.
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Sounding Board: Switching Emergency Contraception to Over-the-Counter Status
Hormonal emergency contraception is safe, effective, and available by prescription in the United States. This article explains why dropping the prescription requirement for emergency contraception would pose no risk to women and would improve public health by preventing unintended pregnancies. The author points out that over-the-counter sale of emergency contraceptive products is appropriate, because women are easily able to determine when and how to use them.
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