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Most physicians consider a PSA value of less than four to be normal, " Carroll explains, although he notes that the upper limit of normal may be lower for younger men. "It has been shown that from 18 percent to 30 percent of men with PSA values between four and 10 have prostate cancer, and the number rises to somewhere between 42 percent and 70 percent for those men whose PSA values exceed 10, " he says. Prostate Cancer Program researchers who are studying the development of the disease also are looking for less ambiguous molecular markers. In the area of prostate cancer chemopreven tion, Cancer Center researchers participated in the now-closed Prostate Cancer Prevention Trial PCPT ; , which was designed to evaluate the efficacy of the drug finasteride 0roscar ; in preventing prostate cancer among the 18, 000 men enrolled in the study nationwide. Finasteride prevents conversion of testosterone to dihydrotestosterone, a hormone known to spur the growth of already-diagnosed prostate tumors, and which already is the target of anti-hormonal therapy. Cancer Center oncologist Chris Kane, who will be involved in follow-up and data analysis for the PCPT trial, also is coordinating UCSF's participation in the largest-ever chemoprevention trial for prostate cancer, called SELECT Selenium and Vitamin E Cancer Prevention Trial ; , in which 32, 000 men in the United States and Canada will participate for seven to 12 years. Selenium and vitamin E both are anti-oxidants that are believed to help prevent harmful mutations that can lead to cancer. A previous study of 1, 000 men and women who were given daily 200-unit doses of selenium to see if the vitamin could prevent skin cancer found no reduction in skin cancer, but did identify a significantly lower incidence of prostate cancer among men who took selenium in comparison to men who took a placebo. Similarly, a Finnish study which investigated the possibility that vitamin E might prevent lung cancer in smokers found no reduction in lung cancer, but again identified a significant reduction in prostate cancer among the men who took vitamin E. In the SELECT trial, men are being randomly assigned to one of four groups. One group will take both anti.
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Targownik LE, Metge CJ, Leung S University of Manitoba, Winnipeg, Canada Corresponding Author: c metge umanitoba Funding Source: Manitoba Medical Services Foundation and the Canadian Institutes of Health Research Background: Proton pump inhibitors PPIs ; are frequently used in persons presenting with upper gastrointestinal GI ; symptoms. Is the initial prescription Rx ; of a higher dose of PPI associated with improved clinical and economic outcomes? Methods: Manitoba Health's population-based database identified persons with a new PPI Rx no PPI Rx in previous 12 months ; from 1997-2002. All persons with new double-dose 2x ; PPI Rxs were matched to a standard dose control on age, sex, socioeconomic status, severe comorbidity, previous GI non-GI hospital admissions, Rx date. GI-related in out-patient resources were tracked for cases controls for 12 months. Results: Double-dose PPI new users n 2236 ; were linked to a standard dose control. No significant difference in resource use was found between cases control in the 12 months before analysis. In the year following initial prescription, there were no differences in overall duration of PPI use between cases and controls 128d vs. 126d, p 0.2 ; , and subjects prescribed 2x-dose PPIs ingested at this dose for a mean of 30 days. Subjects initially prescribed 2x-dose PPIs had an equal number of GI-related ambulatory care visits 2.2 vs. 2.2 visits yr, p 0.2 ; , were not statistically more likely to undergo endoscopy 21.8% vs. 20.8%, p 0.2 ; , or be admitted to hospital for upper GI disease 1.1% vs. 0.6%, p 0.090 ; . 12-month GI related costs are higher for subjects initially prescribed 2x-dose PPIs $680.60 vs. $510.52, p 0.001 ; Conclusions: Initial therapy with double-dose PPIs does not appear to lead to any reduction in GI-related health care utilization. Prescribing double-dose PPIs as initial therapy for upper gastrointestinal symptoms should be discouraged. Keywords: Proton pump inhibitors, healthcare resource use, gastrointestinal symptoms.
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Tained restrictive formularies. Given well-known variations in practice patterns, our physician 29 panels demonstrated a striking degree of consistency. Only five drugs that were judged to be of questionable value by one group were judged to be either beneficial or not beneficial by the other, with the research panel being slightly more critical than the primary care physicians. In no instance did the panels place drugs at opposite ends of the rating scale. This impressive concordance of opinion may have offset the relatively small number of physicians surveyed. Although this result may have stemmed from the physicians' limited geographic diversity although their practice settings differed widely ; , it also may signal a reasonable level of generalizability outside of the greater Boston area. Since we evaluated the effects of a nationwide natural "experiment, " no control group was possible, and we were required to adopt a simple pre post observational design. Even so, threats to validity, such as regression to the mean, are likely to have resulted only in the inclusion of some drugs that might have become more widely available even in the absence of a policy change. Such a result is unlikely to threaten our conclusions. In addition, while some observers have pointed out anomalies in several Medicaid data sets including First Databanks ; , which show artifactually decreased coverage between 1989 when, for example, Kansas covered 64, 642 products ; and 1992 when fewer than 15, 000 products were covered ; , these data probably are a result of unreliable reporting to third-party data collectors about infre30 quently used agents. Since this paper focuses only on the 200 most economically important and most closely watched ; medications with increased coverage after OBRA 1990, such errors would tend to attenuate, rather than exaggerate, our reported findings. Finally, since all of the medications that had significant increases in coverage had been marketed for appreciable periods of time before 1989, it is unlikely that improved market penetration alone accounts for our findings especially in light of the finding that market equilibrium for some drugs may be reached in as few as two 31 years. Instead, the increased coverage seems most likely to be a direct effect of formulary policy changes mandated by OBRA 1990. n Implications. Formulary decision making is an intrinsically difficult task. The use of medications is complex and may include important therapeutic niches that do not correlate with labeled 32 indications. In addition, assessing costs, benefits, and cost benefit ratios is a complicated, socially constructed activity about which 33 reasonable people may, and often do, disagree. Finally, patients often have complex requirements for pharmacotherapy, based on and sertraline.
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