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PURPOSE: Screening for prostate cancer with the prostate-specific antigen (PSA) remains highly controversial. We sought to discern which patient factors predict interest in the PSA and how informed consent impacts these predictors. PATIENTS AND METHODS: In a randomized trial that found that informed consent decreases patient interest in PSA screening, potential predictors of interest were analyzed separately in the uninformed (n = 102) and informed (n = 103) cohorts to examine the effects of the informational intervention. RESULTS: Univariate predictors of PSA screening interest (P [is less than] 0.05) among uninformed patients included perceived efficacy of screening, perceived seriousness of an abnormal PSA, and willingness to accept treatment risks. Among patients who had been informed about PSA screening, univariate predictors included family history of prostate cancer, perceived susceptibility to prostate cancer, age (inverse association), and perceived efficacy, although informed patients rated PSA efficacy significantly lower than uninformed patients (P [is less than] 0.001). In multivariate logistic regression modeling for the uninformed cohort, perceived screening efficacy (P [is less than] 0.001), perceived seriousness (P [is less than] 0.05), and willingness to accept treatment risks (P [is less than] 0.05) together were significant predictors of PSA screening interest. Among informed patients, perceived efficacy (P [is less than] 0.001), perceived susceptibility (P = 0.01), and younger age (P = 0.01) together predicted interest in screening. CONCLUSIONS: In contrast to uninformed patients, patients given information about PSA screening and prostate cancer are more likely to be interested in screening if they have a family history of prostate cancer, are younger, or otherwise consider themselves susceptible to developing prostate cancer. Uninformed patients are more likely to base their screening interest on the perceived seriousness of prostate cancer and on their willingness to accept treatment risks. Am J Med. 1997;103:308-314. [C] 1997 by Excerpta Medica, Inc.

Background: Counseling patients about the risks and benefits of in-hospital cardiopulmonary resuscitation (CPR) can potentially reduce patient suffering and hospital costs. However, there is currently much disagreement regarding the overall rate of in-hospital CPR survival and characteristics that identify patients more or less likely to survive CPR. Methods: The charts of all adults who were pulseless and received basic CPR at a 720-bed university hospital during 1990 and 1991 were reviewed. Patients were excluded if cardiac arrest occurred outside the hospital or in the emergency department, operating room, recovery room, or cardiac catheterization laboratory. Each patient's chart was reviewed to determine the presence of explicitly defined clinical characteristics. Results: Overall, 50 (16.0%) of 313 patients survived to discharge. Before arrest, only impaired functional capacity and sepsis identified patients unlikely to survive CPR. Of adults suffering cardiac arrest during the study period, only 22% underwent CPR, including 13.0% of those with cancer and 18.1% of those 70 years or older. Conclusions: The use of do-not-resuscitate orders to exclude patients who were inappropriate candidates for CPR may explain why the survival rate reported here is higher than similar reports and why more clinical characteristics were not found to predict CPR survival. Investigators of in-hospital CPR should use explicit criteria to describe the conditions studied and report survival for patients who receive basic CPR. The impact of do-not-resuscitate orders on survival rates must be considered. Functional capacity deserves further investigation as a predictor of CPR survival. (Arch Intern Med. 1994;154:2426-2432)

* Background. - Preventing pulmonary embolization by interrupting vena caval flow has been attempted since 1893. Inferior vena cava (IVC) filters have been available for 20 years, and currently there are five filters commercially available in the United States (Greenfield filter, Titanium Greenfield filter, Simon-Nitinol filter, Bird's Nest filter, and LGM or Vena Tech filter) and two other filters under development (Amplatz filter and Gunther filter). Although these devices are widely used, their clinical utility and safety have not been completely evaluated. Controlled clinical trials to determine the clinical role for IVC filters have not been attempted, but numerous case series describing the outcomes of the seven current filters have been published. We have systematically reviewed these studies to clarify what is known about the indications, safety, and effectiveness of IVC filters. Methods. - Using the MEDLINE database, all English-language publications since 1970 that included follow-up clinical information after filter insertion were reviewed and eight methodologic guidelines were employed to assess the scientific quality of the clinical information. Results. - Twenty-four case series were reviewed: 16 concerned the Greenfield filter (1632 patients), and eight dealt with newer designs (925 patients). Commonly noted methodologic problems included failure to report the initial extent of thromboembolic disease, incomplete description of the patient assembly process, and incomplete and potentially biased outcome assessment. Recurrent clinical pulmonary embolism was rare after filter placement, and only eight deaths from pulmonary embolism were reported. Filter complications were common but rarely life threatening; four (0.16%) deaths from filter complications were noted among the reviewed studies. Thrombotic complications following filter placement included insertion-site deep vein thrombosis and IVC obstruction. These events were rare, but they occurred with all filter types. Conclusions. - Inferior vena cava filters appear to be effective in preventing recurrent pulmonary embolism. Despite the large published experience with IVC filters, many questions remain about their indications, safety, and effectiveness. Anticoagulant therapy, if not contraindicated, should be used in conjunction with filters. While there is no ideal filter, some situations call for specific filters. Filter selection and insertion require experience, modern angiographic technique, and collaboration between clinicians caring for patients and the interventional radiologists or surgeons inserting the device.

* Traditionally, patients suspected to have lower-extremity deep vein thrombosis have undergone venography, which is invasive, is expensive, and may cause deep vein thrombosis in healthy individuals. Recent studies have shown the safety and efficacy of alternative noninvasive approaches that employ impedance plethysmography or real-time ultrasonography. We compared these tests using decision analysis to model the consequences of 24 different management strategies for ambulatory patients suspected to have deep vein thrombosis. We also calculated the incremental cost per additional life saved for each strategy. Our analysis revealed that the optimal approach was to perform real-time ultrasonography followed by anticoagulation therapy if deep vein thrombosis is found. This approach was both effective and cost saving compared with no testing or treatment. Serial follow-up studies of patients whose initial study suggested no DVT saved additional lives, but at a cost of $390 000 per each additional life saved for patients with one follow-up study and $3.5 million per each additional life saved for patients with a second follow-up study. Venography should play a limited role in the contemporary evaluation of patients suspected to have deep vein thrombosis. Future research should focus on the determination of clinical predictors of patients who should undergo serial examinations. (Arch Intern Med. 1992;152:165-175)

The axillary and subclavian veins are large veins that return blood from the arms to the heart, and run from the armpit to the area under the clavicle, or collarbone. The formation of blood clots, or thrombi, in these veins has been reported, and can have severe consequences. Axillary and subclavian vein thrombosis, ASDVT, can occur in several clinical situations: spontaneously, especially after strenuous effort; in association with large indwelling intravenous catheters, such as those used for nutrition and dialysis; and other causes, such as intravenous drug use and tumors in the chest. Treatment consists of local measures, including heat and elevation. Blood-thinning drugs, such as intravenous heparin or oral warfarin, are often administered as well. These anticoagulants prevent clots from breaking apart. Other agents sometimes used to treat ASDVT include thrombolytic agents, such as streptokinase, which dissolve clots. Some cases are treated surgically, by opening the vein and removing the clot or by removing an obstruction to blood flow through the vein, such as an unusually shaped rib or collarbone. Some of the adverse effects of ASDVT include the superior vena cava syndrome, in which the return of blood flow from the head to the heart is obstructed, resulting in severe swelling of the head, neck and arm, and pulmonary embolism, in which pieces of the blood clots break away and lodge in the circulation of the lungs. Three deaths from pulmonary embolism resulting from ASDVT have been reported in the medical literature. The studies of ASDVT are mostly case reports, and thus extrapolating advice for the treatment of this condition is difficult. However, the reports seem to suggest that the use of anticoagulants may be indicated to prevent the possible complication of pulmonary embolism. Because ASDVT appears to be common with the use of large intravenous catheters in the axillary and subclavian veins, prophylactic use of low doses of blood thinners may be warranted. Surgery may be warranted when the abnormalities leading to the ASDVT are obviously correctable. Controlled studies of ASDVT and its treatment and outcomes would be useful in making future recommendations. (Consumer Summary produced by Reliance Medical Information, Inc.)

Previously, we reported that the sensitivity of plasma DNA for patients with pulmonary emboli was 83 to 88 percent. To confirm these findings in a more comprehensive study, we collected [...]

The article by Monreal et al in this issue (see page 677) reminds us how much we have learned about venous thromboembolism, as well as how much we have yet [...]