Riobard

Believe me, you took that out of my mouth. Translation: “I’m compellingly interesting by having mic dropped Johns Hopkins … why couldn’t my contrarian input on the PSA topic have been more recognized by other than the non-credentialed? All it takes for me to dismiss what I realize reflects expertise is that what becomes too much for me could only have been boring. Raspberries”.

You’re everywhere. Is that good for everbody?

I’ll give this version of response an interpretative shot. ”My vindictive snap queen dictatorial prerogative to determine the merit of content requires nothing more than smartass labelling what I know to be intelligible as unreadable. Deprived the degree of influence I desperately crave, I’ll gobble up whatever crumbs of validation are sent my way and I’ll regurgitate them with the set habitual response of ‘translation please’ because creativity is not the point of a troll. Hopefully not many will notice that I have no more to say than a media hack.”

I’m taken aback by your capacity to hold all of that extremely detailed content in mind for such an extensive written rendering months later. How do you do it? It’s like a vacuum cleaner bag exploded and you nevertheless organized and packaged all of the content into a vastly quantitative yet qualitive narrative.

I give up. Backslapping brigade much? You must be a cut above simply because you could never be deficient because you imply such and you are the arbiter of whose intelligence is substandard and incongruent with education. Nobody but somebody with a superiority complex would express such an observation. Nobody with an evident superiority complex is not somewhat stupid as well as unpainted into their corner.

This is not a very bright or useful comment and it conveys that you can only lazily skim the surface of what is not so very complex a topic. A recommendation is, de facto, an opinion. Clearly your choice of language “only an opinion” was intended to sarcastically devalue the content of another poster, with whom you have a bone to pick, whose entries were no less supported by evidence than that of a reputable cherry-picked facility that you name dropped as if it rendered said poster’s perspective inferior. Every bit of the stratified by age PSA screening guidance is accompanied by a grade of strength of clinical evidence and a grade of strength of recommendation. There is nothing about it that is not opinion and accompanied by the imperative of flexibility. That your clinician recommended an MRI was an opinion. The only certainty was that there could be more info to augment an opinion about whether the PSA value denoted malignancy. Your pressing need to have singled out your case experience as if it truly contradicted the prevailing established guidance is fraught comparatively with zero evidence as well as zero strength of application to the recommendation agenda. Your desire to butt heads was the only message that came through. Decentre.

A response that would be deemed unnecessarily aggressive but for the reality that you cannot restrain yourself. Cheap gets cheap laughs. Sad case. … Academic English. I haven’t been asked to alter writing style in published work because manuscript peer review, either side of that endeavour wherein I’ve been subject to review or expected to review, is a process that is vetted to exclude the obnoxious. I think that in your case you often only have something to say because you have a pressing need to be part of something. But you can shut it and still belong. Try it. Because otherwise who has trapped you here? Who hurt you?

What’s important here is that your analysis will have been useful to you. I’m paying by time denominator about the same as 10 years ago although prices in reais have trended up in absolute terms that are nevertheless considerably fractionated in percentage terms and objectively paltry amounts according to my home currency. Moreover, it is home-based escort price increases that have escalated when Brazil prices have been comparatively static against the only currency that has valid meaning. Hiring at home has been ruined because my overall impression is half the appeal for several multiples the cost. My set point was established at a historical juncture that anchored the financial meaning that I assign today. That reference point renders visitor-to-visitor comparison pointless. Because my disposable income is much higher 10 years on, that entire duration unbroken in retirement status, it would take a lot of deterioration in Brazil trade quality to erode the wow factor that I find consistently accessed. I feel more deprived than ever in between visits. That said, a decade is a solid period of time to accrue a stellar reliable roster of good matches. I haven’t one bit based that membership on some degree of price variation that arises between escorts and that I consider par for the course. Bien sur another advantage with having a trusted roster is removing the necessity of double-dipping into funds for where deeds are done. It’s not a large roster of guys but trading off a huge group of different guys for profoundly satisfying consistency seems worth it. Ten years has afforded dozens of connects that contribute to a sense of grazing an entire buffet. My analysis is only useful to me. It wouldn’t occur to me to approach it the way others do in spite of absolute clarity regarding those data collection practices that deviate from mine. Life is too short and shortening. I also cannot replicate a data acquisition design in which cost is explicitly inquired about. Me not do it that way. I’ve been to Barcelona as much as Brazil over the past year. Getting there costs about the same. Being there is more expensive. Hiring there considerably pricier. I have neither mental yearning nor desire to repeat with any particular guy I’ve met. In contrast, my erotic thoughts are highly populated by memories of several Brazil-based guys. The larger resource pool where you can see them in person before committing is a plus. I don’t need to budget much for disappointment.

Outside of the meta-communication tone, mostly valueless, in which forum opinion is expressed, the opinion divide here is not so unbridgeable in that one must consider that for some the screening leans to being essential for them in spite of some guidance entities putting forward the recommendation of non-screening. Such entities are not indicating that it’s essentialist that screening be assiduously avoided as opposed to discretionary even to the extent that testing deviates from the recommended guidance. They are referring to overall population benefit while also aware of epidemiological data regarding incidence and prevalence of disease occurrence, morbidity, and mortality. There are extant examples of clinical guidance that come across as much more rigid and dogmatic. For example, try to get a refill of HIV PrEP without a venipuncture lab test following a period of time in which you engaged in no activity for which PrEP is indicated and consumed none of the previous supply. I would think that disease transmissibility combined with personal vulnerability to undiagnosed disease and disease exacerbated by the inadequate antiretroviral uptake that characterizes PrEP come into play. That said, I am tasked with the aggravation of accepting this apparent rigidity with equanimity because while my personal circumstances appear to place me above the requirement the overall population benefit of required testing for eligibility of PrEP access the barrier imposed has considered multiple factors, like PSA guidance entities have done without an absolute manifest hurdle. What characterizes disagreement in the clinical guidance domain is that they are less at each others’ throats and tend to acknowledge the challenge of constructing definitive recommendations based on the data at hand. All sides include elaboration of the material they reference. There is no absence of common ground. However, discretion is often an artefact of uncertainly, is tantamount to equivocating. That leads to more heated splits in opinion within the general population rank and file. Guidance can be thou shall or shall not in certain contexts. Not so with PSA screening. The discussion launched with questions about prostate cancer screening for an old man who may have benefited from code blue paddles at the podium a year ago. Also, the adage that two things can be simultaneously true, as exemplified in the clinical literature. The number of lives saved by PSA screening is not indisputably zero and the overall population offset, by standard denominator, of PCa mortality conferred by screening is small enough to tip the guidance away from widespread application.

Wabbit so wahskawee!

Pardon me as I likely jumped the gun. The proposition to reinstate the visa exemption was dispatched following Senate approval to the Chamber of Deputies some weeks ago but it actually does not seem to have been included on the extensive list of proposals to be discussed and decided this week by the relevant government Foreign Relations division.

Tough call, though. Mythical vs Biblical.

I just read the 15-year results of the huge UK cluster randomized PSA surveillance study. I believe that many guidance entities have been holding out for how it might influence recommendations. I would think that it strengthens the grade of evidentiary reliability for the Canadian guidelines for age 50-69 (no benefit outside of shared decision-making) and explains why that health protection entity has not revised its position relative to having been published several years ago, in spite of reasonable-seeming critiques that have not yet integrated the implications of the aforementioned UK PSA CAP research. https://jamanetwork.com/journals/jama/fullarticle/2817322

Edit: as well as missing the boat by overlooking financial …

That’s good. The correct guess was made and would then seem to have been an incontrovertible judgement, as if overdiagnosis with deleterious effects were outside the realm of possibility. If your situation were to be the norm the guidance would evolve differently. So I’ll chime in with my recent experience of a near collision with biopsy needles. I went to a different MRI program that yielded a higher PI-RADS score and the urologist pushed biopsy. However, the report text included apparently humanly impossible anomalies that may have been typos, yet dismissed by the urologist, that prompted me to pony up much more cash for a confirmatory MRI in the clinic with which I had been previously consistently engaged, in which new results were consistent with lower scores within the same program over time. Averted biopsy conundrum, and PSA in spite of increasing age has been lower than the past 10 years median value. Parenthetically, why I wouldn’t do a home PSA kit but rather pursue standard venipuncture with the same unique lab result delineation for temporal comparative tracking if possible to use the same resource. Works both ways.

Unless you subsequently lose your prostate gland based on an educated guess, however reasonable seeming at the time, in which the exigency would ultimately have been disputable.

Well interestingly one critique made regarding the Canadian guidelines, in fact by clinicians that opine that the age-based recommendations should be more flexible, is that they are too narrowly constructed, overly weighted by clinical evidence review, and in fact miss the boat on person-specific variables that should temper the assertion of screening non-value as well as overlook financial cost considerations that should constrain flexibility in guidance due to burden on resources. While deficiencies in approach to recommendations exist, I don’t think that one can satisfactorily argue that bureaucratic influence is a major determinant of the health protection guidance for PSA screening.

For Kryst sake, man, do you need to be so selectively contrarian and pompously oriented to shaming attempts when you add potentially interesting and illuminating content that would go down better with a spoonful of sugar? Why would a truly bright and informed person almost consistently require a salvo accompanying their input? Surely the average reader could pick up that I haven’t objected to the age 70 cutoff and that what I mean by arbitrary is not the randomly whimsical connotation but rather the meaning that is based on choice and discretion, as patient self-determination in shared decision-making is a constant running theme through the related literature and 70 could be considered more an inappropriately rigidly delineated threshold at which screening is not recommended if general life and health preservation benefit were to be established as, say, 15 years as opposed to 10 years past the cutoff, given that even 2nd standard deviation bounds around the average age of male mortality nevertheless bins millions of men whose ancient life status nevertheless has objective value? Who is to say that zero sum is exactly one decade? A person being arbitrary.

Our situations are similar in terms of bundled sequential testing but actually don’t support the value of screening past age 70. Other posters are suggesting the value of screening is that prostate cancer is ubiquitous; the rates are high and only ambiguous in terms of the grade of risk they pose. A clean bill of prostate health is nevertheless tempered by the increasing probability of prostate cancer with age, notwithstanding that the older one’s age at diagnosis the less likely prostate cancer as future cause of death. What perhaps changes the picture is the advantage of early detection in the context of prostate-sparing and pelvic nerve complex protection intervention developments that I think have not yet been adequately integrated into surveillance guidance. The simple binary of mortality or increased longevity seems to me to be a perspective that lacks attention to progressively emerging early intervention possibilities that preserve life quality and function. At this point, follow up of PSA and MRI in one’s 70s … and I’m in that parade … is often pursued as if diagnosis is an inevitable eventuality in spite of no evidence of risk higher than the next guy without having had any screening or disease. The negative result prompts follow up surveillance but we’d likely never have had an MRI but for the combination of PSA above normal range and BPH, both inadequate prognosticators at which juncture MRI is the next step. Essentially, a negative MRI has triggered the next scan, ie, 2 years on. Blood draws and MRI with/out gadolinium contrast are tolerable, but in the same way a PSA value prompts MR imaging, the latter often prompts the far more invasive procedure of needle core biopsy. Perhaps the relief and gratitude of a clear MRI PI-RADS score promotes willingness to undertake more MRI regularly. But an equivocal score then graduates you to the prospect of a negative initial biopsy result as determinant of repeat routine biopsy procedures because they are also equivocal in accuracy. There has be a point at which further surveillance breaks the imperative of harm avoidance. So much invasiveness to just get to the step of sufficiently differential diagnosis to explore novel intervention such as brachytherapy radiotherapy seeds gland insertion, focused laser ablation, etc. This insidious cascade effect that begins with the no biggie PSA test surely influences guidance according to progressive age category. We are in the same state of health as would occur without screening ever having entered our thoughts. Only a reasonably accurate diagnosis of prostate cancer would have augmented the point of view that screening is salutary. In contrast, repeat and routine STI retesting is not so much a hamster wheel scenario; it’s done based on true behavioural risk accompanying the notion of community prevalence, not merely because the last one was clear.

Well perhaps I can assist in damping down the hyperventilating. @unicornwas making the distinction between all cause mortality (any cause of death) that is not robustly affected by PSA surveillance versus prostate cancer mortality (death attributed to prostate cancer and associated metastasis) that may be more subject to attenuation by screening because some cases present early and are caught by PSA testing that may spur further investigation. That said, it is not definitive that your PSA values age 40-50 were causally predictive of the unfortunate cancer diagnosis that was eventually made by the more reliable diagnostic procedures of MRI and biopsy that (I presume) were instigated by PSA values, perhaps a dual blood draw spread apart by standard time lapse for confirming legitimacy of next level assessment, some years following the age 50 guidance threshold in which PSA screening is considered prognostically superior, more accurately in semantic terms less prognostically inferior. Your specific category and presentation of prostate disease has not been dismissed by academic and clinical bodies that nevertheless do not generally support routine PSA screening below age 50. Your argument related to the liabilities of non-testing before age 50 was not supported by the timelines you provided. Perhaps you weren’t deliberately cherry-picking given that our personal experience naturally lends itself to confirmation bias in opinion.

Right, the arbitrary recommended age cut-off for discretionary PSA screening is 70 (+ / - the relatively small differences of opinion), notwithstanding the parallel guidance for younger age and the less robust evidence for non-screening in the age category leading up to 70. For example, I think Amer Urology Assoc stretches it to 75. This is largely governed in Canada by the average male life expectancy of 79 years. Diagnosis of prostate cancer at age 75 combined with expected post-diagnosis survival of minimally 10 years approaches age 85 or greater, and collective life expectancy currently for age 75 is about 10 years (95% confidence interval bounds round to 10), as standard deviation around the mean of age 79 upticks the likelihood of death delayed to about age 85. This doesn’t mean that absolutely zero PCa cases could be caught upon triggering by PSA values alone at old age with some possibility of mitigating associated disease and extending life that otherwise would have been truncated by PCa prior to when other cause mortality would otherwise kick in, but diminishing returns for widespread screening obviously dictate surveillance legitimacy in spite of outliers essentially not served well by the arbitrary screening guidance cut-off.

I think that some of the confusion and lack of consensus regarding screening benefit is related to the inappropriate interchangeability of the terms ‘harmful’, on the one hand, and on the other hand ‘superfluous’. Harmful seems to relate to more invasive physical diagnostic procedures (I am deliberating omitting considerations of associated psychological stress of diagnostic procedures at this point), the threshold that strikes me as invasive being needle biopsy, as well as diagnostic financial cost burden to public funds particularly where depletion is in public income taxes paid to support health infrastructure. The latter considers the number of men needed to assess at a cumulative financial cost that is justifiable (yes, subjectively of course) in terms of the predicted offset of morbidity and mortality rate. I submitted to PSA screening beginning at age early 60’s based on lab costs covered by social medicine insurance based on primary care recommendations and family history of metastasized prostate cancer that at that time and remains a risk marker. It’s just venipuncture in the context of other routine blood draws. Along with consistent PSA elevation and eventual manageable (no intervention) BPH I began prostate/bladder MRI screening every few years commencing mid-60’s. However, I chose to pay out of pocket for private clinic imaging and at that time consistently paid out of pocket for PSA, GP check-up in general, Urologist consultation, and once only biomarker 4K. Almost 10 years on I am not among the proportionally high number of men at my age with prostate cancer. However, I personally undertook the financial cost and responsibility of testing, essentially capitulating to practitioners’ urging from the point of view of “being on the safe side”. My MRI PI-RADS score consistently at level 2 or lower, where level 3 is equivocal in terms of the possible next step of biopsy, has spared me the conundrum and complications as well as diagnostic limits of invasive needle biopsy. So, on balance no regrets, I didn’t burden public coffers, and I spent money I won’t miss for some degree of peace of mind. I haven’t been unnecessarily treated or had my prostate prematurely yanked out when in fact it will not have been implicated in my eventual demise. One size does not fit all. I paid and stayed within the bounds of the “uselessness” aspect of screening that itself should not be conflated with the level of true harm implicit as foundational for those guidelines that lean towards non-screening. If the appended article content had been accessible a dozen years ago I doubt my trajectory of testing would have been different. The key is shared decision-making. I have no idea what Biden’s check-up history is but I don’t think being in high office necessarily influences the breadth of medical check-up routine that does or should occur. That said, I would personally certainly drill down deeply into the literature if faced with the prospect of ground zero surveillance commencing today. I have likely turned the corner on the necessity and soft value of routine MRI procedures as nearing age 75, based on the life expectancy aspect. One fly in the ointment is that age longevity way way beyond 77 runs in the family even where the grim reaper’s scroll had prostate cancer listed. Decisions decisions. I think there may be at least one typo in the article but if you notice it simply apply logic by looking at theme and sentence structure to determine author intent. https://www.ncbi.nlm.nih.gov/sites/books/NBK556081/

Yes, the west side as depicted several times in this forum. That shot was not my search. It was how the club pinned it within its social media, illustrating how helpful they are when the location is ambiguous in the first place.

Typo surpassing edit window: should be Av Vergueiro.

I’ve done it in but there have been wooden board barriers extending quite a hike around street repair, obscuring visibility upon exiting São Joaquim station. They may have since cleared. If you leave the station using exit A that emerges directly to the busy intersection where Liberdade northerly becomes Vegueiro southerly, cross westerly to the notably red building Habib’s Restaurant, immediately bear left/south to Pedroso, then right/west on Pedroso that bridges over the tangle of thoroughfares below. If you exit the station by the secondary exit B you will be directly on the west side and of course Habib’s will be to your right, then proceed to Pedroso, etc. Alternatively, Uber one way was trending at 25-30 reais before tip from Hotel Renaissance near Paulista/Augusta, not much distance difference from 555 via vehicle. The latter operates Fri, Sat, Sun.