Objective Rheumatology is among the least compensated specialties in medicine today. This is a significant problem for clinical rheumatologists in academic medicine who are often expected to earn their salaries through clinical practice alone. Additionally, academic rheumatologists usually cannot generate revenue through office laboratory monitoring, radiographs, or bone densitometry to supplement their income (i.e., downstream income). The purpose of our study was to examine revenue generated from downstream income to a university by a clinical‐academic rheumatologist. Methods Consecutive outpatients (n = 127) seen predominately by one academic rheumatologist over one month of clinic were followed for 18 months. The total physician compensation for patient visits was calculated and compared with the revenue generated from laboratory tests, radiologic studies, consultations, and specific rheumatologic treatments and procedures performed or ordered. Medicare reimbursement rates for 2003 were used as compensation standards for all charges. Results Physician office visit billing generated $36,297 from 730 office visits. The total amount of downstream income from these office visits was $363,813 ($47,386 from laboratory tests, $35,582 from radiologic studies, $8,159 from rheumatologic procedures, $261,584 from rheumatologic infusions, and $11,101 from initial consultations). Therefore, $10.02 of downstream revenue was generated for every $1.00 of office visit compensation applied to the academic rheumatologist's salary. Conclusion Although academic rheumatologists struggle to bill their salaries through seeing more patients, they are clearly a bargain for a university hospital because they generate >$10.00 for every $1.00 they receive for an office visit.

Aims: To compare the pathological stage and surgical margin status in patients undergoing either immediate radical prostatectomy or 12 and 24 weeks of neoadjuvant hormonal treatment (NHT) in a prospective, randomised study. Methods: Whole mount sections of 393 radical prostatectomy specimens were evaluated: 128 patients had immediate surgery, 143 were treated for 12 weeks and 122 for 24 weeks with complete androgen blockade. Results: Histopathology revealed organ confined tumours in 40.4% of patients with clinical stage B disease in the immediate surgery group, whereas 12 and 24 weeks of NHT increased the number of organ confined tumours to 54.6% and 64.8%, respectively. Among patients with clinical stage C tumours, pathological staging found organ confined disease in 10.4%, 31.4%, and 61.2% in the immediate surgery, 12 weeks of NHT, and 24 weeks of NHT groups, respectively. Preoperative NHT caused a significant decrease in positive margins both in patients with clinical stage B and C disease. The extent of margin involvement was not influenced by preoperative treatment. Conclusions: Neoadjuvant androgenic suppression is effective in reducing both the pathological stage and the positive margin rate in patients with stage B and C prostatic cancer undergoing radical surgery. Some beneficial effects are evident in those patients treated for 24 weeks, and it is reasonable to assume that the optimal duration of NHT is longer than three months.

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In an open, randomized phase II pharmacokinetic study conducted in Germany and Italy, a total of 42 patients with advanced or metastatic prostate cancer (PCa) were treated for 9 months with the luteinizing hormone-releasing hormone analogue (LH-RH-a) leuprorelin acetate depot in two different formulations. Fifteen patients received the 1-month depot and 27 patients received the newly developed 3-month depot, containing 3.75 mg and 11.25 mg, respectively. In both groups, subcutaneous injections of leuprorelin acetate injected monthly or at 3-month intervals produced a complete down-regulation of the pituitary and led to persistent suppression of testosterone and dihydrotestosterone to the castrate range (≤50 ng/dl for testosterone) within the first month of treatment, which thereafter could be maintained over the entire observation period of 9 months. In 10 patients, pretreatment with an antiandrogen for the prevention of clinical flare-up resulted in a slightly more profound and earlier drop in serum testosterone. The 3-month depot showed a higher median peak serum concentration (C_max) of leuprorelin at 20.8 ng/ml than the 1-month depot at 10.7 ng/ml but, conversely, this did not influence the rise in serum testosterone levels. C_max occurred at 3 h for the 3-month and at 1 h for the 1-month depot formulation. During the steady state, constant release could be detected, starting on day 3 and day 7 for the 1-month and 3-month depot, respectively. A marked decrease in median prostate-specific antigen levels of 97.8% (1-month depot) and 96.6% (3-month depot) compared with baseline was observed, indicating an objective clinical response for more than 80% of all patients in both arms. Based on European Organization for Research and Treatment of Cancer criteria, the best response in terms of complete/partial remissions and stabilization was comparable in the two arms at 86.7% (1-month depot) and 85.2% (3-month depot). 6.7% in the 1-month group and 3% in the 3-month depot group showed progression of the disease. The most common side effects in both treatment groups were related to hormone deprivation. Both formulations of the potent LH-RH-a leuprorelin acetate were highly effective in the treatment of advanced PCa and led to comparable endocrine and clinical effects.