Affairs Puget Sound Health Care Research Articles

Albumin cobalt binding test: A gold standard to rule out acute coronary syndrome?

Study objectives: The purpose of this study is to validate the Albumin Cobalt Binding (ACB) test at the Veterans Affairs (VA) Puget Sound Health Care System. This study measures the distribution of ACB values for our normal VA population and determines an initial ACB rule-out value for acute coronary syndrome. Methods: ACB values were determined photometrically with Ischemia Technologies reagents on the P-module of a Roche Modular Analytical System. We retrospectively measured serum ACB levels in 21 first-draw troponin samples obtained from patients presenting to the emergency department with chest pain. Specifically, we chose these samples only if the patient's initial troponin was negative and subsequent troponin levels became elevated. According to the correlations between the initial negative and subsequently elevated troponin, we constructed a receiver operating characteristic (ROC) curve to identify the highest ACB rule-out value. Furthermore, using 30 patients not experiencing chest pain, we established an initial normal range for our population. Results: There was a statistically significant difference between ACB values in the 30 apparently healthy individuals (85.5±10.3 U/mL; 95% confidence interval [CI] 81.7 to 89.4) compared with the 21 patients whose troponin became positive (123.8±17.2 U/mL; 95% CI 115.9 to 131.6; <i>P</i><.0001). The area under the ROC curve was 99.1% (<i>P</i><.0001), and there was almost complete discrimination between the 2 groups when a 96 U/mL decision level was used. Conclusion: This preliminary study suggests that the ACB test has a strong negative predictive value and sensitivity in the initial study group for predicting positive troponin results 6 to 24 hours after presentation. The ACB test, when used in conjunction with cardiac injury markers, holds promise in reducing inappropriate low-risk admissions.

Increased incidence of diagnosed depressive illness in hypogonadal older men.

Age-associated hypogonadism (testosterone deficit) occurs in 30% of men after the age of 55; it is associated with decreased muscle mass, bone mineral density, and libido, and with anorexia, fatigue, and irritability. Although some of these symptoms overlap with those of depression, the association between the 2 disorders is unclear. To determine if hypogonadal men have an increased incidence of depressive illness compared with eugonadal men. Historical cohort study using computerized medical records, followed by a manual medical record review. Veterans Affairs Puget Sound Health Care System. Two hundred seventy-eight men 45 years and older, without prior diagnosed depressive illness and with consistently normal or low testosterone levels (total testosterone level < or =200 ng/dL [< or =6.94 nmol/L]; or free testosterone level < or =0.9 ng/dL [< or =0.03 nmol/L]) at baseline and during a 2-year follow-up period. Incidence of, and time to, a depression diagnosis. The 2-year incidence of diagnosed depressive illness was 21.7% in hypogonadal men vs 7.1% in others (chi2(1)=6.0, P=.01). A Kaplan-Meier survival analysis showed a significant difference between hypogonadal and eugonadal men in time to diagnosed depression (log-rank test chi2(1)=6.9, P=.008). We used Cox proportional hazards regression models to examine the association of hypogonadism and time to depression diagnosis, adjusting for age, race, number of clinic visits, alcohol use disorders, prostate cancer, and overall medical comorbidity. The unadjusted hazard ratio for depression with hypogonadism was 3.5 (95% confidence interval, 1.3-9.4) (P=.01). Controlling for all covariates, hypogonadism remained significantly associated with depression (adjusted hazard ratio, 4.2; 95% confidence interval, 1.5-12.0) (P=.008). Hypogonadal men showed an increased incidence of depressive illness and a shorter time to diagnosis of depression. Further prospective studies are needed to confirm these preliminary findings and to clarify the role of testosterone in the treatment of depressive illness in older men.

Talking about …

Talking about …

Evaluation of a minimal services treatment track for noncompliant patients in opioid substitution treatment.

Opioid substitution treatment (OST) is the most widely used treatment for opiate dependence.1,2 The preponderance of evidence suggests that retention in OST is associated with decreased opiate use and criminality.3–5 However, continued illicit drug use among patients in OST is common.6–8 Program responses to ongoing use vary widely,9 though discharge is a frequent response. Some patients nevertheless are unable or unwilling to cease illicit use despite the threat of treatment termination. Unfortunately, outcomes for out-of-treatment opiate addicts are very poor.3 Recently published OST guidelines recommend that programs find alternatives to treatment termination for ongoing drug use.10 For treatment programs, such a no-discharge policy poses certain dilemmas. If a program retains patients despite ongoing drug use, harm may be reduced for that subset of patients. However, the potential benefits of retention of drug-using patients in treatment could be offset if illicit use were to increase among other patients in the program who might have otherwise been motivated to cease or reduce their use by the threat of discharge. The value of a putative harmreduction strategy is determined not only by its effectiveness in reducing harm among members of the target group (i.e., microharm) but also by the extent to which it does not inadvertently increase harm among members of other groups or the larger population (macroharm).11 In April 1998, the OST program at the Veterans Affairs Puget Sound Health Care System (VAPSHCS) in Seattle, Washington, instituted a minimal services (MS) treatment track as an alternative to discharge for patients who continued to use illicit drugs. MS was designed to retain these patients in treatment. MS also was designed to introduce additional contingencies that 1) encouraged abstinence and 2) simultaneously minimized demands on clinic and staff resources and opened additional treatment slots to reduce the waiting list for new patients. The components of the MS program are listed in Table 1 ▶. After the MS program was in place for 1 year, the new policy’s impact on both MS patients and the clinic population at large was assessed by means of a program evaluation. TABLE 1— Components of the Minimal Services Treatment Track

Daily weight-bearing activity does not increase the risk of diabetic foot ulcers.

This study had two purposes: to identify characteristics associated with participants' usual weight-bearing activity, and to determine whether weight-bearing activity increased the risk of foot ulcer among persons with diabetes and prior foot ulcer. We conducted a prospective cohort study of 400 participants with diabetes and a prior history of foot ulcer. Participants were from the Veterans Affairs Puget Sound Health Care System and Group Health Cooperative in Seattle, WA, and were originally assembled for a randomized controlled trial of footwear. Feet were examined and demographic and health history information was collected at enrollment. Daily weight-bearing activity was reported at enrollment and every 17 wk thereafter for 2 yr. All incident foot lesions were recorded. Weight-bearing activity was significantly higher among women. Activity was lower among participants who were older, unmarried, or who had a history of congestive heart failure, respiratory disease, stroke, or depression. Activity decreased significantly over the study period but remained similar in those with or without insensate feet. After adjustment for foot-related and health-status characteristics, moderately active participants (4.5-7.4 weight-bearing h.d-1) were at substantially but nonsignificantly reduced risk of foot ulcer compared with "least active" participants (<4.5 weight-bearing h.d-1) (OR 0.50, 95% CI 0.22-1.16). "Most active" participants (>or=7.5 weight-bearing h.d-1) were at significantly reduced risk (OR 0.20, 95% CI 0.04-0.87). Weight-bearing activity exerted similar effects on foot ulcer risk in participants with insensate versus sensate feet . Increased weight-bearing activity did not increase the risk of foot re-ulceration. Further studies are needed to explore weight-bearing activities that are safe for those with diabetes and insensate feet.

From the USA: understanding requests for physician-assisted death

Dr Ganzini is Professor of Psychiatry at Oregon Health and Science University and Director of the Interprofessional Pallia tive Care Fellowship at the Portland Veterans Affairs Medical Center. Her research is focused on the Oregon Death with Dignity Act. Dr Back is an Associate Professor of Medicine at the University of Washington and Director of Palliative Care Services at the Veterans Affairs Puget Sound Health Care System.

Leptin levels are appropriate for body mass index in older men who experience involuntary weight loss.

To determine the relationship between leptin and unintentional weight loss in older adults. Prospective cohort study over 2 years. University-affiliated Veterans Affairs Medical Center. The subjects were 105 community-dwelling male veterans aged 65 and older who had participated in a prospective cohort study on nutrition and health conducted at the Veterans Affairs Puget Sound Health Care System from 1986 to 1989. Anthropometric data and fasting blood specimens were collected at baseline and annually for the subsequent 2 years. Stored blood specimens were analyzed for leptin, insulin, glucose, C-reactive protein, sex hormone binding globulin, and testosterone levels. Over 2 years, 75 men were weight stable (weight loss <4% of baseline) and 30 men had unintentional weight loss (weight loss>4% of baseline). The baseline body mass index (BMI) and leptin levels for the two groups were not statistically different. Positive correlations existed between leptin level and BMI at each time point for weight-stable and weight-loss subjects. Furthermore, a significant relationship existed between changes in leptin and changes in BMI over 1 year in multiple regression analysis (r =.436, P <.001 after the first year; and r =.630, P =.027 after the second year). Like in younger adults, plasma leptin levels remained proportional to BMI, and changes in BMI were accurately reflected by changes in leptin levels in older individuals. Fasting leptin levels did not predict involuntary weight loss over 2 years of follow-up.

Argon plasma coagulation for rectal bleeding after prostate brachytherapy

Purpose: To better define the efficacy and safety of argon plasma coagulation (APC), specifically for brachytherapy-related proctitis, we reviewed the clinical course of 7 patients treated for persistent rectal bleeding. Approximately 2–10% of prostate cancer patients treated with 125I or 103Pd brachytherapy will develop radiation proctitis. The optimum treatment for patients with persistent bleeding is unclear from the paucity of available data. Prior reports lack specific dosimetric information, and patients with widely divergent forms of radiation were grouped together in the analyses.Methods and Materials: Seven patients were treated with APC at the Veterans Affairs Puget Sound Health Care System and the University of Washington from 1997 to 1999 for persistent rectal bleeding due to prostate brachytherapy-related proctitis. Four patients received supplemental external beam radiation, delivered by a four-field technique. A single gastroenterologist at the Veterans Affairs Puget Sound Health Care System treated 6 of the 7 patients. If the degree of proctitis was limited, all sites of active bleeding were coagulated in symptomatic patients. An argon plasma coagulator electrosurgical system was used to administer treatments every 4–8 weeks as needed. The argon gas flow was set at 1.6 L/min, with an electrical power setting of 40–45 W.Results: The rectal V100 (the total rectal volume, including the lumen, receiving the prescription dose or greater) for the 7 patients ranged from 0.13 to 4.61 cc. Rectal bleeding was first noticed 3–18 months after implantation. APC (range 1–3 sessions) was performed 9–22 months after implantation. Five patients had complete resolution of their bleeding, usually within days of completing APC. Two patients had only partial relief from bleeding, but declined additional APC therapy. No patient developed clinically evident progressive rectal wall abnormalities after APC, (post-APC follow-up range 4–13 months).Conclusions: Most patients benefited from APC, and no cases of clinically evident progressive tissue destruction were noted. Although APC appears to be efficacious and safe in the setting of the rectal doses described here, caution is in order when contemplating APC for brachytherapy patients.

Percutaneous transluminal revascularization for renal artery stenosis: Veterans Affairs Puget Sound Health Care System experience

Purpose: The safety and efficacy of percutaneous transluminal intervention for renal artery stenosis is improving. This study evaluates the immediate and long-term anatomic and functional outcomes of percutaneous transluminal angioplasty and stenting for atherosclerotic renal artery stenosis in a Veterans Affairs population. Methods: We performed a retrospective analysis of records from patients who underwent renal artery angioplasty with or without stenting at the Veterans Affairs Puget Sound Health Care System between January 1990 and June 1999. Indications for intervention included hypertension (78%) and rising serum creatinine (78%). Seventy-six patients (74 men, average age of 67 years, range 42-83 years) underwent 88 attempted interventions. Seventy-two percent of contralateral kidneys had significant disease (47% had a >60% stenosis; 16% were nonfunctioning or absent). Results: Of the 88 planned interventions, 86 were successfully performed with placement of 46 stents (52%). Technical success (defined by <30% residual stenosis) was achieved in 78 vessels (89%). The procedure-related complication rate was 5%. Patient mortality by life table analysis was 49% at 5 years. Assisted primary patency rate at 5 years was 100%. Primary and secondary restenosis rates were 37% ± 8% and 31% ± 8% at 5 years, respectively. Sixty-eight percent of patients treated for hypertension demonstrated clinical benefit (improved or cured hypertension). This clinical benefit was maintained in 52% of the patients at 5 years, as measured by life table analysis. Serum creatinine was lowered or maintained in 88% of the patients, but this clinical benefit was only maintained in 25% of patients at 5 years. Conclusions: Transluminal intervention for clinically symptomatic atherosclerotic renal artery stenosis is technically successful and safe. There are excellent assisted-patency and low restenosis rates. There is immediate clinical benefit for most patients, as evidenced by improved control of hypertension and preservation of renal function. However, within 5 years the benefit is not maintained for either hypertension (50%) or renal function (20%). Therefore, although technically successful, functional outcomes after endoluminal intervention are not maintained in the long term. (J Vasc Surg 2001;34:685-93.)

A comparison of stenting and conventional coronary angioplasty: Long-term survival and rehospitalization in the Department of Veterans Affairs Medical Centers Charles Maynard, Nathan R. Every, Steven M. Wright, James L. Ritchie. Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, Massachusetts Veterans Epidemiology Research Information Center, Boston, MA

A comparison of stenting and conventional coronary angioplasty: Long-term survival and rehospitalization in the Department of Veterans Affairs Medical Centers Charles Maynard, Nathan R. Every, Steven M. Wright, James L. Ritchie. Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, Massachusetts Veterans Epidemiology Research Information Center, Boston, MA

Atypical gastrointestinal symptoms are not associated with gallstones in patients with spinal cord injury

Moonka R, Stiens SA, Stelzner M. Atypical gastrointestinal symptoms are not associated with gallstones in patients with spinal cord injury. Arch Phys Med Rehabil 2000;81:1085-9. Objective: To determine if nonspecific gastrointestinal (GI) symptoms justify cholecystectomy in patients with spinal cord injury (SCI). Design: The frequency of GI symptoms was determined in a sample of patients with SCI in whom the presence or absence of gallstones had been previously determined by screening ultrasonography or a known history of cholecystectomy. The prevalence of various symptoms in patients with and without gallstones was compared. Setting: The Spinal Cord Injury Unit of the Veterans Affairs Puget Sound Health Care System, which provides rehabilitation and longitudinal primary care for SCI veterans. Patients: Two hundred ninety-four patients who had undergone either right upper quadrant ultrasonography or cholecystectomy in the past, and who completed a questionnaire concerning GI symptoms. Main Outcome Measure: Bivariate logistic regression was used to calculate odds ratios (ORs) to determine the strength of associations between the presence of each symptom and the presence of gallstones. Results: Pain in the right upper quadrant or epigastrium that occurred after meals or at night was significantly associated with gallstones (OR: 3.5; 95% confidence interval [CI] 1.02-11.73). Abdominal pain in other locations and nonspecific symptoms such as bloating and nausea, were not predictive of the presence of gallstones. Conclusions: Nonspecific symptoms in patients with SCI are not associated with gallstones and do not justify cholecystectomy in patients with otherwise asymptomatic gallstones. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Trends in the post-hospitalization medical treatment of unstable angina pectoris: 1990 to 1995

This study provides data on post-hospitalization medication treatment trends for unstable angina between 1990 and 1995. We conducted an observational cohort study at the Veterans Affairs Puget Sound Health Care System (VAPSHCS). Computerized records of hospital discharges and cardiac catheterizations were used to identify unstable angina diagnoses among veterans between 1990 and 1995. Discharge medications issued within 90 days after discharge were ascertained from computerized outpatient pharmacy records. Of the 1,100 veterans discharged with unstable angina, 885 (80%) filled a prescription through the VAPSHCS within 90 days after discharge. Neither use of aspirin nor use of β blockers increased between 1990 and 1995: overall use averaged 76% for aspirin (78% of those without potential contraindications) and 32% for β blockers (36% of those without potential contraindications). Use of non-dihydropyridine calcium antagonists—primarily diltiazem—decreased from 57% to 40% (p <0.01), whereas use of dihydropyridine calcium antagonists increased from 12% to 26% (p <0.01). Thus, pharmacy records indicated that aspirin use was high although it was lower than expected, possibly due to ready availability outside the VAPSHCS pharmacy. The low frequency of β-blocker use and the increasing reliance on dihydropyridine calcium antagonists through 1995 to treat unstable angina may be an opportunity to improve veteran care according to Agency for Health Care Policy Research recommendations.

Health outcomes associated with beta-blocker and diltiazem treatment of unstable angina

Objective. We compared long-term health outcomes associated with beta-adrenergic blocking agents and diltiazem treatment for unstable angina.Background. No long-term data have been published comparing these two antianginal treatments in this setting.Methods. Eligible veterans were discharged from the Veterans Affairs Puget Sound Health Care System (VAPSHCS), Seattle Division, between October 1989 and September 1995 with an unstable angina diagnosis and were prescribed monotherapy beta-blocker or diltiazem treatment at discharge. Medication data were collected from medical records and computerized VAPSHCS outpatient pharmacy files. Follow-up death and coronary artery disease rehospitalization data were collected through 1996. Proportional hazards regression compared survival among diltiazem and beta-blocker users, controlling for patient characteristics with propensity scores.Results. Two hundred forty-seven veterans (24% on beta-blockers, 76% on diltiazem) were included in this study. There were 54 (22%) deaths during an average follow-up of 51 months. After propensity score adjustment, there was no difference in risk of death comparing diltiazem to beta-blocker treatment (hazards ratios [HR] 1.1; 95% confidence interval [CI] 0.49 to 2.4). Among Washington residents (n = 207), there were 146 (71%) coronary artery disease rehospitalizations or deaths during follow-up. After adjustment, there was a nonsignificant increase in risk of rehospitalization or death associated with diltiazem use (HR 1.4; 95% CI 0.80 to 2.4). For both analyses, similar risks were found among veterans without relative contraindications to beta-blockers.Conclusions. We found no survival benefit of diltiazem over beta-blocker treatment for unstable angina in this cohort of veterans.

THE EFFECT OF PROSTATE VOLUME ON THE YIELD OF NEEDLE BIOPSY

Purpose Early diagnosis of prostate carcinoma has undergone significant evolution mainly due to the widespread use of serum prostate specific antigen, transrectal ultrasonography and spring loaded biopsy devices. A common dilemma faced by clinicians arises when a negative biopsy is obtained in a patient and there is a high suspicion for prostate carcinoma. The literature reveals a 20 to 40% positive repeat biopsy rate in men with elevated prostate specific antigen who had an initial negative biopsy. [1-3] We determined the yield of 6 systematic sector biopsies as a function of total gland and peripheral zone volumes. Materials and Methods The database of transrectal ultrasound guided prostate needle biopsies performed at the Department of Urology, University of Washington Medical Center and Veterans Affairs Puget Sound Health Care System was reviewed. The yield of the 6 biopsies was determined as a function of the total gland and peripheral zone volumes. Results A total of 1,057 men who underwent transrectal ultrasound guided prostate needle biopsies were investigated in our study. Of the men 326 were diagnosed with prostate cancer for a positive biopsy rate of 30.8%. No relationship between gland size and cancer yield was seen using total gland volume compared to the first quartile until the largest quartile when a significantly lower cancer detection rate was noted (odds ratio 1.5). Conclusions The positive yield of the systematic 6-sector biopsy decreases significantly when the total gland volume is greater than 55.6 cc or peripheral zone volume is greater than 33.61 cc. In men with smaller prostates 6 systematic sector biopsies should be adequate.

Hemodynamic Response and Change in Organ Blood Volume During Spinal Anesthesia in Elderly Men with Cardiac Disease

Anesthesia Service and Nuclear Medicine Section, Veterans Affairs Puget Sound Health Care Center and Departments of Anesthesiology and Radiology, University of Washington, Seattle, Washington

Beyond the needle: expanding the role of anesthesiologists in the management of chronic non-malignant pain.

Beyond the needle: expanding the role of anesthesiologists in the management of chronic non-malignant pain.