Beach Veterans Affairs Medical Center Research Articles

Retrospective Review of Perioperative Multimodal Analgesia for Orthopedic Patients in a Veterans Affairs Setting.

To determine adherence of perioperative knee/hip arthroplasties and hip fracture repairs to the American Pain Society (APS) guideline recommendations for perioperative pain control. One secondary objective was to perform an internal quality audit on the use of enhanced recovery after surgery (ERAS) protocols; another secondary objective was to design an evidence-based, multi-modal perioperative quick-order menu (if warranted). A retrospective quality improvement (QI) review of uncomplicated knee/hip replacement and hip fracture repairs from January 2018 through March 2018. West Palm Beach Veterans Affairs Medical Center (WPB VAMC) including acute care, subacute rehabilitation, and outpatient setting. Analgesic use in the perioperative setting via electronic health record review. Forty-seven patients were retrospectively reviewed. Perioperative multi-modal analgesia was used in 85% of patients. Eighty-seven percent were discharged on multi-modal analgesia. There was a 67% response rate to the internal quality audit on ERAS protocol usage from the orthopedic team. A retrospective QI review completed approximately two years after APS guideline publication showed that compliance with these recommendations for multi-modal analgesia (consisting of the use of at least two medication classes) at the WPB VAMC in the postoperative setting for knee/hip arthroplasties and hip fracture repairs was 85%. This indicated potential for improvement in achieving a pharmacologic multimodal and ERAS intervention. The authors developed an evidence-based quick-order menu to further reinforce adherence to the APS perioperative guidelines.

Drive Through Point of Care International Normalized Ratio Testing During the COVID-19 Pandemic

In order to help combat COVID-19 and provide consistent and safe care for the veterans at the West Palm Beach Veterans Affairs Medical Center (WPVAMC), a drive through Point of Care International Normalized Ratio (POC-INR) testing site was implemented. This drive through clinic allows veterans taking warfarin to safely obtain anticoagulation management while complying with social distancing guidelines.

Retreatment of Hepatitis C Infection With Direct-Acting Antivirals

Treatment of hepatitis C virus (HCV) infection with direct-acting antivirals (DAAs) results in sustained virologic response (SVR) in > 90% of patients. However, some patients required retreatment with newer DAA options. Treatment was selected after consultation with a clinical pharmacy specialist. A retrospective chart review of patients at the West Palm Beach Veterans Affairs Medical Center (WPBVAMC) in Florida retreated from January 2015 to December 2019 was conducted. Data collected included HCV genotype, previous therapy, newly prescribed medications, and treatment outcomes. Since 2015, > 900 patients have been treated at WPBVAMC, including 22 patients who had previously failed interferon combined with DAA regimens and 46 patients who needed retreatment after failure with an all-oral therapy. This review documents the outcomes of retreatment with DAA after initial failure to achieve SVR Of 28 patients treated with a boceprevir-based regimen, 10 ended in failure. All 10 were retreated, and all achieved SVR with ledipasvir/sofosbuvir. Of 53 patients treated with a sofosbuvir-based interferon regimen, 12 failed treatment. All 12 were retreated and all achieved SVR. Thirty patients were retreated after failure with an all-oral DAA. Of 27 tested, 21 achieved SVR. All patients who failed therapy again had cirrhosis. Veterans retreated with DAAs for HCV infection had a high success rate. Repeat failures of DAAs were rare, but cirrhosis seems to be common among these patients.

Pharmacy-Led Quality Improvement Project on Pain Control Using Continuous Subcutaneous Infusion of Opioids in an Inpatient Hospice Unit.

The purpose of this quality improvement (QI) project was to improve the overall process of implementing continuous subcutaneous infusion of opioids (CSCIOs) at the West Palm Beach Veterans Affairs Medical Center and characterize their use in the hospice unit. A retrospective chart review from July 2014 to August 2017 was conducted to identify patients who had received CSCIO. Results were analyzed with descriptive statistics.The business philosphy, LEANmethodology "The 5 Whys" was utilized to identify the root causes for delayed infusion timeliness and corrections were implemented by August 2018. Follow-up retrospective time study completed from September 2018 to February 2019. Of the 107 patients identified, 7 were excluded and 100 were reviewed. The mean age was 73 years, 94% male, and 86% Caucasian. A total of 55 veterans received morphine with an average final infusion rate of 2.5 mg/h. A total of 45 Veterans received hydromorphone with a final infusion rate of 1.3 mg/h. The average infusion duration until death was 5 days. Pharmacy verified 94 (94%) orders and nursing verified 55 (55%) orders within 1 hour (gold standard). Sixteen (16%) patients received CSCIO within 1 hour. The 5 Whys identified nursing order verification and pharmacy lack of visual STAT order notification for priority as the potential sources for infusion timeliness improvement. The follow-up time study confirmed improvement in pharmacy delivery time from 29% to 75% on time. Pharmacist-led intervention directed to improve CSCIO processes in an inpatient hospice unit utilizing LEAN QI methodology increased timeliness of pharmacy CSCIO delivery.

Implementation and evaluation of Parkinson disease management in an outpatient clinical pharmacist-run neurology telephone clinic.

Parkinson disease (PD) is a progressive, debilitating neurodegenerative disease that often requires complex pharmacologic treatment regimens. Prior to this clinic, there was no involvement of a clinical pharmacy specialist (CPS) in the outpatient neurology clinic at the West Palm Beach Veterans Affairs Medical Center. This was a prospective, quality-improvement project to develop a clinical pharmacist–run neurology telephone clinic and evaluate pharmacologic and nonpharmacologic interventions in an effort to improve the quality of care for patients with PD. Additionally, the CPS conducted medication education groups to 24 patients with PD and their caregivers, if applicable, at this medical center with the purpose of promoting patient knowledge and medication awareness. Medication management was performed via telephone rather than face to face. Only patients with a concomitant mental health diagnosis for which they were receiving at least one psychotropic medication were included for individual visits due to the established scope of practice of the CPS being limited to mental health and primary care medications. Data collection included patient and clinic demographics as well as pharmacologic and nonpharmacologic interventions made for patients enrolled from January 6, 2017, through March 31, 2017. A total of 49 pharmacologic and nonpharmacologic interventions were made for 10 patients. We successfully implemented and evaluated a clinical pharmacist–run neurology telephone clinic for patients with PD. Expansion of this clinic to patients with various neurological disorders may improve access to care using an innovative method of medication management expertise by a CPS.

Integration of a Clinical Pharmacist into an Interdisciplinary Palliative Care Outpatient Clinic

The primary objective of this quality improvement (QI) project was to determine if the Interdisciplinary Palliative Care Outpatient Clinic (IPCOC) at the West Palm Beach Veterans Affairs Medical Center offered improved symptom assessment and palliative care treatment outcomes. Secondary objectives were to identify, classify, and resolve medication problems and calculate the number of pharmacist recommendations accepted by prescribing providers. An IPCOC was created by selecting disciplines for a core group including a nurse practitioner, clinical pharmacist, social worker, chaplain, and physician. Consult referrals were recruited by providing educational sessions. The patient assessments were completed using the Edmonton Symptom Assessment System: (revised version; ESAS-R). The clinical pharmacist classified and resolved drug-related problems. The pharmacy resident telephoned veterans for completion of the "Patient Assessment: Overall Satisfaction with Outpatient Palliative Care Clinic." Seventeen consults were received, 6 patients were excluded, and 11 were seen in clinic. One (9%) of 11 patients met the outcomes measure of system assessment documentation in the past year. At completion, 11 (100%) of 11 patients met the outcomes data measure. The Patient Satisfaction Assessment revealed veterans strongly agree to recommend the IPCOC. The clinical pharmacist identified 20 drug-related problems, made 16 recommendations, had a 93.7% implementation rate, and facilitated implementation of medication changes. This QI project demonstrates that an IPCOC improved symptom assessment and palliative care outcomes in addition to resolution of medication prescribing issues in veterans with advanced cancer by integration of a clinical pharmacist into the core team.

Racial parity in tumor burden, treatment choice and survival outcomes in men with prostate cancer in the VA healthcare system.

African-American men with prostate cancer typically have higher tumor risk at diagnosis, lower rates of surgical treatment and poorer cancer-specific survival compared with Caucasians. Receipt of care within the Veterans Affairs (VA) healthcare system may reduce barriers that influence these disparities. We sampled 1258 men with nonmetastatic prostate cancer diagnosed at the Greater Los Angeles and Long Beach VA Medical Centers between 1998 and 2004. We compared African Americans and Caucasians with respect to tumor characteristics using ordinal logistic regression, treatment choice across substrata of tumor risk using logistic regression, and cancer-specific and other-cause mortality using competing risks regression analysis. Multivariate ordinal logistic regression revealed no significant differences in odds of higher tumor risk (odds ratio (OR) 1.22, 95% confidence interval (CI) 0.98-1.53, P=0.08), Gleason score (OR 0.90, 95% CI 0.7-1.16, P=0.4) or clinical stage (OR 1.04, 95% CI 0.79-1.38, P=0.8) for African Americans compared with Caucasians. African-American men had similar odds of aggressive treatment as did Caucasians for low-risk (OR 0.92, 95% CI 0.57-1.53, P=0.8), intermediate-risk (OR 0.75, 95% CI 0.44-1.26, P=0.3) and high-risk disease (OR 0.87, 95% CI 0.52-1.44, P=0.6). In competing risks regression analysis, African Americans had a lower but nonsignificant hazard of cancer-specific mortality compared with Caucasians (sub-hazard ratio 0.6, 95% CI 0.28-1.26, P=0.2) and nearly identical risk of other-cause mortality (sub-hazard ratio 0.98, 95% CI 0.78-1.22, P=0.8). We found no significant differences in tumor burden, treatment choice or survival outcomes between African Americans and Caucasians cared for in the equal-access VA Healthcare setting.

Re-implementation of a pharmacist-managed metabolic syndrome clinic in an outpatient mental health clinic setting

Introduction: Second-generation antipsychotics (SGA) are often prescribed prior to first-generation antipsychotics (FGA) for mental health disorders by reason of proposed improved tolerability. Patients on SGA are not always appropriately screened for metabolic parameters in the clinical setting. A metabolic clinic was previously established for a limited time period at the West Palm Beach Veterans Affairs Medical Center (WPB VAMC) with beneficial outcomes. Re-implementation expanded the clinic to assess the impact when patients were referred from outpatient mental health and primary care providers. The objectives of this quality improvement initiative were to evaluate pharmacologic and nonpharmacologic interventions and compare the patient load preexpansion and postexpansion of the metabolic clinic. Methods: Patients receiving SGA at the WPB VAMC who met the criteria for metabolic syndrome were referred to the metabolic clinic. Preclinic data variables collected include demographics, social history, SGA, and assessment for presence of hypertension, diabetes, or dyslipidemia. Pharmacologic and nonpharmacologic intervention variables were collected throughout clinic involvement. The patient load post clinic expansion was reported. Results: Of the 17 patients evaluated, 88.2% had hypertension, 94.1% had dyslipidemia, and 88.2% had diabetes mellitus. The average number of components of metabolic syndrome was 3.7 out of 5 possible components. Most patients were taking risperidone (47.1%). An average of 1.5 medication interventions were made per patient. Only 28 patients were referred during reimplementation phase. Discussion: Metabolic syndrome commonly occurs in patients receiving SGA. Appropriately trained clinical pharmacists can help fill a gap in care by providing the recommended monitoring criteria and interventions for patients taking SGA.

Dialogue on Geriatrics: How Should We Fix the Problem?

Letters18 September 2012Dialogue on Geriatrics: How Should We Fix the Problem?Adam G. Golden, MD, MBA, Michael A. Silverman, MD, MPH, CMD, and Michael J. Mintzer, MDAdam G. Golden, MD, MBAFrom University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando, FL 32803; West Palm Beach Veterans Affairs Medical Center, West Palm Beach, FL 33410; and University of Miami Miller School of Medicine and Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125.Search for more papers by this author, Michael A. Silverman, MD, MPH, CMDFrom University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando, FL 32803; West Palm Beach Veterans Affairs Medical Center, West Palm Beach, FL 33410; and University of Miami Miller School of Medicine and Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125.Search for more papers by this author, and Michael J. Mintzer, MDFrom University of Central Florida College of Medicine and Orlando Veterans Affairs Medical Center, Orlando, FL 32803; West Palm Beach Veterans Affairs Medical Center, West Palm Beach, FL 33410; and University of Miami Miller School of Medicine and Miami Geriatric Research Education and Clinical Center, Bruce W. Carter Veterans Affairs Medical Center, Miami, FL 33125.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-157-6-201209180-00022 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail IN RESPONSE:Several comments state that our line of reasoning may be “dubious” or “negative.” Drs. Burton and Durso even contend that “geriatrics is very much alive” based on teaching and research efforts occurring at academic medical centers. However, no evidence is provided to dispute that the clinical subspecialty of geriatric medicine in the United States remains an unpopular career choice, is poorly reimbursed, and lacks sufficient research demonstrating its effectiveness compared with nongeriatricians (1). In addition, we agree with Dr. Hamerman that despite much progress in the basic science of aging, these efforts have not translated into geriatrician-specific medical ...

Improved Prediction of Long-Term, Other Cause Mortality in Men With Prostate Cancer

Comorbidity assessment is essential to triage of care for men with prostate cancer. We identified long-term risks of other cause mortality associated with comorbidities in the Charlson index and applied these to the creation of a prostate cancer specific comorbidity index. We sampled 1,598 cases of prostate cancer diagnosed in 1997 to 2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. We used Cox proportional hazards modeling to determine the risks of other cause mortality associated with comorbidities and used these hazard ratios to re-weight the Charlson index. We then compared the ability of each index to predict other cause mortality. Cox modeling showed that moderate to severe liver disease, metastatic solid tumor, lymphoma and leukemia carried the highest risk (HR greater than 5) for other cause mortality, followed by moderate to severe chronic obstructive pulmonary disease, moderate to severe renal disease, dementia, hemiplegia and congestive heart failure (HR 2.5 to less than 3.5). The revised and original Charlson indices performed similarly in predicting other cause mortality across all patients (c-index 0.816 vs 0.802). However, in survival analysis our revised index identified 137 men with a greater than 90% probability of other cause mortality within 10 years while the original Charlson identified only 51. In multivariate modeling the odds of 5-year other cause mortality for men with original Charlson scores 1, 2, 3 and 4+ were 2.9, 6.0, 9.2 and 29.8, respectively, compared with 3.9, 6.2, 12.8 and 84.2 for the revised index. Re-weighting the Charlson index allowed for more accurate identification of men at highest risk for other cause mortality. Our revised index may be used to aid medical decision making for men with prostate cancer.

Comorbidities, Treatment and Ensuing Survival in Men with Prostate Cancer

Comorbidity is poorly integrated into prostate cancer decision making. We sought to characterize treatment type and subsequent survival for men with no more than a single comorbid condition. We conducted a retrospective study of 1,031 veterans with non-metastatic prostate cancer diagnosed in 1997-2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers and followed until 2010. We used multivariate analyses to determine probabilities and relative risks of undergoing treatment for each health state and competing-risks regression analyses to model non-prostate cancer mortality. Compared with subjects without any comorbid conditions, only men with moderate-severe chronic obstructive pulmonary disease were less likely to receive definitive treatment for their prostate cancer (RR 0.74; 95% CI 0.44-0.99). Men with all other individual comorbidities were equally likely as men without comorbidity to receive definitive treatment. Compared with men without any comorbidities, a higher hazard rate for non-prostate cancer mortality was identified among men with diabetes without end-organ damage (HR 2.32; 95% CI 1.32-4.08), peripheral vascular disease (HR 2.77; 95% CI 1.14-6.73), moderate-severe chronic obstructive pulmonary disease (HR 5.46; 95% CI 2.68-11.12), diabetes with end-organ damage (HR 4.27; 95% CI 1.64-11.10), those in need of a mobility device (HR 3.29; 95% CI 1.87-5.80), and men with history of alcoholism (HR 1.77; 95% CI 1.07-2.93). Men with comorbid conditions and health states that portend poor prognoses are nonetheless aggressively treated for their prostate cancer. Advancing age modulates this effect.

Bone Scan Overuse in Staging of Prostate Cancer: An Analysis of a Veterans Affairs Cohort

To determine the use and subsequent yield of bone scan imaging in a contemporary Veterans Affairs (VA) cohort of men with prostate cancer. With contemporary widespread prostate-specific antigen (PSA) screening, more patients are being diagnosed with low- and intermediate-risk prostate cancer, reducing the need and yield of bone scan imaging. We retrospectively reviewed the charts of 1598 men diagnosed with prostate cancer from 1998 to 2004 at the Greater Los Angeles and Long Beach VA Medical Centers. We used univariate and multivariate analyses to measure the association between patient (age, race, and comorbidities) and tumor (PSA, clinical stage, Gleason grade) characteristics with bone scan use and subsequent positivity. We conducted the analysis for scans for the entire cohort and those with low and high risk of metastatic disease. Of 519 men with low-risk disease, 132 (25%) underwent bone scan imaging, none with positive findings. On multivariate analysis for the entire cohort, younger age, Long Beach VA site, increasing PSA level (≥10 ng/mL), clinical stage (cT2 or greater), and Gleason score (≥7) were all positively associated with bone scan use; however, only PSA level ≥20 ng/mL, clinical stage cT3 or greater, and Gleason score ≥4 + 3 corresponded with positivity. A bone scan positivity rate of ≥10% was limited to men with clinical stage cT3 or greater, Gleason score of ≥8, or PSA level of ≥20 ng/mL. Although decreasing in incidence with time, our results demonstrate extensive overuse of bone scan imaging among VA patients with low-risk prostate cancer. These patterns of overuse for men with low-risk cancer, yielding no positive findings, result in unnecessary patient anxiety and significant economic waste for the VA Healthcare System.

Comorbidity and competing risks for mortality in men with prostate cancer

Accurate estimation of life expectancy is essential for men deciding between aggressive and conservative treatment of prostate cancer. The authors sought to assess the competing risks of nonprostate cancer and prostate cancer mortality among men with differing Charlson comorbidity index scores and tumor risks. The authors conducted a retrospective study of 1482 men with nonmetastatic prostate cancer diagnosed from 1997 to 2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. They performed Kaplan-Meier and competing risks regression analyses to assess survival outcomes. After a mean follow-up of 6.0 years, 370 (25%) men died from other causes, whereas 44 (3%) died of prostate cancer. At 10 years after diagnosis, men with Charlson scores 0, 1, 2, and 3+ had nonprostate cancer mortality rates of 17%, 34%, 52%, and 74%, respectively. In competing risks regression analysis, each point increase in Charlson score was associated with a 2-fold increase in hazard of nonprostate mortality. Men with Charlson 3+ had 8.5× the hazard of death from other causes, compared with men with the lowest scores (subhazard ratio, 8.5; 95% confidence interval, 6.2-11.7). After stratification by tumor risk, nonprostate mortality rates remained markedly elevated among men with higher Charlson scores, whereas prostate cancer mortality was rare, especially among low-risk and intermediate-risk groups (0.4%, 3%, and 8% for low, intermediate, and high risk, respectively). Men with the highest Charlson scores should consider conservative management of low-risk and intermediate-risk tumors, given their exceedingly high risk of death from other causes and low risk of prostate cancer mortality.

437 OVERTREATMENT OF MEN WITH LOW-RISK PROSTATE CANCER AND SIGNIFICANT COMORBIDITY

INTRODUCTION AND OBJECTIVES: Men with low-risk prostate cancer and significant comorbidity are susceptible to overtreatment. We sought to compare the impact of comorbidity and age on treatment choice in men with low-risk disease. METHODS: We sampled 509 men with low-risk prostate cancer diagnosed at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers in 1997–2004. We determined rates of aggressive treatment (radical prostatectomy, radiation therapy, brachytherapy) among men with different ages and Charlson comorbidity scores. We used multivariate modeling to determine the influence of each in predicting non-aggressive treatment. We used Cox proportional hazards analysis to compare risks of othercause mortality among Charlson and age groups. RESULTS: Men with Charlson scores 3 were treated aggressively in 30 of 56 cases (54%), while men 75 years at diagnosis were treated aggressively in 7 of 44 cases (16%). In multivariate analysis, age 75 was a much stronger predictor of non-aggressive treatment (RR12.0, 95%CI 5.4– 28.3) than Charlson 3 (RR2.0, 95%CI 1.3–2.9). In survival analysis, men with Charlson 3 had an eightfold increased risk (HR8.4, 95%CI 4.2–16.6) and 70% probability of other-cause mortality at 10 years, while age 75 was associated with a fivefold increased risk (HR4.9, 95%CI 1.7–13.8) and 24% probability of other-cause mortality. CONCLUSIONS: Men with significant comorbidity were often overtreated for low-risk prostate cancer. Like advanced age, significant comorbidity should be a strong relative contraindication to aggressive treatment in men with low-risk disease.

37 IMPROVED PREDICTION OF LONG-TERM, OTHER-CAUSE MORTALITY IN MEN WITH PROSTATE CANCER

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes1 Apr 201137 IMPROVED PREDICTION OF LONG-TERM, OTHER-CAUSE MORTALITY IN MEN WITH PROSTATE CANCER Timothy Daskivich, Lorna Kwan, Karim Chamie, Jessica Labo, Atreya Dash, Sheldon Greenfield, and Mark Litwin Timothy DaskivichTimothy Daskivich Los Angeles, CA More articles by this author , Lorna KwanLorna Kwan Los Angeles, CA More articles by this author , Karim ChamieKarim Chamie Los Angeles, CA More articles by this author , Jessica LaboJessica Labo Los Angeles, CA More articles by this author , Atreya DashAtreya Dash Irvine, CA More articles by this author , Sheldon GreenfieldSheldon Greenfield Irvine, CA More articles by this author , and Mark LitwinMark Litwin Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.100AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Comorbidity assessment is essential to triage of care for men with prostate cancer. We sought to identify long-term risks of other-cause mortality associated with comorbidities in the Charlson index and apply these to creation of a prostate cancer-specific comorbidity index. METHODS We sampled 1,598 men with prostate cancer diagnosed in 1997–2004 at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers. We used a Cox proportional hazards model to determine risks of other-cause mortality associated with comorbidities and used these hazard ratios to reweigh the Charlson index. We then compared the ability of each index to predict other-cause mortality using survival analysis and multivariate logistic regression. RESULTS Cox proportional hazards modeling showed that moderate-severe liver disease, metastatic solid tumor, lymphoma, and leukemia carried the highest risk(HR>5) for other-cause mortality, followed by moderate-severe COPD, moderate-severe renal disease, dementia, hemiplegia, and congestive heart failure(2.5≤HR<3.5). In survival analysis, our revised index identified 137 men with >90% probability of other-cause mortality within 10 years; the original Charlson identified only 51. In a multivariate model, the odds of 5-year other-cause mortality for men with original Charlson scores 1, 2, 3, and 4+ were 2.9, 6.0, 9.2, and 29.8(p<0.0001), respectively, compared with 3.9, 6.2, 12.8, and 84.2(p<0.0001) for the revised index. CONCLUSIONS Reweighing the Charlson index using disease-specific risks allowed for more accurate identification of men at highest risk for other-cause mortality. Our revision of the Charlson index may be used to aid medical decision making in men with prostate cancer. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e15 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information Timothy Daskivich Los Angeles, CA More articles by this author Lorna Kwan Los Angeles, CA More articles by this author Karim Chamie Los Angeles, CA More articles by this author Jessica Labo Los Angeles, CA More articles by this author Atreya Dash Irvine, CA More articles by this author Sheldon Greenfield Irvine, CA More articles by this author Mark Litwin Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

Overtreatment of men with low‐risk prostate cancer and significant comorbidity

Men with low-risk prostate cancer and significant comorbidity are susceptible to overtreatment. The authors sought to compare the impact of comorbidity and age on treatment choice in men with low-risk disease. The authors sampled 509 men with low-risk prostate cancer diagnosed at the Greater Los Angeles and Long Beach Veterans Affairs Medical Centers between 1997 and 2004. Rates of aggressive treatment (radical prostatectomy, radiation therapy, brachytherapy) were determined among men of different ages and with different Charlson comorbidity scores. Multivariate modeling was used to determine the influence of both variables in predicting nonaggressive treatment, and Cox proportional hazards analysis was used to compare the risk of other-cause mortality among groups according to Charlson score and age. Men with Charlson scores ≥ 3 were treated aggressively in 54% of cases (30 of 56 men), while men aged >75 years at diagnosis were treated aggressively in 16% of cases (7 of 44 men). In multivariate analysis, age >75 years was a much stronger predictor of nonaggressive treatment (relative risk, 12.0; 95% confidence interval [CI], 5.4-28.3) than a Charlson score ≥ 3 (relative risk, 2.0; 95% CI, 1.3-2.9). In survival analysis, men with Charlson scores ≥ 3 had an 8-fold increased risk (hazard ratio, 8.4; 95% CI, 4.2-16.6) and 70% probability of other-cause mortality at 10 years, whereas age >75 years was associated with a 5-fold increased risk (hazard ratio, 4.9; 95%CI, 1.7-13.8) and a 24% probability of other-cause mortality. Men with significant comorbidity often were overtreated for low-risk prostate cancer. Like advanced age, significant comorbidity should be a strong relative contraindication to aggressive treatment in men with low-risk disease.

Sepsis Due to Fluoroquinolone-resistant Escherichia coli After Transrectal Ultrasound-guided Prostate Needle Biopsy

To report a series of patients with sepsis due to fluoroquinolone-resistant Escherichia coli after prostate needle biopsy across 4 hospitals in southern California. Five patients presented with fever and blood cultures positive for fluoroquinolone-resistant E. coli after prostate needle biopsy with pre-procedure fluoroquinolone antimicrobial prophylaxis. The cases are described and the published data reviewed. Of the 5 patients, 1 was treated at Hoag Memorial Hospital in 2008, 2 were treated at the Long Beach Veterans Affairs Medical Center, 1 was treated at Kaiser Permanente Hospital in 2007, and 1 presented to University of California, Irvine, Medical Center in 2006. All patients received an oral fluoroquinolone antibiotic the morning of or 1 hour before biopsy. Of the 5 patients, 4 also received gentamicin intramuscularly before biopsy. The estimated incidence of sepsis was 0.1%-0.9%, assuming patients reported to the hospital at which the biopsy was performed. From a review of the published data, we recommend a fluoroquinolone antibiotic before and after biopsy for < or =24 hours. From our findings, if the patient has taken a fluoroquinolone antibiotic in the past 8 months, a second- or third-generation cephalosporin should be used or an aminoglycoside (1.5-2 mg/kg intramuscularly) with metronidazole or clindamycin. A carbapenem should be substituted if the patient has a history of infections with extended-spectrum beta-lactamase producers. Cases of fluoroquinolone-resistant E. coli should be tracked in a nationalized database.

Estrogen Prevents Cardiomyocyte Apoptosis through Inhibition of Reactive Oxygen Species and Differential Regulation of p38 Kinase Isoforms

From human and animal studies, estrogen is known to protect the myocardium from an ischemic insult. However, there is limited knowledge regarding mechanisms by which estrogen directly protects cardiomyocytes. In this report, we employed an in vitro model, in which cultured rat cardiomyocytes underwent prolonged hypoxia followed by reoxygenation (H/R), to study the cardioprotective mechanism of estrogen. 17-beta-estradiol (E2) acting via estrogen receptors inhibited H/R-induced apoptosis of cardiomyocytes. Mitochondrial reactive oxygen species (ROS) generated from H/R activated p38alpha MAPK, and inhibition of p38alpha with SB203580 significantly prevented H/R-induced cell death. E2 suppressed ROS formation and p38alpha activation by H/R and concomitantly augmented the activity of p38beta. Unlike p38alpha, p38beta was little affected by H/R. Dominant negative p38beta protein expression decreased E2-mediated cardiomyocyte survival and ROS suppression during H/R stress. The prosurvival signaling molecule, phosphoinositol-3 kinase (PI3K), has previously been linked to cell survival following ischemia-reperfusion injury. Here, E2-activated PI3K was found to inhibit ROS generated from H/R injury, leading to inhibition of downstream p38alpha. We further linked these signaling pathways in that p38beta was activated by E2 stimulation of PI3K. Thus, E2 differentially modulated two major isoforms of p38, leading to cardiomyocyte survival. This was achieved by signaling through PI3K, integrating cell survival mediators.

Retrospective Review of Megestrol Use for Weight Loss in an Elderly Veteran Population

Evaluate the efficacy of megestrol acetate therapy for nonmalignancy and/or non-AIDS-related weight loss in the elderly. Retrospective chart review. Inpatients or outpatients at the West Palm Beach Veterans Affairs Medical Center. Two inclusion criteria were applied: patients older than 65 years and patients initiated on megestrol therapy from January 1 to December 31, 2002. All eligible patients meeting the above criteria were eligible for inclusion in the study. Patients who had a diagnosis of malignancy and/or AIDS, no baseline weight, no follow-up weights, no record of laboratory values, and/or were receiving enteral or parenteral nutrition available at the West Palm Beach Veterans Affairs Medical Center, were excluded. Patients who received megestrol therapy for less than one week also were excluded. Weight loss in the previous six months, baseline weight, follow-up weights at 3, 6, 9, and 12 months after megestrol initiation, baseline and follow-up albumin for 12 months after megestrol initiation, and any adverse effects from megestrol. Fifty-seven patients (males 56, females 1) were included. The average age was 78.5 years old. The average duration of therapy was 3.2 months, and the average starting dose of megestrol was 436 mg per day. At baseline, patients were, on average, 102% of their ideal body weight. Baseline measurement of albumin was obtained in 89% (N = 23) of patients. Six out of 23 (26%) patients had a baseline albumin less than 3 g/dL. The average baseline albumin was 3.6. Weight loss in the six months prior to megestrol initiation occurred in 63% of patients. Over the 12-month follow-up period, the percentage of patients who gained weight was 40%, lost weight was 49%, and had no change in weight was 11%. There were no differences in baseline characteristics between the patients who did or did not gain weight during the 12-month period after megestrol initiation. No documented adverse side effects were attributed to megestrol. Patients both gained and lost weight when receiving megestrol therapy. There was no difference between the patients who did or did not gain weight using objective measures of weight loss.

Effect of Age and End Point on the Prognostic Value of the Exercise Test

The clinical and exercise test variables chosen for predicting prognosis vary in the available studies. This could be due to the effect of age of the patients tested and the choice of outcomes used as end points in these follow-up studies. To evaluate the effect of age and end points on exercise test variables chosen as significantly and independently associated with time to death. Analyses were performed on the first treadmill test performed on consecutive male veterans at the Palo Alto and Long Beach Veterans Affairs Medical Centers since 1987. After removal of patients with congestive heart failure, coronary interventions, left bundle-branch block, atrial fibrillation, myocardial infarction and/or Q wave, and digoxin use, 3,745 male subjects remained. The outcomes were cardiovascular and all-cause mortality. The study population was divided into subsets according to age; exercise test and clinical variables were analyzed within the age subsets using the Cox hazard model. The mean age at the time of testing was 57 +/- 12 years (+/- SD) and they were followed up for a mean of 6.6 years. There were 544 all-cause deaths, with 206 of the deaths being due to cardiovascular causes (38%). When the study group was classified into subsets based on age, exercise capacity (in metabolic equivalents [METs]) was chosen by the Cox hazard model most consistently in the age groups using either end point. Even when age was added to the Duke treadmill score, prediction of death did not improve in those > 70 years of age because of the nonlinear relationship between age, the exercise test variables, and time to death. The most important age cut points for clinically important differences in exercise test predictors appeared to be 70 years and 75 years of age. In the patients 70 to 75 years of age, peak METs was the only variable predictive of all-cause mortality, and exercise-induced ST-segment depression was the only predictor of cardiovascular death; in the patients > 75 years of age, none of the exercise test responses were predictive of either death outcome. Both age and the outcome selected as an end point affect the exercise test responses chosen for scores to predict prognosis. Differences in age of the subjects tested and/or the outcome selected as the end point can explain the differences in the studies using exercise testing to predict prognosis.