University Of Michigan Health System Research Articles

Abstract 2397: Mutation signatures and intratumor heterogeneity of esophageal squamous cell carcinoma in a Chinese cohort

Abstract Esophageal squamous cell carcinoma (ESCC) is one of the most common and most aggressive cancers. The epidemiological features of ESCC are extremely complex, with strong geographic differentiation among world's populations. Rural Anyang in the Henan Province of China is a well-known high-incidence area, however the causal factors in this population remain elusive. We performed exome sequencing of 81 tumor-normal pairs, identified TP53, ZNF750 and NOTCH1 as significantly mutated genes, and observed highly recurrent aberrations in several other genes previously reported for ESCC (PIK3CA, KMT2D, FAT2 and FAT1). Our catalog of ∼7,000 single-nucleotide mutations revealed two main signatures: C>T transitions at NpCpG due to spontaneous deamination of 5-methyl-cytosine, and C>T and C>G mutations at TpCpW attributed to the APOBEC family of cytidine deaminases. The latter signature points to HPV infection as one of the potential mutagenic sources, consistent with our previous studies that detected HPV DNA in tumor samples and anti-HPV-E7 antibody in patient's blood. To characterize intratumor heterogeneity we applied our newly developed method, CHAT, to estimate the clonal frequencies of copy number alternations and single nucleotide mutations in each tumor. Many tumors show a multi-modal distribution of clonal frequencies, suggesting extensive within-tumor diversity due to coexistence of multiple clones. Known ESCC-related genes tend to show mutations of higher clonality than those in other genes. To better understand the patterns of growth, migration and metastatic potential among different cells within a tumor we performing exome sequencing to compare multiple regions in 10 ESCC as well as 2 esophageal neuroendocrine carcinoma tumors. For each, we analyzed 4-6 sectors of the tumor, 2-4 of adjacent normal tissue samples, and 1-2 nearby lymph nodes. In many ESCC’s, each local region still contains multiple clones, which are often shared with another region, suggesting extensive dispersal of the clonal populations and relatively slow sweep by the most dominant clone. We constructed “clone trees” to depict the most likely lineage relationship of the clones and the likely driver genes or pathways for each branch. Metastatic samples at lymph node often contain multiple clones, including those appearing in the early portions of the evolutionary tree, suggesting polyclonal seeding to the lymph nodes as well as invasion of early-stage tumor cells. The analysis of spatial heterogeneity of molecular lesions thus revealed likely temporal progression of tumorigenic events that may have driven the initiation, outgrowth as well as metastasis of ESCC. (This work is supported by funding from the Joint Institute for Translational and Clinical Research of the University of Michigan Health System and Peking University Health Sciences Center.) Citation Format: Yu Wang, Wenqing Yuan, Mengfei Liu, Jian Bai, Qingxuan Song, Zhen Liu, Jingjing Li, Amir Abliz, Changqing Zeng, Hong Cai, Yang Ke, Jun Li. Mutation signatures and intratumor heterogeneity of esophageal squamous cell carcinoma in a Chinese cohort. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 2397.

2015 James W. Freston Single Topic Conference: A Renaissance in the Understanding and Management of Irritable Bowel Syndrome

Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Biobehavioral Nursing & Health Systems, School of Nursing, Division of Gastroenterology, School of Medicine, University of Washington, Seattle, Washington; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota

2015 James W. Freston Single Topic Conference: A Renaissance in the Understanding and Management of Irritable Bowel Syndrome

Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Biobehavioral Nursing & Health Systems, School of Nursing, Division of Gastroenterology, School of Medicine, University of Washington, Seattle, Washington; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota

2015 James W. Freston Single Topic Conference: A Renaissance in the Understanding and Management of Irritable Bowel Syndrome

Department of Medicine, Division of Digestive Diseases, David Geffen School of Medicine at UCLA, Los Angeles, California; Department of Biobehavioral Nursing & Health Systems, School of Nursing, Division of Gastroenterology, School of Medicine, University of Washington, Seattle, Washington; Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan; Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota

Effects of Total Dose Infusion of Iron Intravenously in Patients With Acute Heart Failure and Anemia (Hemoglobin < 13 g/dl)

Iron deficiency is common in heart failure (HF), and intravenous (IV) iron therapy has been associated with improved clinical status in ambulatory patients with HF. There are limited data to support the safety and efficacy of IV iron administration in patients with acute HF. This was a retrospective cohort study of patients admitted to the University of Michigan Health System for HF with low iron studies during admission. Patients were grouped based on the receipt of IV iron therapy. Study outcomes included change in hemoglobin, 30-day readmission, and adverse events. Forty-four patients who received IV iron and 128 control patients were identified. The mean dose of IV iron received was 1,057 (±336) mg. IV iron resulted in a significantly greater increase in hemoglobin over time (p= 0.0001). The mean change in hemoglobin in the iron and control groups was 0.74g/dl and 0.01g/dl at day 7 and 2.61g/dl and 0.23g/dl at day 28, respectively. Thirty-day readmission rates were 30% and 22% for patients in the iron and control groups, respectively (p= 0.2787). In conclusion, total dose infusion IV iron is well tolerated and associated with significant improvement in hemoglobin in acute HF.

Low-Cost Intervention to Increase Influenza Vaccination Rate at a Comprehensive Cancer Center.

Influenza morbidity and mortality can be severe and costly. Vaccination rates remain suboptimal in cancer patients due to provider- and patient-related factors. The objective of this study was to evaluate whether low-cost provider- and patient-focused interventions would increase influenza vaccination rates at the University of Michigan Comprehensive Cancer Center (UMCCC). This quality improvement project included all patients without documentation of influenza vaccination prior to their first outpatient appointment during the 2011-2012 and 2012-2013 influenza seasons. The multi-stepped intervention included provider and patient reminders. Influenza vaccination rates were compiled using CPT-4 codes. Same-day (with appointment) vaccination rates during the intervention seasons were compared to historical (2005-2011 seasons) controls; vaccination rates were also compared to contemporary control population at the University of Michigan Health System (UMHS). Reasons for non-adherence with vaccination were explored. The cumulative same-day vaccination rate in eligible adults was 10.1% (2011-2012) and 9.4% (2012-2013) compared to an average 6.9% during influenza seasons 2005-2011. Based on logistic regression analysis, there was a 37.6% (95% CI 35-40.3%) and 56.1% (95% CI 40.9-73%) relative increase in the adult vaccination rate associated with the intervention, with 399 and 697 additional vaccinations, respectively, for each season. During the 2012-2013 season, the UMCCC adult vaccination rate was higher compared to the remainder of that of the UMHS. The intervention was well accepted by providers. Reasons for no vaccination were provider- and patient-related. Increasing provider and patient awareness with a simple, inexpensive intervention was associated with higher influenza vaccination rates at a large academic cancer center. The intervention is permanently implemented during influenza seasons.

Molecularly targeted therapy for the treatment of head and neck cancer: a review of the ErbB family inhibitors.

The majority of patients with head and neck squamous cell carcinoma (HNSCC) present with locally advanced disease, which requires site-specific combinations of surgery, radiation, and chemotherapy. Despite aggressive therapy, survival outcomes remain poor, and treatment-related morbidity is not negligible. For patients with recurrent or metastatic disease, therapeutic options are further limited and prognosis is dismal. With this in mind, molecularly targeted therapy provides a promising approach to optimizing treatment efficacy while minimizing associated toxicity. The ErbB family of receptors (ie, epidermal growth factor receptor [EGFR], ErbB2/human epidermal growth factor receptor [HER]-2, ErbB3/HER3, and ErbB4/HER4) is known to contribute to oncogenic processes, such as cellular proliferation and survival. EGFR, specifically, is upregulated in more than 90% of HNSCC, has been implicated in radiation resistance, and correlates with poorer clinical outcomes. The central role of EGFR in the pathogenesis of HNSCC suggests that inhibition of this pathway represents an attractive treatment strategy. As a result, EGFR inhibition has been extensively studied, with the emergence of two classes of drug therapy: monoclonal antibodies and tyrosine kinase inhibitors. While the monoclonal antibody cetuximab is currently the only US Food and Drug Administration–approved EGFR inhibitor for the treatment of HNSCC, numerous investigational drugs are being evaluated in clinical trials. This paper will review the role of the ErbB family in the pathogenesis of HNSCC, as well as the evidence-based data for the use of ErbB family inhibition in clinical practice.

Affordable Care Act Implementation: Challenges and Opportunities to Impact Patients With Diabetes.

Departments of Medicine and Molecular Physiology and Biophysics (A.C.P.), Vanderbilt University Medical Center, Nashville, Tennessee 37232; Medtronic Diabetes (R.A.V.), Minneapolis, Minnesota 55432; Walter Reed National Military Medical Center (R.A.V.), Bethesda, Maryland 20814; MedStar Washington Hospital Center (J.A.W.), Washington, DC 20010; University of Michigan Health System (R.W.L.), Ann Arbor, Michigan 48108; and the Endocrine Society (M.C.D., M.N.B.), Washington, DC 20036

Candor Laws Growing, but Are They Effective?

Candor Laws Growing, but Are They Effective?

Optimizing the post-graduate institutional program evaluation process.

BackgroundReviewing program educational efforts is an important component of postgraduate medical education program accreditation. The post-graduate review process has evolved over time to include centralized oversight based on accreditation standards. The institutional review process and the impact on participating faculty are topics not well described in the literature.MethodsWe conducted multiple Plan-Do-Study-Act (PDSA) cycles to identify and implement areas for change to improve productivity in our institutional program review committee. We also conducted one focus group and six in-person interviews with 18 committee members to explore their perspectives on the committee’s evolution. One author (MLL) reviewed the transcripts and performed the initial thematic coding with a PhD level research associate and identified and categorized themes. These themes were confirmed by all participating committee members upon review of a detailed summary. Emergent themes were triangulated with the University of Michigan Medical School’s Admissions Executive Committee (AEC).ResultsWe present an overview of adopted new practices to the educational program evaluation process at the University of Michigan Health System that includes standardization of meetings, inclusion of resident members, development of area content experts, solicitation of committed committee members, transition from paper to electronic committee materials, and focus on continuous improvement. Faculty and resident committee members identified multiple improvement areas including the ability to provide high quality reviews of training programs, personal and professional development, and improved feedback from program trainees.ConclusionsA standing committee that utilizes the expertise of a group of committed faculty members and which includes formal resident membership has significant advantages over ad hoc or other organizational structures for program evaluation committees.

Join In and Speak Up: We Want to Hear Your Voice

Join In and Speak Up: We Want to Hear Your Voice

Muslim patients' expectations and attitudes about Ramadan fasting during pregnancy.

To investigate Muslim women's attitudes concerning Ramadan fasting during pregnancy and determine how healthcare providers can better serve this population. A cross-sectional study targeted Muslim patients with active obstetric records within the University of Michigan Health System who received care at clinics in metro Detroit (MI, USA) during Ramadan in 2013. Patients aged 18-50 years were approached between July 7 and August 15, and asked to complete a written survey on perceptions of fasting, influences on decision making, and healthcare expectations. Among the 37 women who completed the survey, 26 (70%) did not fast in their current or most recent pregnancy during Ramadan. Overall, 23 (62%) women believed that fasting was harmful to themselves, their fetus, or both. Seven (19%) women reported consulting others about fasting during pregnancy, with the most influential individuals being Muslim scholars, followed by family/relatives and healthcare providers. The most important characteristics desired in a physician included being respectful of Islamic beliefs and possessing knowledge about Ramadan. Most women chose not to fast during pregnancy. Although few consulted healthcare providers, pregnant Muslim women valued their opinions. Healthcare providers need to educate themselves about which topics to discuss with Muslim patients to provide care on an individual basis.

General Surgery Resident Satisfaction on Cardiothoracic Rotations

General surgery residents' exposure to cardiothoracic (CT) surgery rotations has decreased, which may affect resident satisfaction. We surveyed general surgery graduates to assess the relationships among rotation satisfaction, CT disease exposure, rotation length, mentorship, and mistreatment. A survey assessing CT curriculum, exposure, mentorship, and satisfaction was forwarded to general surgery graduates from 17 residency programs. A Wilcoxon rank-sum test was used to assess statistical significance of ordinal level data. Statistical significance was defined as p < 0.05. This study was conducted at the University of Michigan Health System in Ann Arbor, MI, a tertiary care center. The survey was sent to approximately 1300 graduates of general surgery residency programs who graduated between the years of 1999 to 2014. A total of 94 responses were completed and received. Receiving adequate exposure to CT procedures and disease management was significantly associated with higher satisfaction ratings for all procedures, particularly thoracotomy incisions (p < 0.001), empyemas and pleural effusions (p < 0.001), and lung cancer care (p < 0.001). The absence of mistreatment and good/very good mentorship were both positively associated with higher reported satisfaction (p = 0.018 and p < 0.001, respectively). Increased length of time on CT rotation was neither associated with improved levels of satisfaction nor with an improvement in the quality of mentorship. Rotation satisfaction is positively associated with procedure exposure, better mentorship, and the absence of mistreatment. Longer rotation length was not associated with satisfaction. Shorter rotations are not detrimental to training if they have focused clinical exposure and invested mentors to maximize resident satisfaction. These specific markers of rotation quality are useful in curricular design.

Resident Surgeons Underrate Their Laparoscopic Skills and Comfort Level When Compared With the Rating by Attending Surgeons

The development of operative skills during general surgery residency depends largely on the resident surgeons' (residents) ability to accurately self-assess and identify areas for improvement. We compared evaluations of laparoscopic skills and comfort level of residents from both the residents' and attending surgeons' (attendings') perspectives. We prospectively observed 111 elective cholecystectomies at the University of Michigan as part of a larger quality improvement initiative. Immediately after the operation, both residents and attendings completed a survey in which they rated the residents' operative proficiency, comfort level, and the difficulty of the case using a previously validated instrument. Residents' and attendings' evaluations of residents' performance were compared using 2-sided t tests. The University of Michigan Health System in Ann Arbor, MI. Large academic, tertiary care institution. All general surgery residents and faculty at the University of Michigan performing laparoscopic cholecystectomy between June 1 and August 31, 2013. Data were collected for 28 of the institution's 54 trainees. Attendings rated residents higher than what residents rated themselves on a 5-point Likert-type scale regarding depth perception (3.86 vs. 3.38, p < 0.005), bimanual dexterity (3.75 vs. 3.36, p = 0.005), efficiency (3.58 vs. 3.18, p < 0.005), tissue handling (3.69 vs. 3.23, p < 0.005), and comfort while performing a case (3.86 vs. 3.38, p < 0.005). Attendings and residents were in agreement on the level of autonomy displayed by the resident during the case (3.31 vs. 3.34, p = 0.85), the level of difficulty of the case (2.98 vs. 2.85, p = 0.443), and the degree of teaching done by the attending during the case (3.61 vs. 3.54, p = 0.701). A gap exists between residents' and attendings' perception of residents' laparoscopic skills and comfort level in performing laparoscopic cholecystectomy. These findings call for improved communication between residents and attendings to ensure that graduates are adequately prepared to operate independently. In the context of changing methods of resident evaluations that call for explicitly defined competencies in surgery, it is essential that residents are able to accurately self-assess and be in general agreement with attendings on their level of laparoscopic skills and comfort level while performing a case.

Evaluating Positron Emission Tomography Use in Differentiated Thyroid Cancer.

Using the Surveillance, Epidemiology, and End Results-Medicare database, a substantial increase was found in the use of positron emission tomography (PET) scans after 2004 in differentiated thyroid cancer (DTC) patients. The reason for the increased utilization of the PET scan was not clear based on available the data. Therefore, the indications for and outcomes of PET scans performed at an academic institution were evaluated. A retrospective cohort study was performed of DTC patients who underwent surgery at the University of Michigan Health System from 2006 to 2011. After identifying patients who underwent a PET scan, indications, rate of positive PET scans, and impact on management were evaluated. For positive scans, the location of disease was characterized, and presence of disease on other imaging was determined. Of the 585 patients in the cohort, 111 (19%) patients had 200 PET scans performed for evaluation of DTC. Indications for PET scan included: elevated thyroglobulin and negative radioiodine scan in 52 scans (26.0%), thyroglobulin antibodies in 13 scans (6.5%), rising thyroglobulin in 18 scans (9.0%), evaluation of abnormality on other imaging in 22 scans (11.0%), evaluation of extent of disease in 33 scans (16.5%), follow-up of previous scan in 57 scans (28.5%), other indications in two scans (1.0%), and unclear indications in three scans (1.5%). The PET scan was positive in 124 studies (62.0%); positivity was identified in the thyroid bed on 25 scans, cervical or mediastinal lymph nodes on 105 scans, lung on 28 scans, bone on four scans, and other areas on 14 scans. Therapy following PET scan was surgery in 66 cases (33.0%), chemotherapy or radiation in 23 cases (11.5%), observation in 110 cases (55.0%), and palliative care in one case (0.5%). Disease was identifiable on other imaging in 66% of cases. PET scan results changed management in 59 cases (29.5%). In this academic medical center, the PET scan was utilized in 19% of patients. Indications for the PET scan included conventional indications, such as elevated thyroglobulin with noniodine avid disease, and more controversial uses, such as evaluation of extent of disease or abnormalities on other imaging tests. PET scan results changed management in about 30% of cases.

Innovative Scheduling Solutions for Graduate Medical Education.

Innovative Scheduling Solutions for Graduate Medical Education.

Low-cost stepped intervention to increase influenza vaccination rates at a Comprehensive Cancer Center.

Influenza morbidity and mortality can be severe and costly. Vaccination rates remain suboptimal in cancer patients due to provider- and patient-related factors. The objective of this study was to evaluate whether low-cost provider- and patient-focused interventions would increase influenza vaccination rates at the University of Michigan Comprehensive Cancer Center (UMCCC). This quality improvement project included all patients without documentation of influenza vaccination prior to their first outpatient appointment during the 2011–2012 and 2012–2013 influenza seasons. The multi-stepped intervention included provider and patient reminders. Influenza vaccination rates were compiled using CPT-4 codes. Same-day (with appointment) vaccination rates during the intervention seasons were compared to historical (2005–2011 seasons) controls; vaccination rates were also compared to contemporary control population at the University of Michigan Health System (UMHS). Reasons for non-adherence with vaccination were explored. The cumulative same-day vaccination rate in eligible adults was 10.1 % (2011–2012) and 9.4 % (2012–2013) compared to an average 6.9 % during influenza seasons 2005–2011. Based on logistic regression analysis, there was a 37.6 % (95 % CI 35–40.3 %) and 56.1 % (95 % CI 40.9–73 %) relative increase in the adult vaccination rate associated with the intervention, with 399 and 697 additional vaccinations, respectively, for each season. During the 2012–2013 season, the UMCCC adult vaccination rate was higher compared to the remainder of that of the UMHS. The intervention was well accepted by providers. Reasons for no vaccination were provider- and patient-related. Increasing provider and patient awareness with a simple, inexpensive intervention was associated with higher influenza vaccination rates at a large academic cancer center. The intervention is permanently implemented during influenza seasons.

Abstract 237: Protocol-guided Weaning From Mechanical Ventilation in The Cardiac Intensive Care Unit

Background: Rates of prolonged mechanical ventilation (MV) in cardiac intensive care units (CICU) have significantly increased over the past few decades. MV is associated with numerous complications including prolonged ICU length of stay as well as increased mortality. The most effective method of liberation from MV includes a daily assessment of weaning readiness, interruption of sedation, and spontaneous breathing trials (SBTs). Effective weaning protocols require multidisciplinary collaboration between physicians, nurses, and respiratory therapists. Methods: We identified and implemented several quality improvement interventions to improve weaning from MV in the University of Michigan Health System (UMHS) CICU. We specifically changed the time of SBTs from 4-5 AM to 8-9 AM to promote physician involvement in weaning and improve physician-nursing-respiratory therapist communication. By performing SBTs during morning rounds, we intended to optimize physician communication with nursing and respiratory therapy regarding selection of patients for SBT, evaluation of SBT success, identification of barriers to weaning, and selection of patients for extubation. We hypothesized that these interventions would decrease MV time to initial SBT, duration of MV, and ICU length of stay. Results: We reviewed the clinical data and outcomes of 172 mechanically ventilated patients in the UMHS CICU (83 prior to and 89 following our intervention). Our intervention was associated with a trend toward decreased duration of MV (mean duration 4.95 vs. 3.66 days, p=0.13) and a trend toward a shorter ICU length of stay (mean duration 9.91 vs. 8.10 days, p=0.22) (Figure). Nonsignificant reductions in MV time to initial SBT (2.31 vs. 2.09 days, p not significant) and time from initial SBT to end of MV (2.40 vs. 1.82 days, p not significant) were also observed. Conclusions: These results suggest that a collaborative, multidisciplinary effort including physicians, nurses, and respiratory therapists may be effective in improving the care of mechanically ventilated patients in the CICU. Larger, multicenter studies further evaluating our protocol-guided weaning strategy are warranted to establish its efficacy in the management of these patients.

Mortality Risk High for Dementia Patients Taking Antipsychotics

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessMortality Risk High for Dementia Patients Taking AntipsychoticsVabren WattsVabren WattsSearch for more papers by this authorPublished Online:16 Apr 2015https://doi.org/10.1176/appi.pn.2015.4b5AbstractBecause of the heightened risk for mortality associated with antipsychotic use in the elderly with neurocognitive decline, researchers are calling for safer alternatives to treat agitation and aggression.Though studies have shown that antipsychotic medications are associated with increased mortality risk in older adults with dementia, little is known about such risk relative to no treatment or to alternative psychotropic therapies, according to researchers from the University of Michigan Health System. “The harms associated with using antipsychotics in dementia patients are clear, yet clinicians continue to use them,” said the study’s lead author, Donovan Maust, M.D., M.S., an assistant professor of geriatric psychiatry. Clinical trials and meta-analyses of research have suggested modest benefit from some antipsychotic agents over placebo for the treatment of psychosis and aggression in patients with dementia. These symptoms occur in more than 90 percent of affected patients, Maust said in a statement. In 2005, the Food and Drug Administration issued a black-box warning indicating that the use of atyptical, or second-generation, antipsychotics lead to increased all-cause mortality when used to treat behavioral disturbances in patients with dementia. This was followed by a 2008 black-box warning for first-generation antipsychotics after additional analysis showed an even higher mortality risk for this category of medication.Despite major risks associated with use of antipsychotics in older adults with dementia, these drugs are among the most widely prescribed in this vulnerable population, with approximately 1 in 7 elderly individuals with dementia—who are not in nursing homes—being prescribed such medications, according to data from the Government Accountability Office. Helen Kales, M.D., says that psychiatrists must look into alternative therapies—both pharmacological and nonpharmacological—to reduce rates of antipsychotic use among older people with Alzheimer’s disease and other dementias.UM Health SystemsBecause of the heightened risk for all-cause mortality and the high prevalence of antipsychotic use in elderly patients with dementia, Maust, along with senior author Helen Kales, M.D., a professor of psychiatry and director of the Program for Positive Aging, and colleagues decided to investigate if less-risky options exist to treat neuropsychiatric symptoms in this population. The researchers analyzed health records of more than 90,500 individuals aged 65 and older with dementia to assess the risk for death in patients who received antipsychotics and to compare that risk with those who did not take these medications. They simplified the rate of risk for mortality by estimating how many elderly patients would have to be on a drug for one of them to die within six months, known as the “number needed to harm (NNH).”The results, published online in JAMA Psychiatry on March 18, showed that mortality risks statistically increased in patients taking antipsychotics to reduce symptoms of dementia compared with individuals not being treated with the drugs. Haloperidol was linked with the highest level of risk—with one death per 26 individuals taking the drug. Risperidone had a NNH of 27, followed by olanzapine and quetiapine with NNHs of, respectively, 40 and 50. The risk increased with increasing antipsychotic dosage.The researchers also evaluated the mortality risk for older adults with dementia who took antidepressants, representing alternative pharmacotherapies in the study. The mortality risks were lower—with one person dying for every 166 individuals taking these medications.“Our research indicates that antipsychotics may increase mortality more than previously realized,” Kales told Psychiatric News. “We hope this creates a dialogue about the advantages and disadvantages of antipsychotic and other psychotropic use as first-line treatment strategies for behavioral symptoms, which are universal and require effective treatments to address serious suffering among patients, families, and caregivers.”One first-line treatment strategy is the “DICE” approach, which emphasizes using nonpharmacological strategies first (Psychiatric News, October 10, 2014). “This approach takes more time than writing a prescription,” said Kales. “Nonpharmacologic approaches will succeed only if we as a society agree to pay front-line providers for the time needed to ‘do the right thing,’ ” she emphasized.Kales, Maust, and colleagues indicated that they intend to continue studying the issue of mortality risk from the use of psychotropic drugs for dementia using other datasets.The study was funded by the National Institute of Mental Health and the National Institute on Aging. ■An abstract of “Antipsychotics, Other Psychotropics, and the Risk of Death in Patients With Dementia” can be accessed here. 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MP48-17 ANTERIOR PROSTATE CANCER: CLINICOPATHOLOGIC CHARACTERIZATION WITH BIOPSY CORRELATION

MP48-17 ANTERIOR PROSTATE CANCER: CLINICOPATHOLOGIC CHARACTERIZATION WITH BIOPSY CORRELATION