Publications

Whether automated estimated glomerular filtration rate (eGFR) reporting for patients is associated with improved provider recognition of chronic kidney disease (CKD), as measured by diagnostic coding of CKD in those with laboratory evidence of the disease, has not been explored in a poor, ethnically diverse, high-risk urban patient population. A retrospective cohort of 237 adult patients (≥ 20 years) with incident CKD (≥ 1 eGFR ≥ 60 ml/min/1.73 m(2), followed by ≥ 2 eGFRs <60 ml/min/1.73 m(2) ≥ 3 months apart)-pre- or post automated eGFR reporting-was identified within the San Francisco Department of Public Health Community Health Network (January 2005-July 2009). Patients were considered coded if any ICD-9-CM diagnostic codes for CKD (585.x), other kidney disease (580.x-581.x, 586.x), or diabetes (250.4) or hypertension (403.x, 404.x) CKD were present in the medical record within 6 months of incident CKD. Multivariable logistic regression was used to obtain adjusted odds ratios (ORs) for CKD coding. We found that, pre-eGFR reporting, 42.5 % of incident CKD patients were coded for CKD. Female gender, increased age, and non-Black race were associated with lower serum creatinine and lower prevalence of coding but comparable eGFR. Prevalence of coding was not statistically significantly higher overall (49.6 %, P = 0.27) or in subgroups after the institution of automated eGFR reporting. However, gaps in coding by age and gender were narrowed post-eGFR, even after adjustment for sociodemographic and clinical characteristics: 47.9 % of those <65 and 30.3 % of those ≥ 65 were coded pre-eGFR, compared to 49.0 % and 52.0 % post-eGFR (OR = 0.43 and 1.16); similarly, 53.2 % of males and 25.4 % of females were coded pre-eGFR compared to 52.8 % and 44.0 % post-eGFR (OR 0.28 vs. 0.64). Blacks were more likely to be coded in the post-eGFR period: OR = 1.08 and 1.43 (P (interaction) > 0.05). Automated eGFR reporting may help improve CKD recognition, but it is not sufficient to resolve under identification of CKD by safety net providers.

The nose and upper airways form the initial area of impact for air pollutants and allergens. The development of nasal allergies in the workplace (occupational rhinitis) may herald subsequent development of occupational asthma. Exposure controls, periodic surveillance, and early intervention may circumvent work-related airways disease and prevent unnecessary worker impairment and disability.

UNLABELLED

Study purposes were to determine the prevalence of persistent pain in the breast; characterize distinct persistent pain classes using growth mixture modeling; and evaluate for differences among these pain classes in demographic, preoperative, intraoperative, and postoperative characteristics. In addition, differences in the severity of common symptoms and quality of life outcomes measured prior to surgery, among the pain classes, were evaluated. Patients (n = 398) were recruited prior to surgery and followed for 6 months. Using growth mixture modeling, patients were classified into no (31.7%), mild (43.4%), moderate (13.3%), and severe (11.6%) pain groups based on ratings of worst breast pain. Differences in a number of demographic, preoperative, intraoperative, and postoperative characteristics differentiated among the pain classes. In addition, patients in the moderate and severe pain classes reported higher preoperative levels of depression, anxiety, and sleep disturbance than the no pain class. Findings suggest that approximately 25% of women experience significant and persistent levels of breast pain in the first 6 months following breast cancer surgery.

PERSPECTIVE

Persistent pain is a significant problem for 25% of women following surgery for breast cancer. Severe breast pain is associated with clinically meaningful decrements in functional status and quality of life.

BACKGROUND

As the population ages, an increasing number of elderly persons will undergo surgery for rectal cancer. The use of sphincter-sparing surgery in frail older adults is controversial.

OBJECTIVE

The aim of this study was to examine mortality and bowel function after proctectomy in nursing home residents.

DESIGN

This is a retrospective cohort study.

SETTING

This investigation was conducted in nursing homes in the United States contracted with the Center for Medicare and Medicaid Services.

PATIENTS

Nursing home residents age 65 and older undergoing proctectomy for rectal cancer (2000-2005) were included.

MAIN OUTCOME MEASURES

The primary outcomes measured were fecal incontinence and the 1-year mortality rate.

RESULTS

Operative mortality was 18% after proctectomy with permanent colostomy and 13% after sphincter-sparing proctectomy (adjusted relative risk, 1.25 (95% CI 0.90-1.73), p = 0.188). One-year mortality was high: 40% after sphincter-sparing proctectomy and 51% after proctectomy with permanent colostomy (adjusted hazard ratio 1.32 (95% CI 1.09-1.60), p = 0.004). After sphincter-sparing proctectomy, 37% of residents were incontinent of feces. Residents with the poorest functional status (Minimum Data Set-Activities of Daily Living quartile 4) were significantly more likely to be incontinent of feces than residents with the best functional status (Minimum Data Set-Activities of Daily Living quartile 1) (76% vs 13%, adjusted relative risk 3.28 (95% CI 1.74- 6.18), p= 0.0002). Fecal incontinence was also associated with dementia (adjusted relative risk 1.55 (95% CI 1.15-2.09), p = 0.004) and renal failure (adjusted relative risk 1.93 (95% CI 1.10-3.38), p = 0.022).

LIMITATIONS

Measures of fecal incontinence in nursing home registries are not as well studied as those commonly used in clinical practice.

CONCLUSIONS

Sphincter-sparing proctectomy in nursing home residents is frequently associated with postoperative fecal incontinence and should be considered only for continent patients with good functional status.

INTRODUCTION

Prostate cancer is the second leading cause of cancer death in men in the United States. The disease is driven by androgen receptor (AR) signaling, and the majority of patients initially respond to androgen deprivation therapies. The lethal form of this disease occurs when metastatic lesions progress in the setting of low testosterone levels, in what is conventionally referred to as castration-resistant prostate cancer (CRPC). Recent insights suggest that CRPC continues to rely on an active AR pathway for cell survival and growth.

AREAS COVERED

This review summarizes the rationale, mechanism of action and relevant clinical data of abiraterone acetate , an oral androgen biosynthesis inhibitor, in the management of CRPC.

EXPERT OPINION

Abiraterone acetate is an oral, well-tolerated drug that targets a newly elucidated paradigm of continued AR activation in CRPC. Abiraterone acetate is approved in CRPC patients who have received docetaxel, and recent data suggest that the drug will also be effective and utilized in the pre-chemotherapy setting. Significant areas of scientific investigation remain in the optimization and further understanding of the therapy.