Publications

Little is known about trends in depression at antiretroviral therapy (ART) initiation among people living with HIV (PLHIV) in low- and middle-income countries. We used data from an ongoing cohort of treatment-naïve PLHIV in rural Uganda to estimate secular trends in depression among PLHIV at ART initiation. We fitted linear regression models with depression symptom severity as the outcome variable and year of cohort entry (2005-2012) as the explanatory variable, adjusting for socio-demographic variables and assessing physical health score, body mass index (BMI), and CD4 count as potential mediators of a secular trend in depression symptom severity. There was a statistically significant negative association between year of entry and depression symptom severity, suggesting a 3.1 % relative decline in the mean depression symptom severity score at ART initiation in each year of study recruitment after the first year. This trend remained statistically significant after inclusion of baseline socio-demographic characteristics to the model and appeared to be driven by improved physical health scores, but not CD4 count or BMI.

AIMS

Knowledge of consumer perspectives of personalized medicine (PM) is limited. Our study assessed consumer perspectives of PM, with a focus on oncology care, to inform industry, clinician and payer stakeholders' programs and policy.

MATERIALS & METHODS

A nationally representative survey of 602 US consumers' ≥30 years old explored familiarity, perspectives and expected value of PM.

RESULTS

Most (73%) respondents have not heard of 'personalized medicine,' though after understanding the term most (95%) expect PM to have a positive beneft. Consumer's willingness to pay is associated with products' impact on survival, rather than predicting disease risk. If testing indicates consumers are not candidates for oncology therapies, most (84%) would seek a second opinion or want therapy anyway.

CONCLUSIONS

Understanding heterogeneity in consumer perspectives of PM can inform program and policy development.

Understanding the contribution of dysregulated gene silencing to epigenomic alterations in cancer development provides the rationale for the use of epigenetic modulators, such as histone deacetylase (HDAC) inhibitors, in cancer therapy. HDAC inhibitors have been approved as single agents for cutaneous and peripheral T-cell lymphoma and have shown promising activity in reversing therapy resistance in other tumor types. The effects of HDAC inhibitors on immune modulation have created a recent interest in their potential role in immunotherapy. This review describes the current understanding on integrating HDAC inhibitors into various immunotherapeutic approaches, such as cancer vaccines, adoptive T-cell transfer and immune checkpoint inhibitors. Furthermore, it summarizes promising treatment strategies in epigenetic immune priming from clinical trials that are currently underway.

OBJECTIVE

To compare the types of recommendations documented in pharmacy resident and student home-visit notes with those made in the electronic medical record-based drug regimen review (DRR) notes.

SETTING

San Francisco Veterans Affairs Medical Center (SFVAMC), San Francisco, California.

PRACTICE DESCRIPTION

The SFVAMC Home-Based Primary Care (HBPC) program provides primary care services through an interdisciplinary team. The pharmacist performs a DRR-a federally required, quarterly retrospective review of the medications for each patient enrolled in the HBPC program and acts as a preceptor for pharmacy residents and students helping to provide patient care.

PRACTICE INNOVATION

Starting in 2008, residents and students began making home visits with the HBPC primary care providers. Activities and recommendations were documented in a home visit clinical note.

MAIN OUTCOME MEASURES

Number and types of recommendations documented during the DRR and in the home visit notes as well as the clinical change in disease states based on the accepted recommendations.

RESULTS

Ninety-three recommendations were accepted: 27 DRR recommendations and 66 home visit recommendations from August 1, 2008, to July 31, 2009. The most commonly accepted DRR recommendations were to evaluate response to therapy (29%) and home visit recommendations to document medications not listed in the medication profile (26%). Clinical change in disease state based on the majority of the accepted recommendations remained unchanged for both DRR and home visit recommendations.

CONCLUSION

Home visits by pharmacy residents and students resulted in a greater number and different type of recommendations documented in their home visit notes compared with those in the DRR notes.

Approximately four million adults in the United States are homebound, and many of them cannot access office-based primary care. Home-based medical care can improve outcomes and reduce health care costs, but this care operates in a quality measurement desert, having been largely left out of the national conversation on care quality. To address this shortcoming, two of the authors created the National Home-Based Primary and Palliative Care Network, an organization whose members include exemplary home-based medical practices, professional societies, and patient advocacy groups. This article describes the current status of home-based medical care in the United States and offers a brief narrative of a fictional homebound patient and the health events and fragmented care she faces. The article then describes the network's quality-of-care framework, which includes ten quality-of-care domains, thirty-two standards, and twenty quality indicators that are being tested in the field. The same two authors also developed a practice-based registry that will be used for quality-of-care benchmarking, practice-based quality improvement, performance reporting, and comparative effectiveness research. Together, these steps should help bring home-based medical care further into the mainstream of US health care.

OBJECTIVE

To examine the prevalence, predictors, and effects of nocturia in women and evaluate overlaps with established urinary tract disorders.

METHODS

This was a cross-sectional analysis of 2,016 women, aged 40 years and older, recruited from Kaiser Permanente Northern California from 2008 to 2012. Nocturia and other urinary symptoms were assessed using structured interviewer-administered questionnaires. Nocturia was defined as patient-reported nocturnal voiding of two or more times per night over a typical week.

RESULTS

Thirty-four percent (n=692) reported nocturia, and 40% of women with nocturia reported no other urinary tract symptom. Women with nocturia were older (mean age 58 compared with 55 years) (odds ratio [OR] per 5-year increase 1.21, 95% confidence interval [CI] 1.12-1.31), more likely black (45%) (OR 1.75, 95% CI 1.30-2.35) or Latina (37%) (OR 1.36, 95% CI 1.02-1.83) compared with non-Latina white (30%), have worse depression (mean Hospital Anxiety and Depression Scale score 3.8 compared with 2.8) (OR per 1-point increase in Hospital Anxiety and Depression Scale score 1.08, 95% CI 1.04-1.12), and worse mobility (mean Timed Up-and-Go 11.3 compared with 10 seconds) (OR per 5-second increase in Timed Up-and-Go 1.29, 95% CI 1.05-1.58). Nocturia occurred more among women with hysterectomy (53% compared with 33%) (OR 1.78, 95% CI 1.08-2.94), hot flushes (38% compared with 32%) (OR 1.49, 95% CI 1.19-1.87), and vaginal estrogen use (42% compared with 34%) (OR 1.50, 95% CI 1.04-2.18).

CONCLUSION

Nocturia is common in women and not necessarily attributable to other urinary tract disorders. Factors not linked to bladder function may contribute to nocturia risk, underlining the need for multiorgan prevention and treatment strategies.

LEVEL OF EVIDENCE

II.

IMPORTANCE

With an aging population, preoperative assessment of the frail older adult requires evaluation beyond simply accounting for chronic diseases. Impaired cognition is a recognized characteristic of the frail older adult.

OBJECTIVE

To examine the effect of preoperative impaired sensorium (IS) on general surgical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study using data between January 2005 and December 2010 at academic and community hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program. Patients undergoing nonemergent general surgical operations were studied. Multivariable logistic regression involving 45 preoperative patient-level risk factors and comorbidities was used to calculate the conditional probability of having IS. Patients having and not having preoperative IS were matched on their propensity scores using a 1:1 greedy matching technique. Propensity score matching resulted in almost all (n = 1765) patients with IS uniquely matching to a patient without IS, resulting in a cohort size of 3530. Complication rates between patients with and without IS were compared.

MAIN OUTCOMES AND MEASURES

Rates of postoperative complications and death following nonemergent general surgical operations.

RESULTS

In total, 294 037 patients were studied, of whom 1771 (0.6%) had preoperative IS. Patients with IS were older and had more significant preoperative risk factors and comorbidities. As a result, unadjusted analysis found that 22 of 23 postoperative complications were significantly more likely to occur in patients with IS. Within the matched cohort, rates of postoperative pneumonia, ventilator dependence, progressive renal insufficiency, urinary tract infection, stroke, venous thromboembolism, and postoperative death continued to be significantly (P < .05) elevated in patients with IS.

CONCLUSIONS AND RELEVANCE

Impaired sensorium significantly increases postoperative morbidity and mortality independent of other preoperative risk factors and comorbidities following nonemergent general surgical operations. Incorporation of impaired cognitive function into routine preoperative risk assessment and decision making could be an important addition to traditional risk assessment strategies.

BACKGROUND

The poorly healing perineal wound is a significant complication of abdominoperineal resection. The authors examined criteria for immediate flap coverage of the perineum and long-term cross-sectional surgical outcomes.

METHODS

Patients who underwent abdominoperineal resection or pelvic exenteration for anorectal cancer were retrospectively analyzed. Demographic characteristics, premorbid and oncologic data, surgical treatment, reconstruction method, and recovery were recorded. Outcomes of successful wound healing, surgical complications necessitating intervention (admission or return to the operating room), and progression to chronic wounds were assessed.

RESULTS

The authors identified 214 patients who underwent this procedure from 1995 to 2013. Forty-seven patients received pedicled flaps and had higher rates of recurrence and reoperation, active smoking, Crohn disease, human immunodeficiency virus, and anal cancers, and had higher American Joint Committee on Cancer tumor stages. Thirty-day complication rates were equivalent in the two groups. There were no complete flap losses or reconstructive failures. Perineal wound complication rates were marginally but not significantly higher in the flap group (55 percent versus 41 percent; p = 0.088). Infectious complications, readmissions for antibiotics, and operative revision were more frequent in the flap cohort. A larger proportion of the primary closure cohort developed chronic draining perineal wounds (23.3 versus 8.5 percent; p = 0.025).

CONCLUSIONS

Immediate flap coverage of the perineum was less likely to progress to a chronic draining wound, but had higher local infectious complication rates. The authors attribute this to increased comorbidity in the selected patient population, reflecting the surgical decision making in approaching these high-risk closures and ascertainment bias in diagnosis of infectious complications with multidisciplinary examination.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.