Revisiting Infectious Complications Following Total Parenteral Nutrition Use During Hematopoietic Stem Cell Transplantation.

BACKGROUND: Total parenteral nutrition (TPN) is frequently used to manage caloric needs during hematopoietic stem cell transplantation (HSCT). Previous studies in transplant patients who received TPN have reported widely discordant results with regard to infection and mortality, and risk factors for TPN-related infection remain unclear. METHOD: We conducted a retrospective study of all HSCT recipients treated with TPN between 2005 to 2014 at Northwestern Memorial Hospital to determine the incidence and epidemiology of infections. Electronic records were used to identify patients treated with TPN for at least 2 days who developed infection. RESULTS: Among 198 patients treated with TPN, 30% developed documented infection. Total parenteral nutrition treatment duration (13 vs. 7 days; p < .0001) and the timing of TPN initiation (> day 9 post HSCT; p < .0001) were significantly higher in patients who received TPN and developed infection. Receipt of an allogeneic transplant was associated with increased risk for infection (p < .0138), and day 60 mortality was significantly higher in TPN-treated patients with infection (p < .0001). CONCLUSION: Stem cell recipients who receive TPN, especially from an allogeneic donor, have high rates of infection and mortality. Minimizing TPN exposure may reduce the chance for infection.

Screening for unhealthy diet and exercise habits: The electronic health record and a healthier population.

The US spends more money than any other country in the world on health care but does not have the best health outcomes. Most healthcare dollars are spent on treatment of preventable chronic conditions including heart disease, hypertension, diabetes, hypertension, and obesity. Many recent studies have shown that a poor diet and low cardiorespiratory fitness are associated with significant morbidity and an increased risk of all-cause mortality. There is evidence that those with higher cardiorespiratory fitness have lower annual healthcare costs. Despite continued research on the essential role of diet and exercise in optimal health, these vital health behaviors have been slow to change in the US population and do not receive adequate attention. We propose more objective screening, visible and monitored in the Electronic Health Record, to improve awareness, help educate patients, and monitor their progress over time. It would also help identify those individuals that would benefit from referral to interventional behavioral resources in the clinic and community. With an increased focus on preventive and population health measures, now is an ideal time to include both exercise and diet in health metrics. A few relatively simple changes could prompt providers to assess and educate patients about nutrition and fitness and promote a healthier population.

Impact of Acute Kidney Injury on Mortality of Patients Hospitalized for Complications of Cirrhosis.

BACKGROUND/AIMS: The mortality of hospitalized patients for complications of cirrhosis is very high. We examined the independent predictors of mortality, particularly the impact of increments in creatinine, in 339 consecutive patients (636 admissions) who were admitted for complications of cirrhosis. METHODS: Clinical characteristics, biochemical parameters including serum creatinine levels at various time intervals, and mortality data were recorded for all admissions. Data were analyzed for initial as well for all repeated admissions to identify independent predictors of mortality. RESULTS: The in-hospital mortality, 30-day, 90-day, 180 days, and 365 days mortality were 6%, 15%, 23%, 30%, and 41% respectively. Those admitted with spontaneous bacterial peritonitis had the worst survival. Increase in creatinine was noted in 29% of patients and they had lower 30-day (78% vs.91%) and 90-day (73% vs. 82%) survival than those without increase in creatinine. Any increment in serum creatinine (≥0.1 mg/dL) within 48 h after admission (peak 48 h - admission) was associated with a step-wise increase in mortality, but only if peak creatinine reached above 1.2 mg/dL. If peak creatinine levels were below 1.2 mg/dL, increases in serum creatinine had no impact on survival. Cox regression analysis showed that increments in serum creatinine of 0.3 mg/dL or higher had the worst outcome (HR 2.51, CI 1.65-3.81). Etiology of cirrhosis or the use of PPI, beta blockers or rifaxamin did not predict mortality. Other independent predictors of mortality were age, reason for admission, hyponatremia, and INR. CONCLUSION: In patients with cirrhosis, any increment in serum creatinine within 48 h from hospitalization is associated with a higher mortality provided the peak serum creatinine within 48 h is above 1.2 mg/dL.

NCI Funding Trends and Priorities in Physical Activity and Energy Balance Research Among Cancer Survivors.

There is considerable evidence that a healthy lifestyle consisting of physical activity, healthy diet, and weight control is associated with reduced risk of morbidity and mortality after cancer. However, these behavioral interventions are not widely adopted in practice or community settings. Integrating heath behavior change interventions into standard survivorship care for the growing number of cancer survivors requires an understanding of the current state of the science and a coordinated scientific agenda for the future with focused attention in several priority areas. To facilitate this goal, this paper presents trends over the past decade of the National Cancer Institute (NCI) research portfolio, fiscal year 2004 to 2014, by funding mechanism, research focus, research design and methodology, primary study exposures and outcomes, and study team expertise and composition. These data inform a prioritized research agenda for the next decade focused on demonstrating value and feasibility and creating desire for health behavior change interventions at multiple levels including the survivor, clinician, and healthcare payer to facilitate the development and implementation of appropriately targeted, adaptive, effective, and sustainable programs for all survivors.

Evaluation and treatment of shoulder pain.

Shoulder pain is a common symptom in the adult population. The most common cause of shoulder pain is SIS, reflecting a problem with the rotator cuff or subacromial bursa. Determining the cause of a patient's pain is usually a clinical diagnosis based on careful history taking and physical examination. Limited use of imaging studies will be needed in the setting of trauma, possible glenohumeral arthritis, or when a complete tendon tear is suspected. Therapy is based on pain control and therapeutic exercises in almost all cases. Despite the prevalence of shoulder pain, there is no consensus on the best way to achieve pain control or on the type of exercise most likely to achieve speedy recovery.

A Health Survey of Gastroenterologist Prescribing Practices of Adalimumab for Treatment of Crohn's Disease: Final Results.

Adalimumab (Humira, AbbVie) has efficacy in treatment-naive and infliximab (Remicade, Janssen)-exposed patients with Crohn's disease (CD). An e-survey was sent to US gastroenterologists who were members of the American Gastroenterological Association. A total of 398 gastroenterologists (3%) completed the survey. Seventy-two percent prescribed adalimumab more than a few times yearly, 58% followed more than 50 patients with CD, and 15% followed 200 or more patients with CD. Ninety percent of gastroenterologists felt that adalimumab had a moderately significant positive impact on patient care. Eighty-two percent correctly identified the US Food and Drug Administration-approved adalimumab induction and maintenance regimens. These gastroenterologists were more likely to follow 200 or more patients with CD (P=.045) and prescribe adalimumab more than a few times per year (P=.037). Years in practice, practice setting, gender, and region did not impact prescribing. Correct dosing was associated with higher prescribing frequency (P=.014) and volume of patients with CD (P=.025). The frequency of adalimumab prescribing and volume of patients with CD were predictive of the total number of correct survey answers (P=.014 and P=.017, respectively). Only 50% of gastroenterologists always administered loading doses when switching to adalimumab from another anti-tumor necrosis factor (TNF) agent; 43.5% reported unclear loading efficacy and 24.3% reported infection concerns from excess anti-TNF as reasons. Eighteen percent of gastroenterologists reported that pharmacies had reduced their prescribed adalimumab doses. To our knowledge, this is the only study evaluating prescribing patterns of adalimumab in patients with CD in the United States. Our findings demonstrate that many gastroenterologists are not using optimal adalimumab dosing strategies, which may lead to a decreased rate of response in patients with CD. Further research is needed to confirm our findings and identify barriers to optimal adalimumab use by gastroenterologists for treatment of CD.

Idarubicin appears equivalent to dose-intense daunorubicin for remission induction in patients with acute myeloid leukemia.

Daunorubicin has historically been considered the anthracycline of choice at many cancer centers for the treatment of acute myeloid leukemia (AML). Drug shortages have required the substitution of daunorubicin with idarubicin. Randomized studies have shown idarubicin (10-12mg/m(2)) to be comparable or superior to standard dose daunorubicin (45-60mg/m(2)) for achieving complete remission (CR). Whether these results can be extrapolated to dose-intense daunorubicin (90mg/m(2)), recently shown to improve CR rates when compared to standard daunorubicin doses remains uncertain. This observational study was conducted at Northwestern Memorial Hospital (NMH) to compare CR rates. The results suggest idarubicin is equivalent to daunorubicin, and for some subsets of patients, idarubicin may have superior CR rates.

Understanding cervical cancer screening among lesbians: a national survey.

BACKGROUND: Lesbians have low rates of cervical cancer screening, even though they are at risk of developing the disease. The aim of this study was to examine cervical cancer screening behaviors in a national sample of lesbians. METHODS: A standardized internet survey was sent to 3,000 self-identified lesbians to assess cervical cancer screening behaviors and barriers to screening. The sample consisted of 1,006 respondents. RESULTS: Sixty-two percent of the weighted sample of respondents were routine screeners. Lack of a physician referral (17.5%) and lack of a physician (17.3%) were the most commonly-cited top reasons for lack of screening. Adjusting for age, education, relationship status, employments status, and insurance status, women who had disclosed their sexual orientation to their primary care physician (adjusted odds ratio [OR] 2.84 [95% confidence interval 1.82-4.45]) or gynecologist (OR 2.30 [1.33-3.96]) had greater odds of routine screening than those who did not. Those who knew that lack of Pap testing is a risk factor for cervical cancer were also more likely to be routine screeners (OR 1.95 [1.30-2.91]), although no association with screening was apparent for women who had more knowledge of general cervical cancer risk factors. Physician recommendation appeared to be a potent determinant of regular screening behavior. Routine screeners perceived more benefits and fewer barriers to screening, as well as higher susceptibility to cervical cancer. CONCLUSIONS: Some women who identify as lesbian are at a potentially elevated risk of cervical cancer because they are not routinely screened. Evidence-based interventions should be developed to address critical health beliefs that undermine participation in screening. Given the value placed on physician recommendation, patient-provider communication may serve as the optimal focus of effective intervention.

HOXB13:IL17BR and molecular grade index and risk of breast cancer death among patients with lymph node-negative invasive disease.

INTRODUCTION: Studies have shown that a two-gene ratio (HOXB13:IL17BR) and a five-gene (BUB1B, CENPA, NEK2, RACGAP1, RRM2) molecular grade index (MGI) are predictive of clinical outcomes among early-stage breast cancer patients. In an independent population of lymph node-negative breast cancer patients from a community hospital setting, we evaluated the performance of two risk classifiers that have been derived from these gene signatures combined, MGI+HOXB13:IL17BR and the Breast Cancer Index (BCI). METHODS: A case-control study was conducted among 4,964 Kaiser Permanente patients diagnosed with node-negative invasive breast cancer from 1985 to 1994 who did not receive adjuvant chemotherapy. For 191 cases (breast cancer deaths) and 417 matched controls, archived tumor tissues were available and analyzed for expression levels of the seven genes of interest and four normalization genes by RT-PCR. Logistic regression methods were used to estimate the relative risk (RR) and 10-year absolute risk of breast cancer death associated with prespecified risk categories for MGI+HOXB13:IL17BR and BCI. RESULTS: Both MGI+HOXB13:IL17BR and BCI classified over half of all ER-positive patients as low risk. The 10-year absolute risks of breast cancer death for ER-positive, tamoxifen-treated patients classified in the low-, intermediate-, and high-risk groups were 3.7% (95% confidence interval (CI) 1.9% to 5.4%), 5.9% (95% CI 3.0% to 8.6%), and 12.9% (95% CI 7.9% to 17.6%) by MGI+HOXB13:IL17BR and 3.5% (95% CI 1.9% to 5.1%), 7.0% (95% CI 3.8% to 10.1%), and 12.9% (95% CI 7.1% to 18.3%) by BCI. Those for ER-positive, tamoxifen-untreated patients were 5.7% (95% CI 4.0% to 7.4%), 13.8% (95% CI 8.4% to 18.9%), and 15.2% (95% CI 9.4% to 20.5%) by MGI+HOXB13:IL17BR and 5.1% (95% CI 3.6% to 6.6%), 18.6% (95% CI 10.8% to 25.7%), and 17.5% (95% CI 11.1% to 23.5%) by BCI. After adjusting for tumor size and grade, the RRs of breast cancer death comparing high- versus low-risk categories of both classifiers remained elevated but were attenuated for tamoxifen-treated and tamoxifen-untreated patients. CONCLUSION: Among ER-positive, lymph node-negative patients not treated with adjuvant chemotherapy, MGI+HOXB13:IL17BR and BCI were associated with risk of breast cancer death. Both risk classifiers appeared to provide risk information beyond standard prognostic factors.

Questioning the role of a neutropenic diet following hematopoetic stem cell transplantation.

The use of a neutropenic diet (ND) after hematopoietic stem cell transplantation (HSCT) was instituted more than 30 years ago as a means of preventing infection from organisms colonizing the gastrointestinal tract. Evidence supporting this practice is lacking, however, and the actual efficacy of the ND remains unknown. Institutional policy at Northwestern Memorial Hospital discontinued the use of ND in 2006. We conducted a retrospective study of 726 consecutive HSCT recipients, 363 who received an ND and 363 who received a general hospital diet, to determine the incidence of microbiologically confirmed infections during and after transplantation. Our findings indicate a higher rate of infections in the HSCT recipients who received an ND.

Adherence to the U.S. Preventive Services Task Force 2002 osteoporosis screening guidelines in academic primary care settings.

BACKGROUND: Osteoporosis is very common in older women in the United States. Osteoporotic fractures cause significant morbidity and mortality, as well as high healthcare costs. Since 2002, the United States Preventive Services Task Force (USPSTF) has recommended screening for osteoporosis of all women aged ≥65. Our objective was to determine adherence to osteoporosis screening guidelines by primary care internists in a large academic medical center and to assess if adherence varies based on provider gender or practice location. METHODS: This was a retrospective electronic medical record (EMR) review. All women aged ≥65 who were seen in the General Internal Medicine Center (GIMC) or the Women's Health Care Center (WHCC) at the University of Washington Medical Center by internal medicine attending physicians between January 1, 2006, and February 2, 2008, were included in the study. We determined if the patient had a dual energy x-ray absorptiometry (DEXA) study in the EMR database. We calculated the percentage of patients screened per provider and also compared the rate of screening for male vs. female providers and for GIMC vs. WHCC providers. RESULTS: Of the 1363 women included in the study, 70% had documentation of a DEXA study. Adherence to screening recommendations for individual providers varied from 33% to 100%. Screening was more likely to occur in the WHCC than in the GIMC (79.2% vs. 66.7%, p<0.001). Although women providers were more likely to screen than their male counterparts (72.2% vs. 66.1%, p=0.023), this relationship did not hold true after excluding women providers from the WHCC. CONCLUSIONS: We found good adherence to the USPSTF 2002 guidelines for osteoporosis screening in women aged ≥65 years by primary care physicians in a large urban academic medical center. The practice site and not gender of the provider resulted in significantly different screening rates.

A population-based study of tumor gene expression and risk of breast cancer death among lymph node-negative patients.

INTRODUCTION: The Oncotype DX assay was recently reported to predict risk for distant recurrence among a clinical trial population of tamoxifen-treated patients with lymph node-negative, estrogen receptor (ER)-positive breast cancer. To confirm and extend these findings, we evaluated the performance of this 21-gene assay among node-negative patients from a community hospital setting. METHODS: A case-control study was conducted among 4,964 Kaiser Permanente patients diagnosed with node-negative invasive breast cancer from 1985 to 1994 and not treated with adjuvant chemotherapy. Cases (n = 220) were patients who died from breast cancer. Controls (n = 570) were breast cancer patients who were individually matched to cases with respect to age, race, adjuvant tamoxifen, medical facility and diagnosis year, and were alive at the date of death of their matched case. Using an RT-PCR assay, archived tumor tissues were analyzed for expression levels of 16 cancer-related and five reference genes, and a summary risk score (the Recurrence Score) was calculated for each patient. Conditional logistic regression methods were used to estimate the association between risk of breast cancer death and Recurrence Score. RESULTS: After adjusting for tumor size and grade, the Recurrence Score was associated with risk of breast cancer death in ER-positive, tamoxifen-treated and -untreated patients (P = 0.003 and P = 0.03, respectively). At 10 years, the risks for breast cancer death in ER-positive, tamoxifen-treated patients were 2.8% (95% confidence interval [CI] 1.7-3.9%), 10.7% (95% CI 6.3-14.9%), and 15.5% (95% CI 7.6-22.8%) for those in the low, intermediate and high risk Recurrence Score groups, respectively. They were 6.2% (95% CI 4.5-7.9%), 17.8% (95% CI 11.8-23.3%), and 19.9% (95% CI 14.2-25.2%) for ER-positive patients not treated with tamoxifen. In both the tamoxifen-treated and -untreated groups, approximately 50% of patients had low risk Recurrence Score values. CONCLUSION: In this large, population-based study of lymph node-negative patients not treated with chemotherapy, the Recurrence Score was strongly associated with risk of breast cancer death among ER-positive, tamoxifen-treated and -untreated patients.

Final results of the Maryland WIC Food for Life Program.

BACKGROUND: The few randomized community trials in middle-income populations that tried to modify multiple dietary risk factors for cancer only demonstrated small changes. This trial sought to decrease the percent of calories derived from fat and to increase fruit, vegetable, and fiber intake among low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Maryland. METHODS: We conducted six-month intervention programs for 1055 women at ten WIC sites; 1011 women served as controls. Intervention participants were invited to five interactive nutrition sessions and were sent written materials. Controls received usual care. Women were surveyed at baseline, two months post intervention, and one year later. All analyses conducted used an intention-to-treat paradigm. RESULTS: Mean differences (intervention-control) in change from baseline were for percent calories from fat -1.62 +/- 0.33% (P < 0.0001), for consumption of fruits and vegetables 0.40 +/- 0.11 servings (P = 0.0003), and for fiber intake 1.01 +/- 0.31 grams (P = 0.001). These differences in change were related in a dose-response relationship to the number of sessions women attended and remained significant one year post-intervention for the first two outcomes. CONCLUSIONS: Multiple dietary improvements can be achieved in a low-income population with an effective, multi-faceted intervention program. The changes in this trial exceeded those in previous community trials conducted in higher SES populations.

Predictors of perioperative complications in head and neck patients.

BACKGROUND: Patients with significant medical problems requiring major otolaryngology procedures are at high risk for both medical and surgical complications. OBJECTIVE: To identify risk factors associated with perioperative complications in medically compromised patients undergoing major otolaryngology procedures. METHODS: Ninety-three consecutive patients with significant comorbid medical illnesses (eg, diabetes, hypertension) undergoing major head and neck surgical procedures were referred to a medical consultation center for preoperative assessment and medical management. Patient and surgical characteristics as well as perioperative complications were identified and recorded. Univariate and multivariate analyses were performed to determine which characteristics were associated with complications. RESULTS: Thirty-two patients (34%) had postoperative complications. Twenty-six patients (28%) had serious medical complications, and 18 (19%) had surgical complications. No deaths occurred in the study population. On univariate analysis, the factors associated with all complications included history of hepatitis, flap reconstruction, oncologic surgery, preoperative radiation therapy, preoperative gastrostomy placement, intraoperative transfusion, anesthesia time (> or =8 hours), and those with greater intraoperative fluid replacement and estimated blood losses. Only anesthesia time (> or =8 hours) remained independently significant on multivariate analysis. A history of hepatitis and prolonged anesthesia time were the only independent predictors of medical complications. The only independent predictor of surgical complications was the volume of intraoperative fluid administered. CONCLUSIONS: Prolonged anesthesia times of 8 hours or more, a history of hepatitis, and large-volume intraoperative fluid resuscitations predicted adverse outcomes. Special care must be taken in counseling these patients preoperatively and in caring for them during their operative and postoperative course.