Signature of Short-Range van der Waals Forces Observed in Poisson Spot Diffraction with Indium Atoms.

The phase of de Broglie matter waves is a sensitive probe for small forces. In particular, the attractive van der Waals force experienced by polarizable atoms in the close vicinity of neutral surfaces is of importance in nanoscale systems. It results in a phase shift that can be observed in matter-wave diffraction experiments. Here, we observe Poisson spot diffraction of indium atoms at submillimeter distances behind spherical submicron silicon dioxide particles to probe the dispersion forces between atoms and the particle surfaces. We compare the measured relative intensity of Poisson's spot to theoretical results derived from first principles in an earlier communication and find a clear signature of the atom-surface interaction.

Radiographic Sarcopenia and Self-reported Exhaustion Independently Predict NSQIP Serious Complications After Pancreaticoduodenectomy in Older Adults.

INTRODUCTION: Sarcopenia is linked to poor outcomes after abdominal surgery. We hypothesized that radiographic sarcopenia metrics enhance prediction of complications after pancreaticoduodenectomy (PD) when combined with clinical and frailty data. METHODS: Preoperative geriatric assessments and CT scans of patients undergoing PD were reviewed. Sarcopenia was assessed at L3 using total psoas area index (TPAI) and weighted average Hounsfield units (HU), i.e., estimates of psoas muscle volume and density. Outcomes included 30-day American College of Surgeons National Surgical Quality Improvement Program (NSQIP) serious complications, Clavien-Dindo complications, unplanned intensive care unit (ICU) admission, hospital length of stay (LOS), non-home facility (NHF) discharge, and readmission rates. RESULTS: Low HU score correlated with NSQIP serious complications (r = -0.31, p = 0.0098), Clavien-Dindo complication grade (r = -0.29, p = 0.0183), unplanned ICU admission (r = -0.28, p = 0.0239), and NHF discharge (r = -0.25, p = 0.0426). Controlling for a "base model" of age, body mass index, American Society of Anesthesiologists score, and comorbidity burden, Fried's exhaustion (odds ratio [OR] 4.72 [1.23-17.71], p = 0.021), and HU (OR 0.88 [0.79-0.98], p = 0.024) predicted NSQIP serious complications. Area under the receiver-operator characteristic (AUC) curves demonstrated that the combination of the base model, exhaustion, and HU trended towards improving the prediction of NSQIP serious complications compared with the base model alone (AUC = 0.81 vs. 0.70; p = 0.09). Additionally, when controlling for the base model, TPAI (ß-coefficient = 0.55 [0.10-1.01], p = 0.018) and exhaustion (ß-coefficient = 2.47 [0.75-4.20], p = 0.005) predicted LOS and exhaustion (OR 4.14 [1.48-11.6], p = 0.007) predicted readmissions. CONCLUSIONS: When combined with clinical and frailty assessments, radiographic sarcopenia metrics enhance prediction of post-PD outcomes.

Geriatric assessment improves prediction of surgical outcomes in older adults undergoing pancreaticoduodenectomy: a prospective cohort study.

OBJECTIVE: To prospectively evaluate the additional value of geriatric assessment (GA) for predicting surgical outcomes in a cohort of older patients undergoing a pancreaticoduodenectomy (PD) for pancreatic tumors. BACKGROUND: Older patients are less often referred for possible PD. Standard preoperative assessments may underestimate the likelihood of significant adverse outcomes. The prospective utility of validated GA has not been studied in this group. METHODS: PD-eligible patients were enrolled in a prospective outcome study. Standard preoperative assessments were recorded. Elements of validated GA were also measured, including components of Fried's model of frailty, the Vulnerable Elders Survey (VES-13), and the Short Physical Performance Battery (SPPB). All postoperative adverse events were recorded, systematically reviewed, and graded using the Clavien-Dindo system by a surgeon blinded to the GA results. Multivariate regression analyses were conducted. RESULTS: Seventy-six older patients underwent a PD. Significant unrecognized vulnerability was identified at the baseline: Fried's "exhaustion" (37.3%), SPPB <10 (28.5%), and VES-13 >3 (15.4%). Within 30 days of PD, 46% experienced a severe complication (Clavien-Dindo grade ≥III). In regression analyses controlling for age, the body mass index, the American Society of Anesthesiologists score, and comorbidity burden, Fried's "exhaustion" predicted major complications [odds ratio (OR) = 4.06; P = 0.01], longer hospital stays (ß = 0.27; P = 0.02), and surgical intensive care unit admissions (OR = 4.30; P = 0.01). Both SPPB (OR = 0.61; P = 0.04) and older age predicted discharge to a rehabilitation facility (OR = 1.1; P < 0.05) and age correlated with a lower likelihood of hospital readmission (OR = 0.94; P = 0.02). CONCLUSIONS: Controlling for standard preoperative assessments, worse scores on GA prospectively and independently predicted important adverse outcomes. Geriatric assessment may help identify older patients at high risk for complications from PD.

African American men significantly underestimate their risk of having prostate cancer at the time of biopsy.

BACKGROUND: Guidelines for prostate cancer (PCa) screening recommend physicians to have an informational discussion with patients. At the time of biopsy, patients should be informed of their heightened PCa risk, particularly African Americans (AA) who have significantly higher diagnostic and mortality risk. We tested predictors of patients' estimation of their likelihood of having PCa at the time of biopsy. METHODS: A convenience sample of AA (n = 207) and white (n = 271) biopsy patients was surveyed at the time of prostate biopsy. Participants gave likelihood estimations of having PCa and data on their socio-demographics, health, clinical status, and general and PCa-specific anxiety. Binary logistic regressions tested for predictors of the patients' estimations and biopsy results. RESULTS: Fifty-one percent of AA men answered that they had a '0%' likelihood of having PCa versus 19% of whites, whereas 57% of AA men had abnormal biopsies compared with 42% of whites. In logistic regressions, predictors of patient answers of 0% chance of PCa were AA ethnicity (OR = 4.50; p < 0.001), lower cancer-specific anxiety (OR = 0.93; p < 0.01), less education (OR = 2.38; p < 0.05), and less urinary disturbance (OR = 0.70; p < .05). In a second regression, AA patients trended towards higher positive biopsy rates (OR = 1.43; p = 0.17). CONCLUSIONS: At biopsy, AA more often estimated their likelihood of PCa as 0%, despite higher risks. Reasons for these low estimates and their potential contribution to poor treatment outcomes of AA patients require further investigation.

The prevalence, correlates, and impact of logically inconsistent preferences in utility assessments for joint health states in prostate cancer.

BACKGROUND: Variations in health state utilities can impact cost-effectiveness analyses. One potential source of error is when joint health state (JS) utilities are rated higher than the embedded single state (SS) utilities. Knowing when and in whom this occurs can improve cost-effectiveness analyses. METHODS: Men (n = 323) were surveyed at the time of prostate biopsy. Time tradeoff SS and JS utilities for prevalent prostate cancer (PCa) health states were collected. JS utilities assessed included those most prevalent for PCa. "Inconsistency" was defined in the following 3 ways: (1) any size rank order violation; (2) total number of violations; and (3) differences greater than 1 standard deviation (SD). Regression analysis assessed independent patient characteristics associated with inconsistent responses. RESULTS: Aggregate JS utilities were consistent. At the individual level, 36% to 41% of responses violated rank order and 12% to 14% were larger than 1 SD. In all, 69% of respondents had at least 1 JS inconsistency, and 24% had >1 SD inconsistencies. Being married and feeling anxious were independently correlated with giving all types of inconsistent ratings, and lower education correlated with making >SD errors. SS utilities, and not JS utilities, were significantly lower for the inconsistent group. "Correcting" JS inconsistencies decreased aggregate utilities 1 to 9 units. CONCLUSIONS: Inconsistent JS utilities for PCa are prevalent in men at biopsy. Being married, more anxious, and having less education are correlated with inconsistencies. It is the SS utilities, rather than the JS utilities, that differ between consistent and inconsistent raters. Better understanding of the source of these inconsistencies is needed.

Patient and provider determinants of nephrology referral in older adults with severe chronic kidney disease: a survey of provider decision making.

BACKGROUND: Although chronic kidney disease (CKD) disproportionately affects older adults, they are less likely to be referred to a nephrologist. Factors that influence the referral decisions of primary care providers (PCPs) specifically for older CKD patients have been incompletely described. Patient factors such as dementia, functional disability, and co-morbidity may complicate the decision to refer an older adult. This study evaluated the role of patient and PCP factors in the referral decisions for older adults with stage 4 CKD. METHODS: We administered a two-part survey to study the decisions of practicing PCPs. First, using a blocked factorial design, vignettes systematically varied 6 patient characteristics: age, race, gender, co-morbidity, functional status, and cognitive status. CKD severity, patient preferences, and degree of anemia were held constant. Second, covariates from a standard questionnaire included PCP estimates of life expectancy, demographics, reaction to clinical uncertainty, and risk aversion. The main outcome was the decision to refer to the nephrologist. Random effects logistic regression models tested independent associations of predictor variables with the referral decision. RESULTS: More than half (62.5%) of all PCP decisions (n = 680) were to refer to a nephrologist. Vignette-based factors that independently decreased referral included older patient age (OR = 0.27; 95% CI, 0.15 to 0.48) and having moderate dementia (OR = 0.14; 95%CI, 0.07 to 0.25). There were no associations between co-morbidity or impaired functional activity with the referral decision. Survey-based PCP factors that significantly increased the referral likelihood include female gender (OR = 7.75; 95%CI, 2.07 to 28.93), non-white race (OR = 30.29; 95%CI, 1.30 to 703.73), those who expect nephrologists to discuss goals of care (OR = 53.13; 95%CI, 2.42 to 1168.00), those with higher levels of anxiety about uncertainty (OR = 1.28; 95%CI, 1.04 to 1.57), and those with greater risk aversion (OR = 3.39; 95%CI, 1.02 to 11.24). CONCLUSIONS: In this decision making study using hypothetical clinical vignettes, we found that the PCP decision to refer older patients with severe CKD to a nephrologist reflects a complex interplay between patient and provider factors. Age, dementia, and several provider characteristics weighed more heavily than co-morbidity and functional status in PCP referral decisions. These results suggest that practice guidelines should develop a more nuanced approach to the referral of older adults with CKD.

Age-related trends in utilization and outcome of open and endovascular repair for abdominal aortic aneurysm in the United States, 2001-2006.

OBJECTIVE: This study used a large national administrative in-hospital database to compare utilization and age-specific outcomes between open repair (OAR) and endovascular (EVAR) repair for the treatment of abdominal aortic aneurysm (AAA). METHODS: Discharges with the principal International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure codes for EVAR and OAR and principal diagnosis code of intact AAAs were selected from the 2001 to 2006 Nationwide Inpatient Sample (NIS). Weighted least-square regression was used to test the trend of utilization by age. Multiple linear and logistic regression analyses were used to assess the risk-adjusted outcomes. RESULTS: Nationally, the estimated number of elective AAAs treated with EVAR increased from 11,171 in 2001 to 21,725 in 2006 (P = .003). The number of elective AAAs treated with OAR declined from 17,784 to 8451 during the same period (P < .001). By 2006, EVAR was more frequently used than OAR for patients of all ages. Compared with the younger age groups, patients aged >or=85 years had a significant increase in the total number of asymptomatic AAA repairs, driven almost entirely by an increase in the use of EVAR. Compared with open patients, EVAR patients had a significantly shorter length of hospitalization (adjusted mean, 2.99 days [95% confidence interval (CI), 2.97-3.01] vs 8.78 days [95% CI, 8.53-8.57]), less in-hospital mortality (odds ratio [OR], 0.23; 95% CI, 0.19-0.28), fewer in-hospital complications (OR, 0.27; 95% CI, 0.25-0.28), and a higher likelihood of being discharged to home (OR, 3.95; 95% CI, 3.62-4.31). The reduction of complications from the use of EVAR versus OAR was most dramatic for the oldest patients. CONCLUSIONS: As short-term surgical outcomes are consistently improving for patients undergoing AAA repair, elective EVAR has replaced OAR as the more common method of repair in the United States. The introduction of this technology has been rapidly adopted, particularly for the oldest-old surgical patients, aged >or=85 years, who previously may not have been offered surgical intervention for asymptomatic AAA. Further investigation is necessary to examine whether this trend improves the long-term survival and quality of life for this elderly population.

What correlates with the intention to be tested for mild cognitive impairment (MCI) in healthy older adults?

Our purpose was to determine the factors that correlate with healthy older adults' intention to get tested for mild cognitive impairment (MCI) under 3 different hypothetical conditions: (1) if they noticed they were having memory problems; (2) if a family member suggested that they are having memory problems; or (3) as part of a regular medical examination. Older adults were recruited from the waiting rooms of 2 geriatrics outpatient clinics for face-to-face interviews regarding their interest in being screened for MCI. A short description of MCI adapted from The Alzheimer's Association's "Fact Sheet" was presented before asking about MCI testing. Multivariable ordinal regression was used to account for heavily skewed outcome data showing very high levels of interest in screening for MCI. The strongest, most consistent correlate across all of the intention measures was the desire to know as early as possible if one has Alzheimer disease. Another robust correlate was having had normal memory testing in the past. Older adults appear to have psychologically connected MCI to Alzheimer disease, but how well they understand this connection is not known and requires further study.

The influence of retardation and dielectric environments on interatomic Coulombic decay.

Interatomic Coulombic decay (ICD) is a very efficient process by which high-energy radiation is redistributed between molecular systems, often producing a slow electron, which can be damaging to biological tissue. During ICD, an initially-ionised and highly-excited donor species undergoes a transition where an outer-valence electron moves to a lower-lying vacancy, transmitting a photon with sufficient energy to ionise an acceptor species placed close by. Traditionally the ICD process has been described via ab initio quantum chemistry based on electrostatics in free space, which cannot include the effects of retardation stemming from the finite speed of light, nor the influence of a dispersive, absorbing, discontinuous environment. Here we develop a theoretical description of ICD based on macroscopic quantum electrodynamics in dielectrics, which fully incorporates all these effects, enabling the established power and broad applicability of macroscopic quantum electrodynamics to be unleashed across the fast-developing field of ICD.

Can induced anxiety from a negative earlier experience influence vascular surgeons' statistical decision-making? A randomized field experiment with an abdominal aortic aneurysm analog.

BACKGROUND: Increasing detection, new screening recommendations, and popular press attention contribute to the rising prevalence of asymptomatic abdominal aortic aneurysms (AAA). Evidence-based guidelines recommend the optimal time to operate is when the aneurysm is 5.5 cm in diameter. Smaller AAAs are periodically monitored with imaging. Recent events and emotional reactions to risk and uncertainty, including anxiety, can cause decision-making to diverge from cognitively based assessments. It is not known whether this applies to vascular surgeons making statistically-optimal, risky decisions. We tested whether an unexpected, recent negative event might influence vascular surgeons' decisions about a computer-simulation AAA-analog that includes statistical information. STUDY DESIGN: We performed a randomized, computer-based field experiment with evidenced-based statistical information readily available on bursting probabilities. Participants included vascular surgeons with AAA operative experience attending two vascular surgery conferences held in 2005 (n=81). The intervention was a randomly assigned, anxiety-inducing, bursting balloon versus a nonbursting balloon before a statistical decision-making computer simulation. The main outcomes measure was real-time prospective choice to opt out of expanding AAA simulation. A Cox proportional hazard model was used to assess the likelihood of opting out, while controlling for important covariates. RESULTS: The experimental group was more likely to opt out (hazard ratio: 3.32; 95% CI: 1.25 to 8.81), even after controlling for initial anxiety levels, risk attitudes, uncertainty attitudes, use of statistical information, surgical experience, and demographics. CONCLUSIONS: Experiencing a negative, potentially anxiety-provoking, preceding event can influence decision-making, even among experienced vascular surgeons who have ready access to statistical risk information.

Anomalous Evidence, Confidence Change, and Theory Change.

A novel experimental paradigm that measured theory change and confidence in participants' theories was used in three experiments to test the effects of anomalous evidence. Experiment 1 varied the amount of anomalous evidence to see if "dose size" made incremental changes in confidence toward theory change. Experiment 2 varied whether anomalous evidence was convergent (of multiple types) or replicating (similar finding repeated). Experiment 3 varied whether participants were provided with an alternative theory that explained the anomalous evidence. All experiments showed that participants' confidence changes were commensurate with the amount of anomalous evidence presented, and that larger decreases in confidence predicted theory changes. Convergent evidence and the presentation of an alternative theory led to larger confidence change. Convergent evidence also caused more theory changes. Even when people do not change theories, factors pertinent to the evidence and alternative theories decrease their confidence in their current theory and move them incrementally closer to theory change.

Which better predicts mortality among older men, a prostate cancer (PCa) diagnosis or vulnerability on the Vulnerable Elders Survey (VES-13)? A retrospective cohort study.

OBJECTIVES: Older men with a prostate cancer (PCa) diagnosis face competing mortality risks. Little is known about the prevalence of vulnerability and predictors of mortality in this population compared to men without a PCa diagnosis. We examined the predictive utility of the Vulnerable Elders Survey (VES-13) for mortality in older men with a PCa diagnosis as compared to controls. MATERIALS AND METHODS: Men aged ≥65years from an urban geriatrics clinic completed the VES-13 between 2003 and 2008. Each patient with a PCa diagnosis was matched by age to five controls, resulting in 59 patients with a PCa diagnosis and 318 controls. Cox proportional hazard models were used to determine the association of a PCa diagnosis and vulnerability on the VES-13 with mortality. RESULTS AND CONCLUSIONS: The mean age for men with a PCa diagnosis and controls was 77.9years and 76.1years, respectively. Of those with a PCa diagnosis, 74.6% had no active disease or a rising PSA only. Regardless of PCa diagnosis, vulnerable individuals on the VES-13 were more likely to die during the study period (VES-13≥3: HR=4.46, p<0.01; VES13≥6: HR=3.77, p<0.01). Men with a PCa diagnosis were not more likely to die compared to age-matched controls (VES-13≥3: HR=1.14, p=0.59; VES13≥6: HR=1.06, p=0.83). Vulnerability for men with a PCa diagnosis was more predictive of mortality. Therefore, the assessment of vulnerability is important for establishing goals of care.

The Impact of a Frailty Education Module on Surgical Resident Estimates of Lobectomy Risk.

BACKGROUND: Frailty is a risk factor for adverse events after surgery. Residents' ability to recognize frailty is underdeveloped. We assessed the influence of a frailty education module on surgical residents' estimates of lobectomy risk. METHODS: Traditional track cardiothoracic surgery residents were randomly allocated to take an online short course on frailty (experimental group) or to receive no training (control group). Residents read a clinical vignette, made an initial risk estimate of major complications for lobectomy, and rated clinical factors on their importance to their estimates. They viewed a video of a standardized patient portraying the patient in the vignette, randomly selected to exhibit either vigorous or frail behavior, and provided a final risk estimate. After rating five vignettes, they completed a test on their frailty knowledge. RESULTS: Forty-one residents participated (20 in the experimental group). Initial risk estimates were similar between the groups. The experimental group rated clinical factors as "very important" in their initial risk estimates more often than did the control group (47.6% versus 38.5%; p < 0.001). Viewing videos resulted in a significant change from initial to final risk estimates (frail 50% ± 75% increase, p = 0.008; vigorous 14% ± 32% decrease, p = 0.043). The magnitude of change in risk estimates was greater for the experimental group (10.0 ± 8.1 versus 5.1 ± 7.7; p < 0.001). The experimental group answered more frailty test questions correctly (93.7% versus 75.2%; p < 0.001). CONCLUSIONS: A frailty education module improved resident knowledge of frailty and influenced surgical risk estimates. Training in frailty may help educate residents in frailty recognition and surgical risk assessment.

Risk as feelings in the effect of patient outcomes on physicians' future treatment decisions: a randomized trial and manipulation validation.

The present study tested predictions derived from the Risk as Feelings hypothesis about the effects of prior patients' negative treatment outcomes on physicians' subsequent treatment decisions. Two experiments at The University of Chicago, U.S.A., utilized a computer simulation of an abdominal aortic aneurysm (AAA) patient with enhanced realism to present participants with one of three experimental conditions: AAA rupture causing a watchful waiting death (WWD), perioperative death (PD), or a successful operation (SO), as well as the statistical treatment guidelines for AAA. Experiment 1 tested effects of these simulated outcomes on (n = 76) laboratory participants' (university student sample) self-reported emotions, and their ratings of valence and arousal of the AAA rupture simulation and other emotion-inducing picture stimuli. Experiment 2 tested two hypotheses: 1) that experiencing a patient WWD in the practice trial's experimental condition would lead physicians to choose surgery earlier, and 2) experiencing a patient PD would lead physicians to choose surgery later with the next patient. Experiment 2 presented (n = 132) physicians (surgeons and geriatricians) with the same experimental manipulation and a second simulated AAA patient. Physicians then chose to either go to surgery or continue watchful waiting. The results of Experiment 1 demonstrated that the WWD experimental condition significantly increased anxiety, and was rated similarly to other negative and arousing pictures. The results of Experiment 2 demonstrated that, after controlling for demographics, baseline anxiety, intolerance for uncertainty, risk attitudes, and the influence of simulation characteristics, the WWD experimental condition significantly expedited decisions to choose surgery for the next patient. The results support the Risk as Feelings hypothesis on physicians' treatment decisions in a realistic AAA patient computer simulation. Bad outcomes affected emotions and decisions, even with statistical AAA rupture risk guidance present. These results suggest that bad patient outcomes cause physicians to experience anxiety and regret that influences their subsequent treatment decision-making for the next patient.

Effect of specialty and recent experience on perioperative decision-making for abdominal aortic aneurysm repair.

OBJECTIVES: To determine whether recent experience and specialty choice would affect physician adherence to evidence-based guidelines. DESIGN: In a series of computer-simulated encounters, participants weighed the risk of spontaneous abdominal aortic aneurysm (AAA) rupture against the risk of perioperative death to determine timing for elective repair. Guideline recommendations and statistical information on the risks of rupture and surgical death were provided. SETTING: Annual meetings of the American Geriatrics Society, American College of Surgeons, and American Society of Anesthesiologists. PARTICIPANTS: Physicians. INTERVENTION: Before the simulation, each participant was randomly exposed to one of three simulated outcomes: death during watchful waiting (WWD), perioperative death (PD), or successful outcome (SO). MEASUREMENTS: Adherence to recommended guidelines for AAA treatment. RESULTS: Against guideline recommendations, 67% of geriatricians, 74% of anesthesiologists, and 77% of surgeons chose surgery when the rupture risk was lower than the risk of perioperative death (P < .05). Surgeons exposed to the WWD experience chose surgery significantly earlier than if they were exposed to a PD or SO experience (P < .001). Anesthesiologist choices did not differ with recent experience. CONCLUSION: Geriatrician decisions more closely followed guideline recommendations for AAA management than those of two other specialties typically involved in AAA care. A prior WWD affected surgeons most, geriatricians next, and anesthesiologists least. Geriatricians referring patients for AAA surgery should be aware of specialty-specific differences in perioperative decision behavior.

Obese frailty, physical performance deficits, and falls in older men with biochemical recurrence of prostate cancer on androgen deprivation therapy: a case-control study.

OBJECTIVES: To test the hypothesis that early androgen deprivation therapy (ADT) has no proven survival advantage in older men with biochemical recurrence (BCR) of prostate cancer (PCa), and it may contribute to geriatric frailty. METHODS: We conducted a case-control study of men aged 60+ years with BCR on ADT (n = 63) vs PCa survivors without recurrence (n = 71). Frailty prevalence, "obese" frailty, Short Physical Performance Battery (SPPB) scores, and falls were compared. An exploratory analysis of frailty biomarkers (C-reactive protein, erythrocyte sedimentation rate, hemoglobin, albumin, and total cholesterol) was performed. Summary statistics and univariate and multivariate regression analyses were conducted. RESULTS: More patients on ADT were obese (body mass index >30; 46.2% vs 20.6%; P = .03). There were no statistical differences in SPPB (P = .41) or frailty (P = .20). Using a proposed "obese" frailty criteria, 8.7% in ADT group were frail and 56.5% were "prefrail," compared with 2.9% and 48.8% of controls (P = .02). Falls in the last year were higher in the ADT group (14.3% vs 2.8%; P = .02). In analyses controlling for age, clinical characteristics, and comorbidities, the ADT group trended toward significance for "obese" frailty (P = .14) and falls (OR = 4.74, P = .11). Comorbidity significantly increased the likelihood of "obese" frailty (P = .01) and falls (OR 2.02, P = .01). CONCLUSIONS: Men with BCR on ADT are frailer using proposed modified "obese" frailty criteria. They may have lower performance status and more falls. A larger, prospective trial is necessary to establish a causal link between ADT use and progression of frailty and disability.

Palliative Access Through Care at Home: experiences with an urban, geriatric home palliative care program.

The aging of the U.S. population has resulted in a large number of persons with multiple, chronic illnesses and gradual functional decline. Many older adults with these conditions are homebound and have great difficulty accessing medical care. They are also more likely to suffer from unaddressed symptoms and end-of-life care needs. Certain groups, such as African-American patients and patients with dementia, are even less likely to access palliative care and hospice services. Although the informal caregivers attending to such persons may become overwhelmed without adequate support, palliative care, which covers a broad population, is an optimal way to address many of these needs. This article describes a unique, urban, home-based geriatrics palliative care program (Palliative Access Through Care at Home (PATCH)) designed to address some of these unmet needs. After 1 year of providing service, a mixed-methods study consisting of chart review, telephone interviews, and face-to-face interviews was conducted to assess caregiver expectations of and satisfaction with the program. Caregivers for the elderly, mostly African-American patients, more than half of whom had dementia, were overall very satisfied with their experience, despite the large amount of time necessary to provide the care that patients required. Themes extracted during qualitative analysis were the desire to remain at home, the need for easy access to a practitioner specializing in geriatrics and palliative medicine, and the challenges of transitions of care. PATCH was able to address many of these needs and provide high levels of caregiver satisfaction.

Patient anxiety about prostate cancer independently predicts early initiation of androgen deprivation therapy for biochemical cancer recurrence in older men: a prospective cohort study.

PURPOSE: Androgen deprivation therapy (ADT) is first-line therapy for patients with prostate cancer (PCA) who experience biochemical recurrence (BCR). However, the optimal timing of ADT initiation is uncertain, and earlier ADT initiation can cause toxicities that lower quality of life (QOL). We tested the hypothesis that elevated cancer anxiety leads to earlier ADT initiation for BCR in older men. PATIENTS AND METHODS: We conducted a prospective cohort study of older patients with BCR of PCA (n = 67). Patients completed questionnaires at presentation and each follow-up visit until initiation of ADT. PCA-specific anxiety was measured with the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Other collected data included demographics, clinical information, and general anxiety information. Treating oncologists were surveyed about their recommendations for ADT initiation. The primary outcome was the time to ADT initiation. Univariate, multivariate logistic regression, and time-to-event analyses were conducted to evaluate whether cancer anxiety was a predictor of earlier initiation of ADT. RESULTS: Thirty-three percent of patients initiated ADT at the first or second clinic visit. Elevated PCA anxiety (MAX-PC > 16) was the most robust predictor in multivariate analyses of early initiation (odds ratio [OR], 9.19; P = .01). PSA also independently correlated with early initiation (OR, 1.31; P = .01). PSA did not correlate with MAX-PC. CONCLUSION: Cancer anxiety independently and robustly predicts earlier ADT initiation in older men with BCR. For older patients with PCA, earlier ADT initiation may not change life expectancy and can negatively impact QOL. PCA-specific anxiety is a potential target for a decision-making intervention in this setting.

Extending the validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) at the time of prostate biopsy in a racially-mixed population.

The Memorial Anxiety Scale for Prostate Cancer (MAX-PC) has been validated for assessing men with prostate cancer for cancer-specific anxiety. It was originally validated in a predominantly white population. The MAX-PC Prostate Cancer Anxiety Subscale (MAX-PC-PCAS) may be relevant for measuring cancer-specific anxiety in undiagnosed men at risk for prostate cancer. We assess the validity of the MAX-PC-PCAS at the time of prostate biopsy (n = 178). Questions assessed socio-demographic information, health status, patient-estimated risk of cancer, the Hospital Anxiety and Depression Scale--Anxiety Subscale (HADS-A), and the MAX-PC-PCAS. The patients' most recent PSA was recorded. Cronbach's alpha, inter-item correlations, and Pearson correlations with both the HADS-A and clinical variables were compared with the original validation sample. Our sample was younger (63.1 vs 71.1 years), had a larger fraction of African-Americans (43 vs 10%), and had higher PSAs. Cronbach's alpha was equivalent (0.91 vs 0.90), median inter-item correlation was equivalent (0.63 vs 0.61), and Pearson correlation with HADS-A was higher (0.71 vs 0.57). Anxiety levels were not correlated with PSA levels, and there were minor differences in the validation findings by race. The validity of the MAX-PC-PCAS extends to men without cancer undergoing biopsy and to African-Americans.