Relationship between polypharmacy and inpatient hospitalization among older adults with cancer treated with intravenous chemotherapy.

OBJECTIVES: Polypharmacy (≥5 concurrent medications) is common among older patients with cancer (48%-80%) and associated with increased frailty, morbidity, and mortality. This study examined the relationship between polypharmacy and inpatient hospitalization among older adults with cancer treated with intravenous (IV) chemotherapy. MATERIALS AND METHODS: The main data source was the Surveillance, Epidemiology, and End Results-Medicare linked files. Patients (≥65 years) were included if they were diagnosed with prostate (n = 1430), breast (n = 5490), or lung cancer (n = 7309) in 1991-2013 and received IV chemotherapy in 2011-2014. The number of medications during the six-month window pre-IV chemotherapy initiation determined polypharmacy status. Negative binomial models were used to assess the association between polypharmacy and post-chemotherapy inpatient hospitalization. The results were presented as incidence rate ratios. RESULTS: We identified 13,959 patients with prostate, breast, or lung cancer treated with IV chemotherapy. The median number of prescription medications during the six-month window pre-IV chemotherapy initiation was high: ten among patients with prostate cancer, nine among patients with breast cancer, and eleven among patients with lung cancer. Compared to patients taking <5 prescriptions, post-chemotherapy hospitalization rate for patients with prostate cancer was 42%, 75%, and 114% higher among those taking 5-9, 10-14, and 15+ medications, respectively. Patients with breast and lung cancer demonstrated similar patterns. CONCLUSION: This large population-based study found that polypharmacy during the six-month window pre-IV chemotherapy is highly predictive of post-chemotherapy inpatient hospitalization. Further studies are needed to evaluate whether medication management interventions can reduce post-chemotherapy inpatient hospitalization among older patients with cancer.

Post-therapy serum prostate-specific antigen level and survival in patients with androgen-independent prostate cancer.

BACKGROUND: With an hypothesis that post-chemotherapy changes in serum prostate-specific antigen (PSA) levels might serve as a surrogate marker for assessing prostate cancer outcome (i.e., survival), we studied the relationship between pretherapy and post-therapy prognostic factors and survival in patients with androgen-independent prostate cancer. METHODS: A prognostic model for survival based on pretherapy and post-therapy parameters was developed from the clinical data on 254 patients with androgen-independent prostate cancer treated with 11 different protocol therapies at Memorial Sloan-Kettering Cancer Center. The model was validated by use of an independent dataset of 541 patients enrolled in two randomized phase III trials. RESULTS: In multivariate analysis, a post-therapy decline in PSA levels of 50% achieved in 12 weeks was a statistically significant factor associated with survival (two-sided P = .0012). A similar outcome was obtained with the use of an 8-week time frame. Elevated pretherapy level of serum lactate dehydrogenase (two-sided P = .0001), lower pretherapy level of hemoglobin (P = .0001), and younger age (two-sided P = .0430) had a statistically significant negative impact on outcome. Median survival times were 23, 17, and 9 months for low-, intermediate-, and high-risk groups of patients defined by the prognostic model, respectively. CONCLUSION: This study confirms the prognostic value of a post-therapy decline in PSA of 50% or greater from baseline in relation to survival in patients with androgen-independent prostate cancer treated with a variety of therapies. Two consecutive determinations at 4-week intervals can be used as an end point for efficacy in phase II trials of therapies in this disease.

Effect of multislice interference on image contrast in T2- and T1-weighted MR images.

Multislice imaging markedly degrades the contrast of T2-weighted MR images as the separation between slices is reduced. Image contrast was measured clinically at 1.5 T and experimentally at 0.15 T as a function of interslice gap width and shown to be in agreement with calculations based on known relaxation times and excitation profiles. Thus, the cause of T2 contrast degradation in multislice sequences is demonstrated. Contrast in T1-weighted sequences is shown to be minimally affected or even slightly enhanced. Selective excitation pulses with better spatial definition will diminish these contrast changes. Since perfect slice profiles can never be achieved, the clinical implications of these findings are discussed for MR imaging. The choice of slice gaps is an important operator-selected parameter in reducing contrast degradation in T2-weighted sequences.

Spatial misregistration of vascular flow during MR imaging of the CNS: cause and clinical significance.

Spatial misregistration of signal recovered from flowing spins within vascular structures is a common phenomenon seen in MR imaging of the CNS. The condition is displayed as a bright line or dot offset from the true anatomic location of the lumen of the imaged vessel. Its origin is the time delay between application of the phase- and frequency-encoding gradients used to locate spins within the plane of section. The principal condition necessary for the production of spatial misregistration is flow oblique to the axis of the phase-encoding gradient. Flow-related enhancement (entry slice phenomenon), even-echo rephasing, and gradient-moment nulling contribute to the production of the bright signal of spatial misregistration. Familiarity with the typical appearance of flow-dependent spatial misregistration permits confirmation of a vessel's patency; identification of the direction of flow; estimation of the velocity of flow; and differentiation of this flow artifact from atheromas, dissection, intraluminal clot, and artifacts such as chemical shift.

Posterior pituitary ectopia: an MR feature of pituitary dwarfism.

Using high-field-strength, 1.5-T, high-resolution MR, we identified the following complex of neurohypophyseal abnormalities in each of five pituitary dwarfs: (1) severe hypoplasia or total absence of the infundibulum; (2) absence of the posterior pituitary bright spot in its normal location; and (3) a 3-8-mm tissue nodule at the median eminence exhibiting lipidlike signal on T1-weighted images. On the basis of its signal features and the clinical absence of diabetes insipidus in these patients, the median eminence nodule appears to represent an ectopic and functional posterior pituitary gland. We propose that this anatomic derangement is the end result of a localized defect of developmental origin, possibly ischemic in nature, and involving principally the infundibular stem. Thus, human growth hormone deficiency could result from perinatal disruption of the peri-infundibular hypophyseal portal system, which in turn impairs anterior pituitary function through deprivation of direct delivery of crucial hypothalamic-releasing factors. Finally, we suggest that the trophic influence of continued axonal neurosecretion at the median eminence engages proliferation of rest cell pituicytes; a process that induces formation of an ectopic and functional posterior pituitary gland, complete with its characteristic bright spot.

Common artifacts encountered in magnetic resonance imaging.

Magnetic resonance imaging has rapidly become a widely accepted and clinically useful imaging modality primarily because of its excellent contrast resolution, ability to perform multiplanar acquisition, and the lack of ionizing radiation. However, the nuances of image acquisition are not trivial. Many technical factors must be considered and understood in order to knowledgeably choose sequence parameters that suppress artifacts and optimize the diagnostic quality of a particular MR examination. Even then, residual artifacts may persist. The presence of the artifacts and their technical basis must be understood before completely accurate MR interpretation can be rendered.

Idiopathic hypertrophic cranial pachymeningitis. Report of three cases.

Hypertrophic cranial pachymeningitis is a rare, idiopathic form of granulomatous pachymeningitis. This report describes three cases of hypertrophic cranial pachymeningitis and discusses the clinical, radiographic, and pathological findings in these and other reported cases. These lesions typically cause progressive cranial nerve palsies, headaches, and cerebellar dysfunction. They occur in patients of all age groups; the peak incidence is in the sixth decade. Hypertrophic cranial pachymeningitis is best identified by magnetic resonance imaging. The diagnosis is established by excluding all other granulomatous and infectious diseases. A dural biopsy is essential to confirm the diagnosis. Hypertrophic cranial pachymeningitis is initially responsive to steroid therapy, but in most cases it recurs or progresses despite treatment. Surgical excision of granulomas is occasionally necessary to alleviate a mass effect. The long-term outcome remains uncertain for most patients, but progressive disease is usually fatal owing to cranial neuropathies.

Radiographic assessment of discogenic disease of the spine.

Magnetic resonance imaging has gained favor as the imaging modality of choice for evaluation of disc disease that affects the lumbar and thoracic spinal segments. This new noninvasive modality also competes favorably with myelography and CT for evaluation of cervical spine disc disease. An algorithmic approach to use of various imaging modalities for evaluation of suspected disc disease is provided in Figure 15. Important advantages of MR imaging relate to its multiplanar capability and unprecedented soft-tissue contrast for simultaneous evaluation of the thecal sac and spinal canal contents. These advantages often translate to more accurate and specific diagnoses related to degenerative disc disease.

Neuropsychological, neurological, and MRI correlates of dementia in advanced Huntington's disease: a single case study.

Affected Huntington's disease patients present with a progressive dementia that can be detected with a variety of neuropsychological procedures. Neuropsychological findings include impaired mental flexibility and concentration, deterioration of verbal and procedural memory, diminished nonverbal memory, and slowing of both fine and gross motor functions. Magnetic resonance imaging (MRI) offers unique advantages in depicting morphologic changes associated with Huntington's disease. Frontotemporal atrophy and, in particular, atrophy of the corpus striatum are characteristically observed. Given the ease of obtaining coronal images and the improved differentiation of gray matter and white matter, MRI can provide better identification of these findings than traditional imaging methods such as computed tomography (CT). Finally, the presence of steadily progressive neuropsychological deterioration in conjunction with characteristic atrophy observed on MRI can be combined with diminished metabolic activity of the corpus striatum as observed on positron emission tomography (PET) for added diagnostic specificity.

Acquired immunodeficiency syndrome: neuroradiologic findings.

Central nervous system complications depicted by CT in ten patients with acquired immunodeficiency syndrome are described. Three patients had multifocal intra-axial enhancing lesions representing atypical brain abscesses (two with toxoplasmosis, one with candidiasis). A fourth patient with multifocal "ring" lesions whose biopsy was interpreted as suggestive of toxoplasmosis responded poorly to treatment. Following his death three months later of Pneumocystis carinii pneumonia, autopsy revealed primary intracerebral immunoblastic lymphoma. One patient had Kaposi sarcoma involving the right frontal lobe (seen as an enhancing mass on the CT scan). CT findings in the remaining five patients revealed mild to moderate enlargement of cerebrospinal fluid spaces (including ventricles and basal cisternae) as a result of cryptococcal meningitis in three patients and "aseptic" meningitis in two. The two patients in whom early biopsy confirmed toxoplasmosis responded well to anti-infective therapy, resulting in dramatic clinical recoveries.

Epidural block: myelographic evaluation with a single-puncture technique using metrizamide.

A simplified technique using metrizamide for myelographic delineation of extrinsic spinal cord blocks is described. This method was successfully used in eight consecutive examinations without adverse effects. A single lumbar puncture is followed by instillation of metrizamide into the subarachnoid space. With the needle left in place and the patient in the Trendelenburg position, the contrast agent is sequentially displaced above any encountered extradural blocks by further injection of diluent or sterile saline into the caudal thecal sac. Thus, multiple levels of blockage may be defined at their upper and lower margins. This method offers an expedient and safe alternative to combined lumbar and C1-2 lateral cervical puncture, leaves a minimum amount of metrizamide "trapped" below a block, and has several advantages over use of iophendylate. Additionally, the examination may be supplemented with CT scanning when desirable.

Isolated abducens nerve palsy: MR imaging findings.

The abducens nerve, the sixth cranial nerve, innervates the lateral rectus muscle of the eye and is responsible for lateral horizontal ocular movement. A wide variety of abnormalities, both primary to the nerve itself and secondarily involving the nerve, can paralyze the abducens nerve. MR imaging offers the best opportunity to detect the underlying abnormality causing abducens nerve palsy. In this pictorial essay, we illustrate the MR imaging features of numerous conditions that cause isolated abducens nerve palsy.

Rathke cleft cysts: CT, MR imaging, and pathologic features.

The authors retrospectively reviewed the clinical, computed tomography (CT), and magnetic resonance (MR) imaging findings in seven patients with pathologically proved Rathke cleft cysts. All the cysts were located in the anterior sella turcica or the anterior suprasellar cistern. Five cysts had both intra- and suprasellar components, one was entirely intrasellar, and the other was predominantly suprasellar in location. The size of the cysts ranged from 8 to 20 mm. CT scans demonstrated low-density homogeneous lesions in four cases. On MR images of three of these four cases, the cysts had the same intensity as cerebrospinal fluid on T1- and T2-weighted images, while in the fourth case, the cyst was hyperintense on the T1-weighted images. In the remaining three cases, CT showed slight hyperdensity relative to brain parenchyma, suggestive of contrast enhancement. MR showed signal heterogeneity of these lesions with focal components of diminished signal intensity of T2-weighted images. These same foci appeared iso- to slightly hyperintense on T1-weighted images.

Intracranial lesions: flow-related enhancement on MR images using time-of-flight effects.

Many physico-anatomic variables and instrument parameters influence the relative magnetic resonance signal intensity of vascular channels. The interaction of these mechanisms is complex, but their composite effects can be accounted for by two main categories of flow phenomena: time-of-flight effects and spin-phase changes. Of these two mechanisms only the time-of-flight effect known as flow-related enhancement produces augmentation of intravascular signal. Flow-related enhancement can potentially provide positive contrast of diagnostic value in terms of anatomic depiction of vascular detail as well as physiologic characterization of blood flow. The authors have used a single-section, selectively irradiated, spin-echo pulse sequence to maximize flow-related enhancement within a variety of intracranial lesions, as a supplement to their regular imaging. The technique was found to be diagnostically useful in improving the conspicuity of vascular lesions, in determining vessel patency, in distinguishing flow void from calcification, and in obtaining semiquantitative information about flow dynamics.

Beam attenuation devices for digital subtraction angiography.

A set of three contoured and beveled aluminum filters was constructed for routine use in a variety of digital subtraction angiography (DSA) applications. These adjustable devices are designed to compensate for the uneven x-ray penetration that occurs in many radiographic fields and may otherwise lead to video camera saturation, a major source of artifact in DSA. We have used this simple yet versatile adjunct in more than 200 DSA examinations with uniformly satisfactory results. Major advantages include elimination of the procedural delays that may be associated with more conventional approaches (such as the use of a bolus technique) and avoidance of misregistration artifact when pixel-shifting is used.

ECG-synchronized DSA exposure control: improved cervicothoracic image quality.

An electrocardiogram (ECG)-synchronized x-ray exposure sequence was used to acquire digital subtraction angiographic (DSA) images during 13 arterial injection studies of the aortic arch or carotid bifurcations. These "gated" images were compared with matched "ungated" DSA images acquired using the same technical factors, contrast material volume, and patient positioning. Subjective assessments by five experienced observers of edge definition, vessel conspicuousness, and overall diagnostic quality showed overall preference for one of the two acquisition methods in 69% of cases studied. Of these, the ECG-synchronized exposure series were rated superior in 76%. Linear intensity gradients across vessel margins generally showed improved or unchanged edge definition in the gated subtraction images as compared with their ungated pairs. These results, as well as the relatively simple and inexpensive modifications required, suggest that routine use of ECG exposure control can facilitate improved arterial DSA evaluations of suspected cervicothoracic vascular disease.

Intra-arterial DSA: early experience with a 1024(2) matrix.

Twenty patients were studied with intra-arterial digital subtraction angiography (IA DSA), utilizing a 1024(2) matrix memory. Acquisition of the images was through a prototype television camera incorporating a finely focused electron beam. In five cases, comparison between a 512 X 512 (512(2)) matrix acquisition and a 1024 X 1024 (1024(2)) matrix acquisition mode was made, with injections occurring in the same vessel in the same patient. The clinical material demonstrated no significant improvement in image quality at the 4 1/2 as well as the 6 inch image intensifier (II) modes. However, the 1024(2) matrix combined with the 9 inch II mode showed foci of disease and normal anatomy with detail not always seen on the 9 inch II when a 512(2) matrix was used. In no case, however, was the basic diagnosis missed with the 512(2) matrix. Spatial resolution, as measured from lead bar test pattern images, demonstrated that the 1024(2) matrix allows a 70% or greater improvement in spatial resolution over the 512(2) for the 4 1/2, 6 and 9 inch II modes. For a given mode the radiation dose was held constant for the two matrix sizes.