START (screening tool to alert doctors to the right treatment)--an evidence-based screening tool to detect prescribing omissions in elderly patients

BACKGROUND

Inappropriate prescribing encompasses acts of commission i.e. giving drugs that are contraindicated or unsuitable, and acts of omission i.e. failure to prescribe drugs when indicated due to ignorance of evidence base or other irrational basis e.g. ageism. There are considerable published data on the prevalence of inappropriate prescribing; however, there are no recent published data on the prevalence of acts of omission. The aim of this study was to calculate the prevalence of acts of prescribing omission in a population of consecutively hospitalised elderly people.

METHODS

A screening tool (screening tool to alert doctors to the right treatment acronym, START), devised from evidence-based prescribing indicators and arranged according to physiological systems was prepared and validated for identifying prescribing omissions in older adults. Data on active medical problems and prescribed medicines were collected in 600 consecutive elderly patients admitted from the community with acute illness to a teaching hospital. On identification of an omitted medication, the patient's medical records were studied to look for a valid reason for the prescribing omission.

RESULTS

Using the START list, we found one or more prescribing omissions in 57.9% of patients. In order of prevalence, the most common prescribing omissions were: statins in atherosclerotic disease (26%), warfarin in chronic atrial fibrillation (9.5%), anti-platelet therapy in arterial disease (7.3%) and calcium/vitamin D supplementation in symptomatic osteoporosis (6%).

CONCLUSION

Failure to prescribe appropriate medicines is a highly prevalent problem among older people presenting to hospital with acute illness. A validated screening tool (START) is one method of systematically identifying appropriate omitted medicines in clinical practice.

Improving trends in glucocorticoid-induced osteoporosis management: 2002 to 2006

OBJECTIVE

In 2002 we undertook an audit of GIO (glucocorticoid-induced osteoporosis) management in the outpatient clinics of our university teaching hospital and found a wide variation in practice and considerable under-treatment of patients. We re-audited our practice in 2006.

METHODS

A retrospective chart audit was undertaken over a 4-month period of 3,475 patients attending the 3 medical specialty outpatient clinics that were originally audited in 2002. All glucocorticoid (GC) users over the past 6 months were identified. Demographic data and treatment details were extracted, and findings were compared with the previous audit.

RESULTS

Two hundred and fifty-three (7%) patients were identified to be taking GC vs. 104 (2%) in 2002. GIO risk was documented in 71% (179) (p < 0.001) of the charts vs. 13% (19) in the previous audit. In 2002, 56% (58) were on some form of bone protection [53% (55) on Ca/vitamin D and 29% (30) on a bisphosphonate] whereas in 2006 the figures were 86% (219), 82% (207) and 57% (144), respectively. DXA scanning was performed in 32% (82) of our patients in 2006. Nonetheless, considerable variation in practice was still seen, with prescription rates for anti-resorptive therapy varying from 24%-70% and those for Ca/vitamin D supplements ranging from 15%-95% for different services. For the highest risk patients, the prescription rates by specialty ranged from 36%-72% for anti-resorptive therapy and 76%-95% for Ca/vitamin D supplements.

CONCLUSION

Over 4 years, major improvements in GIO management have taken place in our institution, with almost a doubling of the prescription of bone protectants. However, there still remains a considerable variation in individual practices and an under-utilisation of DXA scanning. We believe that these overall, encouraging findings can be generalized to similar institutions elsewhere.

EMD121974 (NSC 707544, cilengitide) in asymptomatic metastatic androgen independent prostate cancer (AIPCa) patients (pts): A randomized trial by the Prostate Cancer Clinical Trials Consortium (NCI 6372)

5137

Background: Integrins avβ3 and avβ5 are essential to PCa metastasis by regulating cell adhesion, migration, invasion and motility. Cilengitide is a potent and selective avβ3 and avβ5 integrin receptor antagonist that in phase I studies has shown clinical activity. Methods: Pts with asymptomatic, metastatic chemo-naive AIPCa with PSA or objective progression, no visceral disease, minimum PSA of 5ng/ml, and adequate organ function were randomized to cilengitide 500 mg or 2,000 mg IV 2X weekly in 6-week cycles, using modified randomized selection design. Disease status was assessed every 12 weeks. The primary end point is objective progression rate (not including PSA) at 6 months. The Simon 2-stage optimal design is used to accrue 53 pts/arm. After first stage (20 pts/arm), accrual continues if ≥ 6 pts have not progressed. If second stage accrual is initiated, at end of study, the better performing arm will be chosen for further study provided at least 18/53 pts in that arm have not progressed. Secondary end points include safety, response rates and correlative measures of cilengitide effect on circulating and bone marrow tumor and endothelial cells and on bone remodeling markers. Results: First stage accrual is complete with 42 pts registered. Median performance status is 0, median age is 71 years (range 52–85), and median PSA is 44ng/ml (range 5–870). Disease progression at registration was defined by PSA in 90%, soft tissue in 36% and bone in 31% of pts. Median number of cilengitide cycles is 3 (range 1–8). To date, 32/42 pts have received ≥ 2 cycles. The most common (>5%) treatment related adverse events (AE): fatigue (38%), constipation (13%), anorexia (10%), leucopenia (8%) and nausea (8%). There were only 3 grade (G) 3 AEs (neutropenia, lymph node pain, lymph NOS) and no G4 AEs. Only 3 pts required dose modification. 25/42 pts were removed from protocol on or before 6 months, 6 pts received therapy for more than 6 months, and 11 are too early to assess. Conclusions: Cilengitide is well tolerated. Final results (efficacy, safety, correlative studies) of the first stage of accrual will be reported. Supported by CTEP, Prostate SPORE Grant P50 CA069568- 09, PC051375, Merck KGaA, PC051382.

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A phase I trial of nordihydroguareacetic acid (NDGA) in patients with non-metastatic prostate cancer and rising PSA

15500

Background: NDGA is a butanediol with effects on tumor cells, including inhibition of insulin growth factor receptor (IGF-1R) autophosphorylation. In vitro studies suggest that NDGA attenuates androgen-mediated prostate cancer growth without competitive androgen receptor blockade. Its effects on PSA in pts were studied. Methods: Eligible pts included men with recurrent prostate cancer following definitive local therapy with a rising PSA and no metastasis. Both androgen dependent prostate cancer (PSA rising with a normal tesosterone - ADPC) and androgen independent prostate cancer (PSA rising with castrate level of testosterone - AIPC) was allowed. Treatment consisted of continuous oral daily dosing of NDGA according to a planned dose escalation of 750, 1,250, 1,750, 2,250 and 2,500 mg. Pts were followed for safety and changes in PSA and PSA doubling time (PSADT). Results: 15 pts were enrolled: 11 pts with ADPC and 4 pts with AIPC. Median baseline serum PSA was 3.6 ng/mL in ADPC pts and 5.74 mg/mL in AIPC pts. Median age was 66 (range 48–81). Following a median of 5.5 cycles (range 1–13), transaminase elevations occurred in five pts (33%): 1 gr 1, 1 gr 2 and 3 gr 3- all occurring in month 3 or later. Transaminase elevations resolved after drug discontinuation but recurred with repeated dosing. Doses up to 2,500 mg/day were otherwise well- tolerated. The median baseline PSADT was 6.1 months for ADPC and 6.7 months for AIPC and was and 8.4 months on therapy (p=0.12) for ADPC and 4.2 months for AIPC. Of 11 ADPC pts, one (9%) had a decline in PSA by >50% compared to baseline and one (9%) had a decline of 3 fold increase in PSADT while on therapy, one from 11 to 46 months (750 mg), one from 9.5 to 49.5 months (1,750 mg), and one from 5.9 to 46.2 months (2,500 mg). There were no PSA reductions in the AIPC pts, however one pt had a >3 fold increase in PSADT (from 1.4 to 7.5 months). No significant effects on testosterone, adrenal androgen or estradiol levels were observed while on study. Conclusions: NDGA is well tolerated with the exception of transaminase elevations which occur after approximately 3 cycles in a minority of patients. Combined with preclinical data, the modest effects on PSA kinetics suggest that further study on androgen dependent tumors is justified.

No significant financial relationships to disclose.

Rectal and cutaneous malakoplakia in an orthotopic cardiac transplant recipient

Malakoplakia, from the Greek term meaning "soft plaque," is a rare granulomatous disease first documented by Michaelis and Gutmann in 1902, and is most commonly found in association with systemic diseases such as systemic lupus erythematosus, tuberculosis, diabetes mellitus, sarcoidosis or neoplasm. We present a case report of malakoplakia in a 55-year-old female patient who had undergone an orthotopic cardiac transplant for ischemic cardiomyopathy. She was found to have an irregular rectal mass, after presenting with a complaint of hematochezia and pressure with defecation as well as a "boil" on her right labia. Malakoplakia is an exceedingly rare disease entity, and this is only the third known report of this condition in a patient after cardiac transplantation. We review the current perspectives on the pathophysiology, diagnosis and treatment of this disease.

Effect of Ca2+ on Protein Kinase A-Mediated Phosphorylation of a Specific Serine Residue in an Expressed Peptide Containing the Ca2+-Regulatory Domain of Scallop Muscle Na+/Ca2+ Exchanger

Sequencing of the scallop muscle Na+/Ca2+ exchanger revealed three consensus sequences for phosphorylation by PK-A in the large cytoplasmic loop (R(363)KLTG, R(379)RASV, and R(618)RGSV). Site-directed mutagenesis of the expressed Glu(384)-Ser(713) segment of the f loop identified Ser(621)as a residue phosphorylated by PK-A. The R(618)RGSV sequence is located at the junction of the mutually exclusive exon and exon 9, a site where many alternatively spliced variants of vertebrate NCX1 and NCX3 are generated. Phosphorylation of Ser(621) by PK-A in the isolated Glu(384)-Ser(713) peptide was blocked under conditions where Ca2+ was bound.

Reduced thromboembolic events with DN-101 (high-dose calcitriol) treatment of androgen-independent prostate cancer: Hypothesis for a new class of anticoagulants

4505

Background: Thromboembolic events (TEs) occur at an increased rate in patients with advanced malignancies including androgen-independent prostate cancer (AIPC). DN-101, a new high-dose oral formulation of calcitriol (1,25-dihydroxycholecalciferol), is the active form of Vitamin D and the natural ligand for the nuclear receptor VDR. Calcitriol upregulates thrombomodulin, a natural anticoagulant, and downregulates tissue factor, a procoagulant both in vitro and in vivo. Further, VDR knockout mice demonstrate increased susceptibility to thrombosis. ASCENT is a double-blind, placebo-controlled study in 250 men with metastatic AIPC. Efficacy results have been previously reported (ASCO, 2005). Methods: 250 patients were randomized 1:1 to docetaxel 36 mg/m2 plus 45 μg DN-101 weekly or to the same docetaxel regimen plus placebo. In this exploratory analysis the incidence of TE (defined as deep venous thrombosis (DVT), pulmonary embolism (PE), myocardial infarction (MI), cerebrovascular accident (CVA) and arterial thrombosis (AT)) in the two study groups was compared using the Fisher’s exact test. Results: There were fewer patients with serious adverse events (SAEs) in the DN-101 group than in the placebo group (27 % vs. 41%). As shown in the table , DN-101 treated patients experienced fewer TEs including fewer TE SAEs, Grade 3 or 4 TEs and all grade TEs. No imbalance in baseline use of anticoagulants was observed. Conclusions: The well-described effects of calcitriol on protein components of the coagulation cascade provide a biologic basis for the observed reduction in thromboembolic events in the DN-101 treated patients. This hypothesis should be tested prospectively in future studies of DN-101.

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Diethylstilbestrol and docetaxel: A phase II study in patients with metastatic, androgen independent prostate cancer

4627

Background: The combination of diethylstilbestrol (DES) and docetaxel has additive to synergistic activity against prostate cancer in preclinical models and DES inhibits expression of taxane resistant tubulin isoforms. The objective of this study is to determine the effects of the combination of DES and docetaxel on PSA, overall response, and toxicity. Methods: Twenty nine patients with metastatic androgen independent prostate cancer progressing by rising PSA or scan were treated with DES 5 mg daily the day prior to docetaxel and 1 mg daily continuously in combination with Docetaxel 36mg/m2 IV weekly for 3 weeks of a 4 week cycle. Prophylactic anticoagulation was used in all patients. All patients were assessed by PSA monthly and CT or bone scans every 3 cycles. Dose modifications for hematologic, hepatic and renal toxicity were made. The RECIST criteria and PSA decline by >50% which was maintained for 4 weeks were used. Results: The median age is 69 years (56–84), SWOG PS 0 (0–1), alkaline phosphatase 120 U/L (45–523), Hgb 12.6 g/dL (9.2–16.3), PSA 67 ng/dL (6–1962). The median number of cycles is 5. The median follow up after completion of therapy is 6 mos (1–18). Soft tissue metastases were present in 46% of patients and bone metastases in 96%. Twenty four patients are evaluable for response and toxicity. Of these, 18 patients (75%) had PSA responses and the PSA declined by >90% in 9 patients (38%). The overall response for was 75%. 11 patients suffered grade 3/4 toxicity. Two patients died of causes unrelated to therapy and another died from a steroid induced ulcer. The median number of cycles for responding patients is 9. Two patients developed thrombosis and were positive for Factor V mutations. Conclusions: The combination of DES and docetaxel is well tolerated and toxicity is indistinguishable from docetaxel alone. The overall response rate was 75%, with approximately half of responding patients achieving a PSA < 4.0, suggesting that DES improves the therapeutic index of docetaxel substantially and is an effective regimen using easily administered drugs. (Supported by Sanofi Aventis).

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A randomised trial in malignant mesothelioma (M) of early (E) versus delayed (D) chemotherapy in symptomatically stable patients: the MED trial

BACKGROUND

Prior phase II trials have demonstrated the therapeutic activity of cytotoxic chemotherapy in mesothelioma. Currently there are few randomised data assessing the role of chemotherapy versus best supportive care (BSC) in the management of patients with stable symptoms after control of any pleural effusion. A policy of observation is often adopted over initial use of chemotherapy. In this prospective randomised trial we assess the use of early versus delayed cytotoxic therapy. The study opened in 1998, and closed in view of a competing national study (MSO 1) in 2003.

METHODS

Eligible patients had a performance status<or=2, life expectancy>3 months and had stable symptoms for at least 4 weeks prior to randomisation. Patients were randomised to receive immediate chemotherapy or initial BSC with the addition of chemotherapy at time of symptomatic progression. All patients received the same platinum-based chemotherapy regimen, MVP [mitomycin C 8 mg/m2 cycles 1, 2, 4 and 6, vinblastine 6 mg/m2, maximum 10 mg, and cisplatin 50 mg/m2 (or carboplatin AUC 5)], every 3 weeks for up to six cycles.

RESULTS

A total of 43 patients were recruited, of which 21 were randomised to the early treatment group and 22 to the delayed treatment group. The median ages were 59 years (range 50-78) and 67 years (range 48-75), respectively (P=0.1); other baseline parameters were well matched between the two groups. All 21 patients in the early group received chemotherapy versus 17 patients in the delayed group. Median time to symptomatic progression was 25 weeks in the early group compared with 11 weeks for the delayed group (P=0.1). Median survival was 14 months (1-year survival 66%) for the early group compared with 10 months (1-year survival 36%) for the delayed group (P=0.1). Quality of life was in general better maintained for early treatment and the health resources use was similar in both arms.

CONCLUSIONS

In this patient group, presenting with stable symptoms after control of pleural effusion, the early use of chemotherapy provided an extended period of symptom control, and in this small trial a trend to survival advantage.

Reduced cerebral blood flow response and compensation among patients with untreated hypertension

OBJECTIVE

To determine whether memory performance in hypertensive subjects induces diminished parietal and prefrontal blood flow activation relative to normotensive subjects but compensatory amygdala/hippocampal activation.

METHODS

Thirty-seven untreated hypertensive subjects and 59 normotensive control subjects performed in two memory and one sensorimotor task while global and regional cerebral blood flow (rCBF) was assessed with [15O]water and PET. Neuropsychological, carotid artery ultrasound, and MRI assessments were obtained.

RESULTS

When they were engaged in memory tasks, increases of CBF in hypertensive subjects were less than in normotensive subjects in the posterior parietal area, as expected; blunted responses were also shown within the middle posterior arterial watershed and thalamus. Relative to all other participants, hypertensive subjects that performed relatively well on verbal memory showed an enhanced rCBF response in the right amygdala/hippocampus. Furthermore, hypertensive, but not normotensive, subjects showed task-induced rCBF in the amygdala/hippocampal area that was significantly correlated with task-induced prefrontal rCBF. No confounding influences were identified from carotid artery or MRI measures.

CONCLUSIONS

Memory performance in hypertensive individuals is related to a blunted regional cerebral blood flow (rCBF) response, particularly in parietal cortex. Potentially compensatory rCBF responses appear to occur in midbrain and correlate with prefrontal rCBF.

Does Valganciclovir Hydrochloride (Valcyte) Provide Effective Prophylaxis Against Cytomegalovirus Infection in Liver Transplant Recipients?

INTRODUCTION

Cytomegalovirus (CMV) infection after solid organ transplantation is one of the most common viral infections, causing significant morbidity and mortality if not treated promptly. Ganciclovir has proven to be effective for the prophylaxis and treatment of CMV. However, oral absorption of ganciclovir is poor. Recently, oral administration of valganciclovir hydrochloride (Valcyte) has been observed to display 10-fold better absorption than oral ganciclovir. Valganciclovir has increasingly been used as prophylaxis against CMV after solid organ transplantation. The purpose of this study was to examine the efficacy of valganciclovir prophylaxis therapy after primary liver transplantation.

PATIENTS AND METHODS

Between July 2001 and May 2003, 203 consecutive liver transplant recipients, including 129 men and 74 women of overall mean age 53 +/- 11 years, received valganciclovir (900 mg/d or 450 mg every other day depending on renal function) for 3 to 6 months after primary liver transplantation. All patients were followed up for a minimum of 6 months. Mean follow-up was 19 +/- 5.8 months. CMV DNA in peripheral blood was tested using polymerase chain reaction (PCR) amplification. Symptomatic CMV was stratified according to the CMV immunoglobulin (Ig)G status of the donor and recipient at the time of liver transplantation. Donors and recipients were classified preoperatively into groups according to the presence or absence of CMV as follows: group 1 (n = 73; donor CMV+, recipient CMV+); group 2 (n = 41; donor CMV-, recipient CMV+); group 3 (n = 54; donor CMV+, recipient CMV-; high-risk group); and group 4 (n = 35; donor CMV-, recipient CMV-).

RESULTS

Twenty-nine patients (14.3%) developed symptomatic CMV disease at 169 +/- 117 days after liver transplantation: group 1, 16.4% versus group 2, 7.3% versus group 3, 25.9% versus group 4, 0%. Of these patients, 5 also had invasive CMV on liver biopsy, which was performed owing to abnormal liver functions. All 29 patients were treated with intravenous ganciclovir. One patient died owing to disseminated CMV, whereas the remaining 28 patients responded to treatment. Interestingly, 8 patients, including 1 who had invasive CMV hepatitis, developed symptomatic CMV within 90 days of liver transplantation even while on prophylactic valganciclovir.

CONCLUSION

Valganciclovir failed to provide adequate prophylaxis following liver transplantation in our patients. The overall rate of CMV in seropositive donors and/or recipients was 17%, and in the high-risk group was 26%. Further prospective studies with measurement of ganciclovir concentrations are needed to elucidate the reasons for this unexpected failure.

Evaluation of a 5-year school-based county-wide smoking education programme

Reports on an evaluation of Smoke Free Leitrim (SFL): a five-year (1996-2001) school-based county-wide smoking education programme that was offered to all fourth class students in all county Leitrim primary schools (n = 450). By programme end 208 (59%) SFL students and 147 (55%) of the control group had tried smoking. Sixty-six (19%) of the SFL group and 63 (24%) of the control group currently smoke. No significant differences were found between the groups for current smoking. Daily smoking of SFL and control males was identical: SFL 19 (10%); control 12 (10%). There was a significant difference between daily smoking of females: 14 (8%) SFL girls and 24 (16%) control group girls smoke everyday. The SFL intervention did not delay or prevent the uptake of smoking, but may have had some gendered effect. It reflected the limited effectiveness of long-term wide-scale smoking education interventions. A more sophisticated approach to young people and tobacco usage is required, that extends beyond the school to focus on tobacco usage in adults, families and the wider community.

Population based study of the cost of inpatient care for HIV-lnfected individuals in an Irish teaching hospital

A microcosting evaluation of the cost of inpatient care of 69 HIV-infected patients in an Irish teaching hospital was conducted from the hospital perspective. The median cost per admission was 6220 Euros and median cost per inpatient day was 557 Euros. HIV related admissions were associated with a greater cost per admission than non-HIV related admissions. There was an inverse relationship between inpatient costs and CD4 count. Ward costs accounted for the majority of inpatient expenditure. This is the first detailed study of the cost of inpatient care for HIV-infected individuals in Ireland. This study provides the data necessary to estimate the burden of HIV disease in Ireland and to evaluate the cost-effectiveness of antiretroviral and other strategies to manage HIV infection in the Irish context.

The diagnosis and management of common inherited bleeding disorders

Inherited bleeding disorders can be associated with significant morbidity and mortality. Bleeding episodes can be safely and effectively managed in the majority of patients provided the coagulation defect is identified and corrected with the appropriate replacement therapy. It is imperative that these patients are treated in centres that can provide full coagulation support, and a comprehensive care plan is formulated for each individual.

Congenital syphilis in the Russian Federation: magnitude, determinants, and consequences

OBJECTIVES

Reported cases of congenital syphilis in the Russian Federation increased 26-fold from 1991-9. Our objectives were to describe the frequency, risk factors, and consequences of delivering an infant with congenital syphilis among pregnant women with active syphilis.

METHODS

In a retrospective record review using consecutive sampling of logs at maternity hospitals in five geographic areas, data were abstracted for 850 women with active syphilis during pregnancy who had completed >/=20 weeks' gestation. Further information was abstracted from records in antenatal clinics, dermatovenereology clinics, and paediatric hospitals. We assessed the frequency of confirmed or probable congenital syphilis, used logistic modelling to identify independent predictors for delivering a baby with congenital syphilis, and calculated the proportion of infants with congenital syphilis who experienced late fetal death (20-27 weeks), stillbirth (>/=28 weeks), or infant death.

RESULTS

A total of 64% (n=544) of 850 pregnant syphilis infected women delivered an infant with confirmed or probable congenital syphilis; 40% of the sample had no prenatal care. Among women with no prenatal care, 77% received either no treatment or inadequate treatment and 86% delivered an infant with congenital syphilis. Important independent and modifiable risk factors for delivery of an infant with congenital syphilis included receiving no prenatal care (adjusted OR 2.8, 95% CI 1.7 to 4.7) and having the first test for syphilis at >/=28 weeks' gestation (adjusted OR 4.0, 95% CI 2.6 to 6.0). Fatal outcomes were observed in 26% of infants with congenital syphilis, including late fetal death (7%), stillbirth (16%), or neonatal death (3%).

CONCLUSIONS

In the Russian Federation, the frequency of congenital syphilis is high, risk factors for congenital syphilis are modifiable, and the consequences of congenital syphilis are severe.