Kerrville VA Medical Center

Heaney, John P. M.D.; Stanton, William K. M.D.; Halbert, David S. M.D.; Seidel, Joshua M.D.; Vice, Tom D.V.M. Author Information

Genetic alterations in primary prostate cancer (CaP) have been extensively studied, yet little is known about the genetic mechanisms underlying progression of primary CaP to metastatic prostate cancer. As a result, it is not possible to distinguish clinically indolent localized disease from potentially life-threatening tumors with high metastatic potential. To address this question, we collected tissue from 34 autopsy-derived metastases, samples rarely analyzed in previous studies. These were compared to a separate set of 17 prostatectomy specimens containing 22 foci of CaP associated with 49 examples of high-grade prostatic intraepithelial neoplasia (PIN), a histological precursor of CaP. We compared the loss of heterozygosity (LOH) profiles of high-grade PIN, primary CaP and metastases by analyzing 33 microsatellite markers previously found to have high frequencies of LOH in primary CaP. These markers were on chromosomes 5q, 6q, 7q, 8p, 9p, 10q, 11p, 13q, 16q, 17, 18q and 21q. In addition, markers on chromosomes 4p, 11q, 14q and 20q with no reported LOH in primary CaP were analyzed to determine the frequency of background LOH. In PIN lesions, the rate of LOH was significant only at D5S806 (20%) and D16S422 (29%). In addition, different PIN lesions within the same prostate gland were genetically diverse, indicating divergent evolution of synchronous neoplastic precursor lesions. LOH frequency was progressively higher in primary CaP and metastatic lesions. In primary CaP, significant losses occurred at the 8p, 10q, 11p, 16q, 17p, 18q and 21q loci (range 17-43%). Distinct patterns of LOH frequencies were observed in primary CaP compared with metastases. Although some loci (D16S422, D17S960, D21S156) showed similar frequencies of LOH in primary CaP and metastatic CaP, most other loci showed up to 7-fold metastasis-related increases. The metastatic samples revealed previously unrecognized prostate cancer LOH at D5S806, D6S262, D9S157, D13S133 and D13S227. These significant stage-specific differences in LOH frequency specify genetic loci that may play key roles in CaP progression and could represent clinically useful biomarkers for CaP aggressiveness.

Bone scans of a 45-year-old man with Tietze's syndrome showed abnormal increased activity at the involved costochondral area. X-ray and biopsy examinations of the abnormal area did not reveal any abnormality.

Previous research has suggested that differences in subtest scatter may be indicated for diagnostic groups, although no one has applied DSM-III categories or used the WAIS—R for this purpose. This study yielded significant differences between small groups of patients diagnosed with Schizophrenia, Depression, and Personality Disorders on Information, Arithmetic subtests, and over-all Verbal-Performance IQ differences.

A program involving a pharmacist in the management of ambulatory hypertensive patients is discussed. A hypertension monitoring protocol was developed by a physician and a pharmacist. The protocol provided for initial patient assessment and treatment by the physician, counseling and education of the patient by the pharmacist, patient follow-up by the pharmacist every one to two months and follow-up by the physician every four to six months. In the first four months of the program, 28 of 75 newly diagnosed hypertensive patients were referred by the physician to the pharmacist for follow-up.

99mTc-diphosphonate bone scans of 13 patients in acute sickle crisis were analyzed. Twelve of the 13 patients had abnormal scans, with increased activity in joints and skull being a common finding. One patient with splenic calcification and two patients without splenic calcification had splenic uptake of diphosphonate. Most of the abnormal scans showed hot areas, with cold areas seen only in four cases. There was no correlation between the site of pain clinically and the abnormal areas on scanning. The pathophysiology of the abnormal uptake of radioactivity and the role of bone scanning on sickle cell disease are discussed.

More and more ambulatory care organizations are using nursing report cards to monitor and evaluate the quality and effectiveness of nursing care in the ambulatory setting. Nurse staffing levels is usually one of the items included in a nursing report card and the one most scrutinized by ambulatory care administrators. One strategy employed by the nursing leadership at the South Texas Veterans Healthcare System to justify nurse staffing levels is linking administrative staffing monitors with nurse-sensitive outcomes via workload and performance indicators. Through this approach, nurse leaders are able to justify nurse staffing level changes, needed technology changes, process improvements, and/or workflow needs to administrators with positive results and support.

Potential conflict of interest: Dr. Tillmann consults for Novartis and Novo Nordisk. He owns stock in AbbVie, Abbott, Gilead, Regeneron, Celldex, and Regulus. Dr. Kiser is on the speakers' bureau for Astellas and received grants from Janssen. Dr. Anderson received grants from Gilead. Dr. Naggie advises and received grants from Gilead. Dr. Patel advises Gilead. To the Editor: We read with interest the article by Boyd et al. addressing patterns of suboptimal response to tenofovir disoproxil fumarate (TDF)‐based therapies in human immunodeficiency virus (HIV)/hepatitis B virus (HBV) coinfected individuals.1 The authors acknowledged that plasma concentrations of tenofovir do not reflect longer‐term adherence. Because of intracellular phosphorylation, monitoring intracellular drug levels of tenofovir‐diphosphate (TFV‐DP) can provide long‐term assessments of adherence given the 17‐day half‐life of TFV‐DP in red blood cells (RBCs).2 An ongoing institutional review board–approved study in the Duke HIV Clinic is assessing adults with HIV/HBV coinfection who were on a stable TDF‐containing antiretroviral regimen and had (1) evidence of HBV viral suppression (<357 IU/mL) and new HBV‐DNA detection and evidence of persistent HIV‐RNA suppression (<50 copies/mL for >6 months) or (2) persistent HBV‐DNA detection and evidence of long‐term HIV‐RNA suppression for >2 consecutive years. Plasma and dried blood spot (DBS) were collected at time of consent. Drugs were measured in plasma and DBS at the University of Colorado Antiviral Pharmacology Laboratory (previously described).2 Tenofovir, emtricitabine (FTC), and raltegravir (RAL) were quantified in plasma, and TFV‐DP and the intracellular form of emtricitabine (FTC‐TP) were quantified in DBSs, both using a validated liquid chromatography tandem mass spectrometry method.2 To date, we have enrolled 2 patients (Table 1). HBV genotyping for both patients was negative for mutations. PID01 had tenofovir and FTC plasma levels suggesting that the patient had not taken TDF/FTC in several days before the study visit (Table 1). In DBS, the FTC‐TP concentration was below the limit of quantification (BLQ), and TFV‐DP concentration was 299 fmol/punch. FTC‐TP has a short half‐life in RBCs and is therefore a measure of short‐term adherence similar to plasma levels. The TFV‐DP concentration is consistent with a TDF/FTC dosing pattern of approximately 2 doses per week. Patient PID02 had plasma and DBS concentrations that were quantifiable for tenofovir, FTC, and RAL, and TFV‐DP and FTC‐TP, respectively, suggesting recent dosing. Again, the TFV‐DP concentration would suggest a dosing pattern of approximately 2 doses of TDF/FTC per week. Table 1 - Assessment of Intracellular and Plasma Drug Levels and Corresponding Viral Outcomes Patient Plasma TDF Level (ng/mL) Plasma FTC Level (ng/mL) Plasma RAL Level (ng/mL) DBS TDF‐DP Level (fmol/punch) DBS FTC‐TP Level (pmol/punch) Most Recent HIV Viral Loadc (copies/mL) CD4 Count (cells/mm3) Most Recent HBV Viral Loadc (IU/mL) PID01a BLQ BLQ N/A 299 BLQ <20 670 20,000 PID02a 223 2,216 8.48 215 0.227 <20 480 300,000 PID02b 103 469 346 — — N/A N/A N/A PID02b 80.8 326 407 — — N/A N/A N/A aAt time of enrollment.bBefore enrollment date from clinic repository.cMost recent viral loads from the medical record and as per inclusion criteria.Abbreviation: N/A, not applicable. The pattern of quantifiable plasma concentrations, but low TFV‐DP intracellular concentrations, is consistent with “white coat adherence.” To further investigate this, HIV RNA was quantified in the study samples, which did not coincide with an HIV clinic visit. Indeed, both samples had evidence of low‐level HIV viremia. Neither patient had evidence of HIV viremia on clinical testing in the previous year, suggesting clinical viral load monitoring does not identify white coat adherence. These data are complementary to the work presented by Boyd et al., providing a measure of long‐term adherence that spot plasma levels cannot. These data further support the concern expressed by the authors that lack of HBV viral control on TDF nucleoside analog therapy is a sign of poor long‐term adherence.

In Brief Restraint litigation ranks among nurses’ most common legal concerns. Better understand legal and regulatory standards to safely incorporate them into policies, procedures, practice, and education. Break free of potential litigation by recognizing patient rights related to physical restraints.

Identification of early-stage Alzheimer's disease (AD) remains a challenge due to limited specialist availability, diagnostic access, disease awareness, and cultural factors. Blood-based biomarkers (BBBM) could play a critical role in the identification and referral of patients suspected of AD to specialty care. A multidisciplinary AD Biomarker Task Force was convened to evaluate current biomarker use cases, define an optimal biomarker-enabled AD diagnostic care pathway, and understand factors impacting adoption. The Task Force identified opportunities to support biomarker-enabled AD diagnostic care pathway adoption, including streamlining risk assessment and screening by leveraging digital tools, activating primary care providers through education, generating data to expand applicability to diverse populations, and advocating for aligned policies and quality measures. Adoption of BBBMs in the primary care setting will be critical to improve early AD detection. However, challenges to pathway adoption persist and will require action from clinicians, payers, policy makers, and patients to address. Highlights: Blood-based biomarkers can streamline the identification of AD in primary care.Future biomarker-enabled diagnostic care pathways will leverage digital assessments.Education, data generation, and policy advocacy are vital to encourage BBBM use.Implementation of AD care pathways requires the activation of diverse stakeholders.

Purpose To identify the importance of and difficulty with valued activities in persons with systemic sclerosis (SSc) and to examine relationships between disease symptoms and difficulty with valued activities using the Valued Activities Scale (VLA). A secondary purpose was to examine the internal consistency of the Short-VLA Scale (S-VLA).Methods A cross-sectional convenience sample of 99 people with SSc completed questionnaires regarding demographics, symptom severity, Health Assessment Questionnaire (HAQ), Center for Epidemiologic Studies Depression Scale (CES-D), and the VLA.Results Obligatory activities were rated as most important; committed activities were significantly more difficult than obligatory and discretionary. Less fatigue (p < 0.01) and lower HAQ (p < 0.001) and CES-D (p < 0.01) scores were associated with higher total VLA scores. Internal consistency of the S-VLA was excellent (Cronbach’s alpha = 0.92; p < 0.0001). The correlation between the S-VLA and the VLA was excellent (r = 0.96; p < 0.001). There were moderate correlations between the S-VLA and the HAQ (r = 0.73; p < 0.0001); the correlation with the CES-D was only fair (r = 0.35; p < 0.001).Conclusions Committed and discretionary activities were more difficult for people with SSc to perform. Results are similar to findings with people with rheumatoid arthritis and systemic lupus erythematosus.IMPLICATIONS FOR REHABILITATIONHome management/caregiving (committed) and leisure and social participation (discretionary) activities are more difficult to perform by people with SSc compared to self-care (obligatory) activities.Our findings that difficulty scores on the VLA were associated with more fatigue and depression suggest the need for rehabilitation to reduce disability in people with SSc.The S-VLA may be a useful screening and monitoring tool for SSc and other chronic conditions.

Based upon non-neuropsychological evaluative data, 150 neuropsychiatric referrals were classified independently into Definite (DBD), Suspected (SBD), or No Brain Damage (NBD) groups. Each S was examined with a brief, 2-hour neuropsychologic battery and the test data clinically rated by two neuropsychologists, blind to group membership. Clinical classifications were compared with criteria for NBD vs. SBD + DBD, NDB vs. SBD, and SBD vs. DBD groupings. Hit rates ranged from 83.3% for the former to 64.3% for the latter. These results compared favorably with hit rates derived from statistical classification trials. Clinicians also classified SBD and DBD cases into one of eight different diagnostic categories. The overall hit rate was 61.3%.

Perhaps the greatest challenge hospitals face today is simultaneously providing high-quality care and containing costs. To meet this challenge, nursing services must master the ability to accurately project staffing that guarantees high-quality care within justifiable cost limits. Nursing is an important cost center in hospitals; therefore, it is necessary to extract nursing care costs from room and board costs. By establishing a PCS and a set of standards of care for each DRG category, nurse administrators can control nursing staff ratios while ensuring quality care, therefore, effectively and efficiently using their nursing resources. This study suggests that direct nursing care can be delivered to meet the patient care needs within the DRG trim points and that by delivering care according to a set of standards, nursing care costs can be determined for a specific group of patients. These findings assist the nurse administrator in establishing control measures and setting resource allocation priorities.

A case is described of bilateral transection of the vas deferens during herniorrhaphy as a child, detected as infertility in the adult, and confirmed upon surgical exploration. A long discontinuity of the vas deferens was encountered preventing primary reanastomosis. The patient was treated with cutaneous vasostomy with plans for ejaculate collection and monthly insemination. However, the vas stoma closed shortly postoperatively. A modification of the technique is proposed for similar cases and a protocol for surgical procedure, should vas transection in a child occur, is presented.

Military personnel serving on active duty suffering from loud, bothersome snoring often require surgical treatment. This elective treatment should not disrupt the command and should have minimal impact on military readiness. Major drawbacks of the standard procedure, uvulopalatopharyngoplasty, include postoperative pain requiring convalescent leave, postoperative bleeding, and velopharyngeal incompetence. In addition, the surgery consumes limited operating room time for what many consider elective surgery. Sequential uvulopalatoplasty was developed as an alternative. This is performed with a carbon dioxide laser under local anesthesia in a clinic setting, but it requires cumbersome laser precautions and expensive laser equipment. Standard electrocautery can be used instead of a laser for this procedure. This avoids additional expense, special precautions, and equipment but is equally safe and effective. We compare time lost from work, duration and level of pain experienced, number of days until regular diet resumed, and effectiveness between uvulopalatopharyngoplasty and sequential uvulopalatoplasty. We found sequential uvulopalatoplasty to have less impact on military readiness while being as effective as uvulopalatopharyngoplasty for snoring. This makes it an ideal treatment modality for patients desiring surgical correction of snoring.

Background: Home-based Primary Care (HBPC) programs serve older Veterans with complex, chronic conditions who cannot access clinic-based care, and delayed referrals result in potentially preventable hospitalizations. Despite VA Directive 1411 establishing eligibility criteria, a systematic search identified no published HBPC referral screening instrument designed for general, interprofessional referral decision-making. Objective: To develop, test, and refine a structured screening consult (SC) to improve timely HBPC referral identification at a rural VA primary care clinic. Methods: Guided by the Institute for Healthcare Improvement Model for Improvement, an SC incorporating the care Assessment Need (CAN) score and VA Directive 1411 eligibility criteria was developed and tested through 2 Plan-Do-Study-Act (PDSA) cycles at a rural geriatric primary care clinic within the South Texas Veterans Health Care System. Pareto analysis prioritized referral considerations, and weighted scoring thresholds were refined iteratively. Results: Across both cycles, 271 Veterans were screened (Cycle 1: n = 128; Cycle 2: n = 143); 124 qualified for HBPC referral, exceeding the goal of 50 by 148%. Cycle 1 (threshold ≥ 3) yielded 85 qualifying Veterans (66%), prompting greater specificity; cycle 2 (threshold ≥ 5) yielded 39 (27%), targeting highest-acuity Veterans. The SC was adopted system-wide, and its data supported 2 additional registered nurse case manager hires. Conclusions: An iteratively refined, electronic health record–integrated SC can close systematic HBPC referral gaps, streamline referral documentation, and generate objective data for home care workforce planning. The SC remains in active system-wide use 3 years post-implementation, demonstrating sustainability. The methodology is adaptable to non-VA home-based and community care programs.