Ari N. Meguerditchian

Improved targeting of cancer care for older patients: a systematic review of the utility of comprehensive geriatric assessment.

A comprehensive geriatric assessment (CGA) provides clinicians with detailed information on a patients physiological age and may aid in the treatment decision-making process. Conducting a CGA, however, is time-consuming, requiring extensive data collection and, in some cases, the involvement of multiple healthcare professionals. The CGA is also not specifically targeted towards assessing patients presenting with neoplastic pathologies. These limitations have precluded this tools inclusion in routine oncologic practice involving seniors. In order to identify CGA domains most predictive of important cancer-specific outcomes, we conducted a systematic review (PROSPERO registration number CRD42012002476) using MEDLINE, CINAHL, EMBASE and CANCERLIT databases. Studies published in English or French between May 1997 and May 2012, in which a CGA was conducted in patients over the age of 65 initiating cancer treatment, were assessed for eligibility, of which 9 studies were selected for this review. As part of the inclusion criteria, all studies must have assessed, at minimum, the following domains: nutritional, cognitive and functional status, polypharmacy, comorbidities and the presence of geriatric syndromes. In predicting mortality, in at least one study or another, all of the aforementioned CGA domains were found to be significant. Most frequently, however, the following domains were reported for predicting mortality: nutritional status (HR=1.84-2.54), the presence of geriatric syndromes such as depression (HR=1.51-1.81), and functional status (HR=1.04-1.33). With regards to chemotherapy-related toxicity, similar findings were obtained where functional status (OR=1.71-2.47) and the presence of geriatric syndromes, such as impaired hearing (OR=1.67, 95% CI 1.04-2.69), had the most significant predictive value. Only one study reported on the incidence of post-operative complications for which severe comorbidity was found to be highly associated with experiencing severe complications (OR=5.62, 95% CI 2.18-14.50), while functional status was found to be significantly associated with experiencing any complication (OR=4.02, 95% CI 1.24-13.09).

Solitary fibrous tumor of the breast and mammary myofibroblastoma: The same lesion?

Abstract:  Benign stromal tumors of the breast are rare mesenchymal neoplasms that have significant clinical and morphologic overlap. We report the case of a spindle cell tumor occurring in the mammary gland with mixed features of solitary fibrous tumor and mammary myofibroblastoma. The significance of this finding as well as the pathologic and radiologic diagnostic strategies used to differentiate these two lesions are presented based on a review of pertinent literature.

The anabolic effect of perioperative nutrition depends on the patient's catabolic state before surgery.

Objective:We tested the hypothesis that the anabolic effect of hypocaloric, isonitrogenous nutrition in patients undergoing colorectal surgery depends on the patients preoperative catabolic state. Background:Although there is evidence to suggest that total parenteral nutrition more effectively spares protein in depleted than in nondepleted cancer patients, the influence of preoperative catabolism on the anabolic effects of hypocaloric nutrition in patients undergoing elective surgery is unknown. Methods:Seventeen patients undergoing colorectal surgery received intravenous infusion of glucose with amino acids. Feeding was administered over 72 hours, from 24 hours before until 48 hours after surgery. Glucose provided 50% of the patients measured resting energy expenditure. Amino acids provided 20% of the resting energy expenditure. Whole-body leucine balance (difference between the incorporation of leucine into protein = protein synthesis and endogenous leucine release = proteolysis) was determined using L-[1-13C]leucine kinetics before and 2 days after surgery. We analyzed the association between the postoperative increase in leucine balance and the following factors: preoperative leucine balance, protein breakdown, weight loss, oxygen consumption, circulating concentrations of glucose, free fatty acids, insulin, glucagon, cortisol, albumin, age, duration of surgery, and blood loss. Results:Of 6 potentially relevant variables, 4 (weight loss, protein breakdown, albumin, and cortisol) were removed because they were not significant during the stepwise linear regression procedure. Leucine balance and age were the remaining 2 factors that remained with the final regression model: &Dgr;leucine balance = 19.1 − (0.20 × age [years]) − (0.58) × leucine balancepreOP). Conclusions:We demonstrate a significant association between the degree of preoperative catabolism, the patients age, and the anabolic effect of hypocaloric nutrition (ClinicalTrials.gov registration ID: NCT01414946).

Effect of Oral Bisphosphonates for Osteoporosis on Development of Skeletal Metastases in Women With Breast Cancer: Results From a Pharmaco-Epidemiological Study

BACKGROUND Treatment with bisphosphonates in women with breast cancer and established bone metastasis delays further skeletal-related events. Evidence is emerging that bisphosphonates are beneficial for secondary prevention of bone metastasis. The study aimed to estimate the effect of oral bisphosphonates for treatment or prevention of osteoporosis on development of bone metastasis in a population of women with breast cancer. METHODS A historical cohort of 21664 women diagnosed with breast cancer was created from health administrative data in Quebec, Canada. The primary outcome was time to develop bone metastasis; exposure was bisphosphonate use prediagnosis, postdiagnosis, both, or neither and a cumulative index of drug exposure. The sample was stratified according to stage (0-II or III) at time of diagnosis. Cox proportional hazards tested the effect of bisphosphonate use on time to develop bone metastases. RESULTS Taking bisphosphonates postdiagnosis of breast cancer only or continuing bisphosphonates started prior to diagnosis after diagnosis was associated with a reduction in risk of bone metastasis from 45% to 28% in women with local disease at diagnosis. In women with regional disease, postdiagnosis bisphosphonate use, with or without prediagnosis use, reduced risk by almost 50%. A statistically significant dose-response trend was observed relating increased use to lower risk (slope = 0.94, 95% confidence interval = 0.90 to 0.99). Bisphosphonates were also associated with a decreased risk of all-cause mortality similar to that of the development of bone metastasis. CONCLUSION Low-dose oral bisphosphonates administered for prevention or treatment of postmenopausal osteoporosis were associated with lower risk of skeletal metastasis in patients with early- or more advanced-stage breast cancer.

Using novel Canadian resources to improve medication reconciliation at discharge: study protocol for a randomized controlled trial

BackgroundAdverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem.Methods/DesignParticipants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units.DiscussionThe goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors.Trial registrationNCT01179867

Educating medical trainees on medication reconciliation: a systematic review

BackgroundEffective medication reconciliation is critical in reducing the risk of preventable adverse drug events. Medical trainees are often responsible for medication reconciliation on admission, transfer and discharge of the most vulnerable patients; therefore, it is important that trainees are educated on this aspect of quality care.MethodsWe conducted a systematic review using MEDLINE and EMBASE databases to identify education initiatives targeted at improving trainee skill and knowledge in carrying out medication reconciliation. Studies published in English or French between July 1980 and July 2013, where the primary focus of the article was the role of medical trainees in conducting medication reconciliation, and where trainee-specific data was reported, were included. Included articles must have reported trainee-specific data. Given the anticipated heterogeneity and array of outcomes, we were unable to employ a specific tool in assessing the risk of bias across studies.ResultsSeven studies met pre-specified eligibility criteria, indicating the lack of published education initiatives targeted towards improving trainee knowledge and experience. Four described an education intervention targeted towards students completing internal medicine clerkship, while the remaining 3 were implemented among residents. Although no two interventions were the same, 5 out of 7 included an experiential component.ConclusionsVarying success was achieved with medication reconciliation education interventions. While some noted improved competence and/or confidence amongst trainees, namely undergraduate medical students, others noted little effect resulting from the intervention.

Adherence to anti-estrogen therapy in seniors with breast cancer: how well are we doing?

A third of breast cancers (BC) occur in women ≥65 years (seniors). Anti‐estrogen therapy (AET) significantly reduces BC recurrence and death. This study characterizes determinants of adherence to AET in seniors with BC. Provincial cancer registry and administrative claims data were accessed for all non‐metastatic BC diagnosed in Quebec (1998–2005) to identify seniors treated for 5 years with AET. Multivariate linear regression was used to assess the association with patient, disease, and physician characteristics and the 5‐year medication possession ratio (MPR) for each patient. 4,715 women were included (mean age: 72.9). Mean MPR was 83.5%, 79% of patients reached a 5‐year MPR of ≥80%, and 34% discontinued AET at some point during treatment. The cumulative probability of discontinuation was 33.8% (mean time to discontinuation 2.3 years). The MPR decreased with increasing age and non‐BC related hospitalizations, p < 0.05. Each new medication added during the 5‐years decreased the MPR by 0.3% (p < 0.05). Women with in situ disease, on antidepressants at baseline, or treated with Tamoxifen had a lower MPR by 6.5% (p = 0.0002), 4.7% (p = 0.003) and 6% (p = 0.001), respectively. Switching AET type was associated with a lower MPR by 5.3% (p = 0.002) if the switch occurred during the first year. Optimal 5‐year adherence to AET in seniors with BC remained a challenge and medication discontinuation rates were high. Advanced age, increasing number of hospitalizations, in situ disease, baseline use of antidepressants, Tamoxifen (versus aromatase inhibitors), early switches of AET type, and newly added medications significantly reduced the MPR.

Pilomatricoma of the male breast: sonographic mammographic MRI features with pathologic correlation.

We report a case of 43-year-old man who presented with an enlarging, painless, palpable mass in the left breast for one year associated with surface blue discoloration of the skin. Mammogram showed a well-defined 2.3-cm mass with microcalcifications. Ultrasound revealed a well-defined, subcutaneous hypoechoic mass adherent to the skin with multiple bright foci. Ultrasound-guided needle biopsy produced a dark-colored sample corresponding to pilomatricoma on final pathology. Bilateral breast magnetic resonance imaging showed heterogeneously hyperintense in T1- and T2-weighted images with heterogeneous enhancement toward the delayed phase. Surgical resection was carried out with wide margins.

Improving patient safety and efficiency of medication reconciliation through the development and adoption of a computer-assisted tool with automated electronic integration of population-based community drug data: the RightRx project

Abstract Background and Objective Many countries require hospitals to implement medication reconciliation for accreditation, but the process is resource-intensive, thus adherence is poor. We report on the impact of prepopulating and aligning community and hospital drug lists with data from population-based and hospital-based drug information systems to reduce workload and enhance adoption and use of an e-medication reconciliation application, RightRx. Methods The prototype e-medical reconciliation web-based software was developed for a cluster-randomized trial at the McGill University Health Centre. User-centered design and agile development processes were used to develop features intended to enhance adoption, safety, and efficiency. RightRx was implemented in medical and surgical wards, with support and training provided by unit champions and field staff. The time spent per professional using RightRx was measured, as well as the medication reconciliation completion rates in the intervention and control units during the first 20 months of the trial. Results Users identified required modifications to the application, including the need for dose-based prescribing, the role of the discharge physician in prescribing community-based medication, and access to the rationale for medication decisions made during hospitalization. In the intervention units, both physicians and pharmacists were involved in discharge reconciliation, for 96.1% and 71.9% of patients, respectively. Medication reconciliation was completed for 80.7% (surgery) to 96.0% (medicine) of patients in the intervention units, and 0.7% (surgery) to 82.7% of patients in the control units. The odds of completing medication reconciliation were 9 times greater in the intervention compared to control units (odds ratio: 9.0, 95% confidence interval, 7.4-10.9, P < .0001) after adjusting for differences in patient characteristics. Conclusion High rates of medication reconciliation completion were achieved with automated prepopulation and alignment of community and hospital medication lists.

Biomarkers and targeted therapeutics in colorectal cancer.

The development of colorectal cancer is characterized by a multitude of molecular events that can occur through the pathways of loss of heterozygosity, microsatellite instability, and CpG-island methylation. The accumulation of these molecular events ultimately results in polyps formed from previously normal mucosa to develop the fundamental characteristics of cancerization: uncontrolled proliferation, growth, and invasion. Advances in the understanding of molecular events leading to colorectal cancer have led to the development of biomarkers, patient-specific and tumor-specific molecular signatures that have potential as tools for accurate risk assessment, personalized treatment planning, development of targeted agents, and evaluation of treatment response.