Daniel P. Hunt

Radiotherapy and Short-Term Androgen Deprivation for Localized Prostate Cancer

BACKGROUNDnIt is not known whether short-term androgen-deprivation therapy (ADT) before and during radiotherapy improves cancer control and overall survival among patients with early, localized prostate adenocarcinoma.nnnMETHODSnFrom 1994 through 2001, we randomly assigned 1979 eligible patients with stage T1b, T1c, T2a, or T2b prostate adenocarcinoma and a prostate-specific antigen (PSA) level of 20 ng per milliliter or less to radiotherapy alone (992 patients) or radiotherapy with 4 months of total androgen suppression starting 2 months before radiotherapy (radiotherapy plus short-term ADT, 987 patients). The primary end point was overall survival. Secondary end points included disease-specific mortality, distant metastases, biochemical failure (an increasing level of PSA), and the rate of positive findings on repeat prostate biopsy at 2 years.nnnRESULTSnThe median follow-up period was 9.1 years. The 10-year rate of overall survival was 62% among patients receiving radiotherapy plus short-term ADT (the combined-therapy group), as compared with 57% among patients receiving radiotherapy alone (hazard ratio for death with radiotherapy alone, 1.17; P=0.03). The addition of short-term ADT was associated with a decrease in the 10-year disease-specific mortality from 8% to 4% (hazard ratio for radiotherapy alone, 1.87; P=0.001). Biochemical failure, distant metastases, and the rate of positive findings on repeat prostate biopsy at 2 years were significantly improved with radiotherapy plus short-term ADT. Acute and late radiation-induced toxic effects were similar in the two groups. The incidence of grade 3 or higher hormone-related toxic effects was less than 5%. Reanalysis according to risk showed reductions in overall and disease-specific mortality primarily among intermediate-risk patients, with no significant reductions among low-risk patients.nnnCONCLUSIONSnAmong patients with stage T1b, T1c, T2a, or T2b prostate adenocarcinoma and a PSA level of 20 ng per milliliter or less, the use of short-term ADT for 4 months before and during radiotherapy was associated with significantly decreased disease-specific mortality and increased overall survival. According to post hoc risk analysis, the benefit was mainly seen in intermediate-risk, but not low-risk, men. (Funded by the National Cancer Institute; RTOG 94-08 ClinicalTrials.gov number, NCT00002597.).

Upper-extremity deep venous thrombosis: a review.

Upper-extremity deep venous thrombosis is less common than lower-extremity deep venous thrombosis. However, upper-extremity deep venous thrombosis is associated with similar adverse consequences and is becoming more common in patients with complex medical conditions requiring central venous catheters or wires. Although guidelines suggest that this disorder be managed using approaches similar to those for lower-extremity deep venous thrombosis, studies are refining the prognosis and management of upper-extremity deep venous thrombosis. Physicians should be familiar with the diagnostic and treatment considerations for this disease. This review will differentiate between primary and secondary upper-extremity deep venous thromboses; assess the risk factors and clinical sequelae associated with upper-extremity deep venous thrombosis, comparing these with lower-extremity deep venous thrombosis; and describe an approach to treatment and prevention of secondary upper-extremity deep venous thrombosis based on clinical evidence.

How to become a better clinical teacher: A collaborative peer observation process

Background: Peer observation of teaching (PoT) is most commonly done as a way of evaluating educators in lecture or small group teaching. Teaching in the clinical environment is a complex and hectic endeavor that requires nimble and innovative teaching on a daily basis. Most junior faculty start their careers with little formal training in education and with limited opportunity to be observed or to observe more experienced faculty. Aim: Formal PoT would potentially ameliorate these challenges. Methods: This article describes a collaborative peer observation process that a group of 11 clinician educators is using as a longitudinal faculty development program. Results: The process described in this article provides detailed and specific teaching feedback for the observed teaching attending while prompting the observing faculty to reflect on their own teaching style and to borrow effective teaching techniques from the observation. Conclusion: This article provides detailed examples from written feedback obtained during collaborative peer observation to emphasize the richness of this combined experience.

Improving the discharge process by embedding a discharge facilitator in a resident team

BACKGROUNDnHospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization.nnnMETHODSnA 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients.nnnRESULTSnIntervention patients had more discharge summaries completed within 24 hours (67% vs. 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs. 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs. 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs. 85%, P = 0.003) and were more satisfied with the discharge process (97% vs. 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs. 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions.nnnCONCLUSIONSnHelping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents time, but had no effect on hospital reutilization for a general medicine population.

Proton Pump Inhibitors for Prophylaxis of Nosocomial Upper Gastrointestinal Tract Bleeding: Effect of Standardized Guidelines on Prescribing Practice

BACKGROUNDnProton pump inhibitors (PPIs) are frequently prescribed for prophylaxis of nosocomial upper gastrointestinal tract bleeding. Some inpatients receiving PPIs may have no risk factors for nosocomial upper gastrointestinal tract bleeding, and PPIs may be continued unnecessarily at hospital discharge. We aimed to assess the effect of standardized guidelines on PPI prescribing practices.nnnMETHODSnGuidelines for PPI use were implemented on the medical service at a tertiary center. We reviewed PPI use among inpatient admissions during the month before implementation of guidelines and then prospectively evaluated PPI use among admissions during the month after implementation of guidelines.nnnRESULTSnAmong an overall cohort of 942 patients, 48% were prescribed PPIs while inpatients, and 41% were prescribed PPIs at hospital discharge. Univariate predictors of inpatient PPI use included age, length of hospital stay, history of gastroesophageal reflux disease or upper gastrointestinal tract bleeding, and outpatient PPI, aspirin, or glucocorticoid use. Among patients not on an outpatient regimen of PPIs at admission, implementation of guidelines resulted in lower rates of inpatient PPI use (27% before vs 16% after, P = .001) and PPI prescription at discharge (16% before vs 10% after, P = .03).nnnCONCLUSIONnIntroduction of standardized guidelines resulted in lower rates of PPI use among a subset of inpatients and reduced the rate of PPI prescriptions at discharge.

Antihistamine-induced rhabdomyolysis

Antihistamines, which are readily available over the counter in sleeping aids, are commonly found in intentional overdoses. We report three new cases of severe rhabdomyolysis related to ingestion of these agents. This is a rarely reported but potentially overlooked complication among patients who present to the emergency center after intentional overdoses. We also describe the potential mechanism of muscle injury in antihistamine overdoses and comment on the potential for cross-reactivity of antihistamines with the urine screen for phencyclidine.

Dosimetric analysis of radiation therapy oncology group 0321: The importance of urethral dose

PURPOSEnRadiation Therapy Oncology Group 0321 is the first multi-institutional cooperative group high-dose-rate (HDR) prostate brachytherapy trial with complete digital brachytherapy dosimetry data. This is a descriptive report of the data and an analysis of toxicity.nnnMETHODS AND MATERIALSnPatients are treated with external beam radiation therapy at 45 Gy and 1 HDR implant with 19 Gy in 2 fractions. Implants are done with transrectal ultrasound guidance, and computed tomography (CT)-compatible nonmetallic catheters. HDR planning is done on ≤3-mm-thick CT slices. The mean DVH (dose-volume histogram) of the planning target volume (PTV), implanted volume (IP), and organs at risk are calculated. This includes the mean and standard deviation (SD) of the volume at 10-percentage-point intervals from 10% to 200% of the prescribed dose. The conformal index (COIN), homogeneity index (HI), catheters per implant, and patients per institution are calculated. Multivariate analysis and hazard ratios calculation of all the variables against reported grade ≥2 (G2+) genitourinary (GU) adverse events (Common Terminology Criteria for Adverse Events, version 3) are performed.nnnRESULTSnDosimetry data are based on 122 eligible patients from 14 institutions. The mean of PTV, IP, catheters per implant, and patients per institution are 54 cc, 63 cc, 19 and 9, respectively. The mean of %V100PTV, V80Bladder, V80Rectum, and V120Urethra were 94%, 0.40 cc, 0.15 cc, and 0.25 cc, respectively. There are too few G2+ gastrointestinal adverse event (GI AE) for correlative analysis; thus, the analysis has been performed on the more common G2+ GU AE. There are positive correlations noted between both acute and late G2+ GU AE and urethral dose at multiple levels. Positive correlations with late AE are seen with PTV and IP at high-dose levels. A negative correlation is seen between HI and acute AE. A higher patient accrual rate is associated with a lower rate of G2+ acute and late AE.nnnCONCLUSIONSnHigher urethral dose, larger high-dose volumes, and lower dose homogeneity are associated with greater toxicities. A mean dose-volume histogram comparison at all dose levels should be used for quality control and future research comparison.

Can electronic web-based technology improve quality of life data collection? Analysis of Radiation Therapy Oncology Group 0828

PURPOSEnMissing data are a significant problem in clinical trials, particularly for quality of life (QOL), which cannot be obtained retrospectively. The purpose of this study was to evaluate the feasibility of an electronic web-based strategy for QOL data collection in a cooperative group radiation oncology trial setting.nnnMETHODS AND MATERIALSnRadiation Therapy Oncology Group (RTOG) 0828 was a prospective National Cancer Institute cooperative group companion study of RTOG-0415, a randomized study of conventional versus hypofractionated radiation. Forty-nine English-speaking patients with favorable risk prostate cancer who enrolled on RTOG-0415 consented to using web-based technology for completing QOL. In RTOG-0415, using paper forms, the 6-month QOL compliance rate was 52%. The purpose of RTOG-0828 was to test the feasibility of a web-based strategy with the goal of increasing the 6-month QOL completion rate by 25% (from 52% to 77%) for a relative improvement of ~50%. The web-based tool used in this study was VisionTree Optimal Care (VTOC; VisionTree Software, Inc, San Diego, CA), a Health-Insurance-Portability-Accountability-Act secure, online technology that allows real-time tracking and e-mail reminders. The primary endpoint was the 6-month compliance rate for the validated QOL instrument, Expanded Prostate Index Composite.nnnRESULTSnThe QOL completion rate at baseline was 98%. Compared with the prior 52% QOL completion rate at 6 months using paper forms, the QOL web-based completion rate at 6 months was 90% (2-sided P value < .001). At 12 months, the EPIC completion rate was 82% (compared with 36% using paper forms).nnnCONCLUSIONSnThis RTOG study suggests that a web-based strategy to collect QOL appears to be feasible in the cooperative group radiation oncology trial setting and is associated with an increase in the 6-month QOL compliance rate compared with the prior method of using paper forms. The RTOG plans to further test this strategy in a head-and-neck cancer trial across all participating RTOG sites.

Bridging the Hospitalist-Primary Care Divide through Collaborative Care

A number of important shortcomings suggest that the current dichotomous division of labor between hospitalists and primary care physicians warrants reconsideration, though any alternative approach needs to respect the achievements of the current system.

Case 21-2012: A 27-year-old man with fatigue, weakness, weight loss, and decreased libido

Dr. Fernando M. Contreras (Medicine): A 27-year-old man with a history of obesity was seen in the endocrinology clinic at this hospital because of fatigue, myalgias, weakness, weight loss, and loss of libido. Thirteen months before presentation, the patient reported weighing 108.9 kg (body-mass index [BMI, the weight in kilograms divided by the square of the height in meters], 35.4) and began aerobic exercises, 2 hours daily, and a calorie-restricted diet (2400 kcal daily), resulting in a loss of 36.3 kg in 10 months. Two months before evaluation, arm weakness, numbness and aching in his legs, decreased libido with loss of morning erections, and a faint lacy rash on his legs developed. He reportedly stopped aerobics, began lifting weights, and increased his caloric intake, without improvement in his symptoms. On evaluation by his physician at another hospital, the white-cell and differential counts and blood levels of calcium, lipids, prolactin, thyrotropin, and vitamin D were normal; testing for IgA autoantibodies to transglutaminase and screening tests for antinuclear antibodies, the human immunodeficiency virus (HIV), viral hepatitis (types A, B, and C), and Lyme disease were negative; and testing for parvovirus suggested past infection. Other test results are shown in Table 1. Topical testosterone gel was prescribed. During the next 3 weeks, additional consultations and testing were obtained. Serum levels of alpha-fetoprotein and complement (C3 and C4) were normal; testing for autoantibodies to double-stranded DNA, rheumatoid factor, Ro (SSA), and La (SSB) were negative; other test results are shown in Table 1. Computed tomography (CT) of the chest, abdomen, and pelvis reportedly revealed multiple small gas bubbles in the mediastinum (a finding consistent with pneumomediastinum), decreased intraabdominal and intrapelvic fat, and opacities suggestive of stool throughout the colon. A magnetic resonance imaging (MRI) scan of the pituitary gland was normal. An MRI scan of the abdomen and liver, obtained after the administration of gadolinium, reportedly showed higher signal intensity in the liver than in the spleen, with no evidence of masses, iron overload, ascites, or lymphadenopathy.