Pragnesh Patel

Testing the utility of the newest vital sign (NVS) health literacy assessment tool in older African-American patients

OBJECTIVE To evaluate utility of the newest vital sign (NVS) which can be completed in 3min compared to the short version test of functional literacy in adults (S-TOFHLA) that takes 7min for health literacy in the older African American patients. METHODS We enrolled 62 older (age>65 years) African American patients and administered the NVS and the S-TOFHLA. A score of less than 4 for the NVS and less than 16 for the S-TOFHLA was indicative of limited health literacy. RESULTS Mean age of our patients was 73.2+7.9 years with an average education level of twelfth grade. Using S-TOFHLA 51% of the subjects were deemed to be sufficiently literate, with a score of 23.0+8.6 compared to 56% on the NVS with a score of 3.0+1.9. The average time for completing the NVS was 11min in our patient population. CONCLUSION Based on our data, while health literacy level can be assessed with the NVS its practicality as a quick screening tool in the elderly population appears limited. PRACTICE IMPLICATIONS Knowing the level of patients health literacy may help physicians deliver health information in the format that patients can understand.

Dieulafoy's lesion-like bleeding: an underrecognized cause of upper gastrointestinal hemorrhage in patients with advanced liver disease.

Dieulafoy’s lesion is a gastrointestinal submucosal artery that ruptures into the lumen causing massive hemorrhage. Until recently, failure to diagnose and treat patients endoscopically may have necessitated blind gastrectomy. Because arteriolar spider nevi abound in patients with liver disease and bleeding from such lesions has been described in the upper gastrointestinal tract, we reviewed our experience to determine whether a diagnosis of advanced liver disease could facilitate recognition and treatment of this type of arterial bleeding. Endoscopy records from 1991 to 1996 for all cases of upper gastrointestinal bleeding at our institution were reviewed. Dieulafoy’s lesion-like bleeding was defined as arterial-type bleeding with no evidence of mucosal ulceration or erosions. Advanced liver disease was defined as signs of portal hypertension and/or cirrhosis or infiltrative liver disease. Dieulafoy’s lesion-like bleeding was the cause in 6 of 4569 cases (0.13%). Five patients with Dieulafoy’s lesion-like gastrointestinal hemorrhage had advanced liver disease compared with 954 of 4569 of all patients endoscoped for gastrointestinal hemorrhage for the period evaluated (OR = 19.04; 95% CI 2.1–900.8; p < 0.002 by Fisher’s exact test). Dieulafoy’s lesion-like bleeding was treated successfully with epinephrine injection and endoscopic cauterization in 5 of 6 patients with 1 patient requiring surgery. No other clinical associations were evident. Dieulafoy’s lesion-like bleeding occurs more commonly in patients with advanced liver disease and should be included as a potential cause for bleeding in advanced liver disease and aggressively sought.

Apnea in Older Adults

Sleep-disordered breathing (SDB) is a highly prevalent chronic disease in older adults. A growing body of evidence demonstrates that SDB in older adults is linked to many adverse cardiovascular, neurocognitive, and metabolic sequelae. However, several unanswered questions remain regarding the diagnosis, consequences, and treatment of SDB in older adults. This review presents the current evidence pertaining to the management of SDB in older adults and identifies crucial gaps in knowledge that need further investigation.

Use of nutrition literacy scale in elderly minority population.

ObjetivesThe major objective of our paper was to test and validate the nutritional literacy scale (NLS) in a pre-dominantly African-American geriatric population.DesignCompletion of the 2 literacy scales Short Test of Functional Health Literacy in Adults (STOHFLA) and nutritional literacy scale (NLS) during a 5-month period from September 2008 to January 2009.SettingThe Rosa Parks Geriatric Center at Detroit Medical Center/Wayne State University.ParticipantsThe study cohort consisted of elderly (>65years old) 150 patients that had presented to the geriatric clinic.MeasurementsNLS and STOHFLA were simultaneously given to the patients. The NLS consists of 28 questions regarding organic foods; calorie intake etc. and questions in each section were arranged from easier to more difficult ones. The baseline characteristics were stratified according to the NLS (< 25 and ≥ 25) and STOHFLA (< 35 and ≥ 35) scores. Additionally we also collected data on demographic information, educational experience, blood pressure recordings from 3 consecutive clinic visits.ResultsThe patients with a higher NLS score were younger (72 ± 9) as compared to those with lower NLS score (76 ± 9) (p = 0.005), and also had more years of education (16 ± 3 years v/s 13 ± 3 years; p <0.001). A higher proportion of patients with lower score on NLS had hypertension (95.10 % for NLS < 25 v/s 77.08 % for NLS > 25; p =0.001).ConclusionWe validated a potentially useful nutritional literacy tool that might prove to be useful intervention aimed at identifying individuals with lower levels of education and insight regarding their nutritional behaviors.

Effect of Percutaneous Endoscopic Gastrostomy Tube Placement on the Outcome of the Fecal Occult Blood Test

Background: Patients undergoing percutaneous, endoscopic gastrostomy tube placement represent a population of patients with a background of serious disease, many at risk from gastrointestinal hemorrhage. It is common practice to monitor stool for GI blood loss using the FOBT. It is unknown whether the presence of a gastrostomy tube will render the FOBT positive. We evaluated a population for the effect of tube placement on FOBT outcome. Methods: 67 consecutive patients undergoing tube placement were selected on basis of a FOBT having been performed before and/or after the procedure and divided in to two groups. In group one, 31 patients had a test before and 10 patients had test after tube placement with 7.3% having positive FOBT before or after placement. In group two, 26 patients were tested both before and after the procedure with 12% having positive FOBT after tube placement. Indications for tube placement were for neurological disease, dysphasia and nutritional support. Indications for performing the FOBT after tube placement were suspicion or confirmation of GI bleeding in 13 patients. Non-steroidal anti-inflammatory medications were taken by 47% of patients. The mean time of pre-procedure FOBT was 9.3 ± 10 months and of post-procedure testing was 4.4 ± 6.0 months. Results: 7.3% patients of group1 were FOBT positive before or after tube placement, as opposed 12% of group 2 were FOBT positive after placement (p>0.05). In group two, 3% remained positive before and after the test, 7.5% reverted to negative after having positive FOBT prior to tube placement, and 16.4% were negative before and after tube placement. Survival in months tended to be less in subgroup of patients who had positive FOBT after tube placement (8.87 ± 8.59 months) compared to patients who had positive FOBT prior to tube placement and negative FOBT respectively (24.00 ± 24.00 months and 18.67 ± 25.78 months; p = 0.15 and p = 0.09 respectively). Conclusion: The tube placement does not appear to affect the outcome of FOBT positive status whether measured cross-sectionally by overall prevalence or longitudinally by status change after tube placement. Although survival in months was not statistically significant between the two groups, there was a strong trend towards reduced survival rate in the group with positive FOBT after tube placement. Thus, presence of a tube is an unlikely explanation for a positive F0BT and other causes may need to be considered. Future larger prospective studies are needed to assess the implication of positive FOBT with regard to survival in patients with a gastrostomy tube.

Abstract 4519: A non-invasive test for right-sided colonic neoplasia in diabetics at increased risk, independent of drug therapy and demographics

Evidence accrues that screening colonoscopy in average-risk patients does not reduce mortality from right-sided neoplasia. A non-invasive test that differentially identifies right-sided neoplasia is urgently needed to direct investigative colonoscopy. The metabolic syndrome is associated with excess colorectal neoplasia but many medications that treat the diabetic component of this syndrome may alter carcinogenesis pathways (PPARδ in de novo for thiazolidinediones etc) and may thus confound our ability to design such a test. Methods: We investigated 122 patients, 45 diabetics and 77 non-diabetics at above average risk identified by screening by a risk questionnaire, for colorectal cancer. The patients were enrolled to participate in a prospective colorectal cancer screening study at the Detroit VAMC and intake of metformin, thiazolidinediones, ASA, NSAID, sulfonylureas, statins, insulin, and multivitamins was determined. We ascertained demographics, nutritional parameters (total caloric, protein and vitamin intake, BMI, alcohol intake, fried food, etc). Primary outcomes were colorectal neoplasia (adenomas & cancers) found on colonoscopy. Secondary endpoints were: adenoma-carcinoma biomarker binding in body fluids and mucosal field effects using the Adnab-9 monoclonal antibody. These diagnostic tests were also examined in the cohort of 77 of non-diabetics to ascertain whethera specific test was also applicable to the non-diabetic population at increased risk for CRC. Results: Of 45 diabetic patients with evaluable data, 26.6% had right-sided neoplasia. Of these 50% had positive binding compared to 13.8% without such neoplasia. There was a significant correlation between Adnab-9 effluent binding and right-sided neoplastic lesions (OR 6.45;CI 1.48-26.39;p Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 4519. doi:1538-7445.AM2012-4519

Abstract 2905: Is obesity the cause for the increasing incidence of CRC in patients under 50 years of age and can an anti-adenoma antibody identify those at risk

Proceedings: AACR 101st Annual Meeting 2010‐‐ Apr 17‐21, 2010; Washington, DC CRC incidence in patients 50 year control at high clinical CRC risk of cancer. Methods: Adnab-9 is an adenoma-carcinoma sequence marker. We performed Adnab-9 immunohistocemistry on colonoscopic rectal biopsies. Results: Our study found that of 25 patients age <50 years, 48% had rectal binding of Adnab-9 versus 21.8% in 220 patients ≥50yrs (p<0.01) and with BMI was confirmed as an independent risk factor by multivariate analysis. Demographics are summarized (Table) and significant differences were seen for gender, ASA intake and BMI, however female gender was equally distributed 58.3 in the positive and 61.5% in the negative group. Hematochezia tended (p=0.23) to associate with positive rectal binding (50 versus 23%) and the colonoscopic finding was more likely to reveal adenomatous tissue in the positive group (58.3 versus 23.1%, p=0.11). Older patients were significantly more likely to take ASA which may have reduced the polyp number in this group and they also have an decreased BMI (p<0.02). In the entire group Adnab-9 positivity correlated with BMI as a continuous variable (U=0.03; p<0.01). Conclusions: Adnab-9 is an independent CRC risk marker in patients <50 years of age suggesting that they are more prone to development of neoplasia. The mechanism appears to be that of an adenoma-carcinoma sequence. ASA may be a factor but was not an independent mitigating marker in this study. BMI is also greater in the younger group and may be the underlying cause of the observed increase in neoplasia in the young. Adnab-9 staining of sigmoidoscopic rectal biopsies may be a convenient way of identifying a high-risk population of patients <50 years of age for CRC surveillance in this population hithertofore not afforded screening. View this table: Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 2905.

Anticoagulant use for atrial fibrillation in older people.

To the Editor: Lopez et al. report that ‘‘cholinesterase inhibitor (CEI) use had a clinically meaningful effect on the natural history of Alzheimer Disease (AD),’’ slowing disease progression and lowering risk of nursing home admission after 2 years. The design of the study is worrisome. Of 1,139 patients who enrolled in the AD Research Center over 7 years, 270 were selected; 135 began taking CEIs ‘‘immediately after enrollment, and continued to take them throughout the following 12 months,’’ and 135 never took the drug. How these individuals were selected is not otherwise described. They were matched on a few characteristics, such as age, Mini-Mental State Examination score, and education. This study resembles a study by Dr. Geldmacher et al. that showed that patients who took a CEI faithfully (80% of pills or more) had a significant delay in nursing home placement (NHP). Both of these nonrandomized studies failed to report important baseline characteristics of the groups being studied. In the Geldmacher article, for example, nonadherent patients were far less likely to have a spouse caregiver than faithful users, yet the authors, who claimed it was the donepezil that ‘‘resulted in significant delays in NHP,’’ omitted this fact. Both papers are easily distinguished from AD 2000, a properly randomized, controlled trial with the largest number of placebo-controlled patient-years of any cholinesterase study. In AD 2000, ‘‘no significant benefits were seen with donepezil compared with placebo in institutionalization or progression of disability . . . [or] in behavioral and psychological symptoms, carer psychopathology, formal care costs, unpaid caregiver time, adverse events, or death or between 5 mg and 10 mg of donepezil.’’ In the United Kingdom, the National Institute for Clinical Excellence Appraisal Committee has recently issued the following preliminary recommendation: ‘‘Donepezil, rivastigmine and galantamine are not recommended for use in the treatment of mild to moderate Alzheimer’s disease (AD).’’ Would Dr. Lopez modify the discussion of his paper, where he emphasizes the important benefits of donepezil, in view of the results from AD 2000, a larger, better-designed trial that failed to show any meaningful difference at all?