Advanced Directive Forms Rarely Completed by Patients Seen For Palliative Care Consult

MedicalResearch.com Interview with:

Kara Bischoff, MD Assistant Clinical Professor, Hospital Medicine & Palliative Care Director of Quality Improvement for the Palliative Care Service UCSF Department of Medicine

Dr. Bischoff

Kara Bischoff, MD
Assistant Clinical Professor, Hospital Medicine & Palliative Care
Director of Quality Improvement for the Palliative Care Service
UCSF Department of Medicine

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Care planning, which we define as including both advance care planning and goals of care discussions, are a common need in seriously ill patients and a key function of palliative care teams.

However, few studies have looked at how often and how care planning is being done by inpatient palliative care teams throughout the United States, and similarly few studies have examined the precise impact of these care planning activities. Therefore, using data from a large quality improvement registry in palliative care called the Palliative Care Quality Network, we examined:

1) the characteristics of hospitalized patients who are referred to inpatient palliative care consult services,

2) the activities that occurred during those inpatient palliative care consults, and

3) the outcomes that resulted.

In looking at data from 73,145 patients who referred for an inpatient palliative care consult, we found that care planning was the most common reason for inpatient palliative care consultation, requested for 71.9% of patients who were referred to palliative care. Further, care planning needs were found in more than half (58%) of palliative care patients even when the consult was requested for reasons other than care planning. Patients referred to palliative care for care planning were somewhat older than patients referred for other reasons, they were less likely to have cancer, and were more often full code at the time of referral. Through care planning conversations, palliative care clinicians frequently identified surrogates and clarified patients’ preferences for life-sustaining treatments (including code status). For instance, 31% more patients chose a code status of DNR/DNI after a conversation with the palliative care team.

However, we also found that legal forms such as advance directives and Physician Orders for Life-Sustaining Treatments (POLST) forms were completed for just 3.2% and 12.3% of the patients see by palliative care teams, respectively. This highlights an important quality gap in need of improvement.

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In Euthyroid Individuals, Higher Free Thyroid Levels Linked To Greater Risk of Atrial Fibrillation

MedicalResearch.com Interview with:
Christine Baumgartner MD
Inselspital
Universitätsspital Bern
Bern, Switzerland
Research Fellow, Division of Hospital Medicine
UCSF

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Overt and subclinical hyperthyroidism increase the risk of atrial fibrillation, but it is unclear whether subclinical hypothyroidism, which is known to increase cardiovascular events, or thyroid function in the normal range are also associated with incident atrial fibrillation. Given the high prevalence of atrial fibrillation and its associated morbidity and mortality, identifying potentially modifiable risk factors is important. Therefore, we aimed to assess the risk of atrial fibrillation in individuals with subclinical hypothyroidism or variations of thyroid function within the normal range.

Our main findings are that higher free thyroxine levels are associated with an increased risk of atrial fibrillation in euthyroid individuals, but thyroid-stimulating hormone levels within the euthyroid or subclinical hypothyroid range was not related to atrial fibrillation risk.

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Patients With Dementia Less Likely To Receive Chemotherapy for Colon Cancer

MedicalResearch.com Interview with:

Yingjia Chen, M.Sc, MPH, Ph.D. Postdoctoral Fellow University of California, San Francisco

Dr. Chen

Yingjia Chen, M.Sc, MPH, Ph.D.
Postdoctoral Fellow
University of California, San Francisco 

MedicalResearch.com: What is the background for this study?

Response: Both colon cancer and dementia are prevalent among the elderly and have a high risk of co-occurrence. Previous studies found that patients with dementia were treated less aggressively. In this study, we hypothesized that presence of pre-existing dementia was associated with worse survival for stage III colon cancer patients, and that post-operative chemotherapy was on the causal pathway.

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Heavy Marijuana Use May Harm Kidneys, But More Study Needed

MedicalResearch.com Interview with:

Dr. Julie H. Ishida MD Division of Nephrology, Department of Medicine San Francisco and San Francisco Veterans Affairs Medical Center University of California

Dr. Ishida

Dr. Julie H. Ishida MD
Division of Nephrology, Department of Medicine
San Francisco and San Francisco Veterans Affairs Medical Center
University of California

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Marijuana is becoming increasingly accepted in the United States, and animal studies suggest that marijuana could affect kidney function. However, data in humans are limited to case reports of acute kidney injury related to synthetic cannabinoid use and small cohort studies of relatively short duration.

Among 3,765 participants with normal kidney function in the Coronary Artery Risk Development in Young Adults or CARDIA study, my colleagues and I found that higher marijuana use was associated with lower kidney function at the start of the our study. However, we did not find that marijuana was associated with change in kidney function or albuminuria, which is a sign of kidney damage, over long-term follow-up.

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Pubic Hair Grooming–Related Injuries Surprisingly Common

MedicalResearch.com Interview with:

Thomas W. Gaither, BS
Department of Urology
University of California, San Francisco
General Hospital, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We study genitourinary trauma and reconstruction. This study was motivated from a previous study showing that Emergency Room visits due to grooming were increasing over the past nine year. We sought to better characterize who was at most risk for grooming injuries. We found that grooming is extremely common in both men and women and minor injuries occur in about 25% of groomers. Surprisingly, a little over one percent sought medical care due to their injury. Participants at most risk our those who remove all of their pubic hair frequently ( as opposed to those who just trim). We did not find any instruments that were necessarily putting participants at risk for injury.

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Clinicians Multitask on Electronic Health Records 30% of Visit Time with Patients

MedicalResearch.com Interview with:

Neda Ratanawongsa, MD, MPH Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network Associate Professor, Division of General Internal Medicine UCSF Center for Vulnerable Populations Physician, Richard H. Fine People's Clinic (RHPC) Zuckerberg San Francisco General Hospital San Francisco, CA 94110 

Dr. Ratanawongsa

Neda Ratanawongsa, MD, MPH
Associate Chief Health Informatics Officer for Ambulatory Services, San Francisco Health Network
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
Zuckerberg San Francisco General Hospital
San Francisco, CA 94110

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: U.S. federal incentives allowed many safety net healthcare systems to afford fully functional electronic health record systems (EHRs). Although EHRs can help clinicians provide care to vulnerable populations, clinicians may struggle with managing the EHR workload, particularly in resource-limited settings. In addition, clinicians’ use of EHRs during clinic visits may affect how they communicate with patients.

There are two forms of EHR use during clinic visits.  Clinicians can multitask, for example, by ordering laboratory tests while chatting with a patient about baseball.  However, like distracted driving, using EHRs while talking with increases risks – in this case, the risk of errors in patient-provider communication or in the EHR task. Alternatively, clinicians can use EHRs in complete silence, which may be appropriate for high-risk tasks like prescribing insulin. However, silence during visits has been associated with lower patient satisfaction and less patient-centered communication.

So we studied how primary and specialty care clinicians used EHRs during visits with English- and Spanish-speaking patients in a safety net system with an EHR certified for Centers for Medicare & Medicaid Services meaningful use incentive programs. We found that multitasking EHR use was more common than silent EHR use (median of 30.5% vs. 4.6% of visit time). Focused patient-clinician talk comprised one-third of visit time.

We also examined the transitions into and out of silent EHR use. Sometimes clinicians explicitly stated a need to focus on the EHR, but at times, clinicians drifted into silence without warning. Patients played a role in breaking silent EHR use, either by introducing small talk or by bringing up their health concerns.

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Why Does Some Eczema Persist Into Adulthood?

MedicalResearch.com Interview with:

Dr. Katrina Abuabara MD, MA, MSCE University of California San Francisco

Dr. Abuabara

Dr. Katrina Abuabara MD, MA, MSCE
University of California San Francisco

MedicalResearch.com: What is the background for this study?

Response: Atopic dermatitis (synonymous with atopic eczema or just “eczema”) is a common and burdensome condition that often presents in childhood but can occur in individuals of any age. It is episodic, meaning that it waxes and wanes over time, and many patients will have periods without signs or symptoms of the disease. Conventional wisdom suggests that “most children” improve by adolescence, but prior studies have not had sufficiently frequent follow-up to detect episodic disease beyond childhood.

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Healthy Diet and Exercise Reduce Colon Cancer Recurrence

MedicalResearch.com Interview with:
Dr. Erin Van Blarigan, ScD
Assistant Professor, Department of Epidemiology and Biostatistics
UC San Francisco

MedicalResearch.com: What is the background for this study?

Response: There are over 1.3 million colorectal cancer survivors in the United States. Cancer survivors often seek guidance on what they can do to lower their risk of cancer recurrence and death. In response to patient interest and the need for improved survivorship care, the American Cancer Society (ACS) published guidelines on nutrition and physical activity for cancer survivors.

The guidelines are to:
1) achieve and maintain a healthy body weight;
2) engage in regular physical activity; and
3) achieve a dietary pattern that is high in vegetables, fruits, and whole grains.

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USPSTF Recommends Men 70 or Older Not Be Screened for Prostate Cancer

MedicalResearch.com Interview with:

Kirsten Bibbins-Domingo, Ph.D., M.D., M.A.S.  Lee Goldman, MD, endowed chair in medicine and professor of medicine and of epidemiology and biostatistics University of California, San Francisco Chair of the U.S. Preventive Services Task Force

Dr. Bibbins-Domingo

Kirsten Bibbins-Domingo, Ph.D., M.D., M.A.S.
Lee Goldman, MD, endowed chair in medicine and professor of medicine and of epidemiology and biostatistics
University of California, San Francisco
Chair of the U.S. Preventive Services Task Force

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Prostate cancer is one of the most common cancers to affect men, and the Task Force believes all men should be aware of the benefits and harms of screening for prostate cancer. Prostate cancer screening with PSA testing can help men reduce their chance of dying of prostate cancer or of having metastatic cancer. These are important benefits but occur in a small number of men. There are risks associated with screening, specifically overdiagnosis and overtreatment with surgery and radiation that can have important side effects like impotence and incontinence.

Since the release of our 2012 recommendation, new evidence has emerged that increased the Task Force’s confidence in the benefits of screening, which include reducing the risk of metastatic cancer (a cancer that spreads) and reducing the chance of dying from prostate cancer. This draft recommendation also reflects new evidence on the use of active surveillance in men with low-risk prostate cancers that may help mitigate some of the harms in these men by allowing some men with low risk cancer to delay or avoid surgery or radiation. Therefore, in our new 2017 draft recommendation, the Task Force encourages men ages 55 to 69 to make an individual decision about whether to be screened after a conversation with their clinician about the potential benefits and harms. For men age 70 years and older, the potential benefits do not outweigh the harms, and these men should not be screened for prostate cancer.

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Better Means to Reduce Breast Density Needed To Decrease Breast Cancer Risk

MedicalResearch.com Interview with:

Natalie Engmann, MSc PhD Candidate, Epidemiology and Translational Science Department of Epidemiology & Biostatistics University of California, San Francisco

Natalie Engmann

Natalie Engmann, MSc
PhD Candidate, Epidemiology and Translational Science
Department of Epidemiology & Biostatistics
University of California, San Francisco

MedicalResearch.com: What is the background for this study?

Response: Breast density is well-established as a strong risk factor for breast cancer. Our study looked at what proportion of breast cancer cases in the entire population can be attributed to risk factors routinely collected in clinical practice, including breast density, measured using the clinical Breast Imaging and Reporting Scale (BI-RADS) categories.
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Recommended Medical Handoff Strategies Remain Underutilized

MedicalResearch.com Interview with:

Charlie M. Wray, DO, MS Assistant Clinical Professor of Medicine University of California, San Francisco | Department of Medicine San Francisco VA Medical Center

Dr. Charlie Wray

Charlie M. Wray, DO, MS
Assistant Clinical Professor of Medicine
University of California, San Francisco Department of Medicine
San Francisco VA Medical Center

MedicalResearch.com: What is the background for this study?

Response: Since the establishment of residency duty hour regulations in 2010, which subsequently lead to increased discontinuity of inpatient care and more resident shift work, educators and researchers have attempted to establish which shift handoff technique(s) or strategies work best.

National organizations, such as the ACGME, AHRQ, and the Joint Commission have made specific recommendations that are considered “best practice”. In our study, using an annual national survey given to Internal Medicine Program Directors, we examined the degree of implementation of these recommended handoff strategies and the proportion of Program Director satisfaction with each of the respective strategies.

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More Medical Students May Have Non-Apparent Disabilities

MedicalResearch.com Interview with:  

Lisa Meeks , PhD
Director, Medical Student Disability
UCSF Medical Center

Lisa Meeks , PhD Director, Medical Student Disability UCSF Medical Center

Dr. Lisa Meeks

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: This was the first study to include students with AD/HD, learning, psychological, and chronic health conditions. This study found that the prevalence of students with disabilities is up to four times higher than previous studies indicated.

AD/HD, learning, and psychological disabilities were the most prevalent, suggesting that most students with disabilities in medicine have non-apparent disabilities. Within MD granting programs, the number of students self-reporting disability varied between 0% and 12%. Explanations for the high variability between programs are unknown, however, anecdotal reports suggest the degree to which programs have dedicated resources and inclusive practices for students with disabilities influence student disclosure.

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No Clear Cut-Off Age To Stop Screening Mammograms

MedicalResearch.com Interview with:
Cindy Lee, MD

Assistant Professor
Department of Radiology and Biomedical Imaging
University of California San Francisco
San Francisco, CA

MedicalResearch.com: What’s new about the research? How is it different than what’s come before?

• The largest study on the topic, including national data from 31 states in the United States. Including 5.7 million screening mammograms with follow up.
• All exams using digital techniques, up to date data, more representative of community practices in the U.S.

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Anion Gap Associated with Risk of ESRD in Adults with Moderate Chronic Kidney Disease

Tanushree Banerjee, PhD Research Specialist in the Department of Medicine Division of General Internal Medicine UCSFMedicalResearch.com Interview with:
Tanushree Banerjee, PhD
Research Specialist in the Department of Medicine
Division of General Internal Medicine
UCSF

MedicalResearch.com: What is the background for this study?

Response: Acidosis is usually noted in advanced chronic kidney disease (CKD) while it is relatively unexplored whether changes in the undetermined anions, as measured by anion gap occur earlier in the course of CKD.

Consumption of animal-sourced protein is acid-inducing and therefore such diet presumably increases undetermined anions. Since higher dietary acid load is associated with progression of CKD, we wanted to explore whether the increase in undetermined anions in moderate CKD is associated with CKD progression.

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Many High Risk Patients Not Screened for Hepatitis B

MedicalResearch.com Interview with:

Robert Wong MD, MS OakCare Medical Group Assistant Clinical Professor UCSF

Dr. Robert Wong

Robert Wong MD, MS
Assistant Clinical Professor of Medicine
Director of Research and Education
Division of Gastroenterology and Hepatology
Alameda Health System – Highland Hospital

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Hepatitis B Virus infection is a leading cause of chronic liver disease leading to hepatocellular carcinoma and cirrhosis worldwide. Early detection of chronic HBV through implementation of effective screening programs can improve early treatment to reduce disease progression and risk of hepatocellular carcinoma. Sub-optimal awareness of the importance of HBV screening among patients and providers and sub-optimal awareness of who constitutes as high risk may further contribute to low HBV screening rates. Our current study prospectively evaluated rates of HBV screening and awareness of HBV screening results among patients at high risk for chronic HBV among an ethnically diverse underserved safety-net hospital population.

Among nearly 900 patients that were evaluated, 62% were high risk and eligible for Hepatitis B screening. However, among this high risk population, less than 25% received HBV screening. Furthermore, among patients that have undergone previous HBV testing only 22% of patients were aware of those results.

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Tamsulosin (Flomax) Improves Passage of Some Kidney Stones

MedicalResearch.com Interview with:
Ralph Wang, MD, MAS

Associate Clinical Professor, Department of Emergency Medicine
University of California, San Francisco

MedicalResearch.com: What is the background for this study?

Response: Medical expulsive therapy, most notably tamsulosin, has been studied extensively to improve stone passage in patients diagnosed with ureteral stone. Prior trials and meta-analyses have identified a benefit. In fact, tamsulosin is
recommended by the American Urologic Association for patients diagnosed with ureteral stones < 10mm that do not require intervention. However, recent well-conducted multi-center randomized trials have not found any improvement in stone passage.

Thus we conducted a systematic review and meta-analysis of all double blinded, placebo controlled randomized trials of tamsulosin to determine whether it improves stone passage.

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Minorities Much Less Likely To Have Advance Care Health Planning

MedicalResearch.com Interview with:

Krista Lyn Harrison, PhD Division of Geriatrics School of Medicine University of California San Francisco VA Medical Center San Francisco, CA 94121

Dr. Krista Lyn Harrison

Krista Lyn Harrison, PhD
Division of Geriatrics School of Medicine
University of California
San Francisco VA Medical Center
San Francisco, CA 94121

MedicalResearch.com: What is the background for this study?

Response: Advance care planning (ACP) is the process of discussing plans and preferences for end-of-life care. It may include completion of advanced directives or a living will and designation of a surrogate decision-maker in a durable power of attorney for health care. There is a growing awareness of the benefits of such discussions for both elders and their families. In absence of these discussions, loved ones are left to guess what the affected individual wanted or may even get mired in unexpected legal issues. But until recently, it was unknown if all races/ethnicities, education levels, and incomes have benefited from efforts to improve engagement in advance care planning, and if these discussions are greater among those in worse health and with a poorer prognosis.

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Low-Intensity Interventions Addressing Social Needs In Pediatric Settings Can Improve Child Health

MedicalResearch.com Interview with:
Laura M. Gottlieb, MD, MPH
Department of Family and Community Medicine,
2Center for Health and Community
University of California, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Numerous studies have demonstrated that childhood exposures to social adversities, like family financial insecurity, food insecurity, and housing instability, lead to poorer health outcomes across the life course. These social adversities disproportionately affect low-income and racial minority populations. In response to this evidence there have been calls to address social needs in pediatric clinical care settings. For example, recently the American Academy of Pediatrics’ Task Force on Childhood Poverty endorsed the promotion of evidenced-based strategies to reduce the negative health effects of poverty on low-income children, including by increasing the availability of clinic-based interventions addressing social risks.

In response to these calls to action, a growing number of pediatric health care organizations are screening for and address families’ social needs. There is a critical need for more evidence on the effectiveness of these types of interventions. Many of the studies conducted so far have focused primarily on assessing program process outcomes or impacts on families’ social needs, but have not evaluated actual health outcomes resulting from program participation.

To our knowledge, this study was the first randomized clinical trial evaluating the impacts of a pediatric social needs navigation program on child health.

The reported number of social needs identified at baseline ranged from 0 to 11 out of 14 possible items, with a mean [SD] of 2.7[2.2] needs identified by participating families. Family participation in the navigation program intervention significantly decreased families’ reports of social needs by a mean (SE) of .39(0.13) vs. an increase of a mean (SE) of .22(0.13) in the active control arm. Participation in the navigation program also significantly improved parent-reported overall child health, with a mean (SE) change of -.036(0.05), compared to the active control arm with a mean (SE) change of -0.12(0.05). At 4 months post enrollment, the number of social needs reported by those that participated in the navigation program decreased by a mean (SE) of .39(0.13).

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Secondhand Pot Smoke Just As Bad For Heart As Tobacco

MedicalResearch.com Interview with:

Matthew L. Springer, Ph.D. Professor of Medicine Division of Cardiology University of California, San Francisco San Francisco, CA

Dr. Matthew Springer

Matthew L. Springer, Ph.D.
Professor of Medicine
Division of Cardiology
University of California, San Francisco
San Francisco, CA

MedicalResearch.com: What is the background for this study?

Response: We’ve known for many years that secondhand smoke from tobacco cigarettes is harmful, and the vast majority of deaths thought to result from secondhand smoke are from cardiovascular disease. However, very little has been known about cardiovascular consequences of exposure to secondhand smoke from marijuana, and people tend to mistake the lack of evidence that it is harmful, for evidence that is it not harmful. As a result, many people seem relatively unconcerned about smoking marijuana and being exposed (or exposing others) to marijuana secondhand smoke. Politicians and policy makers also seem less willing to limit where people can smoke marijuana (under legal circumstances) than tobacco. What has been lacking is research into how exposure to marijuana smoke affects cardiovascular health. It has been difficult to do such experiments because marijuana is illegal in the eyes of the federal government. However, we have been studying the harmful effects of secondhand tobacco smoke on the function of rat blood vessels, which is similar to its harmful effects on human blood vessels, and we now have studied how the function of rat blood vessels is affected by exposure to secondhand marijuana smoke.

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Genital Grooming a Cultural Phenomenon Among Younger, White and Educated Women

MedicalResearch.com Interview with:

Tami Rowen MD MS Obstetrics, Gynecology and Reproductive Sciences UCSF

Dr. Tami Rowen

Tami Rowen MD MS
Obstetrics, Gynecology and Reproductive Sciences
UCSF

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: This study sought to answer the question of which women are engaging in genital grooming and understand their motivations. Prior studies have been limited by geography and age thus our goal was to provide a nationally representative sample of women.

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Prescribing Naloxone To Patients on Chronic Opioids Reduces ER Visits for Opioid Concerns

MedicalResearch.com Interview with:

Phillip O. Coffin, MD, MIA Director of Substance Use Research San Francisco Department of Public Health Assistant Professor, Division of HIV, ID & Global Health University of California, San Francisco

Dr. Phillip Coffin

Phillip O. Coffin, MD, MIA
Director of Substance Use Research
San Francisco Department of Public Health
Assistant Professor, Division of HIV, ID & Global Health
University of California, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: San Francisco has a longstanding naloxone distribution program that primarily works out of syringe exchange programs and is temporally associated with a substantial decline in opioid overdose death due to heroin or involving injection drug use. Over 90% of opioid overdose deaths from 2010-2012 were due to prescription opioids in the absence of heroin, and most of those decedents were prescribed opioids in primary care settings. Based on these data, as well as anecdotal reports from sites such as U.S. Army Fort Bragg in North Carolina – where providing naloxone to pain patients appeared to be associated with a radical decline in opioid overdose admissions to the emergency department – we implemented a naloxone prescribing program in the safety net primary care clinics.

We recommended that providers offer naloxone to all patients who used opioids on a regular basis, or were otherwise at risk for experiencing or witnessing an opioid overdose, although we only measured outcomes related to patients who were prescribed opioids for chronic pain. We also recommended that providers avoid the term “overdose” as that term does not properly reflect the epidemiology of opioid poisoning and is interpreted by many to mean intentionally consuming a large amount of opioids; instead we recommended saying things like: “Opioids can cause bad reactions where you stop breathing or can’t be woken up.” Providers prescribed mostly the jerry-rigged nasal device, with the atomizer and a brochure dispensed at clinic and the naloxone picked up at the patients’ usual pharmacies, to approximate real-world medical practice.

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ACE Inhibitors May Reduce Conduction Defects and Need for a Pacemaker

MedicalResearch.com Interview with:

Dr. Gregory M. Marcus MD Associate Professor UCSF School of Medicine

Dr. Gregory Marcus

Dr. Gregory M. Marcus MD
Gregory M Marcus, MD, MAS, FACC, FAHA, FHRS
Director of Clinical Research
Division of Cardiology
Endowed Professor of Atrial Fibrillation Research 
University of California, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: Conduction system disease, or blockages in the electrically system (as opposed to blockages in the blood vessels, of which most are well-aware), is a common condition responsible for both heart failure in many patients as well as the need for pacemaker implantation. Although treatments for the disease are available, there are no known means to prevent it. This is important as the primary treatment, a pacemaker, can itself cause problems (including procedural complications, a long-term risk of infection with repeated battery changes, and even a greater risk of heart failure). In addition, predictors of what types of individuals are at risk for developing conduction disease has largely remained unknown.

Based on the fact that the majority of conduction disease is due to fibrosis, or scarring, of the conduction system, we sought to test the hypothesis that a common drug for high blood pressure with anti-fibrotic properties, Lisinopril, might reduce the risk of new conduction system disease. We took advantage of the fact that more than 20,000 patients with hypertension were randomized to three common high blood pressure drugs that work via different mechanisms in the ALLHAT trial: Lisinopril, amlodipine, and chlorthalidone. We found that participants randomly assigned to Lisinopril were statistically significantly less likely to develop conduction disease. In addition, our analyses revealed several risk factors for the development of conduction disease: older age, male sex, diabetes, smoking, a thicker heart, and white race (compared to black race).

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Paradox Between Race and Risk of Atrial Fibrillation Remains Unexplained

MedicalResearch.com Interview with:

Gregory M Marcus, MD, MAS, FACC, FAHA, FHRS Director of Clinical Research Division of Cardiology Endowed Professor of Atrial Fibrillation Research University of California, San Francisco

Dr. Gregory Marcus

Gregory M Marcus, MD, MAS, FACC, FAHA, FHRS
Director of Clinical Research
Division of Cardiology
Endowed Professor of Atrial Fibrillation Research
University of California, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Response: We and others have previously demonstrated that, despite the observation that African Americans on average exhibit more risk factors for atrial fibrillation, they demonstrate a substantially reduced risk of the disease. This suggests that, if we could understand the mechanism underlying this apparent paradox, we might learn something fundamentally important to atrial fibrillation that would be relevant to treating or preventing the disease regardless of race.

Building on our previous work demonstrating that, among African Americans, more European ancestry (determined by genomic testing) was a statistically significant predictor of atrial fibrillation, we sought to identify the gene(s) that might underlie this observation. The analysis took two forms.

First, we examined if any differences among several well-established single nucleotide polymorphisms (SNP) associated with atrial fibrillation might mediate the race-atrial fibrillation relationship. One such SNP statistically mediated (rs10824026) up to about a third of the race-atrial fibrillation relationship. It’s important to mention that a causal relationship cannot be proven here.

Perhaps more remarkable was the observation that the disease-associated alleles of the SNPs most closely associated with atrial fibrillation in multiple studies were actually significantly more common among African Americans, pointing to the complex nature of both the race-atrial fibrillation relationship as well as the genetics of atrial fibrillation.

Finally, leveraging the ancestral relationships, we performed a genome wide admixture mapping study with the hope of reducing the penalty for multiple hypothesis testing incurred in conventional genome wide association studies. While several loci revealed associations with atrial fibrillation with small p values, none met our criteria for genome wide significance.

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Panel of Nine Proteins Improves Risk Assessment in Patients With Stable Coronary Artery Disease

MedicalResearch.com Interview with:

Peter Ganz, MD Chief, Division of Cardiology Director, Center of Excellence in Vascular Research Zuckerberg San Francisco General Hospital Maurice Eliaser Distinguished Professor of Medicine University of California, San Francisco

Dr. Peter Ganz

Peter Ganz, MD
Chief, Division of Cardiology
Director, Center of Excellence in Vascular Research
Zuckerberg San Francisco General Hospital
Maurice Eliaser Distinguished Professor of Medicine
University of California, San Francisco

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Ganz:  The research described in the JAMA paper involved measuring 1,130 different proteins in nearly 2000 individuals with apparently stable coronary heart disease, who were followed up to 11 years. Initially, two hundred different proteins were identified whose blood levels could be related to the risk of heart attacks, strokes, heart failure and death, and ultimately a combination of nine proteins was selected for a risk prediction model, based on their combined accuracy and sensitivity.

Application of these findings to samples of patients with stable coronary heart disease demonstrated that some of those who were deemed clinically stable instead had a high risk of adverse cardiovascular outcomes, while other patients with the same clinical diagnosis had a very low risk. Thus, individuals who all carried the same clinical diagnosis of stable coronary heart disease had a risk of an adverse cardiovascular event that varied by as much as 10-fold, as revealed by analysis of the levels of the nine proteins in their blood. Given such large differences in risk and outcomes, patients could reasonably opt to be treated differently, depending on their level of risk. We hope that in the future, management of patients with stable angina will at least in part rely on risk assessment based on levels of blood proteins.

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Inexpensive Sponsored Meals For Doctors Increase Brand Name Prescriptions

MedicalResearch.com Interview with:
Colette DeJong
Medical student at UCSF and
Research Fellow at the UCSF Center for Healthcare Value.

MedicalResearch.com: What is the background for this study?

Response: Data released under the U.S. Sunshine Act reveals that in the last five months of 2013, over half of American physicians received free meals, gifts, or payments from the pharmaceutical industry. Recent studies have shown that doctors who receive large payments from drug companies—such as speaking fees and royalties—are more likely to prescribe expensive brand-name drugs, even when generics are available. Our findings, however, suggest that physicians’ prescribing decisions may be associated with much smaller industry payments than previously thought. We found that doctors who receive a single industry-sponsored meal—with an average value under $20—are up to twice as likely to prescribe the brand-name drug being promoted.

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Direct-To-Consumer Telemedicine Can Miss Diagnoses, Lack Follow-Up Care

MedicalResearch.com Interview with:

Jack Resneck, Jr, MD Professor and Vice-Chair of Dermatology Core Faculty, Philip R. Lee Institute for Health Policy Studies UCSF School of Medicine

Dr. Jack Resneck

Jack Resneck, Jr, MD
Professor and Vice-Chair of Dermatology
Core Faculty, Philip R. Lee Institute for Health Policy Studies
UCSF School of Medicine

MedicalResearch.com: What is the background for this study?

What are the main findings?

Dr. Resneck: Telemedicine, when done right, can improve access and offer convenience to patients.  We have seen proven high-quality care in telemedicine services where patients are using digital platforms to communicate with their existing doctors who know them, and where doctors are getting teleconsultations from other specialists about their patients.  But our study shows major quality problems with the rapidly growing corporate direct-to-consumer services where patients send consults via the web or phone apps to clinicians they don’t know.

Most of these sites aren’t giving patients a choice of the clinician who will care for them or disclosing the credentials of those clinicians – patients should know whether their rash is being cared for by a board-certified dermatologist, a pain management specialist, or a nurse practitioner who usually works in an emergency department.  Some of these sites are even using doctors who aren’t licensed in the US.   We also found that these sites were regularly missing important diagnoses, and prescribing medications without discussing risks and side-effects, putting patients at risk.  We observed that if you upload photos of a highly contagious syphilis rash but state that you think you have psoriasis, most clinicians working for these direct-to-consumer sites will just agree with your self-diagnosis and prescribe psoriasis medications, leaving you with a contagious STD.

Perhaps the biggest problem with many of these sites is the lack of coordinating care for patients – most of them didn’t offer to send records to a patient’s existing local doctors.  And when patients end up needing in-person care if their condition worsens, or they have a medication side-effect, those distant clinicians often don’t have local contacts, and are unable to facilitate needed appointments.

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Multiple Kidney Stones Linked to Increased Coronary Artery Calcium

MedicalResearch.com Interview with:
Dr. Ryan Hsi MD
Clinical Fellow, UCSF Medical School and
Mathew Sorensen, MD, MS
Residency Program Director
Department of Urology
University of Washington
Director, Comprehensive Metabolic Stone Clinic
Puget Sound VA

MedicalResearch.com: What is the background for this study?

Response: Kidney stones affect 1 in 11 people, and the incidence is rising.  When kidney stones pass, they can be very painful, and if they obstruct urinary flow as they pass, they can be a cause of kidney injury and sepsis.  It is well-known that kidney stones are associated with diseases such as coronary artery disease, obesity, diabetes, and hypertension.  Less well established is the relationship with kidney stones and pre-clinical markers of these diseases.  That is, before a person has a heart attack, a person may develop atherosclerosis first – are kidney stones associated with these early warning signs of future disease?

MedicalResearch.com: What are the main findings?

Response: This study evaluated the association of coronary artery calcium and kidney stones.  Coronary artery calcium is a measure of calcification of the blood vessels that supply the heart, and it is a predictor of future cardiovascular events.  Our study of the Muli-Ethnic Study of Atherosclerosis evaluated individuals who had coronary artery calcium measured and compared those who had a history of none, one, or multiple kidney stones.  We found that individuals who had a history of multiple kidney stones were associated with higher levels of coronary artery calcium.

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About 10% Rebound of Multiple Sclerosis When Immunomodulator Fingolimod Stopped

MedicalResearch.com Interview with:

Jennifer Graves, MD, PhD, MAS UCSF Adult and Pediatric MS Centers

Dr. Jennifer Graves

Jennifer Graves, MD, PhD, MAS
Adult and Pediatric Multiple Sclerosis Centers
UCSF

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Graves: Cessation of medications with effects on immune trafficking may be more likely to cause rebound inflammatory activity in autoimmune diseases such as multiple sclerosis.  We observed 5 strikingly severe relapses consistent with rebound events following cessation of fingolimod treatment and identified several similar cases in the literature.  At our center the rebound events occurred with an approximate 10% frequency.

MedicalResearch.com: What should clinicians and patients take away from your report?

Dr. Graves: Fingolimod cessation may be complicated by rebound phenomena in some patients, similar to what has been observed with natalizumab. Both of these medications have effects on immune cell trafficking, likely explaining the association with rebound events.  Careful consideration must be taken in stopping these medications.

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Study Shows Shared Genetic Risks for Alzheimer’s and Autoimmune Disease

MedicalResearch.com Interview with:

Jennifer S. Yokoyama, PhD Assistant Professor, Memory and Aging Center University of California, San Francisco

Dr. Yokoyama

Jennifer S. Yokoyama, PhD
Assistant Professor, Memory and Aging Center
University of California, San Francisco

MedicalResearch.com: What is the background for this study?

Dr. Yokoyama: Alzheimer’s disease is a common neurodegenerative disease that occurs in older adults. Clinically, Alzheimer’s disease is primarily associated with changes in cognition (e.g., declines in memory, language and visuospatial functioning). Pathologically, Alzheimer’s disease is associated with misfolded amyloid beta and tau proteins and can only be definitively diagnosed at autopsy. It has long been appreciated that there is a link between the immune system and Alzheimer’s disease, and there are multiple sources of evidence that suggest that immune activity may be increased in patients with Alzheimer’s. Although there is strong evidence for an association between immune activity and Alzheimer’s disease there has always been a chicken-egg problem because we don’t know whether the Alzheimer’s disease process triggers the immune response or whether altered immune function promotes the Alzheimer’s disease process.

Genetic information can offer important clues about the role of the immune system in Alzheimer’s disease. Each person has a unique genetic fingerprint, and different combinations of gene changes (“variants”) put individuals at higher or lower risk for different diseases. Genetic data enables us to test whether having a certain genetic variant puts people at greater risk for both Alzheimer’s disease and autoimmune diseases, immune system diseases in which the immune system is overactive (e.g., Crohn’s disease, ulcerative colitis, rheumatoid arthritis, type 1 diabetes, Celiac’s disease, and psoriasis). Rather than only responding to foreign objects such as bacteria and viruses, in autoimmune diseases the immune system also responds to the body’s own material, which do not ordinarily create an immune response, thereby leading to symptoms associated with higher levels of inflammation and other long-term problems. A variant that increases risk for both Alzheimer’s disease and autoimmune diseases would suggest a common biological pathway.

MedicalResearch.com: What are the main findings?

Dr. Yokoyama: In our study we tested whether there are genetic variants that put people at increased risk for both Alzheimer’s disease and autoimmune diseases. We found eight genetic variants that influence people’s risk for both Alzheimer’s disease and autoimmune disease. Some of these variants were associated with lower risk of autoimmune disease and Alzheimer’s disease, but two variants were associated with greater risk for both.   Continue reading

Steroid Signal That Makes Sperm React Quickly Identified

MedicalResearch.com Interview with:
Melissa Miller, PhD
Postdoctoral fellow at both UC Berkeley and UC San Francisco 

MedicalResearch.com: What is the background for this study? What are the main findings?

Dr. Miller: This work builds on years of observed, but unexplained, phenomena within sperm cells which respond almost instantaneously to the presence of the steroid hormone progesterone. Typically, steroid signaling occurs through a long, slow process that involves the modification of gene amount within a cell. However, there is an alternative mechanism that is not well understood that works differently and is termed non-genomic progesterone signaling. We found that progesterone in human sperm cells binds to a protein called ABHD2 and activates its activity to clear the cell of the endogenous cannabinoid 2AG.  2AG is an inhibitor of sperm activation and its removal from the cellular membrane allows the sperm cells to change its motility so that it may reach and fertilize the egg. Men who’s sperm is unable to undergo this progesterone activated motility change are infertile.

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Older Adults with Chronically High Depressive Symptoms May Be At Higher Risk of Dementia

MedicalResearch.com Interview with:
Allison R. Kaup, PhD
Assistant Adjunct Professor, UCSF Department of Psychiatry
Clinical Research Psychologist / Clinical Neuropsychologist and
Kristine Yaffe MD
Professor of Psychiatry, Neurology and Epidemiology
Chief of Geriatric Psychiatry and Director of the Memory Evaluation Clinic

San Francisco VA Medical Center 

MedicalResearch.com: What is the background for this study?

Response: Previous research has shown that older adults with depression are more likely to develop dementia.  But, most studies have only examined an older adult’s depressive symptoms at one point in time.  This is an important limitation because we know that depressive symptoms change over time and that older adults show different patterns of depressive symptoms over time.  For the present study, older adults were followed for several years.  We assessed what patterns of depressive symptoms they tended to have during the early years of the study, and then investigated whether these different patterns were associated with who developed dementia during the later years of the study.

MedicalResearch.com: What are the main findings?

Response: Older adults in this study tended to show one of 3 different patterns of depressive symptoms.  Most tended to have few, if any, symptoms over time.  Some tended to have a moderate level of depressive symptoms at the beginning of the study, which increased over time.  And others tended to have a high level of depressive symptoms at the beginning of the study, which increased over time.

We found that older adults with the high-and-increasing depressive symptoms pattern were almost twice as likely to develop dementia than those with minimal symptoms, even when accounting for other important factors.  While older adults with the moderate-and-increasing depressive symptom pattern were also somewhat more likely to develop dementia, this association was not as strong and did not hold up in our statistical models when we accounted for what individuals’ cognitive functioning was like during the early years of the study.

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Only about 25% of Hospital Readmissions are Preventable

MedicalResearch.com Interview with:

Dr. Andrew Auerbach MD Professor of Medicine in Residence Director of Research Division of Hospital Medicine UCSF

Dr. Andrew Auerbach

Dr. Andrew Auerbach MD
Professor of Medicine in Residence
Director of Research Division of Hospital Medicine
UCSF and

Jeffrey L. Schnipper, MD, MPH Associate Physician, Brigham and Women's Hospital Associate Professor of Medicine, Harvard Medical School Department of Medicine Brigham and Women's Hospital

Dr. Jeffrey Scnhipper

Jeffrey L. Schnipper, MD, MPH
Associate Physician, Brigham and Women’s Hospital
Associate Professor of Medicine, Harvard Medical School
Department of Medicine
Brigham and Women’s Hospital

 

 

MedicalResearch.com: What is the background for this study?

Response: The Affordable Care Act required the Department of Health and Human Services to establish a program to reduce what has been dubbed a “revolving door of re-hospitalizations.” Effective October 2012, 1 percent of every Medicare payment was deducted for a hospital that was determined to have excessive readmissions. This percentage has subsequently increased to up to 3 percent. Penalties apply to readmitted Medicare patients with some heart conditions, pneumonia, chronic lung disease, and hip and knee replacements.

Unfortunately, few data exist to guide us in determining how many readmissions are preventable, and in those cases how they might have been prevented.

MedicalResearch.com: What are the main findings?

Response: Our main findings were that 27 percent of readmissions were preventable, and that the most common contributors to readmission were being discharged too soon, poor coordination between inpatient and outpatient care providers, particularly in the Emergency Departments and in arranging post acute care.

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No Treatment for Zika Infections So Prevention is Key

MedicalResearch.com Interview with:

Mary E. Wilson, MD Visiting Professor of Epidemiology and Biostatistics School of Medicine, University of California San Francisco Adjunct Professor of Global Health and Population Harvard T.H. Chan School of Public Health Boston, Massachusetts

Dr. Mary Wilson

Mary E. Wilson, MD
Visiting Professor of Epidemiology and Biostatistics
School of Medicine, University of California
San Francisco
Adjunct Professor of Global Health and Population
Harvard T.H. Chan School of Public Health
Boston, Massachusetts 

Medical Research: What is the background for this study?
Response: Zika virus infections are spreading explosively in the Americas. This flavivirus infection, spread by Aedes mosquitoes, is new to the Americas, so the majority clinicians have little knowledge of the infection and its potential complications. The country most affected so far is Brazil, where more than a million infections have been reported in less than a year. Infection has also spread to at least 20 other countries in the Americas (the Caribbean, Mexico, Central and South America). Prior to 2007 Zika virus was known to cause infections only in Africa and Asia. Since then, it has spread and caused epidemics in Micronesia, French Polynesia, Easter Island, and since 2015 in Brazil. Most of the movement of the virus from one region to another is via travelers who are infected and then are bitten by mosquitoes in a new region.

In Brazil an increase in cases of infants born with microcephaly (small head) has been noted coincident with the Zika epidemic, and the virus has been recovered from amniotic fluid and from fetal tissue, suggesting that Zika infection during pregnancy may cause microcephaly in the developing fetus. An increase in cases of Guillain-Barre syndrome has also been observed during this and previous outbreaks. Studies are underway to determine if Zika virus is the cause of microcephaly and Guillain-Barre syndrome.In Brazil an increase in cases of infants born with microcephaly (small head) has been noted coincident with the Zika epidemic, and the virus has been recovered from amniotic fluid and from fetal tissue, suggesting that Zika infection during pregnancy may cause microcephaly in the developing fetus. An increase in cases of Guillain-Barre syndrome has also been observed during this and previous outbreaks. Studies are underway to determine if Zika virus is the cause of microcephaly and Guillain-Barre syndrome.

Most countries in the Americas, including the United States, are infested with types of mosquitoes that are competent to transmit the virus, but weather conditions also have to be warm enough to permit the virus to disseminate in the mosquito so that it can be transmitted to another person.

The symptoms of Zika virus infection are typically mild and self-limited  – fever, aches, rash, and conjunctivitis. In fact, the majority of those infected have no symptoms. Because the virus can enter the bloodstream even in asymptomatic infected persons, there is concern that the virus could be spread by blood transfusion, if a person donates blood during the short period (probably a few days at most) when virus is in the blood.

Other reasons for the paper are to highlight what is known about some of the insect repellents and to point out important gaps in our knowledge of their use and urgent research needs.

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Belacept Found Superior to Cyclosporin For Kidney Transplantation

MedicalResearch.com Interview with:

Dr. Flavio Vincenti

Dr. Flavio Vincenti

Dr. Flavio Vincenti, M.D
Clinical Professor of Medicine and Surgery
Departments of Medicine and Surgery
Endowed Chair in Kidney Transplantation
University of California, San Francisco
San Francisco, CA 94143

Medical Research: What is the background for this study? What are the main findings?
Dr. Vincenti: This is a phase 3 study of belacept immunosuppression as compared to cyclosporine based immunosuppression in renal transplant recipients randomly assigned to 2 treatments arms of belatacept and a controlled arm consisting of cyclosporine. The main finding of this study is that Belatacept, a fusion receptor protein that blocks co-stimulation and is administered intravenously on the maintenance of a 4 weekly maintenance therapy, had superior outcomes at 5 and 7 years as compared to patients on a CsA-based regimen. The 7 year data show that patients on either arm of belatacept had a 43 percent risk reduction of deaths or grafts loss as compared to patients treated with cyclosporine. In addition, belatcept patients had significantly better preservation of renal function throughout the 7 years of follow up and had lower incidence of donor specific antibodies. Nephrotoxicity from cyclosporine and donor specific antibodies are important causes of late graft loss.
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Mass Casualty Planning Needs To Go Beyond Level 1 Trauma Centers

Dr. Rachael Callcut M.D., M.S.P.H Assistant Professor of Surgery Division of General Surgery UCSF

Dr. Rachael Callcut

MedicalResearch.com Interview with:
Dr. Rachael Callcut M.D., M.S.P.H
Assistant Professor of Surgery
Division of General Surgery
UCSF

Medical Research: What is the background for this study? What are the main findings?

Dr. Callcut: San Francisco General Hospital (SFGH) responded on July 6, 2013 to one of the larger multiple casualty events in the history of our institution.  Asiana Airlines flight 214 crashed on approach to San Francisco International Airport with 307 people on board.  192 patients were injured and SFGH received the highest total of number of patients of area hospitals. The majority of data that is available on disaster response focuses on initial scene triage or initial hospital resources required to respond to these types of major events.  Our paper focuses on some additional considerations for optimizing disaster response not typically included in literature on these events including nursing resources, blood bank needs, and radiology studies. As an example, over 370 hours of nursing overtime were needed just in the first 18 hours following the disaster to care for patients.  This type of information in traditionally not been included in disaster planning, but clearly was a critical element of providing optimum care to our patients.

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Polycystic Ovary Syndrome Linked To Multiple Skin Findings

Kanade Shinkai, MD PhD Associate Professor of Clinical Dermatology Director, Residency Program Endowed Chair in Dermatology Medical Student Education UCSF Department of Dermatology San Francisco, CA 94115

Dr. Shinkai

MedicalResearch.com Interview with:
Kanade Shinkai, MD PhD
Associate Professor of Clinical Dermatology
Director, Residency Program
Endowed Chair in Dermatology Medical Student Education
UCSF Department of Dermatology
San Francisco, CA 94115 

Medical Research: What is the background for this study? What are the main findings?

Dr. Shinkai: Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder in the United States that has important skin manifestations including acne, hair loss, hirsutism, and acanthosis nigricans. We performed a retrospective cross-sectional study of women referred to a multidisciplinary PCOS clinic at UCSF to determine whether skin findings and systemic associations differ between women who meet diagnostic criteria for PCOS versus those suspected of having PCOS but do not meet diagnostic criteria. We found that women with PCOS commonly have skin findings, however, present across a broad spectrum of cutaneous manifestations.

Comparing the skin findings in women who meet diagnostic criteria for PCOS with women who are suspected of having PCOS suggests that it can be very difficult to distinguish a patient with PCOS based on skin findings alone.  Hirsutism and acanthosis nigricans are the most helpful findings to suggest PCOS and require a comprehensive skin examination to diagnose; acne and androgenic alopecia are common findings but do not differentiate. The finding of hirsutism and acanthosis were associated with important systemic abnormalities including elevated free testosterone levels, insulin resistance, obesity, and dyslipidemia. This is the first study to perform systematic comprehensive skin exams on women with PCOS and link the skin findings to key systemic associations that have significant implications for the treatment and prognosis of women with the disease.

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Many Hospitalized Oncology Patients Would Like Complementary Health Treatments

Maria T. Chao, DrPH, MPA Assistant Professor of Medicine Osher Center for Integrative Medicine & Division of General Internal Medicine - SFGH UCSF San Francisco, CA 94143-1726

Dr. Chao

MedicalResearch.com Interview with:
Maria T. Chao, DrPH, MPA

Assistant Professor of Medicine
Osher Center for Integrative Medicine
& Division of General Internal Medicine – SFGH
UCSF
San Francisco, CA 94143-1726

Medical Research: What is the background for this study? What are the main findings?

Dr. Chao: Many Americans use complementary and integrative health (CIH) approaches to help them manage the symptoms of chronic diseases. To date, most of these treatments are only available in outpatient clinics. In this study, we asked oncology inpatients which of 12 different CIH approaches they currently use or have tried in the past, and also which approaches they would like to be available in the hospital. We found that 95% of patients had tried at least one  complementary and integrative health approach in the past, and that a similarly high number were interested in accessing these services as an inpatient. More than three quarters of our sample expressed interest in receiving nutritional counseling and massage during their hospital stay, and approximately half were interested in acupuncture, biofeedback, and mindfulness meditation.

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MRI Study Shows Weight Loss Preserves Knee Cartilage

Alexandra S. Gersing, MD Department of Radiology and Biomedical Imaging University of California, San Francisc

Dr. Gersing

MedicalResearch.com Interview with:
Alexandra S. Gersing, MD
Department of Radiology and Biomedical Imaging
University of California, San Francisco

Medical Research: What is the background for this study? What are the main findings?

Dr. Gersing:  This study is part of a larger NIH-funded project focusing on the effects of weight change in individuals at risk for and with osteoarthritis. Our group has previously shown that weight gain causes substantial worsening of knee joint degeneration in patients with risk factors for osteoarthritis and now we aimed to show that weight loss could protect the knee joint from degeneration and osteoarthritis. Osteoarthritis is one of the major causes of pain and disability worldwide; and cartilage plays a central role in the development of joint degeneration. Since cartilage loss is irreversible, we wanted to assess whether lifestyle interventions, such as weight loss, could make a difference at a very early, potentially reversible stage of cartilage degradation and whether a certain amount of weight loss is more beneficial to prevent cartilage deterioration. To measure these early changes we used a novel Magnetic Resonance Imaging (MRI) technique, called T2 mapping, which allows us to evaluate biochemical cartilage degradation in the patient on a molecular level. The most relevant finding of this study is that patients with more that 10% of weight loss benefited significantly more from losing weight compared to the obese controls that did not lose weight or only lost little weight.

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BRCA1 Depletion in Nerve Cells Contributes To Cognitive Decline in Alzheimer’s disease

Elsa Suberbielle, DVM, PhD Research Scientist Gladstone Institute of Neurological Diseases San Francisco, CA 94158

Dr. Elsa Suberbielle

MedicalResearch.com Interview with:
Elsa Suberbielle, DVM, PhD
Research Scientist
Gladstone Institute of Neurological Diseases
San Francisco, CA 94158

Medical Research: What is the background for this study?

Dr. Suberbielle: BRCA1 is a key protein involved in DNA repair, and mutations that impair its function increase the risk for breast and ovarian cancer. Research into DNA repair mechanisms in dividing cells recently was recently rewarded by the Nobel Prize in Chemistry. In such cells, BRCA1 helps repair a type of DNA damage known as double-strand breaks that can occur when cells are injured. In neurons, though, such breaks can occur even under normal circumstances, for example, after increased brain activity, as shown by the team of Gladstone scientists in an earlier study. The researchers speculated that in brain cells, cycles of DNA damage and repair facilitate learning and memory, whereas an imbalance between damage and repair disrupts these functions.

Medical Research: What are the main findings?

Dr. Suberbielle In a new study published in Nature Communications, Researchers from the Gladstone Institutes demonstrates that Alzheimer’s disease is associated with a depletion of BRCA1 in neurons and that BRCA1 depletion can cause cognitive deficits.

The researchers experimentally reduced BRCA1 levels in the neurons of mice. Reduction of the DNA repair factor led to an accumulation of DNA damage and to neuronal shrinkage. It also caused learning and memory deficits. Because Alzheimer’s disease is associated with similar neuronal and cognitive problems, the scientists wondered whether they might be mediated by depletion of BRCA1. They therefore analyzed neuronal BRCA1 levels in post-mortem brains of Alzheimer’s patients.

Compared with non-demented controls, neuronal BRCA1 levels in the patients were reduced by 65-75%. To determine the causes of this depletion, the investigators treated neurons grown in cell culture with amyloid-beta proteins, which accumulate in Alzheimer brains. These proteins depleted BRCA1 in the cultured neurons, suggesting that they may be an important cause of the faulty DNA repair seen in Alzheimer brains. Further supporting this conclusion, the researchers demonstrated that accumulation of amyloid-beta in the brains of mice also reduced neuronal BRCA1 levels. They are now testing whether increasing BRCA1 levels in these mouse models can prevent or reverse neurodegeneration and memory problems.

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Electronic Records Can Suppress Rapport Between Patients and Providers

Neda Ratanawongsa, MD, MPH CMIO for CareLinkSF Associate Professor, Division of General Internal Medicine UCSF Center for Vulnerable Populations Physician, Richard H. Fine People's Clinic (RHPC) San Francisco, CA 94110

Dr. Ratanawongsa

MedicalResearch.com Interview with:
Neda Ratanawongsa, MD, MPH

CMIO for CareLinkSF
Associate Professor, Division of General Internal Medicine
UCSF Center for Vulnerable Populations
Physician, Richard H. Fine People’s Clinic (RHPC)
San Francisco, CA 94110

Medical Research: What is the background for this study?

Dr. Ratanawongsa: Many people are concerned about the growing intrusion of computers into the patient-provider relationship. Touted as systems that will make care safer and more cost-effective, electronic health records (EHRs) have proliferated rapidly across the country, fueled by HITECH funding. However, some health care professionals feel like computers keep them from connecting with their patients. Also prior research has shown that computer use can change communication in the exam room and shift agenda from patients’ concerns toward medical talk.

Safety net patients already face communication barriers in routine care, particularly language and literacy barriers. Although EHRs could help improve care and communication with these vulnerable patients by helping clinicians fill in the gaps (e.g., what happened in the ED, what medication were you given by that specialist), EHRs could also worsen communication by drawing clinicians’ focus away from patients during visits.

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Progression of Mutations From Moles To Melanoma Identified

Boris C. Bastian, MD, PhD Professor of Dermatology and Pathology Gerson and Barbara Bass Bakar Distinguished Professor in Cancer Research University of California, San Francisco

Dr. Bastian

MedicalResearch.com Interview with:
Boris C. Bastian, MD, PhD
Professor of Dermatology and Pathology
Gerson and Barbara Bass Bakar Distinguished Professor in Cancer Research
University of California, San Francisco

Medical Research: What is the background for this study? What are the main findings?

Dr. Bastian:  The cost of DNA sequencing has dropped substantially since the initial sequencing of the human genome in 2001. As a result, the most common cancer subtypes have now been sequenced, revealing the pathogenic mutations that drive them. A typical cancer is driven by 5-10 mutations, but we still do not understand the order in which these mutations occur for most cancers.

Determining the order in which mutations occur is challenging for cancers that are detected at a late stage. Melanomas, however, lend themselves to this type of analysis because they are pigmented and found on the surface of the skin, allowing them to be identified early. Sometimes, melanomas are even found adjacent to their remnant precursor neoplasms, such as benign nevi (also known as common moles). We performed detailed genetic analyses of 37 cases of melanomas that were adjacent to their intact precursor neoplasms. We microdissected and sequenced the surrounding uninvolved normal tissue, the precursor neoplasm, and the descendent neoplasm. By comparing the genetic abnormalities in each of the microdissected areas, we were able to decipher the order of genetic alterations for each case.

Our work reveals the stereotypic pattern of mutations as they occur in melanoma. Mutations in the MAPK pathway, usually affecting BRAF or NRAS, occur earliest, followed by TERT promoter mutations, then CDKN2Aalterations, and finally TP53 and PTEN alterations. Benign nevi typically harbor a single pathogenic alteration, whereas fully evolved melanomas harbor three or more pathogenic alterations. We also identified an intermediate stage of neoplasia with some but not all of the pathogenic mutations required for fully evolved melanoma. There has been a longstanding debate whether morphologically intermediate lesions, such as dysplastic nevi, truly constitute biological intermediates or whether they simply represent a gray zone of histopathological assessment. Our data indicates that these neoplasms are genuine biological entities. Finally, we observe evidence of UV-radiation-induced DNA damage at all stages of pathogenesis, implicating UV radiation in both the initiation and progression of melanoma.

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IV Iron in Hospitalized Hemodialysis Patients Not Linked With Worsening Infections

Dr. Julie H. Ishida MD San Francisco Veterans Affairs Medical Center Nephrology Section San Francisco, CAMedicalResearch.com Interview with:
Dr. Julie H. Ishida MD
San Francisco Veterans Affairs Medical Center
Nephrology Section
San Francisco, CA

Medical Research: What is the background for this study? What are the main findings?

Dr. Ishida: Intravenous iron is important in the treatment of anemia of end-stage renal disease, but it is biologically plausible that iron may increase infection risk. While results from epidemiologic studies evaluating the association between intravenous iron and infection in hemodialysis patients have been conflicting, guidelines for the treatment of anemia of chronic kidney disease have recommended caution in prescribing, avoidance and withholding of intravenous iron in the setting of active infection. However, no data specifically support the recommendation to withhold intravenous iron during active infection.

Our study observed that among hemodialysis patients hospitalized for bacterial infection who had been receiving intravenous iron as an outpatient, continued receipt of intravenous iron was not associated with higher all-cause mortality, readmission for infection, or longer hospital stay.

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Universal BRCA Screening Not Cost-Effective Until Low-Cost Reliable Genetic Testing Available

Dr. Elisa Long PhD Assistant professor UCLA Anderson School of ManagementMedicalResearch.com Interview with:
Dr. Elisa Long PhD
Assistant professor
UCLA Anderson School of Management

Medical Research: What is the background for this study? What are the main findings?

Dr. Long: The study was motivated by my own diagnosis of triple-negative breast cancer last year, at the age of 33. I also learned that I carried a BRCA1 mutation, despite no family history. As a patient, I would have benefitted tremendously from a universal BRCA screening program, but as a health services researcher, I had to ask if indiscriminate screening of all women in the U.S.—where only 1 in 400 carry a mutation—is a good use of resources.

Using a previously published decision analytic model, we calculated the cost-effectiveness of universal BRCA screening. We find that compared to screening based on family history, it is not cost-effective, assuming a test price of $2,000 to $4,000. However, as the price of genetic testing continues to fall, as indicated by the $249 test now offered by Color Genomics, universal BRCA screening becomes much more affordable. Additionally, population screening of Ashkenazi Jewish women—among whom 1 in 50 carry a BRCA mutation—is very cost-effective, because the chances of finding a carrier are much higher.

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Serious Injuries Rise As Older Age Groups Takes Up Cycling

Benjamin N. Breyer MD, MAS, FACS Associate Professor in Residence Department of Urology University of California, San Francisco Chief of Urology, San Francisco General Hospital Director, UCSF Male Genitourinary Reconstruction and Trauma Surgery Fellowship
MedicalResearch.com Interview with:
Benjamin N. Breyer MD, MAS, FACS
Associate Professor in Residence
Department of Urology
University of California, San Francisco
Chief of Urology, San Francisco General Hospital
Director, UCSF Male Genitourinary Reconstruction and Trauma Surgery Fellowship

 

Medical Research: What is the background for this study? What are the main findings?

Dr. Breyer: Our group has studied genitourinary-specific injuries associated with bicycles using a national surveillance injury database called NEISS (National Electronic Injury Surveillance System), that monitors injuries associated with specific products.  In the current study, we examined trends in all bicycle-related injuries from  1997 to 2013.  We found an increase in bicycle-related injuries over the study period, even after adjusting for growth in the US population.  Even more concerning, we found the percentage of bicycle-related injuries resulting in admission increased 120%, suggesting the injuries sustained while cycling are becoming more severe.  These trends appear to be driven by a substantial rise in both injuries and admissions in individuals over 45 years of age, which likely reflects a change in the demographic of cyclists in the US – multiple studies have shown an increase in the cycling participation of adults over the age of 45.

Bicycles are no longer children’s toys – they are increasingly being used by adults as a means of transportation and physical activity. The rise in cycling in adults over the age 45 appears to be driving both the increase in injuries and admissions, suggesting that older individuals are at increased risk for sustaining severe injury while cycling.

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Several Modifiable Risk Factors for Alzheimer’s Disease Identified

Jin-Tai Yu MD, PhD Memory and Aging Center, Department of Neurology University of California San Francisco San Francisco, CA 94158
MedicalResearch.com Interview with:
Jin-Tai Yu MD, PhD
Memory and Aging Center,
Department of Neurology
University of California San Francisco
San Francisco, CA 94158

Medical Research: What is the background for this study? What are the main findings?

Response: The number of dementia cases in the whole world was estimated to be 35.6 million in 2010 and this number was expected to almost double every 20 years, to 65.7 million in 2030 and 115.4 million in 2050. The global prevalence of dementia was 5-7% and Alzheimer’s disease accounts for roughly 60%. This data means that we are facing an increasing number of global populations of this specific neurodegenerative disease and also the heavy burden brought by it.

Data from the website of global clinical trials (http://clinicalTrials.gov) showed that a total of 1,732 clinical trials for Alzheimer’s disease were under way. However, the previous results are not so optimistic, possibly due to the complex etiological mechanisms. In one word, we had currently no effective drugs for this disease. Figuring out how to effectively prevent its occurrence is increasingly attracting people’s attentions.Therefore, we have done the most extensive and comprehensive systematic review and meta-analysis to date, which employs a full-scale search of observational studies to calculate effect sizes and grade the evidence strength of various modifiable risk factors for this disease. We hope these results will be informative and instructive.

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Dementia Patients on Cholinesterase Inhibitors Risk Substantial Weight Loss

Meera Sheffrin MD Geriatrics Fellow Division of Geriatrics | Department of Medicine San Francisco VA Medical Center University of California, San Francisco MedicalResearch.com Interview with:
Meera Sheffrin MD
Geriatrics Fellow
Division of Geriatrics | Department of Medicine
San Francisco VA Medical Center
University of California, San Francisco

Medical Research: What is the background for this study? What are the main findings?

Dr. Sheffrin: The main drug treatments for dementia are a class of medications called cholinesterase inhibitors. They have only modest effects on cognition and function in most patients, but since they are one of the few available treatments for dementia and thus very commonly prescribed. However,they are known to cause GI side effects (nausea, vomiting, diarrhea, and anorexia) in many patients when first started. It is plausible they could also caust weight loss, espeically considering they cause nausea and anorexia. However, the data on weight loss from randomized controlled trials is very limited and inconclusive, so we did a very large observational study in a real-world of the VA national healthcare system who were newly started on these medications, to see if they were associated with weight loss.

We found that patient with dementia started on cholinesterase inhibitors had a substantially higher risk of clinically significant weight loss over a 12-month period compared to matched controls.

1,188 patients started on cholinesterase inhibitors were matched to 2,189 similar patients who were started on other new chronic medications. The primary outcome was time to a 10-pound weight loss over a 12-month period, as this represents a degree of loss that would be clinically meaningful – not only noticed by a clinician but would perhaps prompt further action in considering the causes of the weight loss and medical work-up.

We found that starting cholinesterase inhibitors was associated with a 24% greater risk of developing weight loss. Overall, 29% of patients started on cholinesterase inhibitors experienced a weight loss of 10 pounds or more, compared with 23% of the control group. This corresponds to a number needed to harm of 21 over 1 year; meaning only 21 patients need to be treated with a cholinesterase inhibitor over the course of a year for one patient to experience a 10 pound weight loss.

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Bilateral Adrenal Incidentalomas May Have Different Etiology Than Unilateral

Quan-Yang Duh MD Endocrine surgeon UCSF Medical CenterMedicalResearch.com Interview with:
Quan-Yang Duh MD
Chief, Section of Endocrine Surgery
UCSF Medical Center

Medical Research: What is the background for this study? What are the main findings?

Dr. Quan-Yang Duh: At UCSF we have a monthly Adrenal Conference (involving surgeons, endocrinologists and radiologists) to discuss patients we are consulted for adrenal tumors. About 30% of these are for incidentally discovered adrenal tumors (versus those found because of specific indications such as clinical suspicion or genetic screening). Of these 15-20% has bilateral adrenal tumors.

The evaluation of unilateral incidentaloma has been very well studied and many national guidelines have been published with specific management recommendations. So during our monthly adrenal conference, we have a routine “script” for evaluation and recommendations (rule out metastasis by looking for primary cancer elsewhere, rule out pheochromocytoma and Cushing, resect secreting tumors or large tumors, and if no operation recommended repeat scan in 6 months, etc.). This “script” has worked very well for patients with unilateral incidentaloma.

However, we were less certain when we made recommendations about bilateral incidentalomas because there was very little literature or guidelines written about it. We had some gut feelings, but we were not sure that we were recommending the right things. We needed more data. That was the main reason for the study.

What we found in our study was that although the possible subclinical diseases were the same – hypercortisolism and pheochromocytoma, the probabilities were different. The patients with bilateral incidentalomas were more likely to have subclinical Cushing’s and less likely to have pheochromocytomas than those with unilateral incidentalomas.

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Patients With Lower Health Literacy May Find Electronic Health Care Portals Challenging

Dr. Courtney Lyles Ph.D. Assistant Professor UCSF School of MedicineMedicalResearch.com Interview with:
Dr. Courtney Lyles Ph.D.
Assistant Professor
UCSF School of Medicine

Medical Research: What is the background for this study? What are the main findings?

Dr. Lyles: In our commentary (http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001852), we describe the Meaningful Use program sponsored by the federal government to incentivize healthcare systems to implement electronic health records (EHRs).  This Meaningful Use program also includes financial incentives for healthcare systems who can get substantial proportions of their patient population to access their electronic health records – that is, by logging into an online patient portal website to view medical information like lab results or immunization lists or to perform a healthcare task like requesting a medication refill or messaging their provider.  Because there are billions of dollars at stake in this program for EHR implementation, there is a lot of attention on this issue right now.  Many thought leaders are discussing how we can transform healthcare by digitizing medical information and connecting with patients in their everyday life outside of office or hospital visits.  Portals are key to a lot of changes we might make in healthcare delivery in an attempt to increase convenience and satisfaction for patients.  Perhaps most importantly, these online portal websites are also one of the first health technologies that will be relatively uniformly distributed across healthcare settings, from private doctor’s offices to public clinics/hospitals serving vulnerable patient populations.

However, our main message is that we in the medical and healthcare fields should be paying more attention to how patients are able to understand and use the information provided through portal websites.  There is a lot of evidence that patients who have lower education/income, are from racial/ethnic minority groups, or have limited health literacy are significantly less likely to use the existing portal websites.  There is also evidence that portal websites are not extremely usable or accessible, which is an additional barrier for those with communication barriers like lower literacy or limited English proficiency.  Therefore, we don’t want widespread EHR implementation to result in only the most well-resourced individuals gaining the potential benefits of portal access.

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Bariatric Surgery Reduces Urinary Incontinence As Well As Obesity

MedicalResearch.com Interview with:
Leslee L. Subak, MD

University of California, San Francisco
Professor, Departments of Obstetrics, Gynecology & Reproductive Sciences, Urology and Epidemiology & Biostatistics
Chief of Gynecology, SF Veterans Affairs Medical Center
UCSF Women’s Health Clinical Research Center

MedicalResearch: What is the background for this study? What are the main findings?

Dr. Subak: Urinary incontinence is very common, affecting an estimated 30 million adults in the U.S., and may account for as much as $60 billion in annual medical costs. Incontinence can cause significant distress, limitations in daily functioning, and reduced quality of life. Obesity is an important risk factor, with each 5-unit increase in body mass index – a ratio of someone’s weight divided by the square of their height – above normal weight associated with far higher rates of incontinence.   The prevalence of incontinence has been reported to be as high as 70 percent among severely obese women, and 24 percent among severely obese men (BMI greater than 40, or more than about 100 pounds greater than ideal body weight).

Since obesity is a risk factor for incontinence, several studies have examined whether weight loss is a treatment for incontinence among obese people with the condition.  Clinical trials have shown the low calorie diets, behavioral weight reduction, and bariatric surgery are associated with improvement in incontinence in obese women and men through one year, but evidence on the durability of this effect is lacking.

We performed this study to examine changes in urinary incontinence and identify factors associated with improvement among women and men in the first 3 years following bariatric surgery.

This study included 1987women and men in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study performed at 10 hospitals at 6 clinical centers in the U.S. who underwent bariatric surgery between 2005 and 2009.  The study participants ranged in age from 18 to 78 years old – the median age was 47. The analysis controlled for factors such as age, race, smoking status and recent pregnancy.  Nearly 79 percent of the participants in the study were women with 49% reporting at least weekly incontinence, compared with 2% of men reporting incontinence.

Following surgery and large weight loss of 29% for women and 26% for men, substantial improvements in incontinence were observed, with a majority of women and men achieving remission at 3 years post-surgery. The more weight lost, the higher the chances of improvement. While the risk of relapse rose with each gain of about 10 pounds, overall there was substantial improvement for both women and men. People who were older, had severe walking limitations or were recently pregnant showed less improvement.

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Blood Pressure Medication ARBs Should Be Resumed As Soon As Possible After Surgery

MedicalResearch.com Interview with:
Susan Ming Lee, MD, FRCPC, MAS (Clinical Research)

Clinical Instructor, Dept. of Anesthesia and Perioperative Care
University of California, San Francisco

Medical Research: What are the main findings?

Dr. Lee: Angiotensin receptor blockers (often referred to as ARBs) are common medications used to treat high blood pressure, heart disease, and kidney disease.  Doctors sometimes stop these medications briefly around the time of surgery, since they are known to cause low blood pressure under general anesthesia.  Doctors may hesitate to restart ARBs after surgery because they are worried about low blood pressure or kidney function.  Prior to our research, there was little information to guide the optimal timing of restarting ARBs after surgery.

Medical Research: What are the main findings?

Dr. Lee: Our study of over 30,000 veterans shows that nearly one third of veterans admitted to hospital for non-cardiac surgery are not restarted on their usual ARBs within two days of their operation.  This delay in resuming ARBs is associated with increased death rates in the first month after surgery.  In fact, even accounting for factors that might contribute to why doctors would withhold ARB (such as low blood pressure, kidney dysfunction, or other comorbidities), 30-day postoperative mortality was increased approximately 50% in those without resumption of ARBs, and this effect was even greater in younger patients under age 60.  Our findings of reduced rates of infections, pneumonia, heart failure, and kidney failure in those that resumed ARBs soon after surgery suggest that early resumption may also reduce complications after surgery.

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