Racial Disparities in End-of-Life Care Among Patients With Prostate Cancer: A Population-Based Study.

OBJECTIVE: To examine racial disparities in end-of-life (EOL) care among black and white patients dying of prostate cancer (PCa). METHODS: Relying on the SEER-Medicare database, 3789 patients who died of metastatic PCa between 1999 and 2009 were identified. Information was assessed regarding diagnostic care, therapeutic interventions, hospitalizations, intensive care unit (ICU) admissions, and emergency department visits in the last 12 months, 3 months, and 1 month of life. Logistic regression tested the relationship between race and the receipt of diagnostic care, therapeutic interventions, and high-intensity EOL care. RESULTS: Overall, 729 patients (19.24%) were black. In the 12-months preceding death, laboratory tests (odds ratio [OR], 0.51; 95% CI, 0.36-0.72), prostate-specific antigen test (OR, 0.54; 95% CI, 0.43-0.67), cystourethroscopy (OR, 0.71; 95% CI, 0.56-0.90), imaging procedure (OR, 0.58; 95% CI, 0.41-0.81), hormonal therapy (OR, 0.53; 95% CI, 0.44-0.65), chemotherapy (OR, 0.59; 95% CI, 0.48-0.72), radiotherapy (OR, 0.74; 95% CI, 0.61-0.90), and office visit (OR, 0.38; 95% CI, 0.28-0.50) were less frequent in black versus white patients. Conversely, high-intensity EOL care, such as ICU admission (OR, 1.27; 95% CI, 1.04-1.58), inpatient admission (OR, 1.49; 95% CI, 1.09-2.05), and cardiopulmonary resuscitation (OR, 1.72; 95% CI, 1.40-2.11), was more frequent in black versus white patients. Similar trends for EOL care were observed at 3-month and 1-month end points. CONCLUSIONS: Although diagnostic and therapeutic interventions are less frequent in black patients with end-stage PCa, the rate of high-intensity and aggressive EOL care is higher in these individuals. These disparities may indicate that race plays an important role in the quality of care for men with end-stage PCa

The Use of Exenatide in Islet Transplant Recipients with Chronic Allograft Dysfunction : Safety, Efficacy, and Metabolic Effects

BACKGROUND: A current limitation of islet transplantation is reduced long term graft function. The glucagon like peptide-1 (GLP-1) receptor agonist, exenatide (Byetta(®), Amylin Pharmaceuticals, CA) has properties that could improve existing islet function, prevent further loss of islet mass and possibly even stimulate islet regeneration. METHODS: This prospective study evaluated the safety, efficacy and metabolic effects of exenatide in subjects with type 1 diabetes mellitus and islet allograft dysfunction requiring exogenous insulin. RESULTS: Sixteen subjects commenced exenatide, twelve continue (follow-up 214±57 days; range 108-287), four (25%) discontinued medication due to side effects. At six months, exogenous insulin was significantly reduced with stable glycemic control (0.15±0.02 vs. 0.11±0.025 Units/kg/day; p<0.0001); three subjects discontinued insulin from 4, 5 and 9 U/day respectively, two sustained insulin independence with A1c reduction below graft dysfunction criteria. Post-prandial capillary blood glucose was significantly decreased (129.4±3.8 vs. 118.7±4.6 mg/dL; p<0.001), C-peptide and C-peptide/glucose ratio increased significantly by 5(th) and 6(th) months of treatment (ratio-1.09±0.15 vs. 1.52±0.18; p<0.05). Weight loss >3 kg occurred in 8/12 (67%) subjects. Stimulation testing demonstrated improved glucose disposal and C-peptide secretion (glucose area under the curve 52,332±3,219 vs. 2,072±1,965; p=0.002 mg·min(-1)·dL(-1), Mixed Meal Stimulation Index 0.50±0.06 vs 0.66±0.09; P=0.03 pMol·mL(-1)), with marked suppression of glucagon secretion and progressive increase in amylin secretion. Side effects were more frequent/severe compared to published reports in type 2 diabetes, tolerated doses were lower. CONCLUSIONS: Exenatide was tolerated in this patient population following appropriate dose titration and there appeared to be gradual but sustained positive effects on glycemic control and islet graft function