Comorbidity Profile and Health Care Utilization in Elderly Patients with Serious Mental Illnesses

Objectives Patients with serious mental illness are living longer. Yet there remain few studies that focus on health care utilization and its relationship to comorbidities in these elderly mentally ill patients. Design Comparative study. Information on demographics, comorbidities and health care utilization were taken from an electronic medical record system. Setting Wishard Health Services senior care and community mental health clinics. Participants Patients age 65 years and over-255 patients with serious mental illness (schizophrenia, major recurrent depression and bipolar illness) attending a mental health clinic and a representative sample of 533 non-demented patients without serious mental illness attending primary care clinics. Results Patients having serious mental illness had significantly higher rates of medical emergency room visits (p=0.0027) and significantly longer lengths of medical hospitalizations (p<0.0001) than did the primary care control group. The frequency of medical comorbidities such as diabetes, coronary artery disease, congestive heart failure, chronic obstructive pulmonary disease, thyroid disease, and cancer were not significantly different between the groups. Hypertension was lower in the mentally ill group (p<0.0001). Reported falls (p<0.0001), diagnoses of substance abuse (p=0.02), and alcoholism (p=0.0016) were higher in the seriously mentally ill. The differences in health care utilization between the groups remained significant after adjusting for comorbidity levels, lifestyle factors, and attending primary care. Conclusions Our findings of higher rates of emergency care, longer hospitalizations, and increased frequency of falls, substance abuse, and alcoholism suggest the elderly seriously mentally ill remain a vulnerable population requiring an integrated model of health care

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

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Genitourinary Paraganglioma: Demographic, Pathologic, and Clinical Characteristics in the Surveillance, Epidemiology and End Results (SEER) Database (2000-2012)

Background: Extra-adrenal paragangliomas (PGL) are infrequent, benign, neuroendocrine tumors arising from chromaffin cells of the autonomic nervous system. Most PGLs are sporadic but up to 32% are associated with inherited syndromes such as neurofibromatosis type 1, von Hippel-Lindau disease, and familial PGL. While most PGL develop above the umbilicus, they have been reported in the genitourinary (GU) tract. Due to the paucity of literature on the rates of GU PGL, the objective of our study is to describe the demographic, pathologic, and clinical characteristics of GU PGL, and compare them to non-GU sites of PGL using the Surveillance, Epidemiology, and End Results (SEER) database. Methods: The SEER 18 database was utilized to identify all cases of PGL from 2000-2012. Demographic, pathologic, and clinical characteristics were described using chi-square and t-test for categorical and continuous variables, respectively. The Kaplan-Meier method was used to compare overall survival between GU and non-GU PGL. Statistical significance was defined as p Results: 299 cases of PGL were retrieved from SEER. 20 (6.7%) of the total PGL arose from the GU tract. The mean age at diagnosis was higher in non-GU than GU PGL (50.4±17.2 vs 40.8±15.6, p=0.026). 83.3% of GU PGLs developed in the bladder, followed by the kidneys/renal pelvis (16.7%), and spermatic cord (2%). Non-GU PGL developed most frequently within the endocrine system (43%). PGL, overall, was more common in men than women, and it was more common in whites than all other races. While 50% of GU PGL was organ confined, only 5.7% of non-GU PGL was localized at diagnosis. All cases of PGL were treated with surgery. There were 2 (10%) cause-specific deaths in the GU PGL groups from 2000-2012. 5-year overall survival was 93.3% for GU PGL versus 65.5% in non-GU PGL (p=0.062). Conclusions: Genitourinary PGL remains rare, with low incidence (6.7% of all PGL cases) in the US population between 2000 and 2012. Also, it had better 5-year overall survival compared to PGL developing outside of the GU tract. The bladder represents the most common site of involvement and surgery is the mainstay of treatment for GU PGL. Clearer prognostic factors are needed to better elucidate PGL management in the future; thus, pooled studies from various institutions with detailed clinical information are needed to delineate these prognostic factors

Targeted biopsy: Benefits and limitations

Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved. Purpose of review To review the current literature regarding the role of multiparametric MRI and fusion-guided biopsies in urologic practice. Recent findings Fusion biopsies consistently show an increase in the detection of clinically significant cancers and decrease in low-risk disease that may be more suitable for active surveillance. Although, when to incorporate multiparametric MRI into workup is not clearly agreed upon, studies have shown a clear benefit in both biopsy naïve and those with prior negative biopsies in determining the appropriate treatment strategy. More recently, cost-analysis models have been published that show that upfront MRIs are more cost-effective when considering missed cancers and treatment courses. Summary With improved accuracy over systematic biopsies, fusion biopsies are a superior method for detection of the true grade of cancer for both biopsy naïve and patients with prior negative biopsies, choosing appropriate candidates for active surveillance, and monitoring progression on active surveillance

An age-Based analysis of pediatric melanoma: Staging, surgery, and mortality in the surveillance, epidemiology, and end results database

The pediatric melanoma population is not well described, and current guidelines for their management are not well defined. Our study aims to identify this population, treatment modalities, and outcomes using a national population-based database. We reviewed the Surveillance, Epidemiology, and End Results database (2004–2008). Patients £21 years old with melanoma were included and grouped into £12 years of age, 13 to 18 years, and 19 to 21 years. Clinical characteristics were analyzed across the groups. A total of 1255 patients were included: 52.7 per cent were 19 to 21 years of age, 36.3 per cent were 13 to 18 years of age, and 11.0 per cent were £12 years of age. The 19- to 21-year-olds had the highest proportion of stage I (50.5%) versus £12 years of age (31.9%); the £12-year-olds had the highest proportion of stage IV (3.6%) versus 19 to 21 years of age (0.9%), P \u3c 0.001. The 19- to 21-year-olds had the highest proportion receiving wide local excisions only (34.8%) versus £12 years of age (26.4%); the £12-year-olds had the highest proportion of patients without any surgeries (16.0%) versus 13 to 18 years of age (9.4%), P 5 0.169. On adjusted analysis, the 19- to 21-year-olds had worse survival compared with £12 years of age (hazard ratio: 5.26, P 5 0.017, 95% confidence interval 1.34–20.65). Disparities were found in the £12-year-old melanoma population, as they had later stage melanomas, less invasive surgery, and lower survival. Clearer prognostic factors are needed to better elucidate their management