Search

Objective: In this descriptive study, we evaluated perceptions and knowledge of inpatient glycemic control among resident physicians. Methods: We performed this study at four academic medical centers: the University of Mississippi Medical Center, University of Virginia Health System, University of Louisville Health Sciences Center, and Emory University. We designed a questionnaire, and Institutional Review Board approval was granted at each institution prior to study initiation. We then administered the questionnaire to Internal Medicine and Medicine-Pediatric resident physicians. Results: A total of 246 of 438 (56.2%) eligible resident physicians completed the Inpatient Glycemic Control Questionnaire (IGCQ). Most respondents (85.4%) reported feeling comfortable treating and managing inpatient hyperglycemia, and a majority (66.3%) agreed they had received adequate education. Despite self-reported comfort with knowledge, only 51.2% of respondents could identify appropriate glycemic targets in critically ill patients. Only 45.5% correctly identified appropriate inpatient random glycemic target values in noncritically ill patients, and only 34.1% of respondents knew appropriate preprandial glycemic targets in noncritically ill patients. A small majority (54.1%) were able to identify the correct fingerstick glucose value that defines hypoglycemia. System issues were the most commonly cited barrier to successful inpatient glycemic control. Conclusion: Most respondents reported feeling comfortable managing inpatient hyperglycemia but had difficulty identifying appropriate inpatient glycemic target values. Future interventions could utilize the IGCQ as a pre- and postassessment tool and focus on early resident education along with improving system environments to aid in successful inpatient glycemic control. Abbreviations: DM = diabetes mellitus; Emory = Emory University Healthcare; IGC = inpatient glycemic control; IGCQ = Inpatient Glycemic Control Questionnaire; IRB = Institutional Review Board; PGY = postgraduate year; UMMC = University of Mississippi Medical Center; UVA = University of Virginia Health System; UL = University of Louisville Health Sciences Center

Recent guidelines recommend direct acting oral anticoagulants (DOAC) over vitamin-k antagonist (VKA) for acute venous thromboembolism (VTE). Non-adherence to anticoagulation has been associated with increased frequency of VTE or stroke. This study evaluated 90 day persistence among patients prescribed rivaroxaban or warfarin for the treatment of acute VTE at an academic safety net hospital. We conducted a single center, retrospective cohort study of 314 consecutive patients newly prescribed rivaroxaban or warfarin for acute VTE between January 2016 and July 2017. Primary outcome was 90 day persistence, and secondary outcomes included 90 day readmission and/or ED visit, time to 90 m day readmission and/or ED visits, and attendance of direct oral anticoagulant education class. Of 314 patients, 78 were prescribed warfarin and 236 rivaroxaban. Patients had a mean age of 52 years, 62% were men, and 96% were diagnosed with deep vein thrombosis and/or pulmonary embolism. Persistence at 90 days was 52.6% among patients prescribed warfarin compared to 45.3% for patients prescribed rivaroxaban (p = 0.2678). Persistencewas associated with decreased 90 day hospital or ED readmission. Among patients prescribed rivaroxaban, attending a pharmacist led educational class was associated with a 2.5 fold increase in persistence (p

Using evidence to guide patient care improves patient outcomes. However, the volume of clinical and scientific literature and demands on provider time make staying current challenging. Primary literature searching or using public search engines to answer clinical questions often results in low-quality or incorrect answers, potentially yielding suboptimal clinical care. This article describes systematic strategies for primary literature searching that can yield higher-quality results than an unstructured approach.

A spontaneous aortocaval fistula is a rare complication of abdominal aortic aneurysms. In 50 percent of the patients, it presents with the classic signs of a pulsatile abdominal mass, continuous bruit, and low back pain. A high degree of clinical suspicion and a well-performed physical examination are important for its timely diagnosis.

The goal of this study was to examine time-dependent effects of prognostic biomarkers of systemic inflammation in patients with metastatic renal cell carcinoma. Retrospective chart reviews were conducted at the Winship Cancer Institute of Emory University and the Atlanta Veterans Administration Medical Center with authorization from the Emory University Institutional Review Board and the Veterans Administration Research and Development Committee. Inclusion criteria included age ⩾18 years, treatment with targeted therapy for clear cell or non–clear cell metastatic renal cell carcinoma and concomitant assessment of C-reactive protein and albumin levels on ⩾3 occasions that were ⩾10 days apart. Discovery, expansion, and external validation cohorts were identified. Established prognostic variables were evaluated by univariate and multivariate analyses. Intensity of systemic inflammation was assessed at all time points with C-reactive protein and albumin as prognostic covariates for overall survival in an extended Cox regression model. Intensity of systemic inflammation was assessed on 3186 occasions in 181 patients. Risk status changed in 131 patients (72%). The hazard ratio for overall survival was 21.41 (95% confidence interval = 8.26–55.50) with a type 3 p value of

e15617 Background: The presence or absence of systemic inflammation has been associated with dramatic changes in prognosis for patients with metastatic renal cell carcinoma (mRCC). In this study we define kinetic inflammatory response (KIR) patterns as changes in the intensity of the systemic inflammatory response (SIR) over time as a result of therapeutic intervention or disease progression with the goal of ascertaining whether such patterns have any clinical utility. Methods: A retrospective, single institution study was conducted at the Winship Cancer Institute of Emory University. Inclusion criteria included treatment with a targeted agent for mRCC of any histology and the concurrent assessment of serum CRP and albumin on a minimum of three occasions at least two weeks apart. The modified Glasgow Prognostic Score (mGPS) was used to quantify the intensity of the SIR at each available time point. Results: A cohort of 55 patients was identified from among 635 patients who were evaluated for kidney cancer during the screening period of January 1, 2005 and June 30, 2011. The SIR was assessed a total of 804 times with a median of 14 time points per patient (range 3 to 49). A total of 113 lines of theapy were administered with a median of 2 per patient (range 1 to 5). KIR patterns were categorized as optimal, suboptimal, relapse, refractory and acquired systemic inflamation. Tandem KIR patterns were also observed. The absence or sustained loss of systemic inflammation was associated with responsiveness to therapy and prolonged overall survival (OS) whereas the persistence or acquisition of systemic inflammation was associated with resistance to therapy and shortened OS. In one instance, active surveillance with biomarkers of systemic inflammation led to the discovery of an occult penile metastasis. Conclusions: KIR pattern recognition provides a simple and inexpensive way for clinicians to monitor interactions between the tumor and the innate immune system with the clinical objective of inducing or maintaining an inflammation free state. Biomarkers of systemic inflammation may prove to be particularly useful for active surveillance of patients with fully resected, locally advanced or mRCC.

Over sixty thousand patients were diagnosed with metastatic renal cell carcinoma (mRCC) in 2010, yet no tumor markers have been identified. Standard prognostic systems only measure characteristics at baseline and do not assess the potential benefit of therapeutic intervention. The introduction of receptor tyrosine kinase inhibitors has significantly changed the management of mRCC. Pazopanib, a selective, multi-targeted, receptor tyrosine kinase inhibitor, was approved for mRCC in 2009. The modified Glasgow Prognostic Score (mGPS), a prognostic system based on inflammatory biomarkers (serum C-reactive protein (CRP) and albumin), has been validated in the pre-treatment setting for mRCC treated with surgery or cytokines. In this study, we present data demonstrating the correlation of serial mGPS measurements with objective responses to targeted therapy with pazopanib in patients with mRCC. We conducted a retrospective chart review of patients seen at the Winship Cancer Institute for whom serial CRP and albumin measurements as well as imaging studies were available while taking pazopanib. In these patients we assessed the correlation of pre- and post-treatment mGPS scores to objective responses by imaging. Twenty patients met inclusion criteria. Of these patients, 12 (60%) had progressive disease, and 8 (40%) had clinical benefit response (defined as stable disease, partial response, or complete response) by imaging. An elevated pre-treatment mGPS score had 75% sensitivity (95% confidence interval 35.5%-95.5%; P Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 103rd Annual Meeting of the American Association for Cancer Research; 2012 Mar 31-Apr 4; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2012;72(8 Suppl):Abstract nr 5571. doi:1538-7445.AM2012-5571

441 Background: The modified Glasgow prognostic score (mGPS) is a pre-treatment prognostic system based on inflammatory biomarkers that is comparable in accuracy to the Memorial Sloan-Kettering Cancer Center (MSKCC) score for patients with metastatic renal cell carcinoma (mRCC) treated with cytokines. However, data are limited regarding the current utility of prognostic models developed in the cytokine era. In this study we examined the correlation between pre-treatment and post-treatment mGPS values and clinical benefit response (CBR) in patients treated with targeted agents for mRCC. Methods: After obtaining approval from the Emory Institutional Review Board, mGPS values were determined retrospectively using published methods and measurements of serum C-reactive protein (CRP) and serum albumin from patients who received targeted therapy for mRCC of any histology at the Emory Winship Cancer Institute between January 1, 2005 and June 30, 2011. CBR was defined as complete response (CR), partial response (PR) and stable disease (SD). Inclusion criteria included availability of at least 3 CRP values per patient. Results: Of the 635 patients who were screened, 56 were found to meet inclusion criteria. Of these, 43 received one evaluable line(s) of therapy (ELOT), 9 received two, 3 received three and 1 received four. The 74 ELOT included temsirolimus (16), sunitinib (20), sorafenib (14), pazopanib (20), everolimus (3) and bevacizumab/interferon (1). The correlation of post-treatment mGPS values to CBR was greater than pre-treatment mGPS values with sensitivity (81%), specificity (87%), positive predictive value (85%) and negative predictive value (83%). The p values were Conclusions: Although these data require prospective validation, they provide evidence for the prognostic utility of mGPS assessments before and after therapy with targeted agents. Of note, the likelihood of having a CBR was much greater in patients who achieved or maintained an mGPS value of 0 after therapy. If confirmed, serial assessments of the mGPS to determine inflammatory response rates may prove to be a valuable and cost effective tool for patient care and drug development in mRCC.