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American Geriatrics Society 2008 Meeting Abstracts
from the Geriatrics Section, UT Southwestern |
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| Primary Small Cell Carcinoma of the Prostate |
Authors: J. Berger and
V. Roche |
Presidential Poster Session
May 2, 4:30-6 p.m. |
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| Differences in Gfr Calculation: Mdrd, Cockcroft/Gault with Ideal Body Weight and Cockcroft/Gault with Measured Body Weight |
Authors: K. Daniel, C.L. Cason,
B. Vicioso, R. Sesso,
P. Gleason-Wynn |
Poster Session
May 1, 2-3 p.m. |
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| Pay For Performance in Geriatric Ambulatory Care-Which Quality Indicators Are Currently Being Met? |
Authors: V. Roche, J. Carment,
S. Qureshi |
Poster Session
May 1, 2-3 p.m. |
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| Primary Small Cell Carcinoma of the Prostate |
| Introduction: |
Small cell carcinoma of the prostate accounts for only 2% of all cases of prostate cancer. Most present in patients who have already been treated for adenocarcinoma of the prostate or in the presence of adenocarcinoma. We present an unusual case of primary small cell carcinoma of the prostate in a patient with no prior history of urologic problems. |
| Case: |
A 67 year old African American male presented with one month onset of poor stream, post void dribbling, and an episode of hematospermia. He had no recollection of prior urinary tract symptoms. He was overall in good health with a past medical history significant for diabetes and hypertension. His social history was remarkable for no tobacco use. Rectal exam revealed an enlarged prostate with a nodule at the right apex. Urinalysis was negative for hematuria or pyuria. PSA was 1.93. Prostate biopsy revealed invasive small cell carcinoma with transitional cell carcinoma in situ. Staging CT scans revealed lesions in the kidneys, spleen, and lungs. He is now undergoing chemotherapy with carboplatin and etoposide. Discussion: Small cell carcinoma of the prostate is uncommon. Review of the literature reveals that the majority of cases occur in patients who have been treated (in some cases, 10 years prior) for adenocarcinoma of the prostate or in co-incidence with adenocarcinoma of the prostate. Patients with small cell of the prostate typically have a normal PSA and may have a paucity of lower urinary tract symptoms, as did our patient. His presentation is noteworthy because he is a non-smoker, he had no prior history of urinary tract pathology, and part of his chief complaint was hematospermia. Unfortunately, small cell of the prostate is a particularly aggressive cancer which frequently presents as widely metastatic disease. We also emphasize the importance of physical exam of the prostate, particularly for symptomatic patients with a normal PSA. For our patient, prostate exam was the only initial clue to the presence of extensive disease. |
| Conclusion: |
Small cell carcinoma is an unusual but important and particularly aggressive form of primary prostate cancer. Physical exam of the prostate is key in detecting prostate cancers (such as small cell) which rarely secrete high levels of PSA. |
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Differences in Gfr Calculation: Mdrd, Cockcroft/Gault with Ideal Body Weight
and Cockcroft/Gault with Measured Body Weight |
| Purpose: |
Evaluate the correspondence in estimated GFR when GFR is computed by 3 different methods of calculation: MDRD, Cockcroft/Gault with ideal body weight(IBW)and Cockcroft/Gault with measured body weight. |
| Methods: |
A retrospective chart review provided data on 170 patients cared for in a publicly funded geriatric clinic referred for dietary counseling. Data collected included age, ethnicity, height, weight, diagnosis of CKD, and creatinine. IBW was calculated from height using CDC tables of IBW for a BMI of = 24.9. Renal insufficiency was defined as GFR < 60. |
| Results: |
Patients' ages ranged from 56-91; most were women (75%) and African American (81%). Five percent of patients had a diagnosis of CKD. Height and weight were used to compute BMI that ranged from 13-57, 29 8. Twenty-two percent were overweight and another 43% were obese. The 3 formulae yielded significantly different estimates of GFR; Cockcroft/Gault using measured body weight(86 36) always produced the highest estimates, the MDRD (75 20) produced middle range estimates and Cockcroft/Gault using IBW(71 23) produced the lowest estimates. In patients with BMIs less than 24.9 Cockcroft/Gault yielded significantly lower estimates of GFR than did either of the other 2 formulae. In patients with BMI greater than 24.9, Cockcroft/Gault yielded significantly higher estimates of GFR than did either of the other two formulae. Cockcroft/Gault identified 35 patients with renal insufficiency, MDRD identified 32 patients with renal insufficiency and Cockroft/Gault with IBW identified 51 patients with renal insufficiency. When GFR is estimated using the Cockcroft/Gault and IBW, the correlation with MDRD estimates is better (r=.82) than is the correlation with Cockcroft/Gault using measured body weight (r=.75). The correlation between MDRD estimates and Cockcroft/Gault estimates using measured body weight is r= .54. |
| Conclusions: |
In this population of older minority subjects, the Cockcroft/Gault using ideal body weight produced the most conservative estimate of glomerular filtration rate. In the presence of obesity, the Cockcroft/Gault computed with measured body weight will underdiagnose renal insufficiency. |
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| Pay For Performance in Geriatric Ambulatory Care-Which Quality Indicators Are Currently Being Met? |
| Purpose: |
To compare adherence with current clinical practice guideline quality indicators (CPGQIs) and proposed functional assessment quality indicators (FAQIs) in older patients at a university geriatrics clinic. |
| Methods: |
A cross-sectional, retrospective study of 100 consecutive established clinic patients aged ?75 years was performed after IRB approval. Subjects were excluded if life-expectancy < 6 months or if enrolled in the clinic < 12 months. Adherence to specified CPGQIs and FAQIs was determined by documentation in the electronic medical record (EMR) over a 12-month period (6/05-7/06). The initial visit note, independent of date, was also reviewed for documentation of prior pneumococcal vaccination. QI adherence was also counted if clinical exceptions (e.g., drug allergy) or patient refusal were clearly documented. |
| Results: |
The mean age ± SD of the subjects (n=100) was 83.1 ± 5.4 years, 77% were female and the racial composition was predominantly white. Adherence rates for most QIs exceeded 70%. The QIs less likely to be documented included pneumococcal vaccination, lipid monitoring and screening for falls and female osteoporosis. Subgroup analysis of two age groups, 75-84 (n=61) and ? 85 (n=39), revealed a statistical difference for falls screening (p=0.05).
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| Discussion: |
The AGS advocates utilization of FAQIs in addition to CPGQIs for assessing quality of care for vulnerable elders. In our clinical sample, overall documented adherence to CPGQIs was greater than FAQIs. Screening for falls occurred more often in the oldest subgroup. Limitations include a racially homogeneous cohort, few subjects with DM or CAD, incomplete EMR data entry, and bias inherent to an academic clinical practice. Additional studies with larger samples should provide further insight on the impact of pay for performance on practicing geriatricians. |
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