Greater Los Angeles Veterans Affairs Medical Center

Los Angeles, CA, United States

Greater Los Angeles Veterans Affairs Medical Center

Los Angeles, CA, United States
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Sugiyama T.,University of California at Los Angeles | Sugiyama T.,University of Tokyo | Zingmond D.,University of California at Los Angeles | Lorenz K.A.,Greater Los Angeles Veterans Affairs Medical Center | And 5 more authors.
Journal of the American Geriatrics Society | Year: 2013

Physician Orders for Life-Sustaining Treatment (POLST) is a tool to document and ensure continuity of end-of-life treatment decisions across healthcare settings that became a legal document in California in January 2009. Hospitals were surveyed to evaluate factors associated with uptake of this intervention and whether a grassroots community coalition intervention facilitated dissemination. A mail and telephone survey of all acute care hospitals in California was conducted between August 2011 and January 2012, and community coalition reports of interaction with hospitals and hospital characteristics from the California Office of Statewide Planning and Development and Census ZIP Code Tabulation Areas were analyzed. Of 349 hospitals, 286 (81.9%) responded to the survey. Sixty-five percent of hospitals had a policy about POLST, 87% had available blank POLST forms, 84% had educated staff, and 94% reported handling POLST properly in the emergency department and on admission. In multivariable analyses, hospitals in poor areas and for-profit (vs nonprofit) hospitals were less likely to stock blank POLST forms and to have educated staff, and hospitals with community coalition interaction and in wealthier areas were more likely to handle POLST forms correctly. Although POLST is widely used in California, a significant minority of hospitals remain unprepared 3 years after implementation. Efforts to improve implementation should emphasize dissemination in poorer areas and in for-profit hospitals. © 2013, The American Geriatrics Society.

Roumie C.L.,Geriatric Research Education Clinical Center | Roumie C.L.,Vanderbilt University | Zillich A.J.,Center for Health Information and Communication | Zillich A.J.,Purdue University | And 10 more authors.
Stroke | Year: 2015

BACKGROUND AND PURPOSE - : We examined blood pressure 1 year after stroke discharge and its association with treatment intensification. METHODS - : We examined the systolic blood pressure (SBP) stratified by discharge SBP (≤140, 141-160, or >160 mm Hg) among a national cohort of Veterans discharged after acute ischemic stroke. Hypertension treatment opportunities were defined as outpatient SBP >160 mm Hg or repeated SBPs >140 mm Hg. Treatment intensification was defined as the proportion of treatment opportunities with antihypertensive changes (range, 0%-100%, where 100% indicates that each elevated SBP always resulted in medication change). RESULTS - : Among 3153 patients with ischemic stroke, 38% had ≥1 elevated outpatient SBP eligible for treatment intensification in the 1 year after stroke. Thirty percent of patients had a discharge SBP ≤140 mm Hg, and an average 1.93 treatment opportunities and treatment intensification occurred in 58% of eligible visits. Forty-seven percent of patients discharged with SBP 141 to160 mm Hg had an average of 2.1 opportunities for intensification and treatment intensification occurred in 60% of visits. Sixty-three percent of the patients discharged with an SBP >160 mm Hg had an average of 2.4 intensification opportunities, and treatment intensification occurred in 65% of visits. CONCLUSIONS - : Patients with discharge SBP >160 mm Hg had numerous opportunities to improve hypertension control. Secondary stroke prevention efforts should focus on initiation and review of antihypertensives before acute stroke discharge; management of antihypertensives and titration; and patient medication adherence counseling. © 2015 American Heart Association, Inc.

Daskivich T.J.,University of California at Los Angeles | Daskivich T.J.,Greater Los Angeles Veterans Affairs Medical Center | Kwan L.,University of California at Los Angeles | Dash A.,University of Washington | And 3 more authors.
Journal of Urology | Year: 2015

Purpose Accurate estimation of life expectancy is critical for men considering aggressive vs nonaggressive treatment of early stage prostate cancer. We created an age adjusted comorbidity index that predicts other cause mortality in men with prostate cancer. Materials and Methods We sampled 1,598 men consecutively diagnosed with prostate cancer between 1998 and 2004 at West Los Angeles and Long Beach Veterans Affairs hospitals. We used competing risks regression in testing and validation cohorts to determine the risk of nonprostate cancer related (ie other cause) mortality associated with age at diagnosis and PCCI score. We converted risk into a 10-point scoring system and calculated 2, 5 and 10-year cumulative incidence of other cause mortality by age adjusted PCCI scores. Results PCCI score and age were associated with similar hazards of other cause mortality in the testing and validation cohorts. Each 6-year increase in age at diagnosis of greater than 60 was equivalent to 1 additional PCCI point. After correcting PCCI score for age the age adjusted PCCI scores were strongly predictive of other cause mortality. The subhazard ratio of other cause mortality vs 0 for a score of 0, 1-2, 3-4, 5-6, 7-9 and 10+ was 2.0 (95% CI 1.3-3.0), 4.0 (95% CI 2.6-6.1), 8.7 (95% CI 5.7-13.3), 14.7 (95% CI 9.4-22.8) and 43.2 (95% CI 26.6-70.4), respectively. The 10-year cumulative incidence of other cause mortality was 10%, 19%, 35%, 60%, 79% and 99%, respectively. Conclusions The age adjusted PCCI strongly stratifies the risk of long-term, other cause mortality. It may be incorporated into shared decision making to decrease overtreatment of older and chronically ill men with prostate cancer. © 2015 American Urological Association Education and Research, Inc.

Daskivich T.J.,University of California at Los Angeles | Daskivich T.J.,Greater Los Angeles Veterans Affairs Medical Center | Kwan L.,University of California at Los Angeles | Dash A.,University of Washington | And 2 more authors.
European Urology | Year: 2014

Outcome measurements and statistical analysis Subhazard ratios and cumulative incidence of other-cause mortality associated with weighted and unweighted Charlson scores, calculated by competing-risks regression accounting for cancer mortality, along with Harrell concordance index (C-index) values.Results and limitations Weighted and unweighted Charlson scores were identical in 88.6% of subjects (1313 of 1482 men) across all scores and in 91.7% of subjects (1359 of 1482 men) across scores of 0, 1, 2, and ≥3. In competing-risks analysis, hazards of other-cause mortality were similar when comparing weighted and unweighted scores. Men with weighted scores of 1, 2, and ≥3 (vs 0) had subhazard ratios of 2.3 (95% confidence interval [CI], 1.6-3.2), 4.1 (95% CI, 2.9-5.8), and 8.3 (95% CI, 5.9-11.5), respectively. Men with unweighted scores of 1, 2, and ≥3 (vs 0) had subhazard ratios of 2.5 (95% CI, 1.8-3.5), 4.5 (95% CI, 3.2-6.3), and 10.3 (95% CI, 7.2-14.7), respectively. The C-indexes for prediction of other-cause mortality were nearly identical for weighted scores (0.759 [95% CI, 0.715-0.780]) and unweighted scores (0.756 [95% CI, 0.717-0.780]). The difference in C-index between the two methods was -0.003 (95% CI, -0.01 to 0.004).Conclusions An unweighted Charlson score yields similar strength of association and variance in predicting long-term, other-cause mortality compared with a weighted Charlson score.Patient summary A simple count of major comorbidities provides similar accuracy to a weighted index in predicting death from other causes in men with early-stage prostate cancer.Background Clinicians need a simple yet accurate method to predict other-cause mortality to inform medical decision making for men with prostate cancer (PCa).Design, setting, and participants A retrospective cohort study of 1482 men with early-stage PCa diagnosed in 1998-2004 at two Southern California Veterans Affairs medical centers. © 2014 European Association of Urology. Published by Elsevier B.V. All rights reserved. -absp. Objective To compare weighted and unweighted Charlson Comorbidity Index scores in predicting long-term, other-cause mortality in men with early-stage PCa.

Daskivich T.J.,University of California at Los Angeles | Daskivich T.J.,Greater Los Angeles Veterans Affairs Medical Center | Chamie K.,University of California at Los Angeles | Kwan L.,University of California at Los Angeles | And 5 more authors.
Cancer | Year: 2013

BACKGROUND Men with multiple comorbidities are often overtreated for low-risk prostate cancer, but it is unclear whether they are undertreated for high-risk cancer, which has appreciable short-term prostate cancer-specific mortality. This study characterized the impact of comorbidity on treatment and survival in men with differing tumor risks. METHODS The researchers sampled 1482 men with nonmetastatic prostate cancer at 2 Veterans Affairs hospitals between 1998 and 2004, using multivariate probit regression to determine probabilities of aggressive treatment among men with differing Charlson comorbidity scores within D'Amico tumor risk strata. Using competing-risks regression, a comparison was made of 8-year cancer-specific mortality for men treated aggressively and nonaggressively among Charlson score-tumor risk pairs. RESULTS The study sample comprised 516 men (36%) with low-risk, 475 men (33%) with intermediate-risk, and 432 men (30%) with high-risk prostate cancer. Men with high-risk disease tended to have lower probability of aggressive treatment than other risk strata, regardless of comorbidity. Among men with Charlson scores 3+, probabilities of aggressive treatment did not increase with higher tumor risk (0.48, 0.61, 0.49 for low-, intermediate-, and high-risk disease, respectively). In competing-risks analysis, aggressive treatment was not associated with cancer-specific survival benefit in men with multiple comorbidities (Charlson scores of 2 or 3+) and low- and intermediate-risk disease, but there was a strong trend toward survival advantage in such men with high-risk disease. CONCLUSIONS Aggressiveness of treatment is poorly matched with tumor risk in men with significant comorbidity. Men with major comorbidities should consider conservative management for low- and intermediate-risk disease and aggressive treatment for high-risk disease. Cancer 2013;119:3446-3453. © 2013 American Cancer Society. Men with multiple comorbidities tended to have lower probability of aggressive treatment for high-risk disease than other tumor risk strata, despite a strong trend toward survival advantage with aggressive treatment of high-risk disease (but not low- or intermediate-risk disease). Men with major comorbidities should consider conservative management for low- and intermediate-risk disease and aggressive treatment for high-risk disease. Copyright © 2013 American Cancer Society.

Guo C.,University of California at Los Angeles | Liu H.,University of California at Los Angeles | Zhang B.,University of California at Los Angeles | Cadaneanu R.M.,University of California at Los Angeles | And 4 more authors.
PLoS ONE | Year: 2012

Background: Human prostate basal cells expressing alpha-6 integrin (CD49f Hi) and/or CD44 form prostaspheres in vitro. This functional trait is often correlated with stem/progenitor (S/P) activity, including the ability to self-renew and induce differentiated tubules in vivo. Antigenic profiles that distinguish tubule-initiating prostate stem cells (SCs) from progenitor cells (PCs) and mature luminal cells (LCs) with less regenerative potential are unknown. Methodology/Principle Findings: Prostasphere assays and RT-PCR analysis was performed following FACS separation of total benign prostate cells based upon combinations of Epcam, CD44, and/or CD49f expression. Epithelial cell fractions were isolated, including Epcam +CD44 + and Epcam+CD44+CD49f Hi basal cells that formed abundant spheres. When non-sphere-forming Epcam +CD44 - cells were fractionated based upon CD49f expression, a distinct subpopulation (Epcam +CD44 -CD49f Hi) was identified that possessed a basal profile similar to Epcam +CD44 +CD49f Hi sphere-forming cells (p63 +AR LoPSA -). Evaluation of tubule induction capability of fractionated cells was performed, in vivo, via a fully humanized prostate tissue regeneration assay. Non-sphere-forming Epcam +CD44 - cells induced significantly more prostate tubular structures than Epcam +CD44 + sphere-forming cells. Further fractionation based upon CD49f co-expression identified Epcam +CD44 -CD49f Hi (non-sphere-forming) basal cells with significantly increased tubule induction activity compared to Epcam +CD44 -CD49f Lo (true) luminal cells. Conclusions/Significance: Our data delineates antigenic profiles that functionally distinguish human prostate epithelial subpopulations, including putative SCs that display superior tubule initiation capability and induce differentiated ductal/acini structures, sphere-forming PCs with relatively decreased tubule initiation activity, and terminally differentiated LCs that lack both sphere-forming and tubule-initiation activity. The results clearly demonstrate that sphere-forming ability is not predictive of tubule-initiation activity. The subpopulations identified are of interest because they may play distinct roles as cells of origin in the development of prostatic diseases, including cancer. © 2012 This is an open-access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

Bradesi S.,University of California at Los Angeles | Bradesi S.,Greater Los Angeles Veterans Affairs Medical Center | Golovatscka V.,University of California at Los Angeles | Golovatscka V.,Greater Los Angeles Veterans Affairs Medical Center | And 6 more authors.
American Journal of Physiology - Gastrointestinal and Liver Physiology | Year: 2011

Glutamate (Glu) is the primary excitatory neurotransmitter in the central nervous system and plays a critical role in the neuroplasticity of nociceptive networks. We aimed to examine the role of spinal astroglia in the modulation of glutamatergic neurotransmission in a model of chronic psychological stressinduced visceral hyperalgesia in male Wistar rats. We assessed the effect of chronic stress on different glial Glu control mechanisms in the spinal cord including N-methyl-D-aspartate receptors (NMDARs), glial Glu transporters (GLT1 and GLAST), the Glu conversion enzyme glutamine synthetase (GS), and glial fibrillary acidic protein (GFAP). We also tested the effect of pharmacological inhibition of NMDAR activation, of extracellular Glu reuptake, and of astrocyte function on visceral nociceptive response in naive and stressed rats. We observed stress-induced decreased expression of spinal GLT1, GFAP, and GS, whereas GLAST expression was upregulated. Although visceral hyperalgesia was blocked by pharmacological inhibition of spinal NMDARs, we observed no stress effects on NMDAR subunit expression or phosphorylation. The glial modulating agent propentofylline blocked stress-induced visceral hyperalgesia, and blockade of GLT1 function in control rats resulted in enhanced visceral nociceptive response. These findings provide evidence for stress-induced modulation of glia-controlled spinal Glu-ergic neurotransmission and its involvement in chronic stress-induced visceral hyperalgesia. The findings reported in this study demonstrate a unique pattern of stress-induced changes in spinal Glu signaling and metabolism associated with enhanced responses to visceral distension. © 2011 the American Physiological Society.

PubMed | Greater Los Angeles Veterans Affairs Medical Center, University of California at Los Angeles and Harvard University
Type: Journal Article | Journal: Medical hypotheses | Year: 2015

Advanced liver disease has long been associated with cerebral abnormalities. These abnormalities, termed acquired hepatocerebral degeneration, are typically visualized as T1 weighted hyperintensity on MRI in the deep gray matter of the basal ganglia. Recent reports, however, have demonstrated that a subset of patients with chronic alcoholic liver disease may also develop white matter abnormalities. Thus far, the morphology of these changes is not well characterized. Previous studies have described these changes as patchy, sporadic white matter abnormalities but have not posited localization of these changes to any particular white matter tracts. This paper hypothesizes that the white matter findings associated with advanced alcoholic liver disease localize to the corticocerebellar tracts. As an initial investigation of this hypothesis, 78 patients with a diagnosis of liver cirrhosis and an MRI showing clearly abnormal T1 weighted hyperintensity in the bilateral globus pallidus, characteristic of chronic liver disease, were examined for white matter signal abnormalities in the corticocerebellar tracts using FLAIR and T2 weighted images. The corticocerebellar tracts were subdivided into two regions: periventricular white matter (consisting of the sum of the centrum-semiovale and corona radiata), and lower white matter (consisting of the corona radiata, internal capsules, middle cerebral peduncles, middle cerebellar peduncles and cerebellum). As compared to matched controls, significantly greater signal abnormalities in both the periventricular white matter and lower white matter regions of the corticocerebellar tracts were observed in patients with known liver cirrhosis and abnormal T1 W hyperintensity in the globi pallidi. This difference was most pronounced in the lower white matter region of the corticocerebellar tract, with statistical significance of p<0.0005. Furthermore, the pathophysiologic mechanism underlying these changes remains unknown. This paper hypothesizes that the etiology of white matter changes associated with advanced liver disease may resemble that of white matter findings in subacute combined degeneration secondary to vitamin B12 deficiency. Specifically, significant evidence suggests that dysfunctional methionine metabolism as well as dysregulated cytokine production secondary to B12 deficiency play a major role in the development of subacute combined degeneration. Similar dysfunction of methionine metabolism and cytokine regulation is seen in alcoholic liver disease and is hypothesized in this paper to, at least in part, lead to white matter findings associated with alcoholic liver disease.

PubMed | Kaiser Permanente, Greater Los Angeles Veterans Affairs Medical Center and University of California at Los Angeles
Type: Journal Article | Journal: International journal of impotence research | Year: 2016

The objective of this study was to define the pattern and time course of use of ED treatments in a Veterans Affairs (VA) medical center and to identify clinical or demographic variables that are associated with the use of second- or third-line ED treatments. We identified 702 men treated for ED at the Greater Los Angeles Veterans Affairs between 2007 and 2013. We extracted demographics, Charlson co-morbidity score, pertinent surgical/medication history as well as use of ED treatments from medical records. On multivariate analysis, age over 65 (OR 1.83, 95% CI: 1.31-2.56) and Charlson co-morbidity score of 1 (OR 1.77, 95% CI: 1.13-2.77) and 2+ (OR 2.07, 95% CI: 1.28-3.36) were significantly associated with use of medicated urethral suppositories for erection (MUSE)/intracorporal injections (ICI) compared with PDE5i/erection devices. Across all men who used second- or third-line treatments, median time until receiving MUSE was 0.6 years and median time until receiving ICI/implant was 2 years. We conclude that men who will ultimately use more invasive ED treatments, such as men with more co-morbidities, tend to have a prolonged treatment course. This information may be incorporated into a shared decision-making model for more efficient treatment of ED.

PubMed | University of Southern California, Greater Los Angeles Veterans Affairs Medical Center and University of California at Los Angeles
Type: Journal Article | Journal: Clinical imaging | Year: 2016

Ulnar neuropathy is a common and frequent reason for referral to hand surgeons. Ulnar neuropathy mostly occurs in the cubital tunnel of the elbow or Guyons canal of the wrist, and it is important for radiologists to understand the imaging anatomy at these common sites of impingement. We will review the imaging and anatomy of the ulnar nerve at the elbow and wrist, and we will present magnetic resonance imaging examples of different causes of ulnar neuropathy, including trauma, overuse, arthritis, masses and mass-like lesions, and systemic diseases. Treatment options will also be briefly discussed.

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