With aging, abnormal benign growth of the prostate results in benign prostate hyperplasia (BPH) with concomitant lower urinary tract symptoms (LUTS). Because the prostate is an androgen target tissue, and transforms testosterone into 5α-dihydrotestosterone (5α-DHT), a potent androgen, via 5α-reductase (5α-R) activity, inhibiting this key metabolic reaction was identified as a target for drug development to treat symptoms of BPH. Two drugs, namely finasteride and dutasteride were developed as specific 5α-reductase inhibitors (5α-RIs) and were approved by the U.S. Food and Drug Administration for the treatment of BPH symptoms. These agents have proven useful in the reducing urinary retention and minimizing surgical intervention in patients with BPH symptoms and considerable literature exists describing the benefits of these agents. In this review we highlight the adverse side effects of 5α-RIs on sexual function, high grade prostate cancer incidence, central nervous system function and on depression. 5α-Rs isoforms (types 1-3) are widely distributed in many tissues including the central nervous system and inhibition of these enzymes results in blockade of synthesis of several key hormones and neuro-active steroids leading to a host of adverse effects, including loss of or reduced libido, erectile dysfunction, orgasmic dysfunction, increased high Gleason grade prostate cancer, observed heart failure and cardiovascular events in clinical trials, and depression. Considerable evidence exists from preclinical and clinical studies, which point to significant and serious adverse effects of 5α-RIs, finasteride and dutasteride, on sexual health, vascular health, psychological health and the overall quality of life. Physicians need to be aware of such potential adverse effects and communicate such information to their patients prior to commencing 5α-RIs therapy.

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Liver transplantation presents unique challenges in patients who do not accept blood transfusions. The difficulty of balancing chemical augmentation and handling the technical difficulty of the surgery make transfusion-free liver transplantation an exception rather than the norm. However, at our center, we have performed 27 successful living donor liver transplants in transfusion-free patients. We describe a case of hepatic artery thrombosis (HAT) after living donor liver transplantation requiring retransplantation. This first report of safe retransplantation without blood products demonstrates that even graft-threatening complications can be safely managed in a transfusion-free setting. However, it remains unclear if the medical augmentation to meet hematologic and coagulation parameters before transfusion-free transplantation may increase the risk of postoperative HAT and other thrombotic complications. Although it is our center’s experience that the thrombosis rate is comparable with the published rate in standard transfusion-eligible living donor liver transplantations and this case demonstrates that HAT can be safely managed in this setting, further study on the risks and benefits of hematopoietic stimulants as pretransplant optimization is warranted.

INTRODUCTION: Colorectal cancer (CRC) is a leading cause of cancer mortality despite being largely preventable. The fecal immunochemical test (FIT) is a recommended screening method, but timely evaluation of abnormal results is critical to the effectiveness of CRC screening. Recent studies indicate low rates of follow up colonoscopy after abnormal FIT within safety net health systems. A patient navigator program (PNP) is an evidence based strategy that has been shown to improve colonoscopy completion. The aim of this study was to evaluate the effectiveness of a PNP to encourage follow up colonoscopy after abnormal FIT within a large safety net hospital system. METHODS: We established an enterprise-wide PNP at five tertiary care hospitals within the Los Angeles County Department of Health Services (LAC-DHS) system. Patients 50–75 years of age with an abnormal FIT result were assisted by the PNP to complete their follow up colonoscopy within 6 months. Here we perform an interim analysis of a prospective cohort of patients from June 1, 2018 to December 31, 2018 assisted by the PNP. We compare the effectiveness of the PNP intervention by comparing colonoscopy rates to a period prior to the intervention. We also summarize the endoscopic findings of patients undergoing colonoscopy. RESULTS: Among 1217 patients with abnormal FIT results, 43% (n = 546) were men with a mean age of 60.3 ± 6.2 years. From a previous baseline of 167 days (SD 118), the mean time from abnormal FIT to colonoscopy improved to 117 days (SD 53) with navigation. The frequency of colonoscopy completion increased in patients who received navigation (53%, n = 642) as compared to patients who did not receive navigation (40.5%, 492/1213). Among PNP patients undergoing colonoscopy (N = 642), 50.2% (n = 322) had adenomatous polyps, 24% (n = 156) had “high risk” adenomas, and 2% (n = 12) had CRC. CONCLUSION: After the introduction of a patient navigator program, there was an overall increase in patients undergoing follow-up colonoscopy after abnormal FIT within a shorter time interval. Over half of the patients undergoing colonoscopy were found to have clinically significant findings including high risk adenomas and CRC. In this interim analysis, we demonstrate that the integration of a patient navigator program for CRC screening may be instrumental in increasing adherence to recommended screening guidelines across a large safety net health system.

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