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La Quinta CA Real Estate & Homes for Sale
885 Properties Found
The median home value in La Quinta, CA is $385,000.
This is
higher than
the county median home value of $267,100.
The national median home value is $177,414.
The average price of homes sold in La Quinta, CA is $385,000.
Approximately 46.51% of La Quinta homes are owned,
compared to 16.66% rented, while
36.84% are vacant.
La Quinta real estate listings include condos, townhomes, and single family homes for sale.
Commercial properties are also available.
If you see a property you're interested in, contact a La Quinta real estate agent to arrange a tour today!
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1 - 25 of 885 Properties Displayed
50480 Orchard Lane La Quinta, CA 92253
Courtesy: Hurwitz James Company Josh Reef
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Spectacular Hilltop Estate at the Estancias in Rancho La Quinta. Rare 1 Acre lot elevated above all the surrounding homes with beautiful Southern Mountain Views and Sunsets. 5 bedrooms and four are guest suites with their own private bathrooms. One of the bedrooms is a Casita with its own separate entrance. Super tall ceilings and large walls of glass with light beaming in, feel like the outdoor is inside the home. Master suite has large closets and a dressing area as well as a bathroom and vanity area allowing comfort and space. The private, rear yard has a custom, very large Pebble Tec pool and spa with waterfalls & a tanning shelf. You will feel like you are swimming with the stars at night! A BBQ and fire pit finish off this exquisite outdoor setting. Large and open chefs kitchen with granite counters, stainless steel appliances, breakfast bar, kitchen island and it all opens to a large family room and breakfast nook.
Courtesy: Maxim Properties Polly Watts
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In Historic La Quinta Cove area is this gorgeously remodeled home. Rugged mountain views, fresh paint and drought tolerant landscaping add curb appeal to this beautiful home. Ready for move in day with wood laminate floors throughout the living areas, plush carpet in the bedrooms, ceramic tile in the bathrooms, fresh paint throughout, ceiling fans, lighting and fixtures. Each bathroom has new vanities, framed mirrors, and lighting. The open kitchen features white Shaker style cabinets, updated quartz counters, and stainless steel appliances. Enjoy winter nights by the cozy living room fireplace. The backyard has a patio accessible from glass paned doors in the dining room. Also includes central air and heat, laundry hook ups, and attached garage. Hiking and biking, golfing, museums and the arts, shopping and dining are all nearby to enjoy. Claim this gem for yourself today! Seller to provide voucher for new washer & dryer at close of escrow.
77354 Vista Flora La Quinta, CA 92253
Courtesy: California Lifestyle Realty Geri Dardi
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Location, Location, Location ! No street noise, parking lots or headlights here. The perfect Single Story, 2 Bedroom Master Villa Located directly on the promenade down from our Spa. This property has great views, privacy, and a premier location within the Waldorf Astoria. This Plan Four is the only single story villa for sale that has been renovated per Hotel requirements and has been in the Resort Rental Management Program. This is Resort living at it's finest. Call Geri or Martha today for your private showing. Furnishings of commercial grade/quality and come with warranty.
Courtesy: Coulter & Associates, Inc Kathy Coulter
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Let your imagination run amok! Enjoy the wafting fragrance of the several fruit trees & the scent of freshly mowed lawns. What is your fancy? A vegetable or herb garden, an outdoor cooking & dining fresco? A big yard for the dogs to enjoy? How about a putting green, or bocce ball? Badminton anyone? There is room for all this and more on this spacious lot of almost 12,000 sq.ft. If you desire a pool, there is room to front load one - or tuck one away in the backyard! And situated perfectly in the middle of this openness is a custom home of over 3000 sq. ft. with vaulted ceilings that will delight those who crave natural light & mountain views. The living room features a wet bar, fireplace & French doors that open to an outdoor dining alcove. A formal dining room has built-in buffet & cabinets. A chef's kitchen with island cook station, brushed stainless appliances & granite counters. The family room/kitchen combo is ideal for casual entertaining. An office + 3 ensuite bedrooms! Sweet!
Courtesy: Keller Williams Luxury Homes Sheri Dettman and Associates
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Here at PGA West in La Quinta, you'll discover this affordable two bedroom and two bath golf course condo located on the 5th hole of the Stadium Course. This penthouse unit is located on the second floor. Upon entering you'll notice upgraded wood style flooring, walls of mirror, and a cozy kitchen. The master bedroom suite features a beautiful master bath with luxurious finishes. The guest suite is nicely sized and includes it's own private bath. Step out to the balcony and fire up the BBQ, or simply relax and watch the golfers go by. This home is just a short stroll from the nearest community pool/spa. Here at PGA West, you can enjoy golf on three public and three private membership golf courses. Golf and social/fitness memberships are optional.
47815 Via Jardin La Quinta, CA 92253
Courtesy: HomeSmart Professionals Rick Cannon
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Highly upgraded 4 bedroom plus office and 4 bath home with a Casita. Located in the guard gated community of Lake La Quinta. There is custom tile throughout the home except for the bedrooms. The living room, family room and master all open to the private backyard with pool, spa, waterfalls, misting system and putting green. The covered patio can either be open or closed. There are 2 remote controlled awnings, TV and BBQ. The kitchen has granite counters newer appliances, large pantry and island. The home has builtin speakers in every room. The Master suite has double vanity, tub, shower and walk in closet. There is a 3 car garage with finished floor. The Casita has a full bath own refrigerator, microwave, coffee maker and sitting area. Lake La Quinta is a great community located close to some of the Desert's best golf, tennis, entertainment, dining and shopping. There is a shared electric boat to entertain you and friends for a relaxing cruise. This home is a must see.
Courtesy: Coldwell Banker Res. Brokerage Thomas Campagna
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An incredibly private corner lot bordering open space with big Santa Rosa Mountain views, a huge backyard with pool, a massive rock waterfall & a custom BBQ, all surrounded with brick pavers. This delightfully bright & cheerful, open concept, decorator's showcase with hardwood & tile floors, 2 fireplaces, a wet bar, en-suites in every bedroom, a casita, plus an office is magical with its rotunda entry surrounded on the outside with stack stone & a 3 car garage is priced for a quick sale. Rancho Santana with its long, exclusive gated entrance is truly a special place to live with its 2 parks, trails, open spaces which include a putting green, a pergola, BBQ's where friendly neighborhood gathering events are held. I LOVE this place as I looked for years to find my own, quality-built residence in this charming community I now call home. We're close to the Polo Fields where many festivals are held & just a few minutes from Old Town La Quinta with its quaint boutiques & diverse eateries!
Courtesy: The Real Estate Company Inc Carlos Pena
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3 BD/2 BA 1,526 sqft Home high in the La Quinta Cove surrounded with great views of the Santa Rosa Mountain Ranges.
Courtesy: The Real Estate Company Inc Carlos Pena
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3 BD/2 BA Home w/ 1,450 SqFt. High in the La Quinta Cove surrounded with views of the Santa Rosa Mountain Ranges.
Courtesy: Desert Prop - Coachella Valley Steven Mogavero
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Elevated high above the Beautiful Pate Course in Rancho La Quinta Country Club this gorgeous Encanto II Plan. Located on the 2nd Hole, This home features 4 bedrooms, 3.5 bathrooms,(2 beds and 1 bath in detached casitia) and is 2,924 sq.ft. The home is warmly appointed with faux/custom painting throughout, lovely tumbled marble backsplash in the kitchen and the family room has an entire wall of fabulous builtins. The yard features a freeform swimming pool and spa with extensive decking and is landscaped to a 10!! Upgraded features include porcelain tile floors,baseboards,shutters,painted wall accents, custom-built media center looking out to the Pool, Golf Course, Lake & Mountains, marble counters in the powder room, elegant chandeliers, custom fans in all rooms, two beautiful cast stone fireplaces and decorative sconces in the entry way niches. The gourmet kitchen has granite counters with travertine backsplash & stainless steel appliances
Courtesy: California Lifestyle Realty Kathryn Ann Schowe
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Are you looking for your little piece of paradise in La Quinta? Welcome to this stunning condo inside the gated community of La Quinta Fairways at La Quinta Country Club. Beyond the gated front courtyard you'll find a spacious 3 bedroom, 2 bathroom floor plan that spans 1800 square feet with a dramatic open feel. An upgraded, remodeled kitchen comes equipped with granite slab countertops, stainless GE Profile appliances, and 36 bottle wine keeper. With beautiful travertine flooring throughout, relax in the living room while enjoying the view and the cozy fireplace. The master suite features private access to the back patio, along with an accommodating master bathroom complete with soaking tub, dual vanity, and elegant tile flooring. The back patio is low maintenance with southern exposure and spectacular views of the 15th green and 16 tee of La Quinta Country Club. Watch the Career Builder Challenge, formerly the Bob Hope Classic from your patio and enjoy the desert lifestyle!
Courtesy: Berkshire Hathaway Home Srvcs The Balog Group
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INCREDIBLE VALUE! Turnkey Furnished, situated on Golf Course with Panoramic Southern and Western Mountain Views. Quiet end unit at back of development with extended patio. Low HOA dues, INCLUDES UNLIMITED GOLF on 18 hole par 3 course. If that isn't enough, they also include clubhouse access, tennis, , cable including HBO.Close proximity to one of six community pools and spas located in private, tropical feel setting. This unit is perfect for a weekend getaway, or seasonal rental. Located conveniently to Indian Wells Tennis Gardens, shopping and dining. Unit is light, bright and lovingly maintained. Seller has paid the $2,000 Special Assessment on behalf of the new Buyer.
Courtesy: Windermere Homes & Estates Mary Ackermann-Gaer
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Located in the gated community of Trilogy La Quinta. Two Bedrooms plus den/office and two full baths. Large corner lot. Easy access and exit for homeowner. Tree lined rear yard with fountain and covered patio. East facing for that morning sun.
80361 Riviera La Quinta, CA 92253
Courtesy: HK Lane Sandi Phillips
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Estate size lot with breathtaking mountain and golf course views looking down the 12th fairway of the Jack Nicklaus Private Course abound in this designer dream home. This elegantly appointed Heritage Four Plan, 4 bdrm, 4.5 bath, plus an office and including a guest casita w/approx. 4,200 sq ft is rare in PGA West, as very few were ever built. Beautifully remodeled, this open great room floorplan is an entertainer's delight w/ slab granite island kitchen, diagonal tile flooring, epoxy garage floors, custom stone backsplash through-out, spacious dining room and walls of glass that look out to the palatial resort style Pebble Tech pool/spa with waterfall feature, firepit and more. This is a must-see property. Offered furnished per inventory.
Courtesy: HK Lane Vicki Annett Martens
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This beautiful home shows like a model. Located on #18 of the Weiskopf course with multiple fairway and lake views this picture perfect home has 4 bedrooms, 4 baths and is offered turnkey furnished. The private gated courtyard has a custom rock waterfall feature with bronze figurine and upgraded landscape lighting. The main house has 3 bedrooms, 3 baths, living room with wet bar, fireplace, and dining room, leading you to a family room which opens to kitchen. The breathtaking views from the patio are highlighted by a rock waterfall spa, firepit and BBQ and open to expansive patio for entertaining. Additional features are: Custom Interior paint, base boards and crown molding, solid core raised panel doors, custom valances and blinds, tile flooring on diagonal, kitchenette in large detached casita, granite counters, ceiling fans, 5-burner gas range with professional hood, wood paneled side-by-side refrigerator and much more.
Courtesy: Coldwell Banker Res. Brokerage Ron Hanna
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Extremely well maintained two story home in the popular area of North La Quinta in Acacia Homes. Featuring a two story home with over 2000 sq ft with 4 bedrooms in which three up stairs and one on the main floor which also could be a home office. Featuring a spacious living and dinning room area that connects into the up graded kitchen which is open to the family room with a fireplace. The sliders opens to a spacious rear yard with a pool/spa. All this plus the beauty of the custom wood shutters in various rooms and located near all of the schools and shopping areas of your daily needs and in the lower cost utility company of IID.
Courtesy: Smart Realty Group Michael Harrison
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A RANCHO SANTANA jewel in the gem of the desert, this easy flowing floorplan sits in the arms of abundant privacy while it nestles against the lush, green preserve of the Madison Club Dev. Very spacious gourmet kitchen w/walk-in pantry, SS and full granite counters/backsplace. Master suite offers a soothing jacuzzi tub + an oversized marble walk-in Shower. Serene desert scape courtyard can be seen from LR/DR, FR and 3rd BR. Perfect for lg. spa or Dipping Pool. Lighted backyard beckons your memories of yesteryear vacations in Mexico or HI.
Courtesy: La Quinta Palms Real Estate Co Jim Young Cathcart
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Wow! What a great home located in La Quinta Cove! This home is approx. 1,730 sqft with 3 bedrooms, 2 bathrooms, large living w/ fireplace and sliding glass doors to rear yard. The kitchen has granite counter tops, oven/stove, dishwasher and eating bar. The master bedroom has a sliding glass door to the rear patio and a private bathroom with H&H sinks. Other features include: indoor laundry room, tile roof, two car garage an more! Short Sale subject to lender approval.
61810 Mesa Court La Quinta, CA 92253
Courtesy: Bennion Deville Homes John Miller
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Move up to this luxurious residence, tucked away inside a quiet cul-de-sac behind the guarded gates of Trilogy at La Quinta. Your tranquil leisure space awaits you in a backyard that includes a stunning rock waterfall feature, mature landscaping, low maintenance artificial turf, peek-a-boo mountain views, and a covered loggia with awning. Indoors, the tile flooring and high ceilings introduce this 1-story arrangement of approximately 1,775 s.f. that boasts 2 bedrooms, a den/office, 2 bathrooms, great room with media niche, and attractive plantation shutters on every window. The custom-caliber island with dining bar takes center stage in a kitchen with slab granite counters, walk-in pantry, stainless steel appliances with double ovens. A spacious private master suite is complete with dressing area, walk-in closet, and an elegant master bathroom with stylish features surrounding the dual vanity.
53600 Del Gato Drive La Quinta, CA 92253
Courtesy: HOM Sotheby's International Team Bergsma. Cerf. Triscari
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Sublime symmetry creates magic on a lush half-acre homesite at the top of coveted Tradition. Vanishing glass walls flank a stylish great room and merge a most private pool yard,an outdoor dining room with fireplace and a dramatic patio with fire pit to form a lux oasis with breathtaking views of a serene pond surrounded by skirted specimen palm trees. A gracious circular driveway and custom gates lead to a lush courtyard entry. More than 2300 SF of covered loggias surround the structure. A fabulous master retreat with formal entry includes a sitting area with fireplace,custom media cabinetry, two separate baths,separate dressing rooms and a private south-facing sanctuary courtyard.Each room has French doors opening to garden spaces for quintessential desert living.Featured rooms include;the Great Room, Formal Dining, Entertainer's Bar,Open Kitchen with Counter Seating,Walk-In Pantry,Formal Study,Detached Casita with private yard,Breakfast Bar and Pool Bath, Secured Dog Run and more.
Courtesy: Azevedo and Associates George Azevedo
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Very well maintained Custom home with three bedroom 2 full baths and one 1/2 bath. This is a spacious 2237 square foot home. Pool and Spa and beautiful manicured back yard. This is the first time this home has been on the market and shows like a new home. Three car garage with RV parking that has its own driveway. Very quite neighborhood with no HOAs on fee land.
79730 Citrus La Quinta, CA 92253
Courtesy: Capitis Real Estate Fred Wilson
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Great location on the 13th green with lake, mountain and double fairway views. Expansive kitchen with slab granite counters, long center breakfast bar, cherry wood finished cabinetry and separate butlers pantry w/wine cooler and wet bar. Elegant living room and dining room with marble fireplace and built-in bookcases, and surround sound in these areas. Large master bedroom with sitting area opens out to patio and fabulous views. Master bath showcases separate tumbled marble his/her sink areas, glass block shower and spa tub. Third bedroom used as a den, with fireplace but can be reconverted into bedroom. Archways and beamed ceilings are everywhere with plantation shutters throughout and open entry courtyard. This home is in pristine condition and 'ready-to-move-in' condition today!
Courtesy: HK Lane Beth Feist
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Three bedroom, two bath Sante Fe home located walking distance to the La Quinta Library, Civic Center, Wellness Center and Old Town La Quinta. The home has new blinds & carpet in bedrooms, saltillo tile throughout living area and has been freshly painted. Ceiling fans in every room and laundry area in the house. Beautiful mountain views, the home is walled all the way around with a gated front courtyard for privacy that is waiting for you to make the way you want it. Furniture is negotiable
Courtesy: HK Lane Vicki Annett Martens
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Sophisticated renovation with beautiful multi fairway and expansive lake views on #6 of the TPC Stadium course...rated Top 100 courses in the World by Golf Magazine. High end design details are everywhere in this popular 3031 sq. foot popular floorplan. This is a very large lot that could afford you options of building your own pool or casita.. Features to this home are: phantom screen, quartz counters in wet bar, kitchen, guest rooms, marble flooring thru-out, 6 burner Italian stove with griddle (Bertazoni)kitchen island with disposal, custom faucets and lighting through-out, professional size stainless steel side by side refrigerator. pull out shelves, spice racks, Bosch dishwasher, all new cabinets throughout, wall opened up between family room and dining room for optimal views, fire & ice stones in fireplace, wine cellar wine cabinet, and private sauna in master bedroom. Full 3 bedroom, 3.5 baths, offered furnished and a community pool/spa is located just across street.
Courtesy: Bennion Deville Homes Linda Langman
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REDUCED!! Enjoy exceptional lake, fairway and mountain views of the Santa Rosa Mountains from the patio of this lower end unit condo. The patio has been extended and offers additional outdoor living space. This end unit is light and bright. This model is single level and does not have a unit above you. The bedrooms have vaulted ceilings. The interior features ceiling fans, bathroom skylights, mirrors and vinyl dual glazed windows. This property is decorated in warm neutral colors. Located close to the community pool and spa. Located next to the clubhouse....what could be more convenient? Features a 1 car garage. This complex offers UNLIMITED GOLF to the owners on a challenging par 3 course. Close to shopping, restaurants, and the freeway. Located across from the Indian Wells Tennis Gardens. Located in the Desert Sands Unified School District with excellent schools.
1 - 25 of 885 Properties Displayed
La Quinta CA Real Estate Listings Provided By:
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La Quinta ZIPs92247 Homes for Sale 92248 Homes for Sale 92253 Homes for Sale


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Shahid Afridi chose to bowl first in the first one-day international match against England on Friday.
Towering fast bowler Mohammad Irfan is set to make his debut after being included in the squad for the first match. In the second change to their Twenty20 side that lost the second match on Tuesday, Pakistan have dropped opener Shahzaib Hasan and included middle-order batsman Asad Shafiq.
Shafiq and Irfan were called up to the Pakistan squad as reinforcements for the three players accused of spot-fixing, Mohamma Amir, Mohammad Asif and Salman Butt.
England have dropped wicketkeeper Craig Kieswetter for Steve Davies, while Jonathan Trott replaces dropped batsman Kevin Pietersen. Batting all-rounder Ravi Bopara is also in the side, replacing Luke Wright.
Meanwhile, the match has been reduced to a 41-overs-a-side match after heavy rain delayed the start in Durham.
Covers were still in place on the pitch at the scheduled 1015BST (0915GMT) start of what was supposed to be a 50-over match following overnight and morning rain.
Pakistan: Mohammad Hafeez, Kamran Akmal, Asad Shafiq, Mohamma Yousuf, Umar Akmal, Fawad Alam, Shahid Afridi, Umar Gul, Saeed Ajmal, Shoaib Akhtar, Mohammad Irfan
England: Andrew Strauss (captain), Steve Davies, Jonathan Trott, Paul Collingwood, Eoin Morgan, Ravi Bopara, Tim Bresnan, Michael Yardy, Graeme Swann, Stuart Broad, James Anderson.
Umpires: Billy Doctrove and Iain Gould
Third umpire: RA Kettleborough
Match referee: Jeff Crowe
Reserve umpire: RK Illingworth

subset: commoncrawl


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Hotfrog NewZealand provides information regarding Wealth Creators in Owaka Otago. Wealth Creators is located at 13 Royal Terrace, Owaka Otago 9535 and provides Financial services. Contact them on 03-455 8763 or by visiting them on their website http://www.wealthcreators.co.nz.
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Wfp Aviation
2315 Airport Dr Alexander City, Alabama 35010(256) 212-1318
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AboutWfp Aviation is located at the address 2315 Airport Dr in Alexander City, Alabama 35010. They can be contacted via phone at (256) 212-1318 for pricing, hours and directions.
Wfp Aviation has an annual sales volume of 501K - 999,999. .
For maps and directions to Wfp Aviation view the map to the right. For reviews of Wfp Aviation see below.
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Solenoid Single Valve with TIR E-Chip™
An excellent valve to use on booms or pulled sprayers, this solenoid valve may be used to transfer water. All the coils are encapsulated and waterproof, and the TIR E-Chip™ allows it to flow large volume capacities at a lower heat. With a maximum pressure PSI of 100.
Designed for agricultural spraying purposes, this solenoid water valve is built with efficient TIR E-Chip™ technology. Consisting of an interface electronic board that is integrated into the power consumption and valve. This reduces heat and increases large water flow volume rates. Construction elements of this water solenoid valve include standard viton seals and encapsulated coils that are waterproof. This sprayer valve has a maximum pressure of 100 PSI, a GPM of 0-10, and a pressure drop of 5 PSI at 10 GPM. There are 3 different NPT measurements on this valve, a female bypass inlet: 3/4 in., a male bypass outlet: 3/4 in., and a female bypass outlet: 1/2 in.Specifications
- Solenoid Single Valve
- 12 Volt valve
- TIR E-Chip™
- Reduces voltage and operating temperatures
- NPT female inlet: 3/4 in.
- NPT male bypass outlet: 3/4 in.
- NPT female boom outlet: 1/2 in.
- Excellent for booms and large tractor sprayers
- Coils are encapsulated and waterproof
- Maximum pressure: 100 PSI
- Pressure dop: 5 PSI at 10 GPM
- Current draw: 2 AMPs
Shipping Information
Your order is important to us and we will strive to process it as quickly as possible. Most in-stock items are shipped within 2-4 business days and typically deliver in 5-7 business days. In-stock items may ship from multiple locations and can arrive on separate days. Heavy or bulky items will ship via Freight/Truck Service and will take 8-10 business days for delivery. For those immediate product needs, we do offer at an additional cost, express service from UPS and Motor freight.
Shipping costs are determined by item weight and your zipcode. Once you have entered your shipping address, city, state, and zip code into checkout, your shipping total will be calculated and available for review. Please see the shipping map below as a guide.
Return Information
Your satisfaction is our priority. If for any reason you are not satisfied with a purchase from Agri Supply, we will gladly refund your money, or exchange the item, or fix it should it break. A minimum one-year warranty applies to all non-perishable items, parts and service from Agri Supply, and all hand tools sold by Agri Supply have a lifetime warranty, regardless of the length of the manufacturer's warranty. See our Agri Supply Guarantee for more details.
To return an item... give us a call at 1-800-345-0169, or visit one of our 8 retail stores near you, and one of our friendly customer service representatives, or store employees, will be glad to assist you.
Standard UPS Ground Shipping Map -
The above shipping chart applies to UPS ground shipments to the 48 contiguous states only. Please call 1-800-345-0169 for timing on shipments to Alaska, Hawaii, and Puerto Rico, thank you!
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text: Your favorit type of Toy Chica i gmod? 14.3% 1 vote THIS 1. She is cute 85.7% 6 votes THIS 1. Is the real 1 GamesFan78 published on September 12 21 quizzes6 stories7 questions74 polls4 pages Follow Create a Poll on Qfeast. It's just too easy! Star Poll Be the first to add this poll to starred list! ▼Scroll down for more polls▼ Comments (1) TheDiBZ This would be forgivable if you were nine. 0 0 reply Report on September 12 Subscribe


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Celebrating 65 years of service to the health care professions & helping professions.
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Author: Lisa A. Gorski MS, RN, HHCNS-BC, CRNI, FAAN
Features bullet points for access "at a glance" along with more in-depth considerations
Providing key information at a glance, this timely resource for the home care nurse, offers clear, salient 2016 practice guidelines for safely delivering IV therapy within the home. Written by one of the foremost experts in the field, the guide delivers not only evidence-based information in an easy-to-access, bulleted format, but also includes more extensive descriptions, discussions, and rationale for in-depth consultation. The resource maintains a cogent focus on infection and complication prevention throughout, along with directives for achieving positive patient outcomes. It also focuses on patient education, an essential component of safe home infusion therapy, and includes case studies and Q and A to reinforce content.
The guide addresses the foundations of home infusion therapy including infusion access devices and infusion delivery methods. Effective and safe management of dehydration, antimicrobial infusions, and parenteral nutrition are addressed along with chemotherapy, pain management, cardiac-related infusion therapy, immunoglobulin infusion, and other home infusion therapies. Home care nurses who provide direct care, home care managers and educators, , and nurses who provide home care discharge planning will find this Fast Facts guide to be an invaluable learning tool.


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Outdoor adventures spice up our lives…and the TG-850 is the perfect camera for preserving the memories. A super-wide lens takes in more of the beauty. A sophisticated sensor/image processor combo ensures vivid image quality. And features like a 180 degree flip LCD (because…selfies!), time interval shooting and pro-quality video make the TG-850 as refined as it is rugged.
Whether you're heading to the ends of the earth or just the end of the hiking trail, the TG-850 is up for the journey. Water doesn't affect it. Falling out* of your pocket won't faze it. Cold? No problem. You know how sometimes you can't decide whether to bring your camera? With the TG-850, you don't have to think twice. *Shockproof when the flip LCD screen is closed.
The TG-850 is perfectly capable of taking care of itself. But even a super-tough camera can use a little help, so we've developed a nice selection of useful accessories for a complete outdoor system. Carabiner straps, floating foam wrist straps, protective cases – all designed to help you get the most out of your TG-850.
We engineered the TG-850 to be one tough outdoor camera. Waterproof (to 10m/33 feet), shockproof* (to 2.1m/7 feet), crushproof* (to 100kg/220 pounds) and freezeproof (to -10°C/14°F), it's built to operate flawlessly in the most extreme conditions – so anything you and the kids can throw at it will be a piece of cake. *When the flip LCD is closed.
Consider things from a new angle
A tilting LCD monitor makes it much easier to do things like taking shots from unusual angles. But a 180-degree flip LCD on a waterproof camera like the TG-850 also lets you shoot cool half-in-the-water shots, and makes taking really good selfies a snap – even when the camera is mounted on your bike or board.
The widest lens on any rugged camera
The TG-850's super-wide 21mm (equivalent) lens captures 25% more of whatever you're shooting than the 28mm versions on other rugged cameras. Your images will be more panoramic, and you can fit more friends into the group shots you'll undoubtedly be taking to document your outdoor adventures.
Speed & Smarts
Combine a powerful DSLR-quality TruePic VII image processor and a best-in-class BSI CMOS sensor, and you've got a camera that provides blazing fast autofocus, superb low-light performance and quick start-up. The TG-850 also enables you to shoot Full HD 60p video, twice as fast as standard 1080/30p, for amazing clarity that smoothly plays back fast action.
Extremely high fun quotient
In case the pristine beauty of nature isn't enough, the TG-850 offers an unmatched array of creative tools to enhance your photos and videos. From interval shooting – great for capturing each step of an action sequence, or stitching together a time-lapse movie (software required) – to Art, Magic and Picture filters, this camera's FQ (Fun Quotient) is off the charts.
- Waterproof: Down to 33 ft / 10 m
- Crushproof*: Up to 220 lbf / 100 kgf
- Shockproof*: Up to 7 ft / 2.1 m
- Freezeproof: Down to 14°F / -10°C
- Dustproof: Yes
- Image Sensor: 16 Megapixel – BSI CMOS 1/2.3
- Image Processor: TruePic VII
- Zoom: 5x Optical Zoom + 2x Super Resolution Zoom + 4x Digital Zoom
- Focal Length: 3.74 - 18.7mm (35mm equivalent: 21 - 105mm)
- Removable Media Card: SD, SDHC, SDXC
- Internal Memory: 37MB
- Battery: LI-50B Lithium-Ion Rechargeable Battery
- Dimension: 4.3" W x 2.5" H x 1.1" D (109.9mm W x 64.1mm H x 27.6mm D)
- Weight: 7.7oz (218g)
- Included accessories: Waterproof Instructions, Premium Wrist Strap, LI-50B Rechargeable Lithium-Ion Battery, USB Cable & AC Adapter, Quick Start Guide, CD-ROM with Instruction Manual and Olympus Viewer 3 Software, Worldwide Warranty Card
Additional Information
|Sensor Size
|Compact (1/2.3")


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Recommendation Needed: Internet Provider
My family has had nothing but problems with Cobridge, now Time Warner. I know they are working on 'transferring/configuring' their network, but I just can't take it anymore and really would like to switch to a new provider. It's infuriating paying for a service that is so sporadic!
Sooo, can anyone suggest a [very] fast alternative in the Rockport area? I require a very fast connection for my home business. Thank you so much!
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15 comments:
We use SBC Global (AT&T) for our internet. We started with both the land line & the internet and later dropped the land line and now just pay for internet service. We highly recommmend it.
Debbie and Don Adams
- 8/16/2012
I have a great connection and speed with a local gentleman,
Kevin Johnson who runs Rockport WiFi. His phone is (512)
496-4556. I stream Hulu, Amazon & Netflix with his service.
The price is GREAT too.
- 8/16/2012
Jack Sheridan of Mr Fix It Computers (361-463-6146) set me up with Clear Wire and it's great. Call him with your concerns and I'm sure he could help you.
Pat Pileggi
- 8/16/2012
I agree with the AT&T. I use it...no problems. It seems expensive for the faster speeds. I have heard so many times that your current provider is a problem. I wonder though if it will get better. I had Time Warner in Pearland and it was excellent service in that area.
- 8/16/2012
I LOVE Clearwire. The price is good and it rarely goes down unlike the AT&T.
- 8/16/2012
Depending on where you live in Rockport, you may have a couple of different options. I am a retailer for CLEAR and also Stelera. They are both wireless services (like your cell phone) so it really depends on where you live. CLEAR doesn't work in Fulton and neither products work in the Lamar area. Please feel free to call Team Satellite at 361-790-8151 to see if we service your area. Thanks, Kim.
- 8/16/2012
AT&T is the way to go around here. Time Warner is actually in the process of updating all of The old equipment they aquired in the merger. I have an inkling that they'll be tremendously more dependable once they switch it all over but, of course, only time will tell!
- 8/18/2012
We use AT&T for internet, telephone and cell phones with a bundled cost price. Would recommend them.
- 8/19/2012
I had Cobridge also (I live in Portland) and it was horrible! I only use their internet and it was always up and down. However since they switched me over to Time Warner last month I have to say it's been a completely different story. My internet has not been down at all! Not one time! I can watch Netflix and Hulu without any lag time. They also offered me 12 months for $29.99 which was cheaper than Cobridge. I would say give Time Warner a shot and see if you see the difference I have seen in their internet service. Good Luck!
- 8/23/2012
I recommend Kevin Johnson as well. He's even starting to branch out to homes here in Lamar, where before we were stuck with the dreaded HughesNet. He's cheap and reliable.
-- Wendy Laubach
- 8/23/2012
FYI, We have been Charter/Cobridge/Time Warner customers for several years and I had been uncharacteristically patient as Time Warner worked through their upgrade & change over process. We just got our new modem as our whole neighborhood switched over from Cobridge to Time Warner today. The self install was harder than it should have been and took a call to tech support to get working, but we are online now and OMG, we are smokin!! The connection is blazing fast compared to what it was yesterday; 20Mbps on a wired connection and 11 Mbps wireless. I give Time Warner a tentative 2 thumbs up. We'll see what their down time is like from here out.
- 8/24/2012
We changed to Clear and love it. I have a business account and a personal account with them. Just check out clear.com.
- 8/24/2012
I'm the one who posted the original inquiry...We decided to try Clearwire....but honestly it's just not as fast as Time Warner *was* when it was working....so we're considering AT&T now. If you really need super fast internet, I can't recommend Clearwire. (We're over by the country club in Rockport--Could be different in different locations like Kim mentioned above). Thank you to EVERYONE who has commented. My family really appreciates all your feedback!! :) - A
- 8/24/2012
Been with Charter that was frequently down, that changed to Cobridge which was a little bit better, and finally with Time/Warner. Since the upgrade, we have been smoking without any down time. There for awhile, I was on the verge of giving up on them and switch to a new provider. Glad to hear about the availability of the others.
Will stick with TW for awhile because the installers said that it was about to get faster.
- 8/24/2012
Stelera has good coverage...as long as you don't want to use it during weekday evenings, Sunday or Saturday afternoon and evenings.
Kim's post of 8/16 is pure salesmanship. Team Satellite's service is slow, Kim can be rude, promises are made but not kept, and it takes WEEKS to get them to come...if they show at all.
- 8/30/2012
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Best Western Marais Bastille
Select your stay dates to check availability at Best Western Marais Bastille
Best Western Marais Bastille
About the Hotel
Property Location
A stay at Best Western Marais Bastille places you in the heart of Paris, walking distance from Place des Vosges and Place de la Bastille. This hotel is within close proximity of Opera Bastille and Picasso Museum.
Make yourself at home in one of the 37 air-conditioned rooms featuring minibars. Complimentary wireless Internet access keeps you connected, and satellite programming is available for your entertainment. Private bathrooms with bathtubs or showers feature complimentary toiletries and hair dryers. Conveniences include safes and desks, and housekeeping is provided daily.
Make use of convenient amenities, which include complimentary wireless Internet access and concierge services.
Take advantage of the hotel's room service (during limited hours).
Business, Other Amenities
Featured amenities include complimentary high-speed (wired) Internet access, a 24-hour business center, and express check-in.
Hotel Facilities
- Breakfast available (surcharge)
- Number of floors - 6
- Dry cleaning/laundry service
- Concierge services
- Conference space
- Safe-deposit box at front desk
- Free newspapers in lobby
- 24-hour business center
- Number of buildings/towers - 1
- 24-hour front desk
- Free wired high-speed Internet
- Multilingual staff
- Total number of rooms - 37
- Free WiFi
- Express check-in
- Luggage storage
- Tours/ticket assistance
- Elevator/lift
- Laundry facilities
Room Facilities
- In-room climate control (air conditioning)
- Daily housekeeping
- Minibar
- Individually furnished
- Satellite TV service
- Free WiFi
- Soundproofed rooms
- Bathtub or shower
- In-room safe
- Iron/ironing board (on request)
- Blackout drapes/curtains
- Hair dryer
- Coffee/tea maker
- Desk
- Individually decorated
- Free toiletries
- Free cribs/infant beds
- Free newspaper
- Private bathroom
- Air conditioning
- Free bottled water
- Room service (limited hours)
Hotel Policy
National Rating
This property has received its official star rating from the French Tourism Development Agency, ATOUT France.
Know Before You Go
- Guests can arrange to bring pets by contacting the property directly, using the contact information on the booking confirmation.
The following fees and deposits are charged by the property at time of service, check-in, or check-out.
- Fee for buffet breakfast: EUR 13 per person (approximately)
The above list may not be comprehensive. Fees and deposits may not include tax and are subject to change.
Mandatory Fees and Taxes
You'll be asked to pay the following charges at the property:
- A tax is imposed by the city: EUR 1.65 per person, per night
We have included all charges provided to us by the property. However, charges can vary, for example, based on length of stay or the room you book.Show all hotel policy Show less hotel policy


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One of more unique ways borrowers in the health care industry can get a mortgage is the doctor's loan. Here's how the flexible program works… One of the benefits of being a … [Read More…]
How your mortgage fees can change
Getting a mortgage can be a costly endeavor if you don't plan accordingly. Deadlines, qualifying, and paperwork are some of the things you're going to be dealing with over the course of … [Read More…]
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Closing costs are a factor you must account for consider when taking out a mortgage to buy or refinance a home. Here's what you need to know across the board… When can … [Read More…]
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FHA loans and conventional loans remain the most popular financing type for today's mortgage borrowers. Here's how to determine which program makes the most financial sense for you… FHA loans are insured … [Read More…]
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One of the financial programs aimed at homeowners wishing to refinance in the economic downturn was Making Homes Affordable Harp 2. The program to this day allows people to refinance even if … [Read More…]
3 things you must have for a mortgage loan
If you've never bought a home before or it has been many years since your last mortgage transaction, you'll need to freshen up on the basics. What lenders look for… The 3 … [Read More…]
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Credit scores play a vital role in your ability to get a home mortgage. Here's what you need to know if you are applying with a low credit score… First things first … [Read More…]
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These things about today's mortgage loan process will drive you crazy. Know what lenders will want…. Patriot Act This says lenders do not make loans to drug dealers, money launderers or terrorists. … [Read More…]
Can you really afford the home? Here is what banks will not share
Just because the bank will let you buy more does not mean you should. Be a well informed home buyer by taking the following tips into consideration when making the big ticket … [Read More…]
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Ever work with a mortgage company to later on find your loan won't work, and another delivers? There's a reason for it. Here's what you should know about mortgage companies. The Consumer … [Read More…]
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March 10, 2008
MARCO CIRIANI AND DOROTHY CIRIANI, HUSBAND AND WIFE, PLAINTIFFS-APPELLANTS,v.ERIN C. FINLEY, LORETTA A. FINLEY AND SIRIUS AMERICA INSURANCE COMPANY, DEFENDANTS-RESPONDENTS.ERIN FINLEY, PLAINTIFF-RESPONDENT,v.MARCO CIRIANI, DEFENDANT, AND PRUDENTIAL PROPERTY AND CASUALTY INSURANCE COMPANY OF NEW JERSEY, DEFENDANT-RESPONDENT.
On appeal from the Superior Court of New Jersey, Law Division, Monmouth County, L-1504-03 and L-4687-03.
Submitted February 11, 2008
Before Judges Lintner and Graves.
On December 15, 2002, Marco Ciriani was driving his Lincoln on the Garden State Parkway, with his wife Dorothy in the front passenger seat, when they were involved in an accident with a vehicle operated by Erin Finley. The accident also involved an alleged phantom vehicle. The Cirianis and Finley filed complaints for personal injury against each another. They also named the phantom vehicle as a defendant. Their insurance carriers answered for the phantom vehicle under their respective Uninsured Motorist Coverage. A jury trial was held on the issue of liability only. The jury returned a verdict finding no liability on the phantom vehicle and both Finely and Marco negligent. The jury apportioned liability 60% for Marco and 40% for Finley.
Following the verdict, Marco and Dorothy moved for a new trial, asserting that the verdict was against the weight of the evidence so as to constitute a clear and convincing miscarriage of justice. The judge disagreed and denied plaintiffs' motion. Marco now appeals from the judgment and order denying the motion for new trial. He contends that the jury's allocation of liability was against the weight of the evidence and that the judge erred in denying his motion for new trial or in not modifying the verdict to allocate liability in his favor. We disagree and affirm.
We restate the proofs established at trial. The accident occurred shortly after 10:00 p.m. Finley, a college freshman, was on her way back to Rutgers in New Brunswick. She was driving her sister's Hyundai Sonata, a car she had used a "handful of times" prior to the accident. She was proceeding northbound on the Parkway in the left lane at the speed limit, 65 miles per hour. Traffic was light. As she passed a rest area, she saw brake lights on a vehicle traveling between fifteen to twenty car lengths ahead of her. She slammed on her brakes and swerved to the right. Her vehicle moved into the middle two lanes and then began to spin around causing her to lose control. The trunk of the Hyundai hit the guardrail and the vehicle came to rest facing in a southeast direction between the fast lane and the next lane. Although she could not tell in seconds, Finley testified that she sat in that position for what seemed to her "a long enough period of time where I could sit there and tell myself that I was okay, and then hear a beep and then turn my head and then see light in my window." The right front of the Hyundai was then struck by the front of the Lincoln.
Dorothy Ciriani described the accident as "happening so fast." She testified that she saw something black in front of her, which she could not make out or identify. Her husband said, "oh my God, a car." She testified that Marco "tried to avoid it and he turned his wheel to the right. And that's all I remember." When asked if Marco used his horn, she responded that he "didn't have time."
Marco testified that he was operating his vehicle in the center lane at the speed limit. As he passed the rest area, the road bears to the left and declines. According to Marco, he "suddenly" saw a car in front of him, facing him with no lights "maybe [fifty to fifty-five feet] away." He "tried to brake . . . tried to turn and get around it, but it was impossible. There was not enough time. Not enough space." He stated that he might have used his horn. The investigating trooper's deposition was read into evidence. It basically confirmed the versions given by the drivers.
In denying Marco's motion for a new trial, the trial judge observed:
My perception is that [Finley] lost control of the car. Whether she wasn't paying attention or whatever . . . she . . . basically jam[med] on the brakes of that vehicle almost without any bearing on what had occurred, what was occurring before her, and the vehicle spun out. And the jury found that she was 40 percent negligent.
With reference to [Marco], you know the jury replayed his testimony. And he basically said he was coming down the parkway, they had spent a day with their grandchildren, and that he couldn't avoid the collision. The jury found otherwise. They found that he could have avoided the collision.
The applicable principles are well settled. Rule 4:49-1(a) entitles a party to a new trial "if, having given due regard to the opportunity of the jury to pass upon the credibility of the witnesses, it clearly and convincingly appears that there was a miscarriage of justice under the law." An appellate court must adhere to essentially the same standard when reviewing a trial judge's action on a new trial motion. R. 2:10-1; see also Dolson v. Anastasia, 55 N.J. 2, 6 (1969). However, we are obliged to give deference to the trial court's "feel of the case" as to matters such as the demeanor or credibility of the witnesses. Carrino v. Novotny, 78 N.J. 355, 360-61 n.2 (1979); see also Baxter v. Fairmont Food Co., 74 N.J. 588, 597-98 (1977).
Applying these principles, we are satisfied that the judge did not err either in denying a new trial or a reapportionment of the liability verdict. The judge aptly determined that the required standard, that the verdict represented a clear and convincing miscarriage of justice, was not met. The role of a judge in determining whether a verdict constitutes a miscarriage of justice involves "'canvass[ing] the record, not to balance the persuasiveness of the evidence on one side as against the other, but to determine whether reasonable minds might accept the evidence as adequate to support the jury['s] [decision].'" Dolson, supra, 55 N.J. at 6 (quoting Kulbacki v. Sochinsky, 38 N.J. 435, 445 (1962)). The judge may not substitute his own judgment for that of the jury. Ibid. In that context, it cannot fairly be said that the evidence was so one-sided as to compel the conclusion that the verdict was a clearly erroneous one. We defer, as we must do, to the judge's feel of the case. Moreover, there is nothing in the record to indicate that the verdict suffered from some evidential insufficiency. Rather, it was reasonable in light of the evidence presented. Accordingly, we see no reason to intervene.
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December 1, 2011
ANGEL AGUIRRE, PLAINTIFF,v.MICHAEL J. ASTRUE, COMMISSIONER OF SOCIAL SECURITY, DEFENDANT.
MEMORANDUM OPINION AND ORDER (Social Security Case)
This matter is before the Court for review of the decision by the Commissioner of Social Security denying Plaintiff's application for disability benefits. Pursuant to 28 U.S.C. §636(c), the parties have consented that the case may be handled by the Magistrate Judge. The action arises under 42 U.S.C. §405(g), which authorizes the Court to enter judgment upon the pleadings and transcript of the Administrative Record ("AR") before the Commissioner. The parties have filed the Joint Stipulation ("JS"), and the Commissioner has filed the certified AR.
Plaintiff raises the following issues:
1. Whether the Administrative Law Judge ("ALJ") properly rejected the opinion of the long time treating mental health professionals and portions of the consultative examiner's opinion. (JS at 3.)
This Memorandum Opinion will constitute the Court's findings of fact and conclusions of law. After reviewing the matter, the Court concludes that for the reasons set forth, the decision of the Commissioner must be reversed and the matter remanded.
As set forth in the parties' "Summary of the Case," Plaintiff's application for Disability and SSI was initially rejected following an August 15, 2007 hearing before an ALJ. (AR 490-504.) The unfavorable decision finding Plaintiff not be disabled was issued on August 23, 2007. (AR 28-37.) Ultimately, the Appeals Council issued a remand order. (AR 52-54.) This resulted in a second hearing for a new ALJ (AR 505-526), and an unfavorable decision by that ALJ (AR 14-20).
The order of the Appeals Council did not require further evaluation of Plaintiff's mental health issues, and consequently, in the second decision, the ALJ adopted the rationale from the prior decision, and thus provided no further discussion as to Plaintiff's mental health. (See AR at 18.) Consequently, the Court will review the first decision to determine whether the ALJ adequately assessed the mental health evidence. For the reasons to be set forth, the Court concluded that he did not.
In the first decision, the ALJ reviewed Plaintiff's mental health history, noting that Plaintiff had received a consultative psychological examination ("CE") from Dr. Brawer on July 19, 2006. (AR 35, 115-121.) The ALJ also briefly summarized a Mental Impairment Questionnaire of July 10, 2007, which was described as a "form ... completed by the nurse and signed by the psychiatrist." (AR 35, 392-397.) Finally, the ALJ noted that Dr. Dudley, a State Agency psychiatrist, had reviewed the evidence and come up with an analysis of Plaintiff's mental functional abilities. The ALJ concluded that he would "give[s] weight to these opinions as they are supported by the objective medical evidence of record (SSR 96-6p)." (AR 36.) Based on the context of the decision, the Court perceives that the ALJ determined to give weight to the opinions of the CE and of the State Agency psychiatrist, and to essentially reject the opinion of the treating psychiatrist, Dr. Baig.
The Court must discern from the ALJ's decision why he determined to reject the opinion of Dr. Baig. The first apparent reason is that the ALJ perceived that the Mental Impairment Questionnaire was completed by the nurse and only signed by the psychiatrist. Indeed, the Commissioner amplifies on this point in his portion of the JS in arguing that the Questionnaire is essentially the opinion of the nurse, and not that of the psychiatrist. As such, the Commissioner argues that the ALJ was entitled to give it less weight. The Court will address this concern, infra. In addition, it appears that the ALJ perceived that the patient's "case manager," who was apparently the same person as the nurse who was involved in the Questionnaire, was an advocate for Plaintiff in his Social Security case because the ALJ read the record as indicating, in his words, that, "The case manager visited the office of the claimant's attorney to 'strategize' for the claimant's hearing [citing AR at 347]." (AR 35.)
The ALJ reported that there were differences between the conclusions of the treating psychiatrist in the Questionnaire and that of the CE on issues such as Plaintiff's memory and concentration. (AR 36.)
Finally, the ALJ provided an overall basis for rejecting Dr. Haig's opinion because it was "not supported by, and is contradicted by, the objective medical evidence of record, including the mental health treatment notes." (AR 36.) No discussion whatsoever is provided, however, as to what those contradictions are, and thus, the Court is left with a bare conclusion which, as will be discussed, provides no basis for review.
First, the Commissioner is incorrect in citing 20 C.F.R. §§ 404.1513 and 416.913 for the proposition that because a nurse or case manager was involved in preparing an evaluation signed by a psychiatrist, that evaluation is entitled to less weight, because it is not, effectively, the evaluation of the psychiatrist, in this case, the treating psychiatrist, Dr. Baig. These regulations do not stand for that proposition, and moreover, there is no reported case of this Court is aware which would support that claim. As such, the opinion set forth in the Questionnaire must be viewed as those of the treating psychiatrist, Dr. Baig.
The ALJ, and also the Commissioner, seem to believe that Dr. Baig's opinion should also be depreciated because the case manager was biased, and acting as an advocate for Plaintiff. To support this, the ALJ and the Commissioner both point to Progress Notes of July 3, 2007, apparently prepared by the case manager, which reference the upcoming hearing on August 15, 2007 before the ALJ. Indeed, as noted, the ALJ put quotes around the word "strategize," apparently believing that this word was contained in the Progress Notes. It is not. Moreover, a fair reading of the Progress Notes simply indicates that the case manager wanted to make sure that all relevant records needed by Plaintiff's attorney would be provided for use at the hearing. Certainly, neither the ALJ or the Commissioner would dispute that full and complete records should be provided so that a correct and adequate evaluation can be made of a Plaintiff's mental health condition. Moreover, in the context of the Progress Notes, the Court finds absolutely nothing wrong with the fact that the case manager helped to prepare Plaintiff to appear at a hearing. This is especially true in a case such as this, where even the ALJ found that Plaintiff suffers from severe impairments of depression/anxiety (AR 30), and has moderate difficulties with concentration, persistence or pace. (AR 31.) It cannot be disputed that even a person without depression or anxiety may experience such things as increased anxiety when preparing for a stressful hearing. Thus, as a part of Plaintiff's mental health treatment, the Court cannot fault his treating professionals with preparing him to be able to undergo the stress of an administrative hearing. In no manner do the records, however, indicate that the case manager was biased because she might have been acting as an advocate for Plaintiff. Helping an individual to mentally prepare for the stress of the hearing, and be able to adequately testify and describe their condition, does not constitute the type of advocacy which would render that mental health professional biased.
Turning to other issues, the ALJ's reliance on the State Agency psychiatrist cannot be sustained, because there is an indication in the record that this psychiatrist did not examine any of Plaintiff's treatment records. ("There are no psychiatric treatment notes for review, so a CE was purchased for this case." [AR 114.]) Further, while seemingly aware of the existence of treating psychiatrist, the State Agency psychiatrist did not obtain, or perhaps was unable to obtain, further information. ("The claimant is prescribed psychotropic medications by his [sic] current treating source who has not responded." [Id.])
Thus, what is left is the ALJ's statement that the treating psychiatrist's assessment is not supported by and is contradicted by "the objective medical evidence of record, including the mental health treatment notes." This type of a generic and conclusory evaluation does not even approach the "specific, legitimate reasons" which must provided in an ALJ's decision so that the Court can conduct an adequate review. See Andrews v. Shalala, 53 F.3d 1035, 1041 (9th Cir. 1995). The Commissioner's multi-page explanation of what the ALJ might have meant by this conclusory statement in his decision is simply a post-hoc evaluation which this Court will not give credence to, because it is the decision which must be reviewed, not the Commissioner's interpretation of it.
For the foregoing reasons, the decision of the Commissioner is reversed, and this matter will be remanded for further hearing consistent with this Memorandum Opinion.
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Google Penguin Penalty Removal Can be Guaranteed… But Recovery Can Not. by Jim Boykin
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There is increasing evidence that proton pump inhibitors (PPIs) increase the rate of infections in patients with decompensated cirrhosis.
Correspondence to:
Dr J. S. Bajaj, Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire Veterans Affairs Medical Center, 1201 Broad Rock Boulevard, Richmond, VA 23249, USA.
E-mail: email@example.com
There is increasing evidence that proton pump inhibitors (PPIs) increase the rate of infections in patients with decompensated cirrhosis.
To estimate the extent to which proton pump inhibitors (PPIs) increase the rate of infections among patients with decompensated cirrhosis.
We conducted a retrospective propensity-matched new user design using US Veterans Health Administration data. Only decompensated cirrhotic patients from 2001 to 2009 were included. New PPI users after decompensation (n = 1268) were 1:1 matched to those who did not initiate gastric acid suppression. Serious infections, defined as infections associated with a hospitalisation, were the outcomes. These were separated into acid suppression-related (SBP, bacteremia, Clostridium difficile and pneumonia) and non-acid suppression-related. Time-varying Cox models were used to estimate adjusted hazard ratios (HR) and 95% CIs of serious infections. Parallel analyses were conducted with H2 receptor antagonists (H2RA).
More than half of persons with decompensated cirrhosis were new users of gastric acid suppressants, with most using PPIs (45.6%) compared with H2RAs (5.9%). In the PPI propensity-matched analysis, 25.3% developed serious infections and 25.9% developed serious infections in the H2RA analysis. PPI users developed serious infections faster than nongastric acid suppression users (adjusted HR: 1.66; 95% CI: 1.31–2.12). For acid suppression-related serious infections, PPI users developed the outcome at a rate 1.75 times faster than non-users (95% CI: 1.32–2.34). The H2RA findings were not statistically significant (HR serious infections: 1.59; 95% CI: 0.80–3.18; HR acid suppression-related infections: 0.92; 95% CI: 0.31–2.73).
Among patients with decompensated cirrhosis, proton pump inhibitors but not H2 receptor antagonists increase the rate of serious infections.
Infections in cirrhosis, especially those associated with intestinal bacterial overgrowth and translocation such as spontaneous bacterial peritonitis (SBP), are responsible for a substantial cost of care and can increase mortality up to four-fold.[1-4] These infections can impact patients directly by causing death or indirectly by precipitating hepatic encephalopathy and renal failure or reducing liver transplant eligibility.[4, 5] The leading pathogenic mechanism behind these infections in cirrhosis is small intestinal bacterial overgrowth (SIBO) leading to bacterial translocation, a process that is enhanced by acid suppression.[5-7] Efforts to reduce this tremendous burden in cirrhosis by potentially reducing the bacterial translocation and overgrowth are needed.[8]
The association of acid-suppressive agents, such as proton pump inhibitors (PPI), with infections such as pneumonia, Clostridium difficile (C. difficile) and infectious gastroenteritis has been studied extensively in noncirrhotic patients.[9-13] The mechanism cited is related to the SIBO and a direct immunosuppressive effect making patients prone to bacterial translocation.[14, 15] PPI use is prevalent in the cirrhotic as well as noncirrhotic population.[16-19] There is also a growing body of evidence that PPIs are related to serious infections related to SIBO in cirrhosis such as SBP and C. difficile.[20-23] However, these were single-centre studies with limited sample sizes.
Our aim was to estimate the extent to which PPIs increase the rate of serious infections among decompensated cirrhotic patients in a national Veterans Health Administration (VHA) database. The a priori hypothesis was that PPI use is associated with a higher rate of serious infections, especially those related to acid suppression, in patients with decompensated cirrhosis.
The McGuire VA Medical Center Institutional Review Board approved this protocol.
We conducted a new-user cohort study among US veterans. Alcoholic liver disease and cirrhosis are epidemic in the US Veteran population.[24] New use of gastric acid suppressant use was defined on the basis of pharmacy information. The new-user design eliminates prevalent use bias and provides better control of confounding.[25] The rate of serious infections associated with PPI monotherapy and H2 receptor antagonists (H2RA) monotherapy was compared with no use of gastric acid suppressants. Propensity-matching was used to create a sample of patients who are similar in all potential confounders, except the exposure variable of interest.[26, 27]
The national shared electronic medical record system of the US Veterans Health Administration (VHA) provided a data source suitable to evaluate this clinically important question. The VHA's Austin Information Technology Center (AITC) database contains information on millions of veterans throughout the country that can be linked to its Pharmacy Benefits Management (PBM) database containing information on medication use and frequency. All information is prospectively collected in these databases and is broadly representative of the US veteran population. A retrospective cohort study using the VHA AITC database from fiscal year 2001 through 2009 and the PBM database was performed. Baseline patient characteristics were obtained from the VA Decision Support System[28] and out-patient medical care datasets.[29] This database does not include details of physical examinations, noncoded events in the patient's history or laboratory values, therefore cirrhosis severity assessment and indications for therapies are not available.
We identified 123 306 patients with a primary or secondary diagnosis coded as ICD-9-CM 571.2 (alcoholic cirrhosis of the liver), 571.5 (cirrhosis without mention of alcohol), in the AITC. In the VA administrative data, these diagnostic codes are highly predictive of the presence of these conditions in medical records and can be reliably used for research.[30] Then, we applied inclusion criteria as indicators that patients received care through the VA regularly. First, at least 1 year of follow-up data post the initial hospitalisation for cirrhosis was needed. Second, patients had to have at least two visits in the VA system. Third, patients had to have evidence of VA Pharmacy activity (at least one prescription). Among this group, we identified patients with decompensated disease. Decompensation was defined as presence of one of the following validated codes [hepatic encephalopathy (572.2), hepatorenal syndrome (572.4), spontaneous bacterial peritonitis (567.23), ascites (789.5) or variceal bleeding (456.0, 456.2)].[31, 32] Patients were included if there was no evidence of a hospitalisation for an infection in the 6 months before date of decompensation. The sample consisted of 7299 patients who met these eligibility criteria.
From this group of eligible patients, we defined three patient cohorts who were new users (the remainder were already on these medications): (i) patients initiating PPI monotherapy (n = 1905); (ii) patient initiating H2RA monotherapy (n = 248); and (iii) patients without any indication of gastric acid suppressant use (n = 2028). The date of the first filling was considered the index date for the former two patient cohorts. The index date for persons who did not user gastric acid suppressants was defined by the index date of the propensity matched PPI or H2RA users. That is, the number of days from cirrhosis diagnosis to index date of PPI or H2RA use was added to the date of cirrhosis diagnosis for the propensity-matched non-user. This method increased comparability with respect to the person time experience given the natural course of disease.
There were two primary outcomes: time to first serious infection and time to first serious acid suppression-related infection. Serious infections were defined as those coded during an in-patient stay. In-patient infections were defined as ICD-9 codes for: (i) Skin infection (including cellulitis):680–686; (ii) lower respiratory infections (480–487); (iii) SBP: 567.23; (iv) urinary and kidney infections: 590.x; (v) Clostridium difficile (C. difficile): 008.45; (vi) Infectious gastroenteritis: 0090; (vii) Sepsis and bacteremia (in the absence of a primary infection) including the following: (i) Bacteremia: 790.7 and; (ii) Septicemia: 038.x. Previous work suggests that bacterial infections in the VA system are coded accurately.[33] To further validate these and additional codes, we identified 128 cirrhotic patients in 2011 who were admitted to the Richmond VA Medical Center with any of the infections listed above. The charts were then reviewed by an MD (J.B.) to evaluate the appropriateness of the coding to the clinical situation. These diagnostic codes are highly predictive of the presence of these conditions in medical records as the positive predicted values were 93% for C. difficile infection, 100% for SBP, 93% for skin infections, 91% for pneumonia, 100% for septicemia, 92% for bacteremia and 94% overall.
The second outcome, acid suppression-related infections, was determined based on literature review: pneumonia, SBP, sepsis and spontaneous bacteremia (in decompensated cirrhosis are likely due to bacterial translocation if no specific organ/vascular entity is the source), infectious gastroenteritis and C. difficile.[11, 34-36] For each outcome of interest, we calculated person-time as time from index date (date of first PPI or for non-PPI users the matched index date) to date of event or the censored date (death or loss to follow-up date).
We used the PBM database to identify exposure to gastric acid suppressants.[37] This database includes details of in-patient and out-patient medication use, including name of medication, doses, fill dates, quantity dispensed and days' supply. Although our initial motivation for conducting the research was focused on PPI use, we also evaluated the extent to which H2RA use was associated with serious infections as both classes reduce gastric acid. We hypothesised that there would be no relation between H2RAs and serious infections. Exposure was defined dichotomously as monotherapy or no receipt of each category during each 30-day window from the index date. The 30-day window was selected as typically days of therapy on VA prescription claims for these medications were not less than 30 days. PPI use included omeprazole, esomeprazole, lansoprazole, rabeprazole, dexlansoprazole and pantoprazole. H2RAs were studied separately to understand the specific contribution of degree of acid suppression. We required users to have received at least a 30-pill regimen.
We considered the following to be potential confounders because they have been known to be independent risk factors for infection: alcoholic aetiology, severity of comorbid conditions and concurrent medications.[38] Studies have shown a potential protective effect of nonselective beta-blockers (NSBB) on SBP, but not in patients with refractory ascites.[39, 40] Rifaximin, which in the VHA system is only used for patients intolerant of lactulose, has been shown to protect against infections, especially C. difficile.[41] Alcoholic cirrhosis was defined using ICD9 Code 571.2. The Charlson comorbidity index was calculated using an ICD-9 search algorithm and was based on data from the year after first cirrhosis diagnosis.[42] Data on the comorbid conditions come from the VHA out-patient and in-patient treatment files.[29] We also created a variable to capture the number of out-patient visits in the previous year. We initially considered the following concomitant medications as potential confounders, but ruled them out for further consideration. These included: corticosteroids, antiparkinson drugs, barbituarates, anxiolytics, antipsychotics and opiates.
We compared the distributions of socio-demographic and clinical characteristics of participants who were new PPI users, new H2RA users, and nongastric acid suppressant users. To improve the balance of potential confounders across the exposure categories (PPI, H2RA, non-use), we conducted propensity score analyses.[26, 27] The propensity score technique attempts to create a sample of patients who are similar on all potential confounders except the exposure variable of interest (in this case PPIs or H2RAs). To create the sample of PPI users matched to nongastric acid suppressant users, we first created a predicted probability for treatment for each person. The predicted probability was estimated from a logistic regression model, which included all risk factors for the serious infections. The propensity score models yielded C statistics suggesting good overlap. The new PPI users were matched to nongastric acid suppressant users with a 1:1 ratio using the greedy algorithm method, which reduces matched-pair bias caused by incomplete matching.[43] This method improves inexact matching by making best matches first and then taking the next best matches, in a hierarchical sequence, until no more matches can be made. We used the same strategy to identify one gastric acid suppressant non-user for each H2RA new user. Despite the use of the greedy algorithm, we were unable to match 537 PPI new users to non-users and 49 H2RA new users to non-users; these are usually subjects with propensity scores at the tail ends and including them would decrease the internal validity of the adjustment for the propensity-matched sample. Visual inspection of the distributions of confounders across the exposure groups was conducted to evaluate the adequacy of the propensity score matching with respect to creating balance on measured confounders. If greater than 5% absolute difference in a potential confounder was observed across the gastric acid suppressant category, the variable would also be considered as a covariate in future analyses.
Using the propensity-matched sample, we conducted several analyses. First, we calculated the crude incidence rates (per 1000 person years) to provide descriptive rates in each population for the primary outcome (all serious infections) and the secondary outcome (acid suppression-related infections). Second, we developed four separate Cox models (PPI and H2RA separately; primary and secondary outcomes) to estimate crude hazard ratios. We developed two separate Cox regression models for PPI and H2RA separately: (i) to estimate the association between PPI (or H2RA) use and incidence rate of all serious infections; and (ii) to estimate the effect of PPI (or H2RA) use on rate of acid suppression-related infections. Although these Cox models included only a term for PPI use (or H2RA use), the propensity score matching adequately controlled for the measured confounders, which achieved balance in the matching process. Despite the tight control for prevalent bias (through the new user design) and confounding (through the propensity matching), we were concerned about the time-varying nature of gastric acid suppressant drug use. Previously, we have shown the importance of considering time-varying drug exposures because the reliance on time-fixed methods may introduce bias.[44] Therefore, we estimated Cox models including time-varying PPI use (or H2RA use), as well as other potential confounders. We used a 90-day window for the time-varying component as the mode days of therapy for VA prescriptions for gastric acid suppressants was 90 days. The models produced hazard rate ratios and 95% confidence intervals. We confirmed the assumption of proportionality by visually inspecting the cumulative hazard function.
More than half of persons with decompensated cirrhosis were new users of gastric acid suppressants, with most using PPIs (45.6%) compared with H2RAs (5.9%). The majority of patients in the new PPI user group were on omeprazole (73%). The rest were on rabeprazole (23%), lansoprazole (2%) or pantoprazole (1%). Table 1 shows the distribution of socio-demographic and clinical characteristics by gastric acid suppressant use. The vast majority of patients with decompensated cirrhosis in the VA were men, and this did not vary by gastric acid suppressant use. Age and known race/ethnicity were also comparably distributed, although the proportion of missing data in the latter variable was very high. Cirrhosis aetiology was commonly alcoholic and slightly more so among H2RA new users (49.6% H2RA vs. 43.8% PPI users and 44.3% non-users). Hepatitis C infection was common with 52.4% of PPI new users and 46.0% of H2RA users and 46.3% non-users infected. The distribution of concomitant medications were similar between groups for antibiotics (and rare) and nonselective beta blockers (~12–14%). Although rifaximin use was relatively low, it was slightly more prevalent among PPI users than non-users (6.8% PPI; 1.6% H2RA; 2.4% in non-users); this was equalised in the matched samples. The PPI and H2RA users had a greater proportion of people with at least five comorbid conditions relative to the non-users (PPI: 41.7%; H2RA: 41.9%; non-user: 31.1%). The majority of the events that led to the inclusion of patients as decompensated cirrhosis were ascites (73%), followed by hepatic encephalopathy (18%), variceal bleeding (8%), hepato-renal syndrome (1%); only 9 patients had SBP as their primary decompensating event.
|Total sample (N = 4181)
|PPI only users (N = 1905)
|H2RA only users (N = 248)
|Gastro suppressant non-users (N = 2028)
|Age (years)
|Drug use at baseline
|Nonselective beta blocker
|Out-patient visits in past year (median, IQR)
|7 (14)
|5 (13)
|8 (16)
|Charlson score
|Alcohol-related cirrhosis
|Hepatitis C
Table 2 also shows the distribution of the potential confounders in the propensity-matched sample. The distributions of the potential confounders of the propensity-matched sample appear well-balanced. Relative to the matched non-users (32.1%), PPI users had five or more comorbid conditions (41.2%). Similar imbalance was observed between H2RA users (41.7%) and non-users (34.7%).
|PPI-matched sample (N = 2536)
|H2RA-matched sample (N = 398)
|PPI only users (N = 1268)
|Non-users (N = 1268)
|H2RA only users (N = 199)
|Non-users (N = 199)
|Age (years)
|Drug use at baseline
|Nonselective beta blocker
|Out-patient visits in past year (median, IQR)
|6 (13)
|8 (15)
|5 (13)
|7 (14)
|Charlson score
|Alcohol-related cirrhosis
|Hepatitis C
Table 3 shows the association between gastric acid suppressant drug use and serious infections stratified by PPI and H2RA use. Among the propensity-matched PPI cohort, 25.3% developed serious infections. Acid suppression-associated infections were common (17.7%). Among the PPI users, acid suppression-related infections formed the bulk (75%) of all infections, whereas among nongastric acid suppressant users, 64% of serious infections were acid suppression-related. Among the propensity-matched H2RA cohort, 25.9% developed serious infections with 15% deemed acid suppressant-related. Although the bulk of serious infections in H2RA users were also acid suppression-related infections (64.7%) among non-users in this cohort, 51.9% were acid suppressant-related infections. There was no significant difference in the patterns of infection occurrence based on the initial decompensating event between the PPI and non-PPI groups. Leading serious infections were SBP/peritonitis (30%), pneumonia (25%), skin infections (23%), spontaneous bacteremia and septicemia (16%), C. difficile (5%) and UTI (1%). During the study period, liver transplant was uncommon.
|PPI propensity-matched sample (N = 2536)
|Number of cases
|Person years
|Incidence rate per 1000 person years
|Crude hazard ratioa
|Adjusted hazard ratiob
|All infections
|PPI users
|1.08 (0.90–1.31)
|1.66 (1.31–2.12)
|Gastric suppressant non-users
|Acid suppression-related infections
|PPI users
|1.22 (0.97–1.52)
|1.75 (1.32–2.34)
|Gastric suppressant non-users
|H2RA propensity-matched sample (N = 398)
|All Infections
|H2RA users
|1.09 (0.68–1.73)
|1.59 (0.80–3.18)
|Gastric suppressant non-users
|Acid suppression-related infections
|H2RA users
|1.10 (0.60–2.02)
|0.92 (0.31–2.73)
|Gastric suppressant non-users
In the propensity-matched sample for PPI users, there was no association between PPI use and the rate of serious infections [crude propensity-matched hazard ratio (HR): 1.08; 95% CI: 0.90–1.31]. However, PPI users tended to develop serious acid suppression-related infections at a rate higher than nongastric acid suppressant users, although the confidence interval included unity (crude HR: 1.22; 95% CI: 0.97–1.52). As these estimates of effect are still prone to bias owing to the time-varying nature of PPI use, we estimated the effect of PPI use on serious infections and acid suppression-related infections accounting for time-varying PPI use. For serious infections, PPI users developed the outcome at a rate 1.66 times that of non-users (95% CI: 1.31–2.12). For acid suppression-related serious infections, PPI users developed the outcome at a rate 1.75 times faster than non-users (95% CI: 1.32–2.34).
In the propensity-matched H2RA analysis, no evidence of an association between H2RA use and infections was observed based on the crude analyses. Although the analyses adjusting for time-varying H2RA use revealed a hazard rate of 1.59 for H2RA use on all serious infections, the confidence interval was quite wide (95% CI: 0.80 and 3.18). No association between H2RA use and acid suppression-associated infections was noted (adjusted HR: 0.92; 95% CI: 0.31–2.73).
We found PPI initiation to be prevalent among patients with decompensated cirrhosis. Furthermore, we documented that the initiation of PPI therapy accelerates the rate of infections associated with hospitalisation, especially those related to intestinal bacterial overgrowth and translocation, in decompensated cirrhotic patients. We also found that the use of H2-receptor antagonists do not appear to accelerate the rate of these infections in decompensated cirrhosis, although our sample size was limited and could have explained the negative findings.
Infections are one of the leading causes of mortality in cirrhosis, most of which have a presumed gut bacterial origin.[5] The effect of PPIs has been studied in case series in cirrhotic patients showing that their use was associated with a significantly higher risk of gut-based infections such as SBP and C. difficile.[20-22] However, those studies were small in sample size and were unable to explore the time-varying nature of PPI use. Previous methodological research in pharmaco-epidemiology point to the bias introduced with treating drug exposures as fixed effects.[44] Therefore, the results need to be expanded in a larger pool of patients who would otherwise be predisposed to develop infections. The AITC and PBM databases represent a large cross-section of veterans treated in the US that can be used to answer clinically relevant questions.
In our study, we chose to use decompensated cirrhotic patients defined stringently according to previously used ICD-9 criteria in which the mode of initial decompensation did not influence the risk of infections. The AITC and PBM databases do not include laboratory variables permitting adjustment for cirrhosis severity. Nevertheless, our findings are likely robust owing to several design features. First, we matched the time period of observation from the date of decompensation for gastric acid suppressant users to non-users. In doing so, we have likely created comparability in the natural history. Second, we conducted a propensity-matched analysis, which included key confounders, as well as emerging risk factors for infections.[39] By matching via the greedy algorithm, our analyses included tight control for a variety of potential confounders (age, race, charlson score, alcoholic aetiology, year of entry, nonselective beta-blockers, rifaximin, antibiotics, number of out-patient and in-patient visits in last year), which were shown to have balance across the gastric acid suppressant categories. Third, the factors we adjusted for are likely highly correlated to Child and MELD scores and are related to the decompensating events. Fourth, we included analyses of H2RAs as a counter factual. Given the similarities in the distributions among H2RA and PPI users, it is highly unlikely that the PPI analyses would experience residual confounding by disease severity, but not the H2RA analyses. Lastly, we implemented a new user design, which also provides better control owing to prevalent use bias, which means the biases owing to relative length of the PPI or H2RA use would be removed. Given these design considerations, we believe that our findings are robust.
Our study specifically concentrated on decompensated cirrhotic patients who were first initiated on gastric acid suppression therapy (PPI or H2RA) after they developed decompensation defined by the complications of cirrhosis such as variceal bleeding, ascites or hepatic encephalopathy. This method ensured that the specific duration of PPI use was available for study as well as the refills and total dose during the follow-up period. It is also the appropriate method to eliminate prevalent use bias. Doing so, however, excluded patients with decompensated cirrhosis who had been on long-term PPI therapy before the decompensating event. This design, therefore, biased our results towards only showing an extreme effect of PPI use on the risk of infections; despite these restrictions, we were able to find that new PPI therapy significantly reduced the time to all infections, and especially time to gastric acid suppression-related infections.
To understand the extent to which PPIs as a class rather than simple acid suppression were associated with infections, we conducted a parallel study using identical methods on H2RA new users. We believed that if the mechanism was entirely through gastric acid suppression, we would find a lessened effect or no effect among H2RA users. Furthermore, this analysis helped evaluate the extent to which the findings may have been due to confounding by indication. Indeed, we found no specific effect of H2RAs on infection risk. This may be a testament to the specificity of PPIs as harbinger of infections in cirrhosis either due to a class effect or due to a higher potency of acid suppression. A key strength of this article was the study of time-varying on the days to infection rather than simply dividing patient groups into users and non-users. This also accounted for the days that the patients were not on PPIs. Indeed, we found that estimates of effect derived from the time-varying analyses were significantly higher than those created by fixed use of PPIs at study initiation.
The mechanisms behind the predisposition towards infections in cirrhotic patients initiated on PPI remain unclear. Studies have shown the appearance of SIBO after PPI therapy, to which cirrhotic patients are predisposed to given the abnormal intestinal motility and neuro-hormonal imbalance in the gut milieu.[15] There is also evidence that PPIs have depressive effects on neutrophil action and innate immunity, adding a direct anti-inflammatory component to this predisposition.[14] The presence of SIBO in cirrhosis is associated with peripheral bacterial DNA isolation signifying intestinal bacterial translocation, which worsens in decompensated patients.[7, 45] Interestingly, recent reports have shown that acid suppression can alter microbial flora even in the lower gastrointestinal tract.[10, 46] The finding that PPI therapy reduces the time to infections may be due to this effect, but mechanistic studies need to be performed to confirm this. However, it is clear that in this dataset, the co-administration of other studied drugs did not change the effect of PPI on rate of infections in cirrhosis. This comparatively rapid development of serious infections, especially in decompensated cirrhotics, can be significant in determining prognosis as determined by eligibility for liver transplantation and can modulate further decompensating events.[4] In our group, indeed we found that patients who were newly initiated on PPIs after decompensation also had a faster progression to death and liver transplant, which is in essence organ death.
Although this study sample is one of the largest in which PPI therapy has been studied in cirrhosis, there are several caveats. Due to the lack of cirrhosis severity parameters, it may be possible that the patients started on PPI could have a worse cirrhosis severity and hence a higher infection, death and transplant rate. To mitigate this, we implemented a variety of robust techniques to ensure that they were comparable in the matched sample, but cannot rule out residual confounding entirely in a nonexperimental study. We used ICD-9 codes to define the population, as well as to define the outcomes of interest. However, the positive predictive values for these outcomes in VHA settings are quite high, indicating their usefulness for research purposes. We also excluded those followed for less than a year, meaning that if a patient died of sepsis within the first year, they would not be counted. This was done to ensure adequate follow-up in the VHA system. Although the study also could not account for the reason for PPI initiation, parallel analyses of H2RA helped rule out confounding by indication as an explanation of these findings. It may be that non-users of gastric acid suppressants filled prescriptions outside of the VA system as veterans may be eligible for more than one health-care system. In 2003, more than 50% of VA enrollees had Medicare coverage, including 22% of those under age 65.[47] We reduced this source of bias by excluding Veterans who had not received at least one medication through the VA. Regardless, if present, this source of bias would have only attenuated the estimate of effect reported in our study.
We conclude that Veterans with decompensated cirrhosis who were started on PPI therapy after decompensation had a significantly higher risk of developing serious infections compared with those who were not initiated on gastric acid suppression. This increase in risk occurs in a time-varying fashion and is not explained by confounding by concomitant drug use, comorbid conditions or age. As patients with decompensated cirrhosis remain at a high risk of serious infections, clinicians should re-evaluate the reason for prescribing PPI and wherever possible, replace their acid suppressive needs with H2RAs. Further studies are required to prospectively analyse the value of PPI withdrawal in patients with decompensated cirrhosis.
Declaration of personal interests: None. Declaration of funding interests: The study was funded in part by the McGuire Research Institute at the Hunter Holmes McGuire VA Medical Center, Richmond, and grants RO1DK087913 from the NIDDK and grant RO1AA020203 from NIAAA, NIH. No other support, writing assistance, data analysis support was provided.