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Balgobin S, Balk EM, Porter AE, Misal M, Grisales T, Meriwether KV, Jeppson PC, Doyle PJ, Aschkenazi SO, Miranne JM, Hobson DT, Howard DL, Mama S, Gupta A, Antosh DD. Enabling Technologies for Gynecologic Vaginal Surgery: A Systematic Review. Obstet Gynecol 2024; 143:524-537. [PMID: 38301255 DOI: 10.1097/aog.0000000000005522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 12/07/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To systematically review the literature to evaluate clinical and surgical outcomes for technologies that facilitate vaginal surgical procedures. DATA SOURCES We systematically searched MEDLINE, EMBASE, and ClinicalTrials.gov from January 1990 to May 2022. METHODS OF STUDY SELECTION Comparative and single-arm studies with data on contemporary tools or technologies facilitating intraoperative performance of vaginal gynecologic surgical procedures for benign indications were included. Citations were independently double screened, and eligible full-text articles were extracted by two reviewers. Data collected included study characteristics, technology, patient demographics, and intraoperative and postoperative outcomes. Risk of bias for comparative studies was assessed using established methods, and restricted maximum likelihood model meta-analyses were conducted as indicated. TABULATION, INTEGRATION, AND RESULTS The search yielded 8,658 abstracts, with 116 eligible studies that evaluated pedicle sealing devices (n=32), nonrobotic and robotic vaginal natural orifice transluminal endoscopic surgery (n=64), suture capture devices (n=17), loop ligatures (n=2), and table-mounted telescopic cameras (n=1). Based on 19 comparative studies, pedicle sealing devices lowered vaginal hysterectomy operative time by 15.9 minutes (95% CI, -23.3 to -85), blood loss by 36.9 mL (95% CI, -56.9 to -17.0), hospital stay by 0.2 days (95% CI, -0.4 to -0.1), and visual analog scale pain scores by 1.4 points on a subjective 10-point scale (95% CI, -1.7 to -1.1). Three nonrandomized comparative studies and 53 single-arm studies supported the feasibility of nonrobotic vaginal natural orifice transluminal endoscopic surgery for hysterectomy, adnexal surgery, pelvic reconstruction, and myomectomy. Data were limited for robotic vaginal natural orifice transluminal endoscopic surgery, suture capture devices, loop ligatures, and table-mounted cameras due to few studies or study heterogeneity. CONCLUSION Pedicle sealing devices lower operative time and blood loss for vaginal hysterectomy, with modest reductions in hospital stay and pain scores. Although other technologies identified in the literature may have potential to facilitate vaginal surgical procedures and improve outcomes, additional comparative effectiveness research is needed. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022327490.
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Affiliation(s)
- Sunil Balgobin
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, the Department of Obstetrics and Gynecology, University of Texas Health Science Center at San Antonio, San Antonio, and the Division of Urogynecology, Department of Obstetrics and Gynecology, Houston Methodist Hospital, Houston, Texas; the Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island; the Department of Obstetrics and Gynecology, The Ohio State University Wexner Medical Center, Columbus, Ohio; the Department of Obstetrics and Gynecology, University of California, Los Angeles, Los Angeles, California; the Division of Urogynecology, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico; the Woman's Center for Advanced Pelvic Surgery, Phoenix, Arizona; the Departments of Obstetrics and Gynecology and Urology, School of Medicine & Dentistry, University of Rochester, Rochester, New York; the Department of Obstetrics and Gynecology, Medical College of Wisconsin, Waukesha, Wisconsin; the Division of Urogynecology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; the Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan; the Department of Obstetrics, Gynecology, and Reproductive Health, Rutgers New Jersey Medical School, Newark, and the Department of Obstetrics and Gynecology, Cooper Medical School of Rowan University, Camden, New Jersey; and the Division of Female Pelvic Medicine & Reconstructive Surgery, University of Louisville Health, Louisville, Kentucky
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Masand DH, Rego ES, Pinero LM, Wright KN, Truong MD, Siedhoff MT, Howard DL. Telemedicine in the Evaluation and Management of Abnormal Uterine Bleeding: A Practical Approach. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2022.0061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Dana H. Masand
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Erica S. Rego
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lisa M. Pinero
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Kelly N. Wright
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mireille D. Truong
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Matthew T. Siedhoff
- Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - David L. Howard
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Orejuela FJ, Aschkenazi SO, Howard DL, Jeppson PC, Balgobin S, Walter AJ, White A, Olivera CK, Sanses TV, Thompson J, Gala RB, Matteson K, Balk EM, Meriwether KV, Rahn DD. Gynecologic surgical skill acquisition through simulation with outcomes at the time of surgery: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 227:29.e1-29.e24. [PMID: 35120886 DOI: 10.1016/j.ajog.2022.01.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 12/26/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the effect of simulation training vs traditional hands-on surgical instruction on learner operative skills and patient outcomes in gynecologic surgeries. DATA SOURCES PubMed, Embase, ClinicalTrials.gov, and the Cochrane Central Register of Controlled Trials from inception to January 12, 2021. STUDY ELIGIBILITY CRITERIA Randomized controlled trials, prospective comparative studies, and prospective single-group studies with pre- and posttraining assessments that reported surgical simulation-based training before gynecologic surgery were included. METHODS Reviewers independently identified the studies, obtained data, and assessed the study quality. The results were analyzed according to the type of gynecologic surgery, simulation, comparator, and outcome data, including clinical and patient-related outcomes. The maximum likelihood random effects model meta-analyses of the odds ratios and standardized mean differences were calculated with estimated 95% confidence intervals. RESULTS Twenty studies, including 13 randomized controlled trials, 1 randomized crossover trial, 5 nonrandomized comparative studies, and 1 prepost study were identified. Most of the included studies (14/21, 67%) were on laparoscopic simulators and had a moderate quality of evidence. Meta-analysis showed that compared with traditional surgical teaching, high- and low-fidelity simulators improved surgical technical skills in the operating room as measured by global rating scales, and high-fidelity simulators decreased the operative time. Moderate quality evidence was found favoring warm-up exercises before laparoscopic surgery. There was insufficient evidence to conduct a meta-analysis for other gynecologic procedures. CONCLUSION Current evidence supports incorporating simulation-based training for a variety of gynecologic surgeries to increase technical skills in the operating room, but data on patient-related outcomes are lacking.
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Affiliation(s)
- Francisco J Orejuela
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX.
| | | | - David L Howard
- Department of Obstetrics and Gynecology, University of Nevada, Las Vegas, NV
| | - Peter C Jeppson
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - Sunil Balgobin
- Department of Obstetrics and Gynecology, The University of Texas, Southwestern, Dallas, TX
| | - Andrew J Walter
- Department of Obstetrics and Gynecology, Kaiser Permanente Medical Center, Roseville, CA
| | - Amanda White
- Department of Obstetrics and Gynecology, Dell Medical Center, The University of Texas at Austin, Austin, TX
| | - Cedric K Olivera
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Tatiana V Sanses
- Department of Obstetrics and Gynecology, Howard University College of Medicine, Washington, DC
| | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Northwest Kaiser Permanente, Portland, OR
| | - Rajiv B Gala
- Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, LA
| | - Kristen Matteson
- Department of Obstetrics and Gynecology, Warren Alpert Medical School of Brown University, Providence, RI
| | - Ethan M Balk
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI
| | - Kate V Meriwether
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, NM
| | - David D Rahn
- Department of Obstetrics and Gynecology, The University of Texas, Southwestern, Dallas, TX
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Masghati S, Parks T, James L, Howard DL. Occult Uterine Malignancy Found at Surgery for Uterine Fibroids: An Updated Systematic Review and Meta-Analysis. J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Salome Masghati
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Tegan Parks
- Touro University of Nevada, Henderson, Nevada, USA
| | - Lucas James
- University of Nevada Las Vegas School of Medicine, Las Vegas, Nevada, USA
| | - David L. Howard
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, New Jersey, USA
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Masghati S, McDaniel A, Swainston D, Howard DL. Residents' Participation in Robotic Surgery and Operative Time: Does Attending Surgeons’ Volume Influence This Relationship? J Gynecol Surg 2021. [DOI: 10.1089/gyn.2020.0152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Salome Masghati
- Fellowship Program in Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/University of Nevada, Las Vegas, Nevada, USA
| | - Alexandra McDaniel
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
| | - Darin Swainston
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
| | - David L. Howard
- Sunrise Health GME Consortium Residency Program in Obstetrics and Gynecology, Las Vegas, Nevada, USA
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Leggett LK, Muldoon O, Howard DL, Kowalski LD. A comparison of surgical outcomes among robotic cases performed with an employed surgical assist versus a second surgeon as the assist. J Robot Surg 2021; 16:229-233. [PMID: 33770350 DOI: 10.1007/s11701-021-01230-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/16/2021] [Indexed: 12/01/2022]
Abstract
To examine whether utilizing an employed surgical first assistant or a physician as an assistant during gynecologic robotic cases affects surgical variables. A high volume gynecologic oncologist's robotic case data spanning fourteen years (2005-2018) was analyzed. We separated the cases based on the type of assistant used: either an employed surgical first assist or another physician. The assisting physicians were either members of the same practice or general gynecologists in the community. The two groups were compared for console time and estimated blood loss. We controlled for patient Body Mass Index (BMI), uterine weight, use of the fourth robotic arm, benign versus malignant pathology, and the surgeon's subjective estimate of the difficulty of the case using a conventional laparoscopic versus robotic approach. Cases with an employed surgical assist had a mean adjusted robotic console time that was 0.32 h (19.2 min) faster than cases with a physician as the assist (95% CI 0.26 h-0.37 h faster, p < 0.001). Cases with an employed surgical assist also had an estimated blood loss (EBL) that was 47.5 cc lower than cases with a physician assisting (95% CI 38.8 cc-56.3 cc lower EBL, p < 0.001). The use of an employed surgical assist was associated with a faster console time and lower blood loss compared to using an available physician even adjusting for confounding factors. This deserves further exploration, particularly in regards to complication rates, operating room efficiency, utilization of health care personnel, and cost.
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Affiliation(s)
- Lindsey K Leggett
- Touro University Nevada College of Osteopathic Medicine, Henderson, NV, USA
| | - Olga Muldoon
- Minimally Invasive Gynecology Surgery Fellow, Vanderbilt University, Nashville, USA
| | - David L Howard
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, NJ, USA.
| | - Lynn D Kowalski
- Department of Obstetrics, Gynecology and Reproductive Health, Rutgers New Jersey Medical School, Newark, NJ, USA.,Department of Obstetrics and Gynecology, MountainView Hospital, Nevada Surgery and Cancer Care, Las Vegas, NV, USA
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Todd C, Howard DL, Tehrune E. 576: The impact of a Nevada law on opioids prescribed to women after uncomplicated vaginal deliveries. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Masghati S, Davenport ER, James L, Howard DL. Occult Uterine Malignancy at the Time of Surgery for Uterine Fibroids: A Systematic Review. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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9
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Munro MG, Brown AN, Saadat S, Gomez NA, Howard DL, Kahn BS, Stockwell EL, Volker W, Thayn K. 2663 Essentials in Minimally Invasive Gynecology (Emig) Manual Skills Pilot Validation Trial. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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10
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Masghati S, Howard DL, Swainston D, McDaniel A. 1960 The Impact of Resident Participation on Operating Time in Robotic Surgery for Benign Gynecological Conditions. J Minim Invasive Gynecol 2019. [DOI: 10.1016/j.jmig.2019.09.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Jones DM, Haikal SO, Whitham MD, Howard DL. Universal versus Risk-Based Management of Unknown Group B Streptococcus Status at Term. AJP Rep 2019; 9:e315-e322. [PMID: 31579529 PMCID: PMC6768794 DOI: 10.1055/s-0039-1695744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 05/14/2019] [Indexed: 11/29/2022] Open
Abstract
Objectives This article estimates and compares public health costs of universal versus risk-based intrapartum antibiotic prophylaxis (IAP) administration for women with unknown Group B streptococcus (GBS) status at term. Study Design The annual number of women in the U.S. who are: unscreened for GBS, without risk factors, delivering vaginally, multiparous, and eligible for discharge within 24 hours was estimated. Under the risk-based strategy, women and neonates were assumed to stay another day for observation and incur the cost of an additional 24-hour stay. With universal IAP administration, women delivering without complications were assumed to be discharged within 24 hours, with an incurred cost of penicillin. Results The estimated cost for the risk-based management of unscreened women at term without rupture of membranes (ROM) > 18 hours ranged from $468,886,831 to $850,556,179. Similarly, the cost of managing unscreened women without maternal intrapartum fever (MIF) ranged from $742,024,791 to $919,269,233. Alternatively, universal IAP administration costs ranged from $470,107,674 to $568,359,086.5. Cost comparisons yielded an equivalence or up to a 33.2% reduction in cost, and 36.6 to 38.2% reduction in cost for women without ROM > 18 hours and MIF, respectively. Conclusions Universal IAP may be cost saving due to the reduction in extended hospitalizations for neonates and healthy mothers.
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Affiliation(s)
- Danielle M Jones
- School of Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada
| | - Samantha O Haikal
- College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada
| | - Megan D Whitham
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, Texas
| | - David L Howard
- School of Medicine, University of Nevada, Las Vegas, Las Vegas, Nevada.,College of Osteopathic Medicine, Touro University Nevada, Henderson, Nevada.,Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center (A Davita Medical Group), Las Vegas, Nevada
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Stiewig M, Jackson DN, Howard DL. Does serum hemoglobin A1C during early pregnancy predict performance on the 1-hour glucose challenge test? J Matern Fetal Neonatal Med 2019; 34:1174-1176. [PMID: 31230488 DOI: 10.1080/14767058.2019.1627317] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
PURPOSE To determine the negative and positive predictive values of hemoglobin A1c (HgbA1c) levels in predicting abnormal 1-hour glucose challenge test (GCT) results in pregnancy. METHODS This retrospective cohort study consisted of pregnant patients from a private practice obstetrics clinic. The primary exposure was early HgbA1c measurement, and the primary outcome was third trimester 1-hour GCT results above or below 140 mg/dL. We calculated the predictive value of early HgbA1c to identify a 1-hour GCT of ≤140 mg/dL or >140 mg/dL. RESULTS Of the 1404 one-hour GCT results, 635 were associated with HgbA1c being measured in a patient on the same day or before the 1-hour GCT. The median interval between the HgbA1c test and the 1-hour GCT was 95 days (IQR 56-122 days). Among women with a hgbA1c less than or equal to 4.9, 5.0 and 5.1, respectively, the probability of their 1 hour GCT being 140 mg/dl or less was 91.3%, 91.0% and 90.1%, respectively (Table 1). Among our study population, 14.5%, 22.8% and 35.0% had an Hgb A1c less than or equal to 4.9, 5.0 and 5.1 respectively. Among women with HgbA1c greater than 6.1, the probability of their 1-hour GCT being greater than 140 mg/dL was 100%. Only 0.3% of our population had HgbA1c greater than 6.1. There was no other cut point for HgbA1c, where the positive predictive value for predicting an abnormal 1-hour GCT was equal to or greater than 90%. CONCLUSIONS The greatest value of an early HgbA1C test appears to be that very low values (5.1 or less) can predict a normal 1 h GCT with high probability (at least 90%). However, it has limited ability to predict abnormal 1 h GCT. Overall, an early HgbA1C cannot replace the 1 h GCT based on the current body of evidence.
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Affiliation(s)
| | - David N Jackson
- Department of Obstetrics and Gynecology, University of Nevada - Las Vegas, Las Vegas, NV, USA
| | - David L Howard
- Department of Obstetrics and Gynecology, University of Nevada - Las Vegas, Las Vegas, NV, USA
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Masghati S, Pedroso J, Gutierrez M, Stockwell E, Volker KW, Howard DL. Comparative Thermal Effects of J-Plasma®, Monopolar, Argon, and Laser Electrosurgery in a Porcine Tissue Model. Surg Technol Int 2019; 34:35-39. [PMID: 30825320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
INTRODUCTION The objective of this study was to understand how J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) surgical energy compares to monopolar, argon beam, and CO2 laser devices in terms of depth of penetration and lateral thermal spread in a porcine tissue model. MATERIALS AND METHODS Using a porcine animal model, we applied the thermal energy of the J-Plasma® laser, Bovie Monopolar Pencil (Bovie Medical Corporation, Clearwater, Florida), argon beam coagulator, and CO2 laser to porcine small bowel, bladder, and peritoneal tissues at equivalent settings. Tissue was excised and sent to pathology for histologic evaluation. Primary outcome was depth of penetration and lateral thermal spread. RESULTS When applied to peritoneum tissue, CO2 laser had the greatest lateral thermal spread at 2.99mm, while the argon beam had the lowest at just under 1.5mm. With regard to depth of penetration, the monopolar pencil had the highest while J-Plasma® had the lowest. When applied to bladder tissue, the argon beam was associated with the greatest lateral thermal spread (3.1mm) as compared to the other three devices (all less than 1mm). In terms of depth of penetration of bladder tissue, J-Plasma® again had the lowest value, while the monopolar pencil had the highest. When applied to small intestine tissue, the argon beam had the greatest lateral spread (3.51mm), while J-Plasma® had the lowest (less than 1mm). Regarding depth of penetration of small intestine tissue, argon beam had the highest value at 1.8mm compared to the other three devices (all below 0.6mm). CONCLUSION Consistent with our previous study, J-Plasma® had minimal lateral and depth spread when applied to various tissue types. J-Plasma® performed better or similar when compared to monopolar, argon beam, and laser electrosurgical devices. Further studies in-vivo are needed to evaluate safety and surgical application of the J-Plasma® device.
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Affiliation(s)
- Salome Masghati
- Las Vegas Minimally Invasive Surgery, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada
| | - Jasmine Pedroso
- Las Vegas Minimally Invasive Surgery, Women's Pelvic Health Center WellHealth QualityCare, a DaVita Medical Group, Las Vegas, Nevada
| | - Melissa Gutierrez
- Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center, WellHealth QualityCare, a DaVita Medical Group, Las Vegas, Nevada
| | - Erica Stockwell
- Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center, WellHealth Quality Care, a DaVita Medical Group, Obstetrics and Gynecology, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada
| | - K Warren Volker
- Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center, WellHealth Quality Care, a DaVita Medical Group, Obstetrics and Gynecology, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada
| | - David L Howard
- Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center, WellHealth Quality Care, a DaVita Medical Group, Obstetrics and Gynecology, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada
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Stockwell E, Howard DL. Intrauterine Pressure During Hysteroscopic Morcellation: A Comparison of Three Commercially-Available Devices. Surg Technol Int 2018; 33:sti33/1048. [PMID: 30204922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
STUDY OBJECTIVE Our objective was to compare intrauterine pressures during resection and aspiration modes among three types of commercially-available hysteroscopic morcellators. DESIGN This was a benchtop study (Canadian Task Force level II-1). This study cannot feasibly and ethically be done in-vivo, so an ex-vivo study design was chosen. SETTING A silicone uterine model was attached to a manometer via tubing, with the tip inside the cavity to allow for intracavity pressure measurements. Each hysteroscopic morcellator was then introduced, and intracavity pressures were recorded every one to two seconds in three modes (static, resection, and aspiration) and at three set point pressures (45, 85, and 125 mmHg). PATIENTS No human subjects were involved in this study. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were a total of 4,872 pressure measurements during this study across the three devices, over the three modes, and at the three set point pressures combined. Using mixed-effects linear regression, the mean observed intracavity pressure was not greater than the set pressure for each of the three devices. This result held true in both aspiration and resection modes. In our statistical models, the coefficient on the terms representing the interaction between device and time were not statistically significant in either resection or aspiration modes. This indicates that, statistically, the change in intracavity pressure over time was not significantly different across the three devices. CONCLUSION In this first of its kind head-to-head benchtop study, we found that all three commercially-available hysteroscopic morcellators appear to be similar to each other in terms of their abilities to maintain intracavity pressure below the set pressure, which is important in avoiding intravasation in-vivo. These findings are important because many gynecologists do not have the ability to choose between the three available devices on the market at their institution.
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Affiliation(s)
- Erica Stockwell
- Minimally Invasive Gynecologic Surgeon, Las Vegas Minimally Invasive Surgery Well Health Quality Care, a DaVita Medical Group, Department of Obstetrics and Gynecology, University of Nevada, Las Vegas School of Medicine, Las Vegas, Nevada
| | - David L Howard
- Las Vegas Minimally Invasive Surgery, Women's Pelvic Health Center/ WellHealth Quality Care, A Davita Medical Group, Department of Obstetrics and Gynecology University of Nevada, Las Vegas School of Medicine Las Vegas, Nevada
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Parks MA, Barnhart KT, Howard DL. Trends in the Management of Nonviable Pregnancies of Unknown Location in the United States. Gynecol Obstet Invest 2018; 83:552-557. [PMID: 29874639 DOI: 10.1159/000488760] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 03/23/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND When managing a nonviable pregnancy of unknown location (PUL), a debate has emerged in the literature whether to perform uterine curettage for definitive diagnosis of pregnancy location or administer methotrexate for a presumed ectopic pregnancy. The purpose of this study is to describe the treatment patterns when managing a PUL. METHODS A prospective, anonymous Internet based-electronic survey of PUL case scenarios was administered to a random sample of physicians across the United States. RESULTS A total of 214 physicians responded. When presented with a PUL by ultrasound and a βhCG measurement of 3,270 mIU/mL, which is above the discriminatory level, 88.3% (188) would choose an additional βhCG measurement before recommending any intervention. When presented with a PUL by ultrasound and serial βhCG measurements demonstrating an inappropriate trend for a viable gestation, 36.5% would offer uterine curettage and 31.3% would offer methotrexate. Resident and private clinicians had a fourfold lower adjusted odds of choosing uterine curettage compared to academic physicians. CONCLUSIONS Based on our findings, there does not appear to be a consensus regarding the management of a PUL.
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Affiliation(s)
- Melissa A Parks
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia,
| | - Kurt T Barnhart
- Department of Reproductive Endocrinology and Infertility, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania, USA
| | - David L Howard
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, USA
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Howard DL, McGlynn A, Greer JA. Military Surgeon Volume and Stress Incontinence Surgery Complications: A Retrospective Cohort Study. J Minim Invasive Gynecol 2018; 25:855-860. [PMID: 29337213 DOI: 10.1016/j.jmig.2018.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 12/28/2017] [Accepted: 01/02/2018] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To compare 12-month postoperative complication rates in women who underwent sling procedures by high-volume versus low-volume surgeons at US military treatment facilities (MTFs). DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING US MTFs. PATIENTS Female military beneficiaries enrolled in TRICARE. INTERVENTIONS Sling surgery for stress urinary incontinence between January 1, 2011 and December 31, 2012. MEASUREMENTS AND MAIN RESULTS The primary exposure was surgeon volume (high vs low). Surgeon volume was categorized as high or low based on the number of slings performed in the previous 2 years at US MTFs (January 1, 2009 to December 31, 2010). The primary outcome was a composite variable indicating at least 1 postoperative complication within 12 months. We used International Classification of Diseases, 9th revision and Current Procedural Terminology codes to identify postoperative complications that occurred in the 12 months after the index sling procedure. During the study period 348 gynecologic and urologic surgeons performed 1632 slings. The average patient age was 47.2 years. Based on our data distribution we classified surgeons as high volume (>12 slings/2 years) or low volume (<4 slings/2 years). High-volume surgeons operated on patients who were older, more likely to have comorbidities, and more likely to receive concomitant prolapse surgery. Using a cluster analysis the overall likelihood of at least 1 postoperative complication in 12 months for high-volume versus low-volume surgeons was 48.4% versus 42.2% (adjusted odds ratio, 1.24; 95% confidence interval, .99-1.54; p = .06). There were no differences between high- and low-volume surgeons in the rate of almost all other postoperative complications. CONCLUSION No significant differences in 12-month complication rates after sling surgery, stratified by surgeon volume, were seen in a setting of overall low-volume military surgeons.
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Affiliation(s)
- David L Howard
- 633rd Medical Group, Joint Base Langley-Eustis, Hampton, VA.
| | | | - Joy A Greer
- Women's Health Department, Division of Urogynecology, Naval Medical Center, Portsmouth, VA
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Howard DL, McGlynn A, Greer JA. Complications of Sling Surgery for Stress Urinary Incontinence Among Female Military Beneficiaries. J Womens Health (Larchmt) 2018; 27:830-835. [PMID: 29320304 DOI: 10.1089/jwh.2017.6503] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Prior studies of complications after sling surgery excluded the large number of women in military treatment facilities (MTFs). OBJECTIVE To characterize the postoperative complication rates after sling surgery for Stress urinary incontinence (SUI) within MTFs in the United States. MATERIALS AND METHODS Retrospective cohort study of women aged 18 and older, with SUI, and who underwent either an outpatient or inpatient mid-urethral sling placement for SUI in any MTF in the United States between January 1, 2011 and December 31, 2012. RESULTS During the study period, 348 surgeons performed 1632 slings. The average patient age was 47.2 years, and 22.4% of the patients had a concomitant pelvic organ prolapse procedure. Overall, 45.5% of subjects had at least one postoperative complication. Of the specific complications, urologic infectious complications were the most frequent, occurring in 25.2% of patients. Overall, only 0.9% of patients underwent a repeat incontinence procedure. In multivariate analyses, concomitant pelvic organ procedure was associated with an increased risk of bladder outlet obstruction and noninfectious urologic complications. Those with a Charlson comorbidity index score of 1 or more were more likely to have an infectious complication and a new diagnosis of pelvic pain. Women older than the median age were less likely than those below to experience treatment failure and a new diagnosis of pelvic pain. CONCLUSIONS The population of women with SUI undergoing sling surgery at MTFs is a young population with postoperative complication rates lower than previously reported. However, the absolute overall complication rate is still high, specifically related to urinary tract infections, suggesting that significant opportunities exist for quality improvement.
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Affiliation(s)
- David L Howard
- 1 MAJ USAF MC, 633rd Medical Group, Joint Base Langley-Eustis, Obstetrics and Gynecology, Hampton, Virginia
| | - Andrea McGlynn
- 2 Department of Clinical Investigation, Naval Medical Center , Portsmouth, Virginia
| | - Joy A Greer
- 3 CDR MC USN, Division of Urogynecology, Department of Women's Health, Naval Medical Center Portsmouth , Portsmouth, Virginia
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Howard DL, Ford A, Ceballos S, Volker KW. Temporal Trends in the Uptake and Continuation of the Etonogestrel Implant in a Large Private Practice Setting. J Womens Health (Larchmt) 2017; 27:191-195. [PMID: 28976797 DOI: 10.1089/jwh.2017.6468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To assess temporal trends in the uptake and continuation of the etonogestrel subdermal implant in a large private practice setting. METHODS This was a retrospective cohort study based on billing records from a large multispecialty private practice in Las Vegas, Nevada. We looked at women of all ages seeking long-acting reversible contraception (LARC) between January 1, 2013, and December 31, 2016. The main outcome measure was uptake of the etonogestrel subdermal implant, expressed as a fraction of all insertions of LARC across four calendar years (2013-2016). The Kaplan-Meier method was used to estimate 12-month continuation stratified by year of insertion. RESULTS There were 3477 total LARC insertions across the 4-year study period. In unadjusted analyses, the uptake of the etonogestrel implant increased from 3.0% of LARC insertions in 2013 to 9% in 2016 among women aged 30 years and older. For women younger than 30 years, the uptake of the implant stayed stable from 2013 to 2015 (22.8%, 21.7%, and 22.4%, respectively), but increased to 30.9% in 2016. We modeled the uptake of the implant as a function of year of insertion adjusted for age (continuous) and insurance status (private vs. Medicaid), and we stratified the models by age (younger than 30 years, 30 years, and older than 30 years). The positive association between year of insertion and uptake of the implant was significantly stronger for women aged 30 years and older, compared to women younger than 30 years. There was a progressive decrease in the 12-month continuation of implant from 2013 (95.7%) to 2015 (57.7%). CONCLUSIONS In this large private practice setting, among women aged 30 years and older, we observed a threefold increase in the uptake of the subdermal implant from 2013 to 2016. We also observed a significant decrease in the 12-month continuation of the implant over time. Further studies of implant uptake and continuation in the private practice setting are needed.
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Affiliation(s)
- David L Howard
- 1 Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center , Las Vegas, Nevada
| | - Avery Ford
- 2 Department of Molecular, Cellular and Developmental Biology, University of Colorado , Boulder, Colorado
| | - Sonia Ceballos
- 1 Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center , Las Vegas, Nevada
| | - K Warren Volker
- 1 Las Vegas Minimally Invasive Surgery and Women's Pelvic Health Center , Las Vegas, Nevada
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Gutierrez MM, Pedroso JD, Volker KW, Howard DL, McCarus SD. The McCarus-Volker ForniSee®: A Novel Trans-illuminating Colpotomy Device and Uterine Manipulator for Use in Conventional and Robotic-Assisted Laparoscopic Hysterectomy. Surg Technol Int 2017; 30:191-196. [PMID: 28277596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
PURPOSE The purpose of this paper is to introduce a novel trans-illuminating culdotomy and uterine manipulator device. MATERIALS AND METHODS The study was a prospective, non-randomized, non-blinded observational clinical study involving 50 female patients undergoing total laparoscopic hysterectomy (TLH) or laparoscopic supracervical hysterectomy (LSH) for benign indications. The surgeries were performed from March through May 2012 at two institutions. The primary study objectives were to demonstrate the safety and adequate clinical performance of the uterine manipulator device and to illustrate its potential widespread future use in minimally invasive gynecologic procedures. RESULTS Average patient age was 45.1 years and, of the 50 patients, 33 had undergone previous intra-abdominal surgery. There were no reports of adverse events, difficulty with placement of the instrument, multiple attempts at placement, or difficulty with uterine manipulation. There was only one device-related uterine perforation, and pneumoperitoneum was maintained in all cases during culdotomy. Vaginal tissue left on subjects was less than 5mm. Overall, there were no ureteral injuries, there were two reported incidental cystotomies, and average blood loss was 99.0cc. Postoperative courses were normal for all patients, with only two reported postoperative complications: a possible vaginal cuff abscess and a 2cm vaginal mucosal cuff separation. CONCLUSIONS The McCarus-Volker ForniSee® (LSI Solutions, Inc., Victor, New York) is a novel trans-illuminating culdotomy device and uterine manipulator that is safe, efficient, functional, and easy to use. Trans-illumination additionally delineates and enhances identification of critical anatomic planes, such as the vesicovaginal junction and cervicovaginal junction.
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Affiliation(s)
- Melissa M Gutierrez
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - Jasmine D Pedroso
- >Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - K Warren Volker
- >Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - David L Howard
- >Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - Steven D McCarus
- McCarus Surgical Specialists for Women, Florida Hospital, Celebration, Florida
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Pedroso JD, Gutierrez MM, Volker KW, Howard DL. Thermal Effect of J-Plasma® Energy in a Porcine Tissue Model: Implications for Minimally Invasive Surgery. Surg Technol Int 2017; 30:19-24. [PMID: 28693047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To evaluate tissue effect of J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) in porcine liver, kidney, muscle, ovarian, and uterine tissue blocks. DESIGN Prospective study utilizing porcine tissue blocks to evaluate the thermal spread of J-Plasma® device on liver, kidney, muscle, ovarian, and uterine tissue at various power settings, gas flow, and exposure times. MATERIALS AND METHODS J-Plasma® helium was used in porcine liver, kidney, and muscle tissue at 20%, 50%, and 100% power, and 1 L/min, 3 L/min, and 5 L/min gas flow at one, five, and 10-second intervals. J-Plasma® was then used in ovarian and uterine tissue at maximum power and gas flow settings in intervals of one, five, 10, and 30 seconds. Histologic evaluation of each tissue was then performed to measure thermal spread. RESULTS Regardless of tissue type, increased power setting, gas flow rate, and exposure time correlated with greater depth of thermal spread in liver, kidney, and muscle tissue. J-Plasma® did not exceed 2 mm thermal spread on liver, kidney, muscle, ovarian, and uterine tissue, even at a maximum setting of 100% power and 5 L/min gas flow after five seconds. Prolonged exposure to J-Plasma® of up to 30 seconds resulted in increased length and width of thermal spread of up to 12 mm, but did not result in significantly increased depth at 2.84 mm. CONCLUSIONS The J-Plasma® helium device has minimal lateral and depth of thermal spread in a variety of tissue types and can likely be used for a multitude of gynecologic surgical procedures. However, further studies are needed to demonstrate device safety in a clinical setting.
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Affiliation(s)
- Jasmine D Pedroso
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - Melissa M Gutierrez
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - K Warren Volker
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
| | - David L Howard
- Minimally Invasive Gynecologic Surgery, Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada
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Abstract
We present a case in which a patient presented with a pregnancy of unknown location and normally rising human chorionic gonadotropin (hCG) levels but with a levonorgestrel intrauterine device (LNG-IUD) present. The LNG-IUD had been placed 4.5 years ago. Although unintended, this pregnancy was desired. Strings were clearly visible and initial 2D ultrasound suggested intrauterine location of the LNG-IUD. The LNG-IUD could not be removed however. The patient was managed expectantly with close follow-up, serial beta-hCGs and serial ultrasounds until definitive diagnosis of the location of the pregnancy. The patient was diagnosed with an ectopic pregnancy and during laparoscopy the body of the IUD was noted in the posterior cul-de-sac. When patients present with multiple competing clinical problems it is important to look at the patient as a whole, taking into account their desires, in order to construct a cohesive management plan.
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Affiliation(s)
- David L Howard
- Las Vegas Minimally Invasive Surgery/Women's Pelvic Health Center, Las Vegas, Nevada, USA
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Howard DL, Soulli B, Johnson N, Cooper S. Women's Understanding of the Term 'Pap smear': A Comparison of Spanish-Speaking Versus English-Speaking Women. Matern Child Health J 2016; 20:2336-2347. [PMID: 27451859 DOI: 10.1007/s10995-016-2057-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Objective To compare the understanding of the term 'Pap smear' among Spanish-speaking women, as compared to their English-speaking counterparts. Methods Surveys were distributed to English and Spanish speaking female patients in an urban Obstetrics and Gynecology clinic. Patients were at least 18 years old or they were less than 18 years old and pregnant. Results A majority of participants (77.3 % English-speaking vs. 74.1 % Spanish-speaking, respectively) were able to identify at least one correct descriptor for the term Pap smear. However, Spanish-speaking women were significantly less likely to choose incorrect descriptors. Spanish-speaking women were much less likely to say that a Pap smear was the same as a Pelvic exam (45.7 vs. 78.8 %; p = 0.001), or a test for a sexually transmitted disease (25 vs. 60.6 %; p = 0.001). Conclusions for Practice Compared to English-speaking women, Spanish-speaking women are much less likely to conflate a pelvic exam with a Pap smear. Overall understanding was suboptimal, regardless of primary language, indicating that major efforts are still needed to improve functional health literacy with respect to cervical cancer screening.
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Affiliation(s)
- David L Howard
- WellHealth Quality Care/Las Vegas Minimally Invasive Surgery, 9260 West Sunset Road, Las Vegas, Nevada, 89147, USA.
| | - Beth Soulli
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, 2301 Holmes Street, Kansas City, MO, 64108, USA
| | - Nicole Johnson
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, 2301 Holmes Street, Kansas City, MO, 64108, USA
| | - Saladin Cooper
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, 2301 Holmes Street, Kansas City, MO, 64108, USA
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Abstract
To assess physician attitude towards making oral contraceptives available over the counter in the United States (US). We assessed physician attitudes towards a transition from prescription only to over-the-counter availability (rx-OTC) for oral contraceptive pills by disseminating an electronic survey directed primarily to residents training in Obstetrics and Gynecology (OBGYN) and Family Practice in the US. An overwhelming majority of 638 respondents (71 %) were against an rx-OTC switch for combined oral contraceptives and among this subset of respondents the primary concern was safety (92.3 %). Overall, respondents were evenly divided on the issue of an rx-OTC switch for progestin-only-pills but of those who opposed, 73.2 % cited safety as their primary concern. For progestin-only-pills female respondents were more likely to support OTC availability. Most OBGYN and Family Practice residents opposed to OTC availability for oral contraceptives cite safety as their primary concern. Considering the abundant evidence as to the overall safety of oral contraceptives, especially progestin-only-pills, there appears to be a knowledge deficit among OBGYN and Family Practice residents regarding the safety of oral contraceptives.
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Affiliation(s)
- David L Howard
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, 2301 Holmes Street, Kansas City, MO, 64108, USA,
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Ryan CG, Siddons DP, Kirkham R, Li ZY, de Jonge MD, Paterson DJ, Kuczewski A, Howard DL, Dunn PA, Falkenberg G, Boesenberg U, De Geronimo G, Fisher LA, Halfpenny A, Lintern MJ, Lombi E, Dyl KA, Jensen M, Moorhead GF, Cleverley JS, Hough RM, Godel B, Barnes SJ, James SA, Spiers KM, Alfeld M, Wellenreuther G, Vukmanovic Z, Borg S. Maia X-ray fluorescence imaging: Capturing detail in complex natural samples. ACTA ACUST UNITED AC 2014. [DOI: 10.1088/1742-6596/499/1/012002] [Citation(s) in RCA: 126] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Howard DL, Wayman R, Strickland JL. Satisfaction with and intention to continue Depo-Provera versus the Mirena IUD among post-partum adolescents through 12 months of follow-up. J Pediatr Adolesc Gynecol 2013; 26:358-65. [PMID: 24238267 DOI: 10.1016/j.jpag.2013.07.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Revised: 07/25/2013] [Accepted: 07/31/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE No prior study has directly compared satisfaction with Depo-Provera to the Mirena intra-uterine device (IUD) among post-partum parous adolescents. Our aim was to make this comparison among post-partum adolescents at 3, 6, and 12 months of follow-up. PARTICIPANTS Post-partum/parous adolescents (aged 20 and younger) choosing either Depo-Provera or the Mirena IUD as their method of contraception. DESIGN Prospective longitudinal survey. SETTING The adolescent clinic at the Truman Medical Center, Kansas City Missouri. MAIN OUTCOME MEASURE Satisfaction with and intention to continue the chosen method at 3, 6, and 12 months of follow-up. INTERVENTIONS None. RESULTS Sixty-six post-partum/parous adolescents were recruited, 37 choosing the Mirena IUD and 29 choosing Depo-Provera for contraception. The 2 groups had similar baseline characteristics. There was no statistically significant difference in overall satisfaction with Depo-Provera versus the Mirena IUD at 3, 6, or 12 months of follow-up. For both contraceptive methods, unpredictable bleeding was most unacceptable at 6 months of follow-up but the trend was only statistically significant for Depo-Provera. For Depo-Provera, there was a significantly lower proportion of participants actually continuing the method at 12 months (42.9%) relative to the proportion who at 6 months had expressed an intention to continue (80.0%; P = .01). This trend was not seen for the Mirena IUD. CONCLUSION Among post-partum/parous adolescents, overall subjective satisfaction with Depo-Provera and the Mirena IUD is similarly high over 12 months of follow-up. With Depo-Provera, however, there appears to be a disconnect between intention to continue at 6 months and actual continuation at 12 months.
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Affiliation(s)
- David L Howard
- Department of Obstetrics and Gynecology, University of Missouri-Kansas City, Kansas City, MO.
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Howard DL, Wall J, Strickland JL. What are the Factors Predictive of Hysterosalpingogram Compliance After Female Sterilization by the Essure Procedure in a Publicly Insured Population? Matern Child Health J 2012; 17:1760-7. [DOI: 10.1007/s10995-012-1195-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Donner E, Ryan CG, Howard DL, Zarcinas B, Scheckel KG, McGrath SP, de Jonge MD, Paterson D, Naidu R, Lombi E. A multi-technique investigation of copper and zinc distribution, speciation and potential bioavailability in biosolids. Environ Pollut 2012; 166:57-64. [PMID: 22475551 DOI: 10.1016/j.envpol.2012.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Revised: 02/15/2012] [Accepted: 02/17/2012] [Indexed: 05/31/2023]
Abstract
The use of biosolids in agriculture continues to be debated, largely in relation to their metal contents. Our knowledge regarding the speciation and bioavailability of biosolids metals is still far from complete. In this study, a multi-technique approach was used to investigate copper and zinc speciation and partitioning in one contemporary and two historical biosolids used extensively in previous research and field trials. Using wet chemistry and synchrotron spectroscopy techniques it was shown that copper/zinc speciation in the biosolids was largely equivalent despite the biosolids being derived from different countries over a 50 year period. Furthermore, copper speciation was consistently dominated by sorption to organic matter whereas Zn partitioned mainly to iron oxides. These data suggest that the results of historical field trials are still relevant for modern biosolids and that further risk assessment studies should concentrate particularly on Cu as this metal is associated with the mineralisable biosolids fraction.
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Affiliation(s)
- E Donner
- Centre for Environmental Risk Assessment and Remediation, University of South Australia, Building X, Mawson Lakes Campus, South Australia 5095, Australia.
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Brandt JS, Downing AC, Howard DL, Kofinas JD, Chasen ST. Citation classics in obstetrics and gynecology: the 100 most frequently cited journal articles in the last 50 years. Am J Obstet Gynecol 2010; 203:355.e1-7. [PMID: 20875501 DOI: 10.1016/j.ajog.2010.07.025] [Citation(s) in RCA: 110] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 07/02/2010] [Accepted: 07/20/2010] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Our objective was to characterize the most frequently cited articles published in obstetrics and gynecology journals during the last 50 years. STUDY DESIGN We utilized the 2008 edition of Journal Citation Reports and Social Sciences Citation Index database to determine the most frequently cited articles published after 1956. Articles were evaluated for several characteristics, and an unadjusted categorical analysis was performed to compare pre- and post-1980 articles. RESULTS The 100 most frequently cited articles were published in 11 journals between 1957 and 2004. Most articles were published by US-based authors. Forty-four articles were related to obstetrics and 56 were related to gynecology. The most common study design was observational. There were only 7 randomized controlled trials, and randomized controlled trials were not more common after 1980 (6.3% vs 8.1%; P = .71). CONCLUSION Most "citation classics" in obstetrics and gynecology are observational studies published in high-impact journals by US-based authors after 1980.
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Affiliation(s)
- Justin S Brandt
- Department of Obstetrics and Gynecology, New York Presbyterian Hospital-Weill Cornell Medical Center, New York, NY 10021, USA
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Abstract
There is still controversy surrounding the effectiveness of prenatal care in reducing low birthweight. In addition, very few studies have assessed the relationship between prenatal care and infant birthweight among pregnant women within the prison system. We sought to ascertain whether there is an association between the quantity of prenatal care and infant birthweight among pregnant women within such a setting. We examined the prison medical records of 147 infants born to women delivering at term (37-41 weeks of gestation) between 1 January 2002 and 31 December 2004 who were incarcerated during pregnancy in Texas state prisons. Linear regression was used to evaluate the association between the number of prison prenatal care visits and infant birthweight while adjusting for potential confounders (age, gravidity, maternal education, maternal race, history of substance use, history of alcohol use, history of tobacco use and the presence of any chronic disease). We also adjusted for the interaction between the gestational age at admission to prison and the number of prison prenatal care visits. There was a statistically significant 120.5 g increase in adjusted mean birthweight with each additional prison prenatal care visit (P = 0.001) among study infants whose mothers entered prison during the first trimester. This trend was not observed among women who came in after the first trimester. There appears to be a positive association between the amount of prison prenatal care and infant birthweight among incarcerated pregnant women delivering at term, but this association appears to be limited to women entering prison during the first trimester of pregnancy.
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Affiliation(s)
- David L Howard
- Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Howard DL, Strobino D, Sherman SG, Crum RM. Timing of incarceration during pregnancy and birth outcomes: exploring racial differences. Matern Child Health J 2008; 13:457-66. [PMID: 18561009 DOI: 10.1007/s10995-008-0376-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2007] [Accepted: 06/05/2008] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To examine whether there are racial differences in the relation between the timing of incarceration during pregnancy and birth outcomes among incarcerated pregnant women. METHODS We examined the medical records associated with 360 infants born to pregnant inmates in Texas state prisons between January 1, 2002 and December 31, 2004. Weighted linear regression was used, within racial strata, to model gestational age at delivery, and infant birth weight, respectively, as functions of gestational age at maternal admission to prison. Models were adjusted for maternal age; gravidity; educational attainment; history of tobacco, substance, and alcohol use and the presence of any maternal chronic disease. RESULTS Among Whites there was a 360.8 g lower mean birth weight for infants born to women incarcerated during weeks 14-20 relative to infants born to women incarcerated during weeks 1-13 (p < 0.10). Among Blacks and Hispanics, incarceration after the first trimester was not associated with a significant decrease in infant birth weight relative to incarceration during the first trimester. White women entering prison during the first trimester delivered infants at higher gestational ages than White women entering in the second trimester but the opposite was the case for Hispanics. CONCLUSIONS The association between the quantity of exposure to prison during pregnancy and birth outcomes appears to be different for Blacks, Whites, and Hispanic women. Future studies of the effect of incarceration on pregnancy outcomes should attempt to uncover potential racial differences in trends by obtaining racially stratified results or by assessing interaction with race.
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Affiliation(s)
- David L Howard
- Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Arakawa H, Murayama Y, Davis CR, Howard DL, Baumgardner WL, Marks MP, Do HM. Endovascular embolization of the swine rete mirabile with Eudragit-E 100 polymer. AJNR Am J Neuroradiol 2007; 28:1191-6. [PMID: 17569986 PMCID: PMC8134130 DOI: 10.3174/ajnr.a0536] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Both adhesive and nonabrasive embolic agents are available for arteriovenous malformation (AVM) embolization. The purpose of this study was to evaluate a novel ethanol-based nonadhesive liquid embolic material in a swine AVM model. MATERIALS AND METHODS Eudragit (copolymer of methyl and butyl methacrylate and dimethylaminoethyl methacrylate) was dissolved in 50% ethanol and 50% iopamidol. Eudragit was injected into 9 retia mirabilia (RMs). Ethanol and iopamidol mixture were injected into 4 RMs for comparison. Three RMs embolized with Eudragit mixture were evaluated both angiographically and histopathologically acutely (3-24 hours) and at 30 days and 90 days after embolization. RESULTS No procedural complications from Eudragrit embolization were noted, including retention or adhesion of the microcatheter. Various degrees of inflammation were observed in the acute and 30-day specimens. Two RMs showed partial recanalization on both histopathology and follow-up angiography in the 30-day group. Arterial fibrosis and calcification were observed in the 30- and 90-day specimens. The internal elastic lamina was disrupted in the 30- and 90-day specimens, but there was no evidence of Eudragit extravasation or hemorrhage. Endothelial damage was seen in all specimens and was particularly severe in the 30- and 90-day specimens. CONCLUSION Eudragit polymer induced inflammation in thrombosis similar to n-butyl 2-cyanoacrylate, but without the disadvantages of perivascular hemorrhage and extravasation of embolization material. Although recanalization of some embolized RMs was noted, further investigation into Eudragit as a potentially useful embolic material for brain AVMs is warranted.
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Affiliation(s)
- H Arakawa
- Department of Radiology, Stanford University Medical Center, Stanford, CA, USA.
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Seifert HA, Howard DL, Silber JH, Jobes DR. Female gender increases the risk of death during hospitalization for pediatric cardiac surgery. J Thorac Cardiovasc Surg 2007; 133:668-75. [PMID: 17320563 DOI: 10.1016/j.jtcvs.2006.11.014] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2006] [Revised: 10/21/2006] [Accepted: 11/01/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVES The study objective was to determine whether gender is a determinant of in-hospital mortality after surgery to repair congenital heart disease in patients aged 20 years or less. Secondary objectives were to determine other factors associated with increased risk of death and whether female gender is associated with increased length of stay or total charges. METHODS The study included a retrospective cohort consisting of all records indicating cardiac operations within the Healthcare Cost and Utilization Project Kids' Inpatient Database for the year 2000. Logistic regression was used to simultaneously evaluate the effect of gender on the risk of death while adjusting for all other factors being considered. Logistic regression was then used to evaluate possible differences in length of stay or total charges. RESULTS Female gender was associated with increased risk of in-hospital death when all of the other measured factors were taken into consideration (odds ratio 1.31, 95% confidence interval 1.02-1.69). Other factors that were significantly associated with increased in-hospital mortality after pediatric cardiac surgery included the number of days between admission and operation; African American race; young age (neonates and infants compared with children aged > or =1 year); pulmonary hypertension; and the Norwood operation. There were no significant gender differences in risk-adjusted length of stay or total charges. CONCLUSIONS In-hospital mortality after pediatric cardiac surgery seems to be associated with patient gender but not with the type of insurance or ability to access higher-volume pediatric facilities or teaching hospitals.
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Affiliation(s)
- Harry A Seifert
- Department of Anesthesiology and Critical Care, The Children's Hospital of Philadelphia, Philadelphia, Pa 19104, USA
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Howard DL, Marshall SS, Kaufman JS, Savitz DA. Variations in low birth weight and preterm delivery among blacks in relation to ancestry and nativity: New York City, 1998-2002. Pediatrics 2006; 118:e1399-405. [PMID: 17079541 DOI: 10.1542/peds.2006-0665] [Citation(s) in RCA: 80] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Black women in the United States are more likely to give birth to preterm and low birth-weight infants than their white counterparts, but little is known about variation in birth outcomes within the black population. This study aimed to test the hypothesis that the risk of low birth weight and preterm birth within the black population varies by maternal ancestry and nativity. POPULATION AND METHODS We conducted a retrospective cohort study using New York City birth records. All of the recorded live births to black women occurring in New York City between January 1, 1998, and December 31, 2002 (N = 168,039), were divided into the following self-reported ancestry groups: African, American, Asian, Cuban, European, Puerto Rican, South and Central American (excluding Brazilian), and West Indian and Brazilian. To estimate adjusted risk ratios for low birth weight (weight at birth <2500 g) and preterm birth (gestational age at delivery <37 weeks, based on clinical estimate), we ran 3 models for each outcome, using negative binomial regression and Poisson regression with robust SE estimation. All of the models used blacks reporting American ancestry as the reference group. The first model included ancestry as the primary exposure variable along with covariates that included maternal age, parity, smoking, and education, as well as paternal education and race. Nativity (US- or foreign-born) was included in the second model, and terms representing interaction effects between ancestry and nativity were included in the third model. RESULTS There was substantial variation in risks of preterm birth and low birth weight among the black subgroups, with all of the groups having lower risks than the American black reference group, even after adjusting for maternal risk factors and other covariates. Risk ratios for low birth weight ranged from 0.55 among South/Central Americans to 0.91 among Cubans; risk ratios for preterm birth showed a similar pattern. Nativity was also associated with low birth weight and preterm birth; births to foreign-born women were less likely to be preterm or low birth weight than births to US-born women. Furthermore, nativity effects varied by ancestry group, with foreign-born status inversely associated with poor birth outcomes among South/Central Americans but not among West Indians/Brazilians. CONCLUSIONS Important health differences may be masked in studies that treat black women in America as a homogeneous group and do not take ethnic variation and nativity into account.
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Affiliation(s)
- David L Howard
- Carolina Population Center, 211 W Cameron Ave, Chapel Hill, NC 27516, USA.
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Abstract
OBJECTIVES To examine factors associated with noninjectors having 1 or more injection drug users as sex partners. METHODS We collected data as a part of the Self-Help in Eliminating Life Threatening Diseases study, a network-oriented experimental HIV prevention intervention. All eligible participants were administered a detailed face-to-face interview on their sociodemographic background, patterns of drug use, HIV prevention and risk behaviors, and social networks. The sample for these analyses consisted of 863 noninjectors, 97 of whom had 1 or more injection drug-using sex partners. RESULTS Among the factors associated with an increased odds of having 1 or more injecting sex partners were long-term unemployment, increasing proportion of women in network (among male noninjectors), increasing number of recent sex partners (among former injectors), increasing number of injecting non-sex partners in the network, and increasing network size above 15. CONCLUSIONS There are specific network characteristics associated with noninjectors having injecting sex partners.
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Affiliation(s)
- David L Howard
- Department of Health, Behavior and Society, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD 21205, USA
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Ardehali H, Howard DL, Hariri A, Qasim A, Hare JM, Baughman KL, Kasper EK. A positive endomyocardial biopsy result for sarcoid is associated with poor prognosis in patients with initially unexplained cardiomyopathy. Am Heart J 2005; 150:459-63. [PMID: 16169324 DOI: 10.1016/j.ahj.2004.10.006] [Citation(s) in RCA: 123] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2004] [Accepted: 10/15/2004] [Indexed: 12/25/2022]
Abstract
BACKGROUND Sarcoidosis is a systemic granulomatous disorder of unknown etiology. In patients with cardiomyopathy, the diagnosis of sarcoidosis has important treatment implications. We studied the prognostic implications of a cardiac biopsy diagnosis of sarcoidosis in patients with unexplained cardiomyopathy. METHODS We evaluated 1235 patients with unexplained cardiomyopathy who underwent endomyocardial biopsy (EMBx) between 1982 and 1997 at the Johns Hopkins Hospital. Twenty-eight patients were referred with a clinical diagnosis of sarcoidosis. RESULTS Seven of these 28 patients (25%) plus 3 more with other initial diagnoses had sarcoidosis on heart biopsy. Of these 10 patients, 3 (30%) died with a median survival time after biopsy of 0.69 years. Of the remaining 21 patients with a clinical diagnosis of sarcoidosis, 20 had negative biopsy results for sarcoidosis and 7 (35%) died with a median survival time of 2.34 years. The odds of death within 1, 2, and 3 years were higher for those with than for those without an EMBx-proven cardiac sarcoid (crude OR 4.75 [P = .23], 8.1 [P = .09], and 1.28 [P = .78], respectively), but the differences failed to reach significance at the .05 level. However, the difference in the odds of death within 2 years did achieve marginal significance. CONCLUSIONS Only a quarter of patients with cardiomyopathy and clinical diagnosis of sarcoid have a noncaseating granuloma on EMBx. Of those with a clinical diagnosis of sarcoidosis, heart biopsy results that are positive for sarcoidosis appear to be associated with a shorter median survival time than heart biopsy results that are negative for sarcoidosis. Finally, a noncaseating granuloma on EMBx is a rare finding in patients with cardiomyopathy without a history of sarcoidosis.
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Affiliation(s)
- Hossein Ardehali
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA.
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Mandelker DL, Yamashita K, Tokumaru Y, Mimori K, Howard DL, Tanaka Y, Carvalho AL, Jiang WW, Park HL, Kim MS, Osada M, Mori M, Sidransky D. PGP9.5 promoter methylation is an independent prognostic factor for esophageal squamous cell carcinoma. Cancer Res 2005; 65:4963-8. [PMID: 15930319 DOI: 10.1158/0008-5472.can-04-3923] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
PGP9.5/UCHL1 is a member of the carboxyl-terminal ubiquitin hydrolase family with a potential role in carcinogenesis. We previously identified PGP9.5 as a putative tumor-suppressor gene and methylation of the promoter as a cancer-specific event in primary cancer tissues. In this current study, we analyzed PGP9.5 methylation in 50 esophageal squamous cell carcinoma (ESCC) primary tumors with well characterized clinicopathologic variables including patient outcome. Two independent modalities for methylation analysis (TaqMan methylation-specific PCR and combined bisulfite restriction analysis) were used to analyze these samples. The two data sets were consistent with each other, as the 21 patients (42%) with highest methylation levels by TaqMan analysis all showed visible combined bisulfite restriction analysis bands on acrylamide gels. Using an optimized cutoff value by TaqMan quantitation, we found that patients with higher PGP9.5 methylation ratios in the primary tumor showed poorer 5-year survival rates than those without PGP9.5 methylation (P = 0.01). A significant correlation was also seen between PGP9.5 promoter methylation and the presence of regional lymph node metastases (P = 0.03). Multivariate analysis subsequently revealed that PGP9.5 methylation was an independent prognostic factor for ESCC survival (P = 0.03). These results suggest that PGP9.5 promoter methylation could be a clinically applicable marker for ESCC progression.
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Affiliation(s)
- Diana L Mandelker
- Department of Otolaryngology, Head and Neck Cancer Research, Johns Hopkins University, Baltimore, Maryland 21205-2196, USA
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Abstract
OBJECTIVE To conduct a statewide analysis of the effect of New York's regulations, limiting internal medicine and family practice residents' work hours, on patient mortality. DESIGN Retrospective study of inpatient discharge files for 1988 (before the regulations) and 1991 (after the regulations). SETTING AND PATIENTS Adult patients discharged from New York teaching hospitals (170214) and nonteaching hospitals (143,455) with a principal diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia, for the years 1988 and 1991 (periods before and after Code 405 regulations went into law). Patients from nonteaching hospitals served as controls. MEASUREMENT In-hospital mortality. RESULTS Combined unadjusted mortality for congestive heart failure, acute myocardial infarction, and pneumonia patients declined between 1988 and 1991 in both teaching (14.1% to 13.0%; P =.0001) and nonteaching hospitals (14.0% to 12.5%; P =.0001). Adjusted mortality also declined between 1988 and 1991 in both teaching (odds ratio [OR], death 1991/1988, 0.868; 95% confidence interval [CI], 0.843 to 0.894; P =.0001) and nonteaching hospitals (OR, death 1991/1988, 0.853; 95% CI, 0.826 to 0.881; P =.0001). This beneficial trend toward lower mortality over time was nearly identical between teaching and nonteaching hospitals (P =.4348). CONCLUSION New York's mandated limitations on residents' work hours do not appear to have positively or negatively affected in-hospital mortality from congestive heart failure, acute myocardial infarction, or pneumonia in teaching hospitals.
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Affiliation(s)
- David L Howard
- Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Abstract
BACKGROUND It is important for both researchers and clinicians to know the spectral composition of the light that reaches the retina. With this in mind, Johnson et al. developed a quick, objective instrument called the Lens Absorption Monitor (LAM) to measure the attenuation of light by the ocular media. Using a more refined method of measuring and correcting for scatter, we compared the results of the LAM against those with a subjective method utilizing a bipartite scotopic brightness-matching procedure (BIP). METHODS We tested 41 healthy subjects (mean age, 35.9 years) with the LAM and BIP. RESULTS Intereye correlation coefficients for the LAM were 0.70 at 410 nm and 0.83 at both 430 and 450 nm; for BIP, intereye correlation coefficients were 0.56 at 410 nm, 0.42 at 430 nm, and 0.38 at 450 nm. For optical density as a function of age, there was no statistically significant difference between the two instruments at 410 nm in either the slope (p > 0.43) or y intercept (p > 0.75). However, at both 430 and 450 nm, there was a significant difference in both slope (p < 0.001) and y intercept (p < 0.05) for the two instruments. CONCLUSIONS With the latest refinements, LAM density measures correlated well with BIP estimates at 410 nm, but not at 430 or 450 nm. This underscores the fact that the LAM measures the spectral density of the anterior segment, whereas the BIP method is a measure of all the ocular media except for macular pigment. The difference between these two measures is consistent with the existence of a prereceptoral, presumably intraretinal, pigment (or pigments) located outside the anatomic fovea that absorbs light at short wavelengths.
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Affiliation(s)
- G L Savage
- College of Optometry, University of Houston, Texas 77204-6052, USA.
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Spry PG, Gibbs ML, Johnson CA, Howard DL. Frequency doubling perimetry using a liquid crystal display. Am J Ophthalmol 2001; 131:332-8. [PMID: 11239865 DOI: 10.1016/s0002-9394(00)00803-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare frequency doubling contrast thresholds using a new liquid crystal window display with those obtained with the commercial video-based Frequency Doubling Technology perimeter. METHODS One eye of 49 glaucoma patients and one eye of 49 normal controls were tested with the liquid crystal window and Frequency Doubling Technology systems. Both displays employed identical stimulus conditions and test strategies, although the dynamic range of the liquid crystal window-based display was approximately 30% smaller than that of the Frequency Doubling Technology system. Measurements were repeated using the video-based Frequency Doubling Technology perimeter in a subset of 21 eyes. Relationships between and within displays were assessed using a chance-corrected agreement measure (quadratic weighted kappa) and paired measurement differences. Variability was quantified using standard deviation from the mean paired measurement difference. RESULTS Over the restricted operating range of the liquid crystal display system, between-display and within-video display variability was 2.3 dB and 3.2 dB, respectively, between-display agreement was 0.66, and within-display agreement (test-retest for Frequency Doubling Technology) was 0.65. CONCLUSIONS Levels of agreement and variability between the two frequency doubling displays were of similar magnitude to repeated (test-retest) Frequency Doubling Technology measures, suggesting that contrast threshold measurements made using the two displays may be used interchangeably. However, the operating range of the current liquid crystal window-based display is smaller.
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Affiliation(s)
- P G Spry
- Discoveries in Sight, Devers Eye Institute, 1225 NE 2nd Ave, Portland, Oregon 92732, USA
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Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, Kasper EK. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077-84. [PMID: 10760308 DOI: 10.1056/nejm200004133421502] [Citation(s) in RCA: 1073] [Impact Index Per Article: 44.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Previous studies of the prognosis of patients with heart failure due to cardiomyopathy categorized patients according to whether they had ischemic or nonischemic disease. The prognostic value of identifying more specific underlying causes of cardiomyopathy is unknown. METHODS We evaluated the outcomes of 1230 patients with cardiomyopathy. The patients were grouped into the following categories according to underlying cause: idiopathic cardiomyopathy (616 patients), peripartum cardiomyopathy (51); and cardiomyopathy due to myocarditis (111), ischemic heart disease (91), infiltrative myocardial disease (59), hypertension (49), human immunodeficiency virus (HIV) infection (45), connective-tissue disease (39), substance abuse (37), therapy with doxorubicin (15), and other causes (117). Cox proportional-hazards analysis was used to assess the association between the underlying cause of cardiomyopathy and survival. RESULTS During a mean follow-up of 4.4 years, 417 patients died and 57 underwent cardiac transplantation. As compared with the patients with idiopathic cardiomyopathy, the patients with peripartum cardiomyopathy had better survival (adjusted hazard ratio for death, 0.31; 95 percent confidence interval, 0.09 to 0.98), and survival was significantly worse among the patients with cardiomyopathy due to infiltrative myocardial disease (adjusted hazard ratio, 4.40; 95 percent confidence interval, 3.04 to 6.39), HIV infection (adjusted hazard ratio, 5.86; 95 percent confidence interval, 3.92 to 8.77), therapy with doxorubicin (adjusted hazard ratio, 3.46; 95 percent confidence interval, 1.67 to 7.18), and ischemic heart disease (adjusted hazard ratio, 1.52; 95 percent confidence interval, 1.07 to 2.17). CONCLUSIONS The underlying cause of heart failure has prognostic value in patients with unexplained cardiomyopathy. Patients with peripartum cardiomyopathy appear to have a better prognosis than those with other forms of cardiomyopathy. Patients with cardiomyopathy due to infiltrative myocardial diseases, HIV infection, or doxorubicin therapy have an especially poor prognosis.
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Affiliation(s)
- G M Felker
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ma JF, Grant G, Staelens B, Howard DL, Melera PW. In vitro translation of a 2.3-kb splicing variant of the hamster pgp1 gene whose presence in transfectants is associated with decreased drug resistance. Cancer Chemother Pharmacol 1999; 43:19-28. [PMID: 9923537 DOI: 10.1007/s002800050858] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE P-glycoprotein (P-gp), a product of the Chinese hamster pgpl gene, confers multidrug resistance to mammalian cells in which it is overexpressed either by transfection or as a result of drug selection. It is encoded by a 4.3-kb mRNA and in its unglycosylated form has a predicted molecular weight of approximately 141 kDa. When a cDNA containing this sequence is transfected into drug-sensitive Chinese hamster lung cells and is expressed under the control of the beta-actin promoter, both the full-length 4.3-kb mRNA and a 2.3-kb transcript are produced. The latter results from a splicing event that utilizes near consensus 5' and 3' splicing signals resident in the full-length mRNA, and it has also been found to be present in cell lines that express the native gene. Therefore, it is a splicing product of pgpl per se. This report is concerned with the biological relevance of this transcript. METHODS In vitro transcription and translation experiments were used to show that the putative open reading frame of the 2.3-kb transcript encodes a novel 57-kDa protein (p57pgp1) that contains transmembrane domains 9-12 and the C-terminal ATP binding fold of P-gp. To elucidate the function of p57pgp1, expression vectors containing cDNAs representing (1) the 2.3-kb transcript, (2) the full-length 4.3-kb mRNA, and (3) a splice-disabled 4.3-kb transcript in which production of the 2.3-kb transcript is eliminated by an in-frame mutation at the 3' splice site, were constructed and transfected into DC-3F cells. Additional expression vectors in which p57pgp1 represented the N-terminus of a green fluorescent protein fusion construct were also prepared and used for transient expression studies. RESULTS Overexpression of the 2.3-kb transcript alone did not confer multidrug resistance. Transfectants in which both the 4.3-kb transcript and the 2.3-kb transcript were present, compared with transfectants in which no 2.3-kb transcript was expressed, but in which the level of expression of the 4.3-kb mRNA alone was the same, showed little change in cross-resistance pattern. However, the overall level of resistance in the latter cells was increased by approximately twofold. Hence the presence of the 2.3-kb transcript was associated with a decrease in drug resistance. In vitro transcription and translation experiments and transient expression studies indicate that p57pgp1 can be expressed both in vitro and in vivo. CONCLUSION These results demonstrate that a splicing variant of pgp1 contains an open reading frame capable of translation in vitro and in vivo and suggest that alterations in splicing may contribute both directly and indirectly to the overall mechanism of pgp1-mediated multidrug resistance in CHL cells.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1/biosynthesis
- ATP Binding Cassette Transporter, Subfamily B, Member 1/chemistry
- ATP Binding Cassette Transporter, Subfamily B, Member 1/genetics
- Alternative Splicing
- Animals
- Blotting, Northern
- Blotting, Western
- Cricetinae
- Cricetulus
- DNA Transposable Elements
- Drug Resistance, Multiple
- Drug Resistance, Neoplasm
- Gene Expression Regulation, Neoplastic/genetics
- Green Fluorescent Proteins
- Luminescent Proteins/genetics
- Molecular Weight
- Protein Biosynthesis
- RNA, Messenger/biosynthesis
- RNA, Neoplasm/biosynthesis
- Recombinant Fusion Proteins/biosynthesis
- Transfection
- Tumor Cells, Cultured
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Affiliation(s)
- J F Ma
- Graduate Program in Molecular and Cell Biology, University of Maryland School of Medicine, Baltimore 21201, USA
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Howard DL, Penchansky R, Brown MB. Disaggregating the effects of race on breast cancer survival. Fam Med 1998; 30:228-35. [PMID: 9532448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND OBJECTIVES This study examines differences in breast cancer survival between African-American and white women to determine whether there is a racial difference in survival after accounting for established influences on outcome, such as stage of cancer, health status, health behavior, utilization patterns, access to care, quality of care, and the doctor-patient relationship. METHODS This study is a retrospective review of clinical records. The sample consists of 246 patients of three staff model HMOs who had mastectomies at stage II or above. Data on patient demographics, stage of cancer, health status, and health behavior and utilization, including preventive care, were extracted from patient records. Multivariate logistic regression was used to predict the determinants of advanced stage of cancer. Cox survival analysis was used to predict the determinants of survival. RESULTS Missed appointments and stage of cancer were the key determinants of survival. The effect of race on survival was marginal after adjusting for these factors. Race, patients who missed appointments, and patients who delayed in reporting breast cancer symptoms were determinants of advanced stage. African-Americans were overrepresented among patients who missed appointments. CONCLUSIONS Missed appointments was a determinant of both advanced stage and shorter survival. This measure is an important component of how race affects survival. Compliance with appointment keeping and alleviating reasons for noncompliance must be considered as factors in breast cancer survival.
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Affiliation(s)
- D L Howard
- University of North Carolina at Chapel Hill, USA.
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Abstract
To study macrophage genes activated by lipopolysaccharide (LPS) we have constructed a cDNA library using the mouse macrophage cell line, RAW 264.7. By differential screening, a gene, designated LRG-21, was identified that showed nucleic acid sequence homology to rat liver regenerating factor-1 (LRF-1) and human activating transcription factor-3 (ATF3). Both LRG-21 and LRF-1 are transcribed within an hour following stimulation and in the absence of protein synthesis. The predicted protein sequence of LRG-21 consists of 181 amino acids with a molecular weight of 20.7 kDa. All three sequences contain basic and leucine zipper regions characteristic of the c-Fos and c-Jun family of transcription factors, but the remainder of the sequences are unrelated to this family. Recombinant LRG-21 has been shown to bind to a phorbol ester promoter element. Additional experiments have shown that LRG-21 is also induced by interferon-gamma (IFN-gamma) and by interleukin-4 (IL-4) in both RAW264.7 cells and murine peritoneal macrophages. Based on these observations, it is likely that LRG-21 plays an important role in macrophage activation.
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Affiliation(s)
- B E Drysdale
- Department of Research Service, Baltimore VA Medical Center, MD 21201, USA
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Abstract
Do outpatient substance misuse treatment organizations have different outcomes for court-mandated and voluntary clients depending on the mix of those clients? Do client characteristics, organizational factors, and treatment practices predict organizational treatment outcome rates? A nationally representative sample of 330 nonmethadone outpatient substance misuse treatment organizations was surveyed in 1990. Sixty-four of the organizations had 75% or more court-mandated clients; 122 of the organizations had 25% or less court-mandated clients. Organizations with 75% or greater court-mandated clients had a greater rate of clients failing to comply with their treatment plan than organizations with 25% or less court-mandated clients, but there were no differences in clients meeting the goals of their treatment. Client characteristics, organizational factors, and treatment practices are evaluated through multivariate regression to determine their impact on organizational rates of treatment success and failure among clients.
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Affiliation(s)
- D L Howard
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio 44106-4945, USA
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Howard DL, LaVeist TA, McCaughrin WC. The effect of social environment on treatment outcomes in outpatient substance misuse treatment organizations: does race really matter? Subst Use Misuse 1996; 31:617-38. [PMID: 8777742 DOI: 10.3109/10826089609045830] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study examines whether the racial mix of clients is related to treatment organization outcome rates after controlling for the social environment in which the organization operates. A nationally representative sample of 326 nonmethadone outpatient substance misuser treatment organizations was surveyed in 1990. Unit analysis is the treatment organization. Outcome measures are the percentages of clients who completed and dropped out of treatment. The percent of Black clients treated at the organization, the socioeconomic status of the organization's area, and other client characteristics, organizational factors, and treatment practices are evaluated through multivariate regression to determine their impact on organizational rates of treatment success and failure among clients. Ordinary least-squares regression analysis indicates that race is not a predictor of treatment success once socioenvironmental factors are included in the analysis. Treatment organizations must be wary of defining a person for treatment only in terms of his or her racial or ethnic group membership. Treatment approaches should place more emphasis on the socioenvironmental influences to which the client is exposed and less emphasis on a client's race.
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Affiliation(s)
- D L Howard
- Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, OH 44106-4945, USA
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Abstract
Access is a multidimensional concept representing the ease with which health services are initiated and sustained. In this study, conceptual domains of access--affordability, acceptability, accommodation, availability, service diversity, and competitive stance--are hypothesized to predict the time clients wait to receive services. A large, recently surveyed, nationally representative sample of outpatient substance abuse treatment organizations provided the data. Multivariate regression analysis of 326 organizations was conducted with the conceptual domains sequentially predicting the time clients waited to receive service. Results show that increased waiting time was positively associated with treatment staff case overload and the average number of months clients spent in treatment and negatively associated with the percent of a treatment organization's client base on public assistance. Implications for policy makers and clinicians concerning client selection strategies by organizations and problems with the organizational capacity to treat clients are discussed. Areas for future research also are highlighted.
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Affiliation(s)
- W C McCaughrin
- Department of Health Care Administration, Trinity University, San Antonio, TX 78212, USA
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Sorace JM, Johnson RJ, Howard DL, Drysdale BE. Identification of an endotoxin and IFN-inducible cDNA: possible identification of a novel protein family. J Leukoc Biol 1995; 58:477-84. [PMID: 7561525 DOI: 10.1002/jlb.58.4.477] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
The response of macrophages to agents such as lipopolysaccharide (LPS) and interferon (IFN) includes the transcriptional activation of numerous genes. We have used the method of differential screening of a RAW 264.7 macrophage cell line cDNA library to isolate and characterize LPS-induced messages. One such message, LRG-47, is induced by LPS, IFN-gamma, and IFN-alpha/beta, but not by a panel of other cytokines or pharmacological activating agents. LRG-47 is homologous to two other IFN-gamma-induced genes, IRG-47 and Mg21. The LRG-47 sequence is approximately 33% identical and 52% similar to both these putative protein products. All three putative proteins, particularly Mg21, bear homology to a T cell product, Tgtp, induced by T cell receptor cross-linking. The three macrophage-derived proteins share areas of homology with GTP-binding proteins, are approximately 415 amino acids in length, and have similar kinetics of induction by IFN-gamma. This suggests that these genes may be members of a new family of IFN-inducible proteins.
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Affiliation(s)
- J M Sorace
- Department of Pathology, Baltimore VA Medical Center, Maryland 21201, USA
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Abstract
The Lens Absorption Monitor (LAM) is an automated video-based system for obtaining rapid objective noninvasive measurements of the spectral transmission properties of the human lens. The technique is based on intensity measurements of the 4th Purkinje image for different wavelengths, and incorporates several features that overcome some of the difficulties associated with previous studies using this approach. LAM transmission measures for the visible spectrum can be obtained in approximately 2 s, and in most instances can be obtained without having to dilate the subject's eye. This paper describes the technique and presents our initial findings for 40 normal observers between the ages of 24 and 77 years. Results of the LAM technique show that it is able to measure the wavelength-dependent properties of the lens accurately and to identify age-related changes in "yellowing" of the lens. Test-retest reliability of the LAM is better than for psychophysical estimates of ocular media transmission. LAM and psychophysical measures in the same subjects were found to be correlated, although LAM measures produced consistently lower values of lens density than the psychophysical determinations. There was only moderate agreement between LAM and psychophysical measures of lens density. Possible explanations for these differences are discussed. Future research will determine whether this technique is able to detect and quantify early cataract development.
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Affiliation(s)
- C A Johnson
- Department of Ophthalmology, University of California, Davis
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Schertel ER, Schneider DA, Howard DL, Green JF. A phrenic nerve-actuated electronically controlled positive-pressure ventilator. J Appl Physiol (1985) 1987; 62:2121-5. [PMID: 3298199 DOI: 10.1152/jappl.1987.62.5.2121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
We have constructed an electronically controlled positive-pressure ventilator actuated by phrenic neural activity for use in open-chested or paralyzed experimental animals for the study of breathing pattern. A Bird Mark 14 positive-pressure ventilator was modified such that flow is a linear function of a command signal. Flow is delivered by advancing an air valve with a servo-motor that is controlled by one of three different operational modes. In two of the modes, the difference between the electronic average of inspiratory phrenic activity (moving average) and a feedback signal determines the inspiratory flow. The feedback signal is derived from either tracheal pressure or an electronic measure of inspired volume. In the third mode, the moving average is differentiated to provide control of inspiratory flow and volume. Physiological flow profiles were created using all three operational modes. Integration of an air-valve position signal provides an electronic measure of tidal volume. An additional feature of this ventilator allows inspiratory flow and duration to be predetermined for a given breath.
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50
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Howard DL. Group therapy for amputees in a ward setting. Mil Med 1983; 148:678-80. [PMID: 6415526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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