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Gallen K, Sonnenberg J, Loughran C, Smith MJ, Sheppard M, Schuster K, Kaufman E, Song JS, Hall EC. Health Effects of Policing in Hospitals: a Narrative Review. J Racial Ethn Health Disparities 2023; 10:870-882. [PMID: 35267188 DOI: 10.1007/s40615-022-01275-w] [Citation(s) in RCA: 1] [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: 12/08/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/25/2022]
Abstract
IMPORTANCE Law enforcement activity, in the form of outside agencies or hospital security forces, is increasingly common in American healthcare. Little is known about the potential effects of this prevalent, modifiable exposure on hospital staff and patient health. This narrative review characterizes existing evidence on the direct and indirect health effects of law enforcement activity in hospitals. OBSERVATIONS Law enforcement activity in hospitals can affect health outcomes through four mechanisms: (1) physical health effects related to workplace violence, restraint use, excessive force, and weapon use; (2) mental health effects involving perceptions of safety and psychological distress; (3) social effects related to the patient-provider relationship, mistrust, and bias and discrimination; and (4) legal and ethical considerations affecting overall well-being. CONCLUSIONS AND RELEVANCE Unchecked law enforcement activity in hospitals may risk patient physical and mental health, reduce patient trust, result in bias and discrimination, and contribute to legal and ethical rights violations. Importantly, law enforcement activity in hospitals may also contribute to staff perceptions of safety. To fill knowledge gaps on the measurable impact of law enforcement activity in the hospital on staff and patients, hospitals should collect and publicly share robust data on law enforcement activity in their facilities, create and adopt patient-centered policies to ensure safety and protect patient health and privacy, and implement evidence-based interventions that safely reduce law enforcement involvement with patients.
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Affiliation(s)
- Kate Gallen
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Jake Sonnenberg
- University of California San Francisco School of Medicine, San Francisco, CA, USA
| | | | | | - Mildred Sheppard
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, DC, 20010, USA
| | - Kirsten Schuster
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA
| | - Elinore Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Ji Seon Song
- School of Law, University of California, Irvine, CA, USA
| | - Erin C Hall
- Division of Trauma, Department of Surgery, Georgetown University School of Medicine, Washington, DC, USA.
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, DC, 20010, USA.
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Kaufman EJ, Khatri U, Hall EC, Alur R, Song J, Beard JH, Jacoby SF. Law enforcement in the trauma bay: a survey of members of the American Academy for the Surgery of Trauma. Trauma Surg Acute Care Open 2023; 8:e001022. [PMID: 36937171 PMCID: PMC10016311 DOI: 10.1136/tsaco-2022-001022] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/20/2023] [Indexed: 03/14/2023] Open
Abstract
Background Trauma patients frequently come into contact with law enforcement officers (LEOs) during the course of their medical care, but little is known about how LEO presence affects processes of care. We surveyed members of the American Association for the Surgery of Trauma (AAST) to assess their perspectives on frequency, circumstances, and implications of LEO presence in trauma bays nationwide. Methods Survey items addressed respondents' experience with the frequency and context of LEO presence and their perspectives on the impact of LEO presence for patients, clinical care, and public safety. Respondent demographics, professional characteristics, and practice setting were collected. The survey was distributed electronically to AAST members in September and October of 2020. Responses were compared by participant age, gender, race, ethnicity, urban versus rural location using χ2 tests. Results Of 234 respondents, 189 (80.7%) were attending surgeons, 169 (72.2%) identified as white, and 144 (61.5%) as male. 187 respondents (79.9%) observed LEO presence at least weekly. Respondents found LEO presence was most helpful for public safety, followed by clinical care, and then for patients. Older respondents rated LEO presence as helpful more often than younger respondents regarding the impact on patients, clinical care, and public safety (p<0.001 across all domains). When determining LEO access, respondents assessed severity of the patient's condition, the safety of emergency department staff, the safety of LEOs, and a patient's potential role as a threat to public safety. Conclusions Respondents described a wide range of perspectives on the impact and consequence of LEO in the trauma bay, with little policy to guide interactions. The overlap of law enforcement and healthcare in the trauma bay deserves attention from institutional and professional policymakers to preserve patient safety and autonomy and patient-centered care. Level of evidence IV, survey study.
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Affiliation(s)
- Elinore J Kaufman
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Utsha Khatri
- Department of Emergency Medicine, Mount Sinai School of Medicine, New York, New York, USA
| | - Erin C Hall
- Department of Surgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Rucha Alur
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jamie Song
- Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica H Beard
- Division of Trauma Surgery and Surgical Critical Care, Temple University Lewis Katz School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara F Jacoby
- School of Nursing, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Gallen KM, Smith MJ, Crane J, Loughran C, Schuster K, Sonnenberg J, Reese M, Girard VW, Song JS, Hall EC. Law Enforcement and Patient Privacy Among Survivors of Violence: A Nationwide Mixed-Methods Study. J Surg Res 2023; 283:648-657. [PMID: 36455418 DOI: 10.1016/j.jss.2022.11.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 03/01/2022] [Revised: 10/31/2022] [Accepted: 11/06/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION During the emergent treatment of violently injured patients, law enforcement (LE) officers and health care providers frequently interact. Both have duties to protect patient health, rights, and public health, however, the balance of these duties may feel at odds. The purpose of this study is to assess hospital-based violence intervention program (HVIP) representatives' experiences with LE officers among survivors of violence and the impact of hospital policies on interactions with LE officers. MATERIALS AND METHODS A nationwide survey was distributed to the 35 HVIPs that form the Health Alliance for Violence Intervention. Data regarding respondent affiliation, programs, and perceptions of hospital policies outlining LE activity were collected. Follow-up video interviews were open coded and qualitatively analyzed using grounded theory. RESULTS Respondents from 32 HVIPs completed the survey (91%), and 22 interviews (63%) were conducted. Common themes from interviews were: police-patient interactions; racism, bias, and victims' treatment as suspects; and training and education. Only 39% of respondents knew that policies existed and were familiar with them. Most representatives believed their hospitals' existing policies were inadequate, ineffective, or biased. Programs that reported good working relationships with LE officers offered insight on how their programs maintain these partnerships and work with LE officers towards a common goal. CONCLUSIONS Unclear or inadequate policies relating to LE activity may jeopardize the health and privacy of violently injured patients. Primary areas identified for improvement include clarifying and revising hospital policies, education of staff and LE officers, and improved communication between health care providers and LE officers to better protect patient rights.
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Affiliation(s)
- Kate M Gallen
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Michael J Smith
- Georgetown University Law Center, Washington, District of Columbia
| | - Joshua Crane
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Carly Loughran
- Georgetown University Law Center, Washington, District of Columbia
| | - Kirsten Schuster
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Jake Sonnenberg
- University of California San Francisco School of Medicine, San Francisco, California
| | - Mildred Reese
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, District of Columbia
| | - Vicki W Girard
- Georgetown University Law Center, Washington, District of Columbia
| | - Ji Seon Song
- University of California, Irvine School of Law, Irvine, California
| | - Erin C Hall
- Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, District of Columbia.
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Gallen K, Loughran C, Smith MJ, Schille C, Schuster K, Reese M, Sonnenberg J, Song JS, Kaufman E, Hall EC. Addressing Legal Needs as Violence Prevention: A National Survey of Legal Services Offered through Hospital-based Violence Intervention Programs. J Health Care Poor Underserved 2023; 34:1427-1444. [PMID: 38661765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Hospital-based violence intervention programs (HVIPs) provide comprehensive services to survivors of community violence to address social determinants of health (SDOH) as risks factors for future violence. Medical-legal partnerships (MLPs) integrate lawyers into health care teams to address SDOH through the application of the law. Despite shared purposes, it is unknown if HVIP-MLPs exist. We sought to quantify the existing landscape of legal services provided by HVIPs, identify HVIP-MLPs, and characterize barriers to formation. Surveys and interviews were conducted in 2020 with 35 HVIPs of the Health Alliance for Violence Intervention (HAVI) concerning civil legal services. Most HVIPs screened for civil legal needs though none had an official MLP. Common civil legal needs included housing, mental health, and education. Barriers included no memorandum of understanding, legal confusion, funding, and overwhelming need. In 2021, no HVIP-MLP partnerships existed within HAVI. Establishing HVIP-MLPs may further support survivors of violence and address health inequity.
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Hall EC, Current J, Sava JA, Rosen JE. The Case for Integrating Medical-Legal Partnerships Into Trauma Care. J Surg Res 2022; 274:153-159. [DOI: 10.1016/j.jss.2021.12.043] [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] [Received: 06/22/2021] [Revised: 12/07/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
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Bailey JA, Jacoby SF, Hall EC, Khatri U, Whitehorn G, Kaufman EJ. Compounding Trauma: the Intersections of Racism, Law Enforcement, and Injury. Curr Trauma Rep 2022; 8:105-112. [PMID: 35578594 PMCID: PMC9096065 DOI: 10.1007/s40719-022-00231-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2022] [Indexed: 11/24/2022]
Abstract
Purpose of Review
Traumatic injury sits at the nexus of law enforcement and structural racism. This narrative review aims to explore the major impacts of law enforcement on health, its intersections with US structural racism, and their joint impacts on traumatic injury and injury care. Recent Findings Many of the same forces of systemic disadvantage that put Black people, other people of color, and other marginalized groups at risk for violent injury also expose these same individuals and communities to intensive policing. Recent evidence speaks to the broad impact of police exposure and police violence on individual and community physical and mental health. Moreover, injured patients who are exposed to law enforcement during their care are at risk for erosion of trust in and relationships with their healthcare providers. To optimize the role of law enforcement agencies in injury prevention, collaboration across sectors and with communities is essential. Summary A broad approach to the prevention of injury and violence must incorporate an understanding of the intersecting impacts of law enforcement and structural racism on health and traumatic injury. Clinicians who seek to provide trauma-informed injury care should incorporate an understanding of the role of law enforcement in individual and community health.
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Affiliation(s)
- Joanelle A. Bailey
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Sara F. Jacoby
- University of Pennsylvania School of Nursing, Philadelphia, PA USA
| | - Erin C. Hall
- Trauma Surgery and Critical Care Medicine, MedStar Health, Washington, DC USA
| | - Utsha Khatri
- Department of Emergency Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Gregory Whitehorn
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
| | - Elinore J. Kaufman
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA USA
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Hall EC, Gallen K, Smith M, Sheppard M, Schuster KA, Girard V. Integration of Civil Legal Services into Hospital-Based Violence Intervention Programs. J Am Coll Surg 2021. [DOI: 10.1016/j.jamcollsurg.2021.07.615] [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: 11/25/2022]
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Njus MM, Vil CS, Sheppard M, Hall EC. Hospital-Based Violence Intervention Programs: An Essential Relief System in the COVID-19 Pandemic. J Am Coll Surg 2021. [PMCID: PMC8531702 DOI: 10.1016/j.jamcollsurg.2021.07.613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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St Vil C, Hall EC, Sheppard M, Williams M. Testing the efficacy of a hospital-based violence intervention programme: protocol and design. Inj Prev 2020; 27:injuryprev-2020-044026. [PMID: 33328172 DOI: 10.1136/injuryprev-2020-044026] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/22/2020] [Accepted: 11/27/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Hospital-based violence intervention programmes (HBVIPs) are a promising strategy to reduce trauma recidivism and promote safety among victims of violent injury. While previous studies have demonstrated cost-effectiveness and positive impact on the lives of victims, there are a number of key limitations in the study designs of this evidence base. This study seeks to address the methodological shortcomings of previous research, determine the efficacy of HBVIPs using a randomised control study design, and provide a better understanding of successful service allocation within an HBVIP. METHODS AND ANALYSIS The current study is 1 of 12 demonstration projects being implemented around the country with the purpose of bolstering the ability to provide effective, culturally appropriate and trauma-informed services for boys and men harmed by violence. We propose a randomised control trial in which male victims of violence receive one of two interventions: treatment as usual versus enhanced services. The purpose is to determine which intervention leads to reductions in trauma recidivism over the period of 1 year from contact with the programme. Differences will also be monitored on measures of mental health, quality of life and attitudes towards violence. Analyses employed will include Kaplan-Meier analysis and Cox proportional hazards regression with death and recidivism being the outcomes of interest. ETHICS AND DISSEMINATION Study procedures have been approved by the Institutional Review Boards of the University at Buffalo and four hospitals. Results will be submitted for publication in peer-reviewed journals.
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Affiliation(s)
- Christopher St Vil
- School of Social Work, University at Buffalo - The State University of New York, Buffalo, New York, USA
- Harborview Injury Prevention & Research Center, Seattle, Washington, USA
| | - Erin C Hall
- Department of Surgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Mildred Sheppard
- Community Violence Intervention Program, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Mallory Williams
- Department of Surgery, Howard University College of Medicine, Washington, District of Columbia, USA
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Sakran JV, Ezzeddine H, Schwab CW, Bonne S, Brasel KJ, Burd RS, Cuschieri J, Ficke J, Gaines BA, Giacino JT, Gibran NS, Haider A, Hall EC, Herrera-Escobar JP, Joseph B, Kao L, Kurowski BG, Livingston D, Mandell SP, Nehra D, Sarani B, Seamon M, Yonclas P, Zarzaur B, Stewart R, Bulger E, Nathens AB. Proceedings from the Consensus Conference on Trauma Patient-Reported Outcome Measures. J Am Coll Surg 2020; 230:819-835. [PMID: 32201197 DOI: 10.1016/j.jamcollsurg.2020.01.032] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 01/07/2020] [Indexed: 11/24/2022]
Affiliation(s)
- Joseph V Sakran
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Hiba Ezzeddine
- Division of Acute Care Surgery, Departments of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - C William Schwab
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Stephanie Bonne
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Karen J Brasel
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Oregon Health Sciences University, Portland, OR
| | - Randall S Burd
- Division of Trauma and Burn Surgery, Department of Surgery, Children's National Medical Center, Washington, DC
| | - Joseph Cuschieri
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - James Ficke
- Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barbara A Gaines
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh; University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Joseph T Giacino
- Division of Rehabilitation Neuropsychology, Department of Physical Medicine and Rehabilitation, Massachusetts General Hospital, Harvard Medical School, Charlestown
| | - Nicole S Gibran
- Division of Restorative Burn Surgery, Division of Trauma, Burn
| | - Adil Haider
- Medical College in Pakistan, The Aga Khan University, Karachi, Pakistan
| | - Erin C Hall
- MedStar Washington Hospital Center, Washington, DC; Department of Surgery, Washington, DC
| | - Juan P Herrera-Escobar
- Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Bellal Joseph
- Division of Trauma, Acute Care, Burn and Emergency Surgery, Department of Surgery, the University of Arizona College of Medicine, Tucson, AZ
| | - Lillian Kao
- Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, McGovern Medical School, Houston
| | - Brad G Kurowski
- Division of Physical Medicine and Rehabilitation, Cincinnati Children's Hospital Medical Center; Department of Pediatrics and Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Livingston
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Samuel P Mandell
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Deepika Nehra
- Divisions of Trauma, Burn, and Critical Care, Division of Trauma, Burn
| | - Babak Sarani
- Division of Trauma and Acute Care Surgery (Sarani), Georgetown University School of Medicine, Washington, DC
| | - Mark Seamon
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perlman School of Medicine, University of Pennsylvania, Philadelphia
| | - Peter Yonclas
- Division of Trauma, Department of Surgery, New Jersey Medical School Rutgers, Newark, NJ
| | - Ben Zarzaur
- Division of Acute Care and Regional General Surgery, Department of Surgery, University of Wisconsin School of Medicine, Madison, WI
| | - Ronald Stewart
- Department of Surgery, University of Texas Health San Antonio, San Antonio, TX; Committee on Trauma, Chicago, IL
| | - Eileen Bulger
- Critical Care, Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA; Committee on Trauma, Chicago, IL
| | - Avery B Nathens
- American College of Surgeons; Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Abstract
BACKGROUND We have previously demonstrated effectiveness of a Trauma Transitional Care Coordination (TTCC) Program in reducing 30-day readmission rates for trauma patients most at risk. With program maturation, we achieved improved readmission rates for specific patient populations. METHODS TTCC is a nursing driven program that supports patients at high risk for 30-day readmission. The TTCC interventions include calls to patients within 72 hours of discharge, complete medication reconciliation, coordination of medical appointments, and individualized problem solving. Account IDs were used to link TTCC patients with the Health Services Cost Review Commission database to collect data on statewide unplanned 30-day readmissions. RESULTS Four hundred seventy-five patients were enrolled in the TTCC program from January 2014 to September 2016. Only 10.5% (n = 50) of TTCC enrollees were privately insured, 54.5% had Medicaid (n = 259), and 13.5% had Medicare (n = 64). Seventy-three percent had Health Services Cost Review Commission severity of injury ratings of 3 or 4 (maximum severity of injury = 4). The most common All Patient Refined Diagnosis Related Groups for participants were: lower-extremity procedures (n = 67, 14%); extensive abdominal/thoracic procedures (n = 40, 8.4%); musculoskeletal procedures (n = 37, 7.8%); complicated tracheostomy and upper extremity procedures (n = 29 each, 6.1%); infectious disease complications (n = 14, 2.9%); major chest/respiratory trauma, major small and large bowel procedures and vascular procedures (n = 13 each, 2.7%). The TTCC participants with lower-extremity injury, complicated tracheostomy, and bowel procedures had 6-point reduction (10% vs. 16%, p = 0.05), 11-point reduction (13% vs. 24%, p = 0.05), and 16-point reduction (11% vs. 27%, p = 0.05) in 30-day readmission rates, respectively, compared to those without TTCC. CONCLUSION Targeted outpatient support for high-risk patients can decrease 30-day readmission rates. As our TTCC program matured, we reduced 30-day readmission in patients with lower-extremity injury, complicated tracheostomy and bowel procedures. This represents over one million-dollar savings for the hospital per year through quality-based reimbursement. LEVEL OF EVIDENCE Therapeutic/care management, level III.
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Affiliation(s)
- Erin C Hall
- From the Department of Surgery (E.C.H.), MedStar Washington Hospital Center, Washington, DC; Department of Surgery (E.C.H.), Georgetown University School of Medicine, Washington, DC. R Adams Cowley Shock Trauma Center (R.T., K.D., T.M.S., D.M.S.), University of Maryland School of Medicine, Baltimore, Maryland
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12
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Hall EC, Tyrrell R, Scalea TM, Stein DM. Trauma Transitional Care Coordination: protecting the most vulnerable trauma patients from hospital readmission. Trauma Surg Acute Care Open 2018; 3:e000149. [PMID: 29766133 PMCID: PMC5887824 DOI: 10.1136/tsaco-2017-000149] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 01/12/2018] [Accepted: 01/16/2018] [Indexed: 12/17/2022] Open
Abstract
Background Unplanned hospital readmissions increase healthcare costs and patient morbidity. We hypothesized that a program designed to reduce trauma readmissions would be effective. Methods A Trauma Transitional Care Coordination (TTCC) program was created to support patients at high risk for readmission. TTCC interventions included call to patient (or caregiver) within 72 hours of discharge to identify barriers to care, complete medication reconciliation, coordination of appointments, and individualized problem solving. Information on all 30-day readmissions was collected. 30-day readmission rates were compared with center-specific readmission rates and population-based, risk-adjusted rates of readmission using published benchmarks. Results 260 patients were enrolled in the TTCC program from January 2014 to September 2015. 30.8% (n=80) of enrollees were uninsured, 41.9% (n=109) reported current substance abuse, and 26.9% (n=70) had a current psychiatric diagnosis. 74.2% (n=193) attended outpatient trauma appointments within 14 days of discharge. 96.3% were successfully followed. Only 6.6% (n=16) of patients were readmitted in the first 30 days after discharge. This was significantly lower than both center-specific readmission rates before start of the program (6.6% vs. 11.3%, P=0.02) and recently published population-based trauma readmission rates (6.6% vs. 27%, P<0.001). Discussion A nursing-led TTCC program successfully followed patients and was associated with a significant decrease in 30-day readmission rates for patients with high-risk trauma. Targeted outpatient support for these most vulnerable patients can lead to better utilization of outpatient resources, increased patient satisfaction, and more consistent attainment of preinjury level of functioning or better. Level of evidence Level IV.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Division of Trauma, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Rebecca Tyrrell
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Thomas M Scalea
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Deborah M Stein
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Hong YK, Zheng C, Langan RC, Hechenbleikner EM, Hall EC, Johnson LB, Shara NM, Al-Refaie WB. Minority-Serving Hospitals and Cancer Surgery Readmissions: A Reason for Concern. J Am Coll Surg 2015. [DOI: 10.1016/j.jamcollsurg.2015.07.306] [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: 11/29/2022]
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Abstract
BACKGROUND Induction immunosuppression is a mainstay of rejection prevention after transplantation. Studies have suggested a connection between antibody induction agents and cancer development, potentially limiting important immunosuppression protocols. METHODS We used a linkage of U.S. transplantation data and cancer registries to explore the relationship between induction and cancer after transplantation. A total of 111,857 kidney recipients (1987-2009) in the Transplant Cancer Match Study, which links the Scientific Registry for Transplant Recipients and U.S. Cancer Registries, were included. Poisson regression models were used to estimate adjusted incidence rate ratios (aIRR) of non-Hodgkin lymphoma (NHL) and other cancers with increased incidence after transplantation (lung, colorectal, kidney, and thyroid cancers, plus melanoma). RESULTS Two thousand seven hundred sixty-three cancers of interest were identified. Muromonab-CD3 was associated with increased NHL (aIRR, 1.37; 95% CI, 1.06-1.76). Alemtuzumab was associated with increased NHL (aIRR, 1.79; 95% CI, 1.02-3.14), colorectal cancer (aIRR, 2.46; 95% CI, 1.03-5.91), and thyroid cancer (aIRR, 3.37; 95% CI, 1.55-7.33). Polyclonal induction was associated with increased melanoma (aIRR, 1.50; 95% CI, 1.06-2.14). CONCLUSION Our findings highlight the relative safety with regard to cancer risk of the most common induction therapies, the need for surveillance of patients treated with alemtuzumab, and the possible role for increased melanoma screening for those patients treated with polyclonal anti-T-cell induction.
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Affiliation(s)
- Erin C Hall
- 1 Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD. 2 Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, MD. 3 Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Losonczy LI, Weygandt PL, Villegas CV, Hall EC, Schneider EB, Cooper LA, Cornwell EE, Haut ER, Efron DT, Haider AH. The severity of disparity: increasing injury intensity accentuates disparate outcomes following trauma. J Health Care Poor Underserved 2015; 25:308-20. [PMID: 24509028 DOI: 10.1353/hpu.2014.0021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Studies have shown disparities in mortality among racial groups and among those with differing insurance coverage. Our goal was to determine if injury severity affects these disparities. METHODS We classified patients from the 2003-2008 National Trauma Data Banks suffering moderate to severe injuries into six groups based on race/ethnicity and insurance, stratifying by injury severity. Logistic regression compared odds of death between races-ethnicities/insurance groups within these strata. We adjusted for age, gender, Injury Severity Score, Glasgow Coma Scale motor component, hypotension, and mechanism of injury. RESULTS Patients meeting inclusion criteria numbered 760,598. Disparities between races-ethnicities/insurance groups increased as injury severity worsened. Odds of death for uninsured Black patients compared with insured Whites increased from 1.82 among moderately injured patients to 3.14 among severely injured, hypotensive patients. A similar pattern was seen among uninsured Hispanic patients. CONCLUSIONS Disparities in trauma mortality suffered by minority and uninsured patients, when compared with non-minority and insured patients, worsen with increasing injury.
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Hall EC, Hashmi ZG, Zafar SN, Zogg CK, Cornwell EE, H. Haider A. Racial/ethnic disparities in emergency general surgery: explained by hospital-level characteristics? Am J Surg 2015; 209:604-9. [DOI: 10.1016/j.amjsurg.2014.11.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 09/24/2014] [Accepted: 11/13/2014] [Indexed: 10/24/2022]
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Hall EC, Boyarsky BJ, Deshpande NA, Garonzik-Wang JM, Berger JC, Dagher NN, Segev DL. Perioperative complications after live-donor hepatectomy. JAMA Surg 2014; 149:288-91. [PMID: 24452612 DOI: 10.1001/jamasurg.2013.3835] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Current studies of complications following donor hepatectomy may not be generalizable to all hospitals performing this procedure. To address this, live liver donors were identified in the Nationwide Inpatient Sample (2000-2008). Complications after donor hepatectomy were categorized using International Classification of Diseases, Ninth Revision codes and risk factors for complications were tested using logistic regression. Negative binomial regression models were used to estimate the increase in length of stay and hospital charge associated with complications. Among 555 donors (representing 2783 donors nationwide), 23% had 1 or more complications and 5% had a major complication. The most common complications were ileus (27%) and atelectasis (26%). No patient or hospital factors were associated with complications. Having any complication was associated with increased length of stay (incidence rate ratio, 1.36; 95% CI, 1.16-1.58; P < .001) and hospital charge (incidence rate ratio, 1.25; 95% CI, 1.09-1.44; P = .002). Approximately 25% of liver donors have complications immediately postoperatively but most are minor, lending support to current practices in live liver donation and donor selection.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland2Department of Surgery, Georgetown University School of Medicine, Washington DC
| | - Brian J Boyarsky
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Neha A Deshpande
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Jonathan C Berger
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nabil N Dagher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dorry L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland3Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Stein DM, Brenner M, Hu PF, Yang S, Hall EC, Stansbury LG, Menaker J, Scalea TM. Timing of intracranial hypertension following severe traumatic brain injury. Neurocrit Care 2014; 18:332-40. [PMID: 23494545 DOI: 10.1007/s12028-013-9832-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We asked whether continuous intracranial pressure (ICP) monitoring data could provide objective measures of the degree and timing of intracranial hypertension (ICH) in the first week of neurotrauma critical care and whether such data could be linked to outcome. METHODS We enrolled adult (>17 years old) patients admitted to our Level I trauma center within 6 h of severe TBI. ICP data were automatically captured and ICP 5-minute means were grouped into 12-hour time periods from admission (hour 0) to >7 days (hour 180). Means, maximum, percent time (% time), and pressure-times-time dose (PTD, mmHg h) of ICP >20 mmHg and >30 mmHg were calculated for each time period. RESULTS From 2008 to 2010, we enrolled 191 patients. Only 2.1% had no episodes of ICH. The timing of maximum PTD20 was relatively equally distributed across the 15 time periods. Median ICP, PTD20, %time20, and %time30 were all significantly higher in the 84-180 h time period than the 0-84 h time period. Stratified by functional outcome, those with poor functional outcome had significantly more ICH in hours 84-180. Multivariate analysis revealed that, after 84 h of monitoring, every 5% increase in PTD20 was independently associated with 21% higher odds of having a poor functional outcome (adjusted odds ratio = 1.21, 95% CI 1.02-1.42, p = 0.03). CONCLUSIONS Although early elevations in ICP occur, ICPs are the highest later in the hospital course than previously understood, and temporal patterns of ICP elevation are associated with functional outcome. Understanding this temporal nature of secondary insults has significant implications for management.
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Affiliation(s)
- Deborah M Stein
- Program in Trauma, Division of Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
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Abstract
BACKGROUND Recipients of ABO-incompatible (ABOi) living-donor kidney transplants often undergo more intense immunosuppression than their ABO-compatible counterparts. It is unknown if this difference leads to higher cancer risk after transplantation. Single-center studies are too small and lack adequate duration of follow-up to answer this question. METHODS We identified 318 ABOi recipients in the Transplant Cancer Match Study, a national linkage between the Scientific Registry of Transplant Recipients and population-based U.S. cancer registries. Seven cancers (non-Hodgkin lymphoma, Merkel cell carcinoma, gastric adenocarcinoma, hepatocellular carcinoma, thyroid cancer, pancreatic cancer, and testicular cancer) were identified among ABOi recipients. We then matched ABOi recipients to ABO-compatible controls by age, gender, race, human leukocyte antigen mismatch, retransplantation, and transplant year. RESULTS There was no demonstrable association between ABOi and cancer in unadjusted (incidence rate ratio, 0.83; 95% confidence interval, 0.33-1.71; P=0.3) or matched control (incidence rate ratio, 0.99; 95% confidence interval, 0.38-2.23; P=0.5) analyses. CONCLUSION To the extent that could be determined in this registry study, current desensitization protocols are not associated with increased risk of cancer after transplantation.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Clarke CA, Morton LM, Lynch C, Pfeiffer RM, Hall EC, Gibson TM, Weisenburger DD, Martínez-Maza O, Hussain SK, Yang J, Chang ET, Engels EA. Risk of lymphoma subtypes after solid organ transplantation in the United States. Br J Cancer 2013; 109:280-8. [PMID: 23756857 PMCID: PMC3708563 DOI: 10.1038/bjc.2013.294] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 04/30/2013] [Accepted: 05/20/2013] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Solid organ transplant recipients have high risk of lymphomas, including non-Hodgkin lymphoma (NHL) and Hodgkin lymphoma (HL). A gap in our understanding of post-transplant lymphomas involves the spectrum and associated risks of their many histologic subtypes. METHODS We linked nationwide data on solid organ transplants from the US Scientific Registry of Transplant Recipients (1987-2008) to 14 state and regional cancer registries, yielding 791 281 person-years of follow-up for 19 distinct NHL subtypes and HL. We calculated standardised incidence ratios (SIRs) and used Poisson regression to compare SIRs by recipient age, transplanted organ, and time since transplantation. RESULTS The risk varied widely across subtypes, with strong elevations (SIRs 10-100) for hepatosplenic T-cell lymphoma, Burkitt's lymphoma, NK/T-cell lymphoma, diffuse large B-cell lymphoma, and anaplastic large-cell lymphoma (both systemic and primary cutaneous forms). Moderate elevations (SIRs 2-4) were observed for HL and lymphoplasmacytic, peripheral T-cell, and marginal zone lymphomas, but SIRs for indolent lymphoma subtypes were not elevated. Generally, SIRs were highest for younger recipients (<20 years) and those receiving organs other than kidneys. CONCLUSION Transplant recipients experience markedly elevated risk of a distinct spectrum of lymphoma subtypes. These findings support the aetiologic relevance of immunosuppression for certain subtypes and underscore the importance of detailed haematopathologic workup for transplant recipients with suspected lymphoma.
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Affiliation(s)
- C A Clarke
- Cancer Prevention Institute of California, 2201 Walnut Avenue, Suite 300, Fremont, CA 94538-2334, USA.
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Hall EC, Pfeiffer RM, Segev DL, Engels EA. Cumulative incidence of cancer after solid organ transplantation. Cancer 2013; 119:2300-8. [PMID: 23559438 PMCID: PMC4241498 DOI: 10.1002/cncr.28043] [Citation(s) in RCA: 125] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2012] [Revised: 11/04/2012] [Accepted: 12/04/2012] [Indexed: 01/07/2023]
Abstract
BACKGROUND Solid organ transplantation recipients have elevated cancer incidence. Estimates of absolute cancer risk after transplantation can inform prevention and screening. METHODS The Transplant Cancer Match Study links the US transplantation registry with 14 state/regional cancer registries. The authors used nonparametric competing risk methods to estimate the cumulative incidence of cancer after transplantation for 2 periods (1987-1999 and 2000-2008). For recipients from 2000 to 2008, the 5-year cumulative incidence, stratified by organ, sex, and age at transplantation, was estimated for 6 preventable or screen-detectable cancers. For comparison, the 5-year cumulative incidence was calculated for the same cancers in the general population at representative ages using Surveillance, Epidemiology, and End Results data. RESULTS Among 164,156 recipients, 8520 incident cancers were identified. The absolute cancer risk was slightly higher for recipients during the period from 2000 to 2008 than during the period from 1987 to 1999 (5-year cumulative incidence: 4.4% vs. 4.2%; P = .006); this difference arose from the decreasing risk of competing events (5-year cumulative incidence of death, graft failure, or retransplantation: 26.6% vs. 31.9%; P < .001). From 2000 to 2008, the 5-year cumulative incidence of non-Hodgkin lymphoma was highest at extremes of age, especially in thoracic organ recipients (ages 0-34 years: range, 1.74%-3.28%; aged >50 years; range, 0.36%-2.22%). For recipients aged >50 years, the 5-year cumulative incidence was higher for colorectal cancer (range, 0.33%-1.94%) than for the general population at the recommended screening age (aged 50 years: range, 0.25%-0.33%). For recipients aged >50 years, the 5-year cumulative incidence was high for lung cancer among thoracic organ recipients (range, 1.16%-3.87%) and for kidney cancer among kidney recipients (range, 0.53%-0.84%). The 5-year cumulative incidence for prostate cancer and breast cancer was similar or lower in transplantation recipients than at the recommended ages of screening in the general population. CONCLUSIONS Subgroups of transplantation recipients have a high absolute risk of some cancers and may benefit from targeted prevention or screening.
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Affiliation(s)
- Erin C. Hall
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Ruth M. Pfeiffer
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Eric A. Engels
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland
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Garonzik-Wang JM, James NT, Arendonk KJV, Gupta N, Orandi BJ, Hall EC, Massie AB, Montgomery RA, Dagher NN, Singer AL, Cameron AM, Segev DL. The aggressive phenotype revisited: utilization of higher-risk liver allografts. Am J Transplant 2013; 13:936-942. [PMID: 23414232 DOI: 10.1111/ajt.12151] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2012] [Revised: 09/30/2012] [Accepted: 11/05/2012] [Indexed: 01/25/2023]
Abstract
Organ shortage has led to increased utilization of higher risk liver allografts. In kidneys, aggressive center-level use of one type of higher risk graft clustered with aggressive use of other types. In this study, we explored center-level behavior in liver utilization. We aggregated national liver transplant recipient data between 2005 and 2009 to the center-level, assigning each center an aggressiveness score based on relative utilization of higher risk livers. Aggressive centers had significantly more patients reaching high MELDs (RR 2.19, 2.33 and 2.28 for number of patients reaching MELD>20, MELD>25 and MELD>30, p<0.001), a higher organ shortage ratio (RR 1.51, 1.60 and 1.51 for number of patients reaching MELD>20, MELD>25 and MELD>30 divided by number of organs recovered at the OPO, p<0.04), and were clustered within various geographic regions, particularly regions 2, 3 and 9. Median MELD at transplant was similar between aggressive and nonaggressive centers, but average annual transplant volume was significantly higher at aggressive centers (RR 2.27, 95% CI 1.47-3.51, p<0.001). In cluster analysis, there were no obvious phenotypic patterns among centers with intermediate levels of aggressiveness. In conclusion, highwaitlist disease severity, geographic differences in organ availability, and transplant volume are the main factors associated with the aggressive utilization of higher risk livers.
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Affiliation(s)
- J M Garonzik-Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N T James
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - K J Van Arendonk
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N Gupta
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - B J Orandi
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E C Hall
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Surgery, Georgetown University, Washington, DC, USA
| | - A B Massie
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R A Montgomery
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - N N Dagher
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A L Singer
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - A M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - D L Segev
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, USA
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Hall EC, Segev DL, Engels EA. Racial/ethnic differences in cancer risk after kidney transplantation. Am J Transplant 2013; 13:714-20. [PMID: 23331953 PMCID: PMC4241757 DOI: 10.1111/ajt.12066] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 10/29/2012] [Accepted: 11/19/2012] [Indexed: 01/25/2023]
Abstract
Transplant recipients have elevated cancer risk, but it is unknown if cancer risk differs across race and ethnicity as in the general population. US kidney recipients (N = 87,895) in the Transplant Cancer Match Study between 1992 and 2008 were evaluated for racial/ethnic differences in risk for six common cancers after transplantation. Compared to white recipients, black recipients had lower incidence of non-Hodgkin lymphoma (NHL) (adjusted incidence rate ratio [aIRR] 0.60, p<0.001) and higher incidence of kidney (aIRR 2.09, p<0.001) and prostate cancer (aIRR 2.14, p<0.001); Hispanic recipients had lower incidence of NHL (aIRR 0.64, p = 0.001), lung (aIRR 0.41, p < 0.001), breast (aIRR 0.53, p = 0.003) and prostate cancer (aIRR 0.72, p = 0.05). Colorectal cancer incidence was similar across groups. Standardized incidence ratios (SIRs) measured the effect of transplantation on cancer risk and were similar for most cancers (p≥0.1). However, black and Hispanic recipients had larger increases in kidney cancer risk with transplantation (SIRs: 8.96 in blacks, 5.95 in Hispanics vs. 4.44 in whites), and only blacks had elevated prostate cancer risk following transplantation (SIR: 1.21). Racial/ethnic differences in cancer risk after transplantation mirror general population patterns, except for kidney and prostate cancers where differences reflect the effects of end-stage renal disease or transplantation.
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Affiliation(s)
- E C Hall
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, MD, USA.
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McAdams-Demarco MA, Grams ME, Hall EC, Coresh J, Segev DL. Early hospital readmission after kidney transplantation: patient and center-level associations. Am J Transplant 2012; 12:3283-8. [PMID: 23016838 DOI: 10.1111/j.1600-6143.2012.04285.x] [Citation(s) in RCA: 128] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Early hospital readmission (EHR) is associated with increased morbidity, costs and transition-of-care errors. We sought to quantify rates of and risk factors for EHR after kidney transplantation (KT). We studied 32 961 Medicare primary KT recipients (2000-2005) linked to Medicare claims through the United States Renal Data System. EHR was defined as at least one hospitalization within 30 days of initial discharge after KT. The association between EHR and recipient and transplant factors was explored using Poisson regression; hierarchical modeling was used to account for study center-level differences. The overall EHR rate was 31%, and 19 independent patient-level factors associated with EHR were identified: recipient factors included older age, African American race and various comorbidities; transplant factors included ECD, length of stay and lack of induction therapy. The unadjusted rate of EHR by center ranged from 18% to 47%, but conventional center-level factors (percent African American, percent age > 60, percent deceased donor and percent expanded criteria donor) were not associated with EHR. However, intermediate total volume and average length of stay were associated with increased EHR risk. Better identification of patients at risk for early hospital readmission following KT may guide discharge planning and early posttransplant outpatient monitoring.
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Affiliation(s)
- M A McAdams-Demarco
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Sun Q, Hall EC, Huang Y, Chen P, Dibadj K, Murawski M, Shraybman R, Van Kirk K, Tang V, Peng R, Patton PR, Clare-Salzler MJ, Kaplan B, Segev DL, Womer KL. Pre-transplant myeloid dendritic cell deficiency associated with cytomegalovirus infection and death after kidney transplantation. Transpl Infect Dis 2012; 14:618-25. [PMID: 22672201 DOI: 10.1111/j.1399-3062.2012.00750.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2011] [Revised: 11/01/2011] [Accepted: 01/21/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND Dendritic cells (DCs) are potent antigen-presenting cells critical for immunity. We previously demonstrated a significant association between pre-transplant blood myeloid dendritic cell (mDC) and plasmacytoid dendritic cell (pDC) deficiency and post-transplant BK viremia in renal transplant recipients. In the current post-hoc analysis, we studied the association of these same pre-transplant DC levels with other post-transplant outcomes. METHODS Pre-transplant peripheral blood mDC and pDC levels were quantified using flow cytometry in 78 patients undergoing kidney transplantation. Post-transplant outcomes were analyzed, including infection, rejection, and patient death, with a median follow-up of 5.3 years. Associations between DC levels and outcomes were assessed using logistic regression analysis and Cox proportional hazards models. RESULTS An independent association of mDC levels with post-transplant cytomegalovirus infection (adjusted odds ratio 7.0, P = 0.01) and patient death (adjusted hazard ratio 13.0, P = 0.015) was found. No associations were demonstrated between levels of either DC subtype and bacterial infections or rejection. CONCLUSIONS Pre-transplant mDC deficiency is significantly associated with CMV infection and death after kidney transplantation.
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Affiliation(s)
- Q Sun
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hall EC, James NT, Garonzik Wang JM, Berger JC, Montgomery RA, Dagher NN, Desai NM, Segev DL. Center-level factors and racial disparities in living donor kidney transplantation. Am J Kidney Dis 2012; 59:849-57. [PMID: 22370021 DOI: 10.1053/j.ajkd.2011.12.021] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 12/19/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND On average, African Americans attain living donor kidney transplantation (LDKT) at decreased rates compared with their non-African American counterparts. However, center-level variations in this disparity or the role of center-level factors is unknown. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS 247,707 adults registered for first-time kidney transplants from 1995-2007 as reported by the Scientific Registry of Transplant Recipients. PREDICTORS Patient-level factors (age, sex, body mass index, insurance status, education, blood type, and panel-reactive antibody level) were adjusted for in all models. The association of center-level characteristics (number of candidates, transplant volume, LDKT volume, median time to transplant, percentage of African American candidates, percentage of prelisted candidates, and percentage of LDKT) and degree of racial disparity in LDKT was quantified. OUTCOMES Hierarchical multivariate logistic regression models were used to derive center-specific estimates of LDKT attainment in African American versus non-African American candidates. RESULTS Racial parity was not seen at any of the 275 transplant centers in the United States. At centers with the least racial disparity, African Americans had 35% lower odds of receiving LDKT; at centers with the most disparity, African Americans had 76% lower odds. Higher percentages of African American candidates (interaction term, 0.86; P = 0.03) and prelisted candidates (interaction term, 0.80; P = 0.001) at a given center were associated with increased racial disparity at that center. Higher rates of LDKT (interaction term, 1.25; P < 0.001) were associated with less racial disparity. LIMITATIONS Some patient-level factors are not captured, including a given patient's pool of potential donors. Geographic disparities in deceased donor availability might affect LDKT rates. Center-level policies and practices are not captured. CONCLUSIONS Racial disparity in attainment of LDKT exists at every transplant center in the country. Centers with higher rates of LDKT attainment for all races had less disparity; these high-performing centers might provide insights into policies that might help address this disparity.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Garonzik-Wang JM, James NT, Weatherspoon KC, Deshpande NA, Berger JA, Hall EC, Montgomery RA, Segev DL. The aggressive phenotype: center-level patterns in the utilization of suboptimal kidneys. Am J Transplant 2012; 12:400-8. [PMID: 21992578 DOI: 10.1111/j.1600-6143.2011.03789.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Despite the fact that suboptimal kidneys have worse outcomes, differences in waiting times and wait-list mortality have led to variations in the use of these kidneys. It is unknown whether aggressive center-level use of one type of suboptimal graft clusters with aggressive use of other types of suboptimal grafts, and what center characteristics are associated with an overall aggressive phenotype. United Network for Organ Sharing (UNOS) data from 2005 to 2009 for adult kidney transplant recipients was aggregated to the center level. An aggressiveness score was assigned to each center based on usage of suboptimal grafts. Deceased-donor transplant volume correlated with aggressiveness in lower volume, but not higher volume centers. Aggressive centers were mostly found in regions 2 and 9. Aggressiveness was associated with wait-list size (RR 1.69, 95% CI 1.20-2.34, p = 0.002), organ shortage (RR 2.30, 95% CI 1.57-3.37, p < 0.001) and waiting times (RR 1.75, 95% CI 1.20-2.57, p = 0.004). No centers in single-center OPOs were classified as aggressive. In cluster analysis, the most aggressive centers were aggressive in all metrics and vice versa; however, centers with intermediate aggressiveness had phenotypic patterns in their usage of suboptimal kidneys. In conclusion, wait-list size, waiting times, geographic region and OPO competition seem to be driving factors in center-level aggressiveness.
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Affiliation(s)
- J M Garonzik-Wang
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Berger JC, Muzaale AD, James N, Hoque M, Wang JMG, Montgomery RA, Massie AB, Hall EC, Segev DL. Living kidney donors ages 70 and older: recipient and donor outcomes. Clin J Am Soc Nephrol 2011; 6:2887-93. [PMID: 22034505 DOI: 10.2215/cjn.04160511] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES The profound organ shortage has resulted in longer waiting times and increased mortality for those awaiting kidney transplantation. Consequently, patients are turning to older living donors. It is unclear if an upper age limit for donation should exist, both in terms of recipient and donor outcomes. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS In the United States, 219 healthy adults aged ≥70 have donated kidneys at 80 of 279 transplant centers. Competing risks models with matched controls were used to study the independent association between older donor age and allograft survival, accounting for the competing risk of recipient mortality as well as other transplant factors. RESULTS Among recipients of older live donor allografts, graft loss was significantly higher than matched 50-to 59-year-old live donor allografts (subhazard ratio [SHR] 1.62, 95% confidence interval [CI] 1.16 to 2.28, P = 0.005) but similar to matched nonextended criteria 50-to 59-year-old deceased donor allografts (SHR 1.19, 95% CI 0.87 to 1.63, P = 0.3). Mortality among living kidney donors aged ≥70 was no higher than healthy matched controls drawn from the NHANES-III cohort; in fact, mortality was lower, probably reflecting higher selectivity among older live donors than could be captured in National Health and Nutrition Examination Survey III (NHANES-III; HR 0.37, 95% CI 0.21 to 0.65, P < 0.001). CONCLUSIONS These findings support living donation among older adults but highlight the advantages of finding a younger donor, particularly for younger recipients.
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Affiliation(s)
- Jonathan C Berger
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hall EC, Massie AB, James NT, Garonzik Wang JM, Montgomery RA, Berger JC, Segev DL. Effect of eliminating priority points for HLA-B matching on racial disparities in kidney transplant rates. Am J Kidney Dis 2011; 58:813-6. [PMID: 21802805 DOI: 10.1053/j.ajkd.2011.05.023] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Accepted: 05/05/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND African Americans have lower rates of obtaining a deceased donor kidney transplant (DDKT) compared with their white counterparts. One proposed mechanism is differential HLA distributions between African Americans and whites. In May 2003, the United Network for Organ Sharing/Organ Procurement and Transplantation Network changed kidney allocation policy to eliminate priority based on HLA-B matching in an effort to address this disparity. The objective of this study was to quantify the effect of the change in policy regarding priority points for HLA-B matching. STUDY DESIGN Observational cohort study. SETTING & PARTICIPANTS A cohort of 178,902 patients registered for a DDKT between January 2000 and August 2009. FACTORS African Americans versus whites before and after the policy change. Cox models were adjusted for age, sex, diabetes, dialysis type, insurance status, education, panel-reactive antibody level, and blood type. OUTCOMES Adjusted relative rates (aRRs) of deceased donor kidney transplant for African Americans compared with whites. MEASUREMENTS Time from initial active wait listing to DDKT, censored for living donor kidney transplant and death. RESULTS Before the policy change, African Americans had 37% lower rates of DDKT (aRR, 0.63; 95% CI, 0.60-0.65; P < 0.001). After the policy change, African Americans had 23% lower rates of DDKT (aRR, 0.77; 95% CI, 0.76-0.79; P < 0.001). There was a 23% reduction in the disparity between African Americans and whites after the policy change (interaction aRR, 1.23; 95% CI, 1.18-1.29; P < 0.001). LIMITATIONS As an observational study, findings could have been affected by residual confounding or other changes in practice patterns. CONCLUSIONS Racial disparity in rates of DDKT was decreased by the HLA-B policy change, but parity was not achieved. There are unaddressed factors in kidney allocation that lead to continued disparity on the kidney transplant waiting list.
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Affiliation(s)
- Erin C Hall
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
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Boyarsky BJ, Hall EC, Singer AL, Montgomery RA, Gebo KA, Segev DL. Estimating the potential pool of HIV-infected deceased organ donors in the United States. Am J Transplant 2011; 11:1209-17. [PMID: 21443677 PMCID: PMC3110583 DOI: 10.1111/j.1600-6143.2011.03506.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [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: 01/25/2023]
Abstract
Human immunodeficiency virus (HIV) is no longer a contraindication to transplantation. For HIV-infected patients, HIV-infected deceased donors (HIVDD) could attenuate the organ shortage and waitlist mortality. However, this practice would violate United States federal law. The goal of this study was to estimate the potential impact of legalizing transplantation of HIV-infected organs by quantifying the potential pool of HIVDD. Using Nationwide Inpatient Sample (NIS) data, HIV-infected deaths compatible with donation were enumerated. Using HIV Research Network (HIVRN) data, CD4 count, plasma HIV-1 RNA level, AIDS-defining illnesses and causes of death were examined in potential HIVDD. Using UNOS data, evaluated donors who later demonstrated unanticipated HIV infections were studied. From NIS, a yearly average of 534 (range: 481-652) potential HIVDD were identified, with 63 (range: 39-90) kidney-only, 221 (range: 182-255) liver-only and 250 (range: 182-342) multiorgan donors. From HIVRN, a yearly average of 494 (range: 441-533) potential HIVDD were identified. Additionally, a yearly average of 20 (range: 11-34) donors with unanticipated HIV infection were identified from UNOS. Deceased HIV-infected patients represent a potential of approximately 500-600 donors per year for HIV-infected transplant candidates. In the current era of HIV management, a legal ban on the use of these organs seems unwarranted and likely harmful.
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Affiliation(s)
- Brian J. Boyarsky
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Erin C. Hall
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, Department of Surgery, Georgetown University School of Medicine, Washington, DC
| | - Andrew L. Singer
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | | | - Kelly A. Gebo
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD, HIV Research Network
| | - Dorry L. Segev
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD, Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD
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Abstract
The aim of this study was to assess the plasticity of human voluntary fixational eye movement control in relation to visual experience/chronic visual deprivation. Twelve blind adults participated (self-reported vision < or = light perception in each eye; age range = 23-56 years; visual experience range = 0-28 years; blindness duration range = 6-55 years). Infrared-based recordings of horizontal eye movements were made before, during, and immediately after three 30-s periods of auditory ocular motor feedback, while participants were instructed to look straight ahead and keep their eyes as steady as possible. Percent change in horizontal displacement of the eye during and after feedback was compared with the no-feedback baseline. Eleven of the 12 individuals demonstrated feedback-mediated increase in eye stability, which improved as a function of visual experience. Improved eye stability was inversely related to duration of blindness. Clearly, blind adults can use nonvisual external feedback to stabilize gaze. Thus, the fixational subsystem can exhibit improved voluntary control despite chronic visual deprivation. Possible cortical and subcortical mechanisms are discussed.
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Affiliation(s)
- E C Hall
- Department of Vision Sciences, State University of New York State College of Optometry, New York, New York, USA.
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Abstract
PURPOSE To quantify the effects of childhood visual experience/chronic visual deprivation upon adult voluntary ocular motor control. METHODS Eye movements of blind and sighted adults were elicited and videotaped in total darkness. The videotaped responses were digitized using an eye tracker, yielding data from 10 congenitally blind (infantile onset, blindness before age 1 year), 16 adventitiously blind, and 9 sighted persons. RESULTS Multivariate analysis of variance, trend analyses and post hoc tests revealed that primary position fixational stability and consistency of return to primary position were lowest in the congenitally blind vs. the adventitiously blind group, and highest in the sighted. Duration of adventitious blindness reduced primary position stability but not consistency of return to primary position. Secondary position maximum amplitudes: congenitally blind mean, 14 degrees; adventitiously blind mean, 40 degrees; sighted mean, 47 degrees. Average velocity (a form of Main Sequence) increased significantly with amplitude in all three groups. CONCLUSIONS Visual deprivation can greatly attenuate but does not abolish human voluntary eye movement. Adventitious blindness exerts minimal to profound effects, commensurate with age of vision loss.
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Affiliation(s)
- E C Hall
- Vision Sciences Department, State University of New York State College of Optometry, New York, USA.
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Abstract
The effects of choice of diets on feed intake were studied using 12 lactating Holstein cows. A switchback design was used that had three periods and two sequential blocks. Diets were 1) a control total mixed ration (TMR), which consisted of alfalfa haylage, corn silage, and a concentrate mixture based on ground corn and soybean meal (25:25:50 on a dry matter basis) and 2) a sweetened TMR in which a brown sugar food product constituted 1.5% of the dietary dry matter. Treatments consisted of the control TMR fed on both sides of divided feed bunks, the sweetened TMR fed on both sides of divided feed bunks, or both TMR fed on alternating (daily) sides of divided feed bunks in tie stalls. Periods were 2 wk in duration, and cows averaged 67 and 53 d of lactation at the start of blocks 1 and 2, respectively. The dry matter intake, body weight, milk yield, and percentages of milk fat, protein, and solids not fat were similar when either TMR was fed alone. A choice of control TMR or sweetened TMR did not affect any of these variables. The dry matter intake, body weight, milk yield, and milk protein percentage were affected by block; however, these effects were probably caused by differences between the blocks in environment and stage of lactation. The results of this experiment might have been affected by the composition of the control TMR, its similarity to the sweetened TMR, availability of both diets simultaneously when a choice was offered, and use of a TMR instead of separate feeds or simpler mixtures.
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Affiliation(s)
- M R Murphy
- Department of Animal Sciences, University of Hlinois, Urbana 61801 USA
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Taylor A, Lewis C, Giacometti A, Hall EC, Barefield KP. Improved formulas for the estimation of renal depth in adults. J Nucl Med 1993; 34:1766-9. [PMID: 8410296] [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: 01/30/2023] Open
Abstract
Commercial techniques are available to calculate effective renal plasma flow (ERPF) or glomerular filtration rate (GFR) based on the percent injected dose in the kidney 1-2 or 2-3 min post-injection; renal depth is estimated by the Tonnesen equations. Since the Tonnesen equations were derived from ultrasound measurements obtained at an oblique angle in sitting patients, we compared the renal depths obtained from the Tonnesen equations with the renal depth measured by computed tomography in supine patients, the most common position for radionuclide renography. The renal depth, height, weight, age and sex were determined for 126 patients undergoing CT scanning. Patients with obvious renal or abdominal pathology were excluded. The Tonnesen equations significantly underestimated renal depth. Using stepwise linear regression analysis, we derived a set of equations based on age, height and weight and applied these prospectively to a new set of 75 patients. In addition, a second set of equations were derived for the new data. There was no difference in the results for the two equations. We then pooled both studies and derived a combined set of equations: right renal depth (mm) = 153.1 weight/height + 0.22 age + 0.77 and left renal depth (mm) = 161.7 weight/height + 0.27 age - 9.4, where weight is in kilograms and height is in centimeters. The correlation coefficients were 0.81 and 0.83 for the right and left kidneys respectively with standard errors of the estimate of 10.2 and 10.1 mm. These equations provide a much better estimate of renal depth in the supine patient than the Tonnesen equations.
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Affiliation(s)
- A Taylor
- Department of Radiology, Emory University, Atlanta, Georgia 30322
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Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH. Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error. J Bone Joint Surg Am 1990; 72:320-7. [PMID: 2312527] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
To quantitate the intrinsic error in measurement, fifty anteroposterior radiographs of patients who had scoliosis were each measured on six separate occasions by four orthopaedic surgeons using the Cobb method. For the first two measurements (Set I), each observer selected the end-vertebrae of the curve; for the next two measurements (Set II), the end-vertebrae were pre-selected and constant. The last two measurements (Set III) were obtained in the same manner as Set II, except that each examiner used the same protractor rather than the one that he carried with him. The pooled results of all four observers suggested that the 95 per cent confidence limit for intraobserver variability was 4.9 degrees for Set I, 3.8 degrees for Set II, and 2.8 degrees for Set III. The interobserver variability was 7.2 degrees for Set I and 6.3 degrees for Sets II and III. The mean angles differed significantly between observers, but the difference was smaller when the observers used the same protractor.
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Affiliation(s)
- R T Morrissy
- Scottish Rite Children's Medical Center, Atlanta, Georgia 30363
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Morrissy RT, Goldsmith GS, Hall EC, Kehl D, Cowie GH. Measurement of the Cobb angle on radiographs of patients who have scoliosis. Evaluation of intrinsic error. J Bone Joint Surg Am 1990. [DOI: 10.2106/00004623-199072030-00002] [Citation(s) in RCA: 436] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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McGowan JE, Hall EC, Parrott PL. Antimicrobial susceptibility in gram-negative bacteremia: are nosocomial isolates really more resistant? Antimicrob Agents Chemother 1989; 33:1855-9. [PMID: 2610495 PMCID: PMC172776 DOI: 10.1128/aac.33.11.1855] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.6] [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: 01/01/2023] Open
Abstract
Bloodstream isolates of gram-negative aerobic bacilli from nosocomial infections are more likely to be resistant to antimicrobial agents than isolates from community-acquired cases are. It is not clear, however, how much this is due to the markedly different distribution of organisms in the two groups. We compared the susceptibilities of organisms of a given species which caused community-acquired bacteremia with the susceptibilities of isolates from nosocomial cases. Nine antimicrobial agents were tested against 1,077 isolates which were obtained during a 4-year nonepidemic period. Marked differences in crude rates of resistance were noted for all isolates from nosocomial cases versus all isolates from cases acquired in the community. When results were adjusted for the different organism distributions in the two groups, statistically significant differences were found for only six drug-organism pairs; in each of these, resistance rates were higher in nosocomial isolates. However, when results were further adjusted for the effect of multiple analyses, no significant differences were seen. The major factor leading to the greater prevalence of antimicrobial resistance in our hospital organisms was the markedly different distribution of organisms in the nosocomial and community-acquired groups. For individual organisms, greater resistance in nosocomial strains was confined to certain drugs. Factors that influence differences in organism distribution may not be solely the result of antimicrobial use.
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Affiliation(s)
- J E McGowan
- Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia 30322
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Heymsfield SB, Bethel RA, Hall EC, Mills JB, Moseley MH, Kostyo JL, Rudman D. Anabolic actions of reduced and S-carbamidomethylated human growth hormone and its plasmin digest in man. J Clin Invest 1977; 60:563-70. [PMID: 142777 PMCID: PMC372401 DOI: 10.1172/jci108808] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Six children aged 12-15 yr, deficient in endogenous growth hormone, were each treated, after a 7-day control period, for 7 days with 0.0168, 0.052, and 0.168 U/kg body wt3/4 human growth (hGH) (doses A, B, and C, respectively) in separate metabolic balance studies. Doses B and C caused a dose-related retention of N, P, K, Na, and Cl in ratios of 1/0.069/4.5/7.5/5.6. These ratios indicate increments in masses of protoplasm/extracellular fluid (ECF)/bone in ratios of 1/2.0/ less than 0.001. Three of the children were also treated with doses A, B, and C of reduced and carbamidomethylated hGH (RCAM-hGH). Doses B and C caused 1.2-2.8 times as much retention of N, P, and K, and 0.3-0.5 times as much retention of Na and Cl, as did the corresponding doses of hGH. The plasmin digest of RCAM-hGH gave results generally similar to RCAM-hGH. For RCAM-hGH and its plasmin digest, N, P, K, Na, and Cl were retained in ratios of about 1/0.14/5.4/2.2/2.1, indicating increments of protoplasm/ECF/bone of about 1/0.8/0.05. These findings indicate that reduction and carbamidomethylation alter the anabolic actions of hGH in man in both quantitative and qualitative manner. RCAM-hGH is more potent in stimulating enlargement of protoplasm and bone, and less potent in stimulating expansion of ECF, than is the native hormone. The profile of anabolic actions of RCAM-hGH in man does not appear to be further altered by digestion with plasmin.
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Abstract
22 nonneoplastic, noninflammatory effusions (cirrhosis and congestive heart failure), 12 non-neoplastic inflammatory effusions (tuberculosis, lupus erythematosus, rheumatoid arthritis, and idiopathic pleuropericarditis), and 58 neoplastic effusions (cancer of lung, breast, ovary, and pancreas, and lymphoma) were analyzed by radial immunodiffusion for orosomucoid concentration. The average concentration +/-SE was 35+/-4, 65+/-17, and 130+/-13 mg/100 ml in the three types of effusion, respectively. By gel filtration and ion exchange chromatography, orosomucoid was isolated from 12 nonmalignant and 14 malignant fluids. The orosomucoid preparations reacted as single components in acrylamide gel electrophoresis at pH 9.0, and in immunodiffusion and immunoelectrophoresis against antisera to human serum and to human plasma orosomucoid. In radial immunodiffusion, the slope of the line relating concentration to the square of the diameter of the precipitate area was identical for orosomucoid isolated from normal human plasma and from nonneoplastic effusions, but was subnormal for orosomucoid isolated from neoplastic fluids. All orosomucoid preparations had normal amino acid composition. Orosomucoid from the nonmalignant effusions had normal carbohydrate content. 11 of 14 samples of orosomucoid isolated from neoplastic fluids had abnormalities in carbohydrate composition, consisting of subnormal content of sialic acid (11 of 14), hexose (10 of 14), and hexosamine (3 of 14), and abnormally high content of hexosamine (4 of 14). Discriminant analysis showed that concentration of orosomucoid distinguished between neoplastic and nonneoplastic noninflammatory effusions more effectively than concentration of total protein, albumin, alpha(1), alpha(2), beta, or gamma-globulin.
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Griffin RF, Humienny ME, Hall EC, Elsas LJ. Classic phenylketonuria: heterozygote detection during pregnancy. Am J Hum Genet 1973; 25:646-54. [PMID: 4773479 PMCID: PMC1762571] [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: 01/12/2023] Open
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Bowyer FP, Stratos M, Goldenfarb P, Hall EC. Reproducibility in the hematology laboratory: one-stage prothrombin times. Am J Clin Pathol 1972; 57:482-6. [PMID: 5012940 DOI: 10.1093/ajcp/57.4.482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Hall EC, Hardaker J, Lindsay KM, Wright V. An improved wax-oil bath. Physiotherapy 1971; 57:589-91. [PMID: 5145743] [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: 01/14/2023]
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Lord RD, Vilches AM, Maiztegui JI, Hall EC, Soldini CA. Frequency of rodents in habitats near Pergamino, Argentina, as related to Junín virus. Am J Trop Med Hyg 1971; 20:338-42. [PMID: 5553268 DOI: 10.4269/ajtmh.1971.20.338] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
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Kaufman L, Hall EC, Clark MJ, McLaughlin D. Comparison of macrocomplement and microcomplement fixation techniques used in fungus serology. Appl Microbiol 1970; 20:579-82. [PMID: 5498606 PMCID: PMC376992 DOI: 10.1128/am.20.4.579-582.1970] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
A comparative evaluation was performed on the micro- and macrocomplement fixation (CF) tests that are used as standard procedures in the serodiagnosis of blastomycosis, coccidioidomycosis, and histoplasmosis. Tests with 937 sera from suspected and culturally proven cases of these diseases against yeast-form antigens of Blastomyces dermatitidis and Histoplasma capsulatum and against the soluble antigens, coccidioidin and histoplasmin, revealed that the microtiters were within +/- 1 dilution of the macrotiters in 83 to 93% of the sera. Tests on randomly coded quality control sera revealed the microform of the CF test to be highly reproducible. Our studies indicate that the results obtained by the two tests have similar diagnostic and prognostic interpretations. Because of the sensitivity, reproducibility, economy, and ease of performance, the microtest is highly recommended for use in fungus serology.
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Pond HS, Bokat RB, Johnson JP, Knight JL, Healy GR, Gleason NN, Hall EC. Mass treatment for ascariasis: value of prophylactic use of piperazine in groups heavily infected with Ascaris lumbricoides. South Med J 1970; 63:599-602. [PMID: 5446832] [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: 01/15/2023]
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Hall EC, Felker MB. Reproducibility in the serological laboratory. Health Lab Sci 1970; 7:63-8. [PMID: 5507755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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