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Caso R, Watson TJ, Tefera E, Cerfolio R, Abbas AE, Lazar JF, Margolis M, Hwalek AE, Khaitan PG. Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis. J Surg Res 2024; 296:674-680. [PMID: 38359682 DOI: 10.1016/j.jss.2024.01.028] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/17/2024]
Abstract
INTRODUCTION Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database. METHODS NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival. RESULTS 22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001). CONCLUSIONS For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.
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Affiliation(s)
- Raul Caso
- Department of Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia
| | - Thomas J Watson
- Division of Thoracic Surgery, Department of Surgery, Beaumont Health, Detroit, Michigan
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical Informatics, Medstar Health Research Institute, Washington, District of Columbia
| | - Robert Cerfolio
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, NYU Langone Health, New York, New York
| | - Abbas E Abbas
- Division of Thoracic Surgery, Department of Surgery, Brown University, Providence, Rhode Island
| | - John F Lazar
- Department of Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; Division of Thoracic Surgery, Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Marc Margolis
- Department of Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; Division of Thoracic Surgery, Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Ann E Hwalek
- Department of Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; Division of Thoracic Surgery, Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Puja Gaur Khaitan
- Department of Surgery, Georgetown University School of Medicine, Medstar Washington Hospital Center, Washington, District of Columbia; Division of Thoracic Surgery, Department of Surgery, Georgetown University School of Medicine, Washington, District of Columbia; Division of Thoracic Surgery, Department of Surgery, Sheikh Shakhbout Medical City, Khalifa University, Abu Dhabi, UAE.
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Januzzi JL, Mohebi R, Liu Y, Sattar N, Heerspink HJL, Tefera E, Vaduganathan M, Butler J, Yavin Y, Li J, Pollock CA, Perkovic V, Neal B, Hansen MK. Cardiorenal Biomarkers, Canagliflozin, and Outcomes in Diabetic Kidney Disease: The CREDENCE Trial. Circulation 2023; 148:651-660. [PMID: 37603600 DOI: 10.1161/circulationaha.123.065251] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Accepted: 06/13/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND People with type 2 diabetes and albuminuria are at an elevated risk for cardiac and renal events. The optimal biomarkers to aid disease prediction and to understand the benefits of sodium-glucose cotransporter-2 inhibition remain unclear. METHODS Among 2627 study participants in the CREDENCE trial (Canagliflozin and Renal Events in Diabetes With Established Nephropathy Clinical Evaluation), concentrations of NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity cardiac troponin T, growth differentiation factor-15, and IGFBP7 (insulin-like growth factor binding protein 7) were measured. The effect of canagliflozin on biomarker concentrations was evaluated. The prognostic potential of each biomarker on the primary outcome (a composite of end-stage kidney disease [dialysis, transplantation, or a sustained estimated glomerular filtration rate of <15 mL·min-1·1.73 m-2], doubling of the serum creatinine level, or renal death or cardiovascular death) was assessed. RESULTS The median (quartiles 1 and 3) concentration of each biomarker was generally elevated: NT-proBNP, 180 ng/L (82, 442 ng/L); high-sensitivity cardiac troponin T, 19 ng/L (12, 29 ng/L); growth differentiation factor-15, 2595 ng/L (1852, 3775 ng/L); and IGFBP7, 121.8 ng/mL (105.4, 141.5 ng/mL). At 1 year, the biomarkers all rose by 6% to 29% in the placebo arm but only by 3% to 10% in the canagliflozin arm (all P<0.01 in multivariable linear mixed-effect models). Baseline concentrations of each biomarker were strongly predictive of cardiac and renal outcomes. When the biomarkers were analyzed together in a multimarker panel, individuals with high risk scores (hazard ratio [HR], 4.01 [95% CI, 2.52-6.35]) and moderate risk scores (HR, 2.39 [95% CI, 1.48-3.87]) showed a higher risk for the primary outcome compared with those with low risk scores. By 1 year, a 50% increase in NT-proBNP (HR, 1.11 [95% CI, 1.08-1.15]), high-sensitivity cardiac troponin T (HR, 1.86 [95% CI, 1.64-2.10]), growth differentiation factor-15 (HR, 1.45 [95% CI, 1.24-1.70]), and IGFBP7 (HR, 3.76 [95% CI, 2.54-5.56]) was associated with risk of the primary outcome. CONCLUSIONS Multiple cardiorenal stress biomarkers are strongly prognostic in people with type 2 diabetes and albuminuria. Canagliflozin modestly reduced the longitudinal trajectory of rise in each biomarker. Change in the biomarker level in addition to the baseline level augments the primary outcome prediction. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02065791.
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
- Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, MA (J.L.J.)
| | - Reza Mohebi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
| | - Yuxi Liu
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston (J.L.J., R.M., Y.L.)
| | - Naveed Sattar
- BHF Glasgow Cardiovascular Research Centre, University of Glasgow, UK (N.S.)
| | - Hiddo J L Heerspink
- Department Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, the Netherlands (H.J.L.H.)
| | - Eshetu Tefera
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
| | - Muthiah Vaduganathan
- Cardiology Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (M.V.)
| | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
- Baylor Scott & White Institute, Dallas, TX (J.B.)
| | - Yshai Yavin
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
| | - Jingwei Li
- Department of Cardiology, People's Liberation Army General Hospital, Beijing, China (J.L.)
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China (J.L.)
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
| | - Carol A Pollock
- Kolling Institute, Royal North Shore Hospital University of Sydney, NSW, Australia (C.A.P.)
| | - Vlado Perkovic
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
- Faculty of Medicine (V.P.), UNSW Sydney, Australia
- The Royal North Shore Hospital, Sydney, Australia (V.P.)
| | - Bruce Neal
- The George Institute for Global Health (J.L., V.P., B.N.), UNSW Sydney, Australia
- Charles Perkins Centre, University of Sydney, NSW, Australia (B.N.)
- Imperial College London, UK (B.N.)
| | - Michael K Hansen
- Janssen Research & Development, LLC, Spring House, PA (E.T., Y.Y., M.K.H.)
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Harvey H, Cacciapuoti M, Ramadan L, Brodie K, Gibson C, Tefera E, Yu GG, Motov SM, Nelson LS, Mazer-Amirshahi M. Efficacy and tolerability of oral morphine versus oxycodone/acetaminophen for analgesia in the emergency department. J Opioid Manag 2023; 19:273-280. [PMID: 37145929 DOI: 10.5055/jom.2023.0782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
OBJECTIVE Oxycodone/acetaminophen is one of the most commonly prescribed medications for pain management in the emergency department (ED) despite its high abuse liability. Our objective was to determine whether oral immediate-release morphine is as effective and well tolerated as oral oxycodone/acetaminophen for pain relief in stable ED patients. DESIGN This is a prospective comparative study in which stable adult patients with acute painful conditions who had either oral morphine (15 or 30 mg) or oxycodone/acetaminophen (5/325 mg or 10/650 mg) ordered for them at the discretion of a triage physician were recruited. SETTING This study took place in an urban, academic ED from 2016 to 2019. PARTICIPANTS Seventy-three percent of the subjects were between the ages of 18 and 59, 57 percent were female, and 85 percent were African American. Most presented with abdominal, extremity, or back pain. Patient characteristics were similar between treatment groups. INTERVENTIONS Of the 364 enrolled patients, 182 were given oral morphine and 182 were given oxycodone/acetaminophen at the discretion of the triage provider. They were asked to rate their pain score prior to receiving analgesia and at 60 and 90 minutes after administration. MAIN OUTCOME MEASURES We examined pain scores, adverse effects, overall satisfaction, willingness to accept the same treatment again, and the need for additional analgesia. RESULTS There was no difference in satisfaction reported by patients who received morphine versus oxycodone/acetaminophen: 15.9 percent vs 16.5 percent were very satisfied, 31.9 percent vs 26.4 percent were somewhat satisfied, and 23.6 percent vs 22.5 percent were not satisfied, p = 0.56. Secondary outcomes also showed no significant difference: net change in pain score -2 vs -2 at 60 and 90 minutes, p = 0.91 and p = 0.72, respectively; adverse effects 20.9 percent vs 19.2 percent, p = 0.69; need for further analgesia 9.3 percent vs 7.1 percent, p = 0.44; willingness to accept analgesic again 73.1 percent vs 78.6 percent, p = 0.22. CONCLUSIONS Oral morphine is a feasible alternative to oxycodone/acetaminophen for analgesia in the ED.
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Affiliation(s)
- Hayley Harvey
- Department of Emergency Medicine, Georgetown University Hospital/Medstar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC. ORCID: https://orcid.org/0000-0002-8407-1062
| | | | - Leena Ramadan
- Georgetown University School of Medicine, Washington, DC; Department of Emergency Medicine, NYU Medical Center/Bellevue Hospital Center, New York, New York. ORCID: https://orcid.org/0000-0003-2257-1624
| | - Katherine Brodie
- Georgetown University School of Medicine, Washington, DC; Department of Emergency Medicine, Univer-sity of Pennsylvania, Philadelphia, Pennsylvania
| | - Colin Gibson
- Georgetown University School of Medicine, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC. ORCID: https://orcid.org/0000-0001-5041-8438
| | - Gregory G Yu
- Department of Emergency Medicine, Georgetown University Hospital/Medstar Washing-ton Hospital Center, Washington, DC
| | - Sergey M Motov
- Department of Emergency Medicine, Maimonides Medical Center, Brooklyn, New York. ORCID: https://orcid.org/0000-0002-9668-216X
| | - Lewis S Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey. ORCID: https://orcid.org/0000-0001-9551-3922
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC. ORCID: https://orcid.org/0000-0001-8362-2013
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Dieter AA, Iglesia CB, Lee JH, Etcheverry MJ, Gonzales MK, Sokol AI, Tefera E, Cardis MA. A prospective pilot study to assess for histologic changes on vulvar biopsies in postmenopausal women with lichen sclerosus treated with fractionated CO 2 laser therapy. Lasers Surg Med 2023. [PMID: 37061890 DOI: 10.1002/lsm.23669] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/17/2023]
Abstract
OBJECTIVES To investigate the histologic characteristics of vulvar tissues before and after completion of fractionated carbon dioxide (CO2 ) laser therapy (FxCO2) for vulvar lichen sclerosus (LS). The secondary objective was to assess subjective improvement in symptoms via the Skindex-16 questionnaire. METHODS This prospective single-arm study was conducted from April 2021 to August 2022 at one academic medical center. Ten postmenopausal women with biopsy-proven LS planning FxCO2 laser treatment were enrolled. Exclusion criteria included prior transvaginal mesh for prolapse, topical corticosteroid use within 8 weeks, prior pelvic radiation, malignancy, active genital infection, or pregnancy. The vulvovaginal SmartXide2-V2-LR laser system fractionated CO2 laser (DEKA) was utilized to treat visually affected areas of vulvar and perianal LS with a single pass. Subjects underwent three treatments 4-6 weeks apart. Subjects completed the Skindex-16 questionnaire and had vulvar biopsy at baseline and at 4 weeks after completion of fractionated CO2 laser therapy. Blinded histologic slides were scored by one dermatopathologist (Michael A. Cardis) rating from 1 to 5 the degree of dermal sclerosis, inflammation, and epidermal atrophy. Change scores were calculated as the difference between pre- and post-treatment scores for each subject. RESULTS The 10 subjects enrolled had a mean age of 61 and most were white, privately insured, and had a college/graduate-level education. Post-fractionated CO2 laser treatment vulvar biopsies showed significant improvement in sclerosis and epidermal atrophy compared with pretreatment baseline biopsy specimens (p < 0.05) with no statistically significant change found in inflammation score. Skindex-16 and FSFI scores showed a trend towards improvement (p > 0.05 for both). A statistically significant correlation was found between change in sclerosis and Skindex-16 symptoms scores with an average change of 21.4 units in Skindex-16 symptoms score for every one-point change in histologic sclerosis score (p = 0.03). CONCLUSIONS In postmenopausal women with vulvar LS undergoing fractionated CO2 laser, symptomatic improvements correlated with histologic change in degree of sclerosis on vulvar biopsy. These results demonstrate FxCO2 laser therapy as a promising option for the treatment of LS and suggest that further studies should assess degree of sclerosis on histopathology.
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Affiliation(s)
- Alexis A Dieter
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Cheryl B Iglesia
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jennifer H Lee
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Maria J Etcheverry
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | | | - Andrew I Sokol
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Eshetu Tefera
- MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Michael A Cardis
- MedStar Washington Hospital Center, Washington, District of Columbia, USA
- Georgetown University School of Medicine, Washington, District of Columbia, USA
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Glousman BN, Cragon R, Steinberg JS, Evans KK, Attinger CE, Kiguchi MM, Tefera E, Akbari CM. Presence of a patent pedal arch is the primary predictor of transmetatarsal amputation healing and limb salvage. J Vasc Surg 2023; 77:1487-1494. [PMID: 36717038 DOI: 10.1016/j.jvs.2023.01.184] [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: 12/07/2022] [Revised: 01/17/2023] [Accepted: 01/22/2023] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Transmetatarsal amputation (TMA) is a durable and important functional limb salvage option. We have presented our results in identifying the angiographic predictors of TMA healing using single-institution retrospective data. METHODS Consecutive patients within our institution who had undergone TMA and lower extremity arteriography from 2012 to 2020 were included. Patients whose TMA had healed were compared with those whose TMA had not healed. Using pre- and perioperative patient factors, in addition to the Global Limb Anatomic Staging System (GLASS) and evaluation of the tibial runoff vessels, multivariate analysis was used to define the predictors of TMA healing at 30 days and 1 year. For those patients who had undergone an intervention after TMA, including repeat interventions, the postintervention GLASS stage was calculated. All patients were followed up by the vascular surgeon using standard ultrasound surveillance and clinical examinations. Once the predictors had been identified, an analysis was performed to correlate the 30-day and 1-year limb salvage rates. RESULTS A total of 89 patients had met the inclusion criteria for the study period. No difference was found in the GLASS femoropopliteal or infrapopliteal stages for those with a healed TMA and those without. After multivariate regression analysis, the presence of a patent pedal arch vs a nonintact arch had a 5.5 greater odds of TMA healing at 30 days but not at 1 year. Additionally, the presence of a patent arch was strongly associated with limb salvage at both 30 days (86% vs 49%; P < .01) and 1 year (79% vs 49%; P < .01). CONCLUSIONS In the present series of patients who had undergone TMA and arteriography, with appropriate GLASS staging, we found patency of the pedal arch was a significant predictor of healing and limb salvage. The GLASS femoropopliteal and infrapopliteal stages did not predict for TMA healing.
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Affiliation(s)
- Brandon N Glousman
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC.
| | - Robert Cragon
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Karen K Evans
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Misaki M Kiguchi
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
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Polland A, Hamner JJ, Arunachalam D, Dwarica DS, Gupta A, Pennycuff JF, Tran AD, Tefera E, Meriwether KV, Gutman RE. STOMp: sexual function trial of overactive bladder medication. Sex Med 2023; 11:qfac001. [PMID: 37007850 PMCID: PMC10065174 DOI: 10.1093/sexmed/qfac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 01/13/2023] Open
Abstract
Abstract
Background
Female sexual function has been shown to improve with overactive bladder (OAB) treatment.
Aim
The objective of this study was to evaluate the effects of anticholinergics (ACHs) or a beta-agonist (BAG) on female sexual function.
Methods
This was a prospective multicenter cohort study. Sexually active women with OAB completed the Overactive Bladder questionnaire (OAB-q) and Female Sexual Function Index (FSFI) prior to and after 12 weeks of therapy. Sample sizes of 63 per group were calculated to detect a clinically relevant difference in the FSFI.
Outcomes
The primary outcome was FSFI change from baseline at 12 weeks.
Results
A total of 157 patients were recruited, and 91 completed follow-up (58/108, ACH; 31/49, BAG). There were within-group FSFI differences from pre- to posttreatment: a worsening of arousal in the ACH group (P = .046) and an improvement in overall FSFI (P = .04) and pain (P = .04) in the BAG group. After treatment, postmenopausal women in the BAG group had significantly better overall FSFI (P = .01), desire (P = .003), arousal (P = .009), and orgasm (P = .01).
Clinical Implications
While further research is necessary, this study provides information about the comparative effects of OAB treatments on female sexual function, which may ultimately lead to better patient selection and outcomes.
Strengths and Limitations
While there was no difference between the subjects who completed the study and those who did not, the study remained underpowered after the loss to follow-up. The multicenter cohort design allows for generalizability of results.
Conclusion
Although this study was underpowered, an improvement in overall sexual function was seen with BAGs, while ACHs were associated with worsening aspects of sexual function.
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Affiliation(s)
- Allison Polland
- Department of Surgery/Urology, Maimonides Medical Center , Brooklyn, NY 11220 , USA
| | | | - Divya Arunachalam
- Department of Gynecology, Kaiser Permanente Fontana Medical Center , Fontana, CA 92553 , USA
| | | | - Ankita Gupta
- Department of Gynecology, University of Louisville , Louisville, KY 40215 , USA
| | - Jon F Pennycuff
- Department of Gynecology, University of Wisconsin , Madison, WI 53715 , USA
| | - Ann D Tran
- Department of Gynecology, Icahn School of Medicine at Mount Sinai , New York, NY 10029 , USA
| | - Eshetu Tefera
- Department of Biostatistics, Medstar Health Research Institute , Hyattsville, MD 20782 , USA
| | - Kate V Meriwether
- Department of Gynecology, University of New Mexico , Albuquerque, NM 87131 , USA
| | - Robert E Gutman
- Department of Gynecology, MedStar Georgetown University , Washington, DC 20010 , USA
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Gomes-Lima CJ, Chittimoju S, Wehbeh L, Dia S, Pagadala P, Al-Jundi M, Jhawar S, Tefera E, Mete M, Klubo-Gwiezdzinska J, Van Nostrand D, Jonklaas J, Wartofsky L, Burman KD. Response to Letter to the Editor from Zandee and Links: "Metastatic Differentiated Thyroid Cancer Survival Is Unaffected by Mode of Preparation for 131I Administration". J Endocr Soc 2023; 7:bvad005. [PMID: 36777465 PMCID: PMC9909159 DOI: 10.1210/jendso/bvad005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Cristiane J Gomes-Lima
- MedStar Clinical Research Center, MedStar Health Research Institute (MHRI),Hyattsville, MD 20782-2031, USA
- Section of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sanjita Chittimoju
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Leen Wehbeh
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sunita Dia
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Prathyusha Pagadala
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Mohammad Al-Jundi
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Sakshi Jhawar
- Department of Internal Medicine, Sinai Hospital of Baltimore, Research Volunteer, Baltimore, MD 21215, USA
| | - Eshetu Tefera
- Department of Biostatistics, MedStar Health Research Institute (MHRI), Hyattsville, MD 20782-2031, USA
| | - Mihriye Mete
- Department of Biostatistics, MedStar Health Research Institute (MHRI), Hyattsville, MD 20782-2031, USA
| | - Joanna Klubo-Gwiezdzinska
- Thyroid Tumors and Functional Thyroid Disorders Section, National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK), Bethesda, MD 20892, USA
| | - Douglas Van Nostrand
- MedStar Clinical Research Center, MedStar Health Research Institute (MHRI),Hyattsville, MD 20782-2031, USA
- Nuclear Medicine Research, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Jacqueline Jonklaas
- Division of Endocrinology, Department of Medicine, Georgetown University, Washington, DC 20057, USA
| | - Leonard Wartofsky
- Section of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, USA
| | - Kenneth D Burman
- Section of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, USA
- Division of Endocrinology, Department of Medicine, Georgetown University, Washington, DC 20057, USA
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Choi HY, Corder W, Tefera E, Abubakar KM. Comparison of Point-of-Care versus Central Laboratory Testing of Electrolytes, Hemoglobin, and Bilirubin in Neonates. Am J Perinatol 2022; 39:1786-1791. [PMID: 33757138 DOI: 10.1055/s-0041-1726125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE Electrolyte, hemoglobin, and bilirubin values are routinely reported with point-of-care (POC) testing for blood gases. Results are rapidly available and require a small blood volume. Yet, these results are underutilized due to noted discrepancies between central laboratory (CL) and POC testing. The study aimed to determine the correlation between POC and CL measurement of electrolytes, hemoglobin, and bilirubin in neonates. STUDY DESIGN Electrolyte, hemoglobin, and bilirubin results obtained from capillary blood over a 4-month period were analyzed. Each CL value was matched with a POC value from the same sample or another sample less than 1-hour apart. Agreement was determined by measuring the mean difference (MD) between paired samples with 95% limits of agreement (LOA) and Lin's concordance correlation (LCC). RESULTS There were 355-paired sodium/potassium, 139 paired hemoglobin, and 197 paired bilirubin values analyzed. POC sodium values were lower (133.5 ± 5.8 mmol/L) than CL (140.2 ± 5.8 mmol/L), p <0.00001 with poor agreement (LCC = 0.49; MD = 6.7; 95% LOA: -13.6 to 0.14). POC potassium values were lower (4.6 ± 0.98 mmol/L) than CL (4.98 ± 1.24mEq/L), p < 0.0001, but with better concordance and agreement. (LCC = 0.6; MD = 0.4; 95% LOA: -2.3 to 1.4). There were no differences in hemoglobin between POC (14.3 ± 3.2 g/dL) and CL (14.4 ± 3.1 g/dL), p = 0.2 with good LCC (0.93) and in bilirubin values between POC (6.0 ± 3.2 mg/dL) and CL (5.8 ± 3.0 mg/dL), MD = 0.18, and p = 0.07. CONCLUSION POC Sodium values are lower than CL. POC potassium levels are also lower, but the differences may not be clinically important while hemoglobin and bilirubin levels are similar between POC and CL. As POC potassium, hemoglobin, and bilirubin levels closely reflect CL values, these results can be relied upon to make clinical judgments in neonates. KEY POINTS · Electrolyte, hemoglobin, and bilirubin are available as POC.. · POC sodium and potassium values are lower than CL results.. · Hemoglobin and bilirubin values are similar between POC and CL..
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Affiliation(s)
- Ha-Young Choi
- Division of Neonatology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - William Corder
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Eshetu Tefera
- Statistics, MedStar Research Institute, Washington, District of Columbia
| | - Kabir M Abubakar
- Division of Neonatology, MedStar Georgetown University Hospital, Washington, District of Columbia
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9
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McCormick BP, Rigor P, Trent SM, Lee JW, Tefera E, Mistretta KL, Boucher HR. Short-Term Outcomes Following Cemented Versus Cementless Robotic-Assisted Total Knee Arthroplasty. Cureus 2022; 14:e30667. [DOI: 10.7759/cureus.30667] [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] [Accepted: 10/25/2022] [Indexed: 11/07/2022] Open
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10
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Glousman BN, Cragon R, Steinberg JS, Evans KK, Attinger CE, Kiguchi MM, Tefera E, Akbari CM. Presence of a Patent Pedal Arch Is the Primary Predictor of Transmetatarsal Amputation Healing and Limb Salvage. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.07.064] [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: 11/16/2022]
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11
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Cook HR, Cates NK, Kennedy CJ, Tefera E, Popovsky D, Delijani K, Kim PJ, Attinger CE, Steinberg JS. Risks Factors Associated With Major Lower Extremity Amputation After Vertical Contour Calcanectomy. J Foot Ankle Surg 2022; 61:1046-1051. [PMID: 35168902 DOI: 10.1053/j.jfas.2022.01.013] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/22/2020] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
The primary aim of the study is to determine risks for major lower extremity amputation after undergoing Vertical Contour Calcanectomy. Subanalysis was performed comparing patients who underwent Vertical Contour Calcanectomy who were fully ambulatory to those who were partially or nonambulatory postoperatively. Within the cohort of 63 patients included in the Vertical Contour Calcanectomy 85.71% (54/63) of patients had diabetes mellitus, 53.97% (34/63) had peripheral arterial disease, and 19.05% (12/63) had Charcot Neuroarthropathy. Multivariate logistic regression, found that (1) patients that underwent primary closure at the time of the Vertical Contour Calcanectomy, were 79.9% more likely (odds ratio [OR] 0.20; 95% confidence interval [CI] 0.04-0.96) to have limb salvage and that (2) female patients were 85.4% less likely compared to male patients (OR 0.15; 95% CI 0.02-0.99) to undergo major lower extremity amputation. Patients with coronary artery disease were 5.2 times more likely (OR 5.18; 95% CI 1.120-23.94) and patients that were nonambulatory preoperatively, were 10.3 times more likely (OR 10.28; 95% CI 1.60-66.26), to be partially or nonambulatory after Vertical Contour Calcanectomy. Primary closure at time of Vertical Contour Calcanectomy significantly decreases the risk of major lower extremity amputation, and diminished preoperative ambulatory status as well as coronary artery disease makes it less likely that patients return to full ambulation after Vertical Contour Calcanectomy.
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Affiliation(s)
- Helene R Cook
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Nicole K Cates
- Limb Preservation and Deformity Correction Fellow, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Christopher J Kennedy
- MedStar Georgetown University Hospital Diabetic Limb Salvage Fellow, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - Daniel Popovsky
- Medical Student, Georgetown University Medical School, Washington, DC
| | - Kevin Delijani
- Medical Student, Georgetown University Medical School, Washington, DC
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC.
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12
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Cates NK, Mayer A, Tenley J, Wynes J, Tefera E, Steinberg JS, Kim PJ, Weinraub GM. Double Versus Triple Arthrodesis Fusion Rates: A Systematic Review. J Foot Ankle Surg 2022; 61:907-913. [PMID: 35221217 DOI: 10.1053/j.jfas.2022.01.012] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/20/2021] [Accepted: 01/10/2022] [Indexed: 02/03/2023]
Abstract
Hindfoot arthrodesis is often required for end-staged deformities, such as posterior tibial tendon dysfunction, osteoarthritis, or rheumatoid arthritis. Although the need for hindfoot arthrodesis is generally accepted in severe deformities, there is a debate whether a double or triple arthrodesis should be performed. The aim of our systematic review is to review the fusion rates and mean time to fusion in double and triple arthrodesis. A total of 184 articles were identified using the keyword search through the database of articles published from 2005 to 2017. After review by 3 physicians, a total of 13 articles met the eligibility criteria. The reason for double or triple arthrodesis within the studies were posterior tibial tendon dysfunction, tarsal coalition, degenerative joint disease, osteoarthritis, rheumatoid arthritis, Charcot Marie Tooth, Multiple Sclerosis, Polio, neuromuscular disorder, cerebral palsy, acrodystrophic neuropathy, clubfoot, post-traumatic, and seronegative arthropathy (spondyloarthritis). Within these 13 studies, there were a total of 343 (6-95) subjects extremities operated on. The overall fusion rate for double arthrodesis was 91.75% (289/315) compared to 92.86% (26/28) triple arthrodesis fusion rate, p value .8370. The mean time to fusion for double arthrodesis was 17.96 ± 7.96 weeks compared to 16.70 ± 8.18 weeks for triple arthrodesis, p value = .8133. There are risks associated with triple arthrodesis including increased surgical times, lateral wound complications, residual deformity, surgical costs and peri-articular arthritis. Given the benefits of double arthrodesis over triple arthrodesis and the nearly equivalent fusion rates and time to fusion, double arthrodesis is an effective alternative to triple arthrodesis. The authors of this systematic review recommend double arthrodesis as the hindfoot fusion procedure of choice.
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Affiliation(s)
- Nicole K Cates
- Fellowship Trained Foot and Ankle Surgeon, Hand & Microsurgery Medical Group, San Francisco, CA.
| | - Alissa Mayer
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jonathan Tenley
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Jacob Wynes
- Asistant Professor, Fellowship Program Director, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - John S Steinberg
- Co-Director of the Center for Wound Healing and Director of Podiatric Residency Training Program, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Paul J Kim
- Professor, Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Glenn M Weinraub
- Attending Physician, Department of Orthopaedics, Kaiser Permanente, San Leandro, CA
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13
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Gomes-Lima CJ, Chittimoju S, Wehbeh L, Dia S, Pagadala P, Al-Jundi M, Jhawar S, Tefera E, Mete M, Klubo-Gwiezdzinska J, Van Nostrand D, Jonklaas J, Wartofsky L, Burman KD. Metastatic Differentiated Thyroid Cancer Survival Is Unaffected by Mode of Preparation for 131I Administration. J Endocr Soc 2022; 6:bvac032. [PMID: 35356009 PMCID: PMC8962448 DOI: 10.1210/jendso/bvac032] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Indexed: 01/13/2023] Open
Abstract
Context Recombinant human thyrotropin (rhTSH) is currently not Food and Drug Administration approved for the treatment of high-risk patients with differentiated thyroid cancer (DTC). Objective The goal of our study was to compare the outcomes in higher-risk patients with metastatic DTC prepared for radioiodine (RAI) therapy with rhTSH vs thyroid hormone withdrawal (THW). Methods A retrospective chart review was performed of patients with metastatic DTC in follow-up at MedStar Washington Hospital Center and MedStar Georgetown University Hospital from 2009 to 2017. Patients were divided according to their preparation for RAI therapy, with assessment of progression-free survival (PFS) and overall survival (OS). Results Fifty-five patients with distant metastases (16 men, 39 women) were prepared for RAI therapy exclusively either with rhTSH (n = 27) or with THW (n = 28). There were no statistically significant differences between the groups regarding clinicopathological features and history of RAI therapies. The median follow-up time for patients with rhTSH-aided therapies was 4.2 years (range, 3.3-5.5 years) and for patients with THW-aided therapies was 6.8 years (range, 4.2-11.6 years) (P = .002). Multivariate analysis showed that the method of thyrotropin stimulation was not associated with a difference in PFS or OS. Conclusion As has been shown previously for low-risk DTC, this study indicates that the mode of preparation for RAI therapy does not appear to influence the outcomes of patients with metastatic DTC. PFS and OS were similar for patients with THW-aided or rhTSH-aided RAI therapies.
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Affiliation(s)
- Cristiane J Gomes-Lima
- MedStar Clinical Research Center, MedStar Health Research Institute (MHRI), Hyattsville 20782-2031, Maryland, USA,Section of Endocrinology, MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Sanjita Chittimoju
- Internal Medicine - MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Leen Wehbeh
- Internal Medicine - MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Sunita Dia
- Internal Medicine - MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Prathyusha Pagadala
- Internal Medicine - MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Mohammad Al-Jundi
- Internal Medicine - MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Sakshi Jhawar
- Internal Medicine, Sinai Hospital of Baltimore, Baltimore, Maryland 21215, USA
| | - Eshetu Tefera
- MedStar Health Research Institute (MHRI), Hyattsville 20782-2031, Maryland, USA
| | - Mihriye Mete
- MedStar Health Research Institute (MHRI), Hyattsville 20782-2031, Maryland, USA
| | - Joanna Klubo-Gwiezdzinska
- National Institutes of Health/National Institute of Diabetes and Digestive and Kidney Diseases (NIH/NIDDK), Bethesda, Maryland 20892, USA
| | - Douglas Van Nostrand
- MedStar Clinical Research Center, MedStar Health Research Institute (MHRI), Hyattsville 20782-2031, Maryland, USA,Nuclear Medicine Research, MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Jacqueline Jonklaas
- Division of Endocrinology, Department of Medicine Georgetown University, Washington, District of Columbia 20057, USA
| | - Leonard Wartofsky
- Section of Endocrinology, MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA
| | - Kenneth D Burman
- Section of Endocrinology, MedStar Washington Hospital Center, Washington, District of Columbia 20010, USA,Division of Endocrinology, Department of Medicine Georgetown University, Washington, District of Columbia 20057, USA,Correspondence: Kenneth D. Burman, MD, Section of Endocrinology, MedStar Washington Hospital Center, Suite 2A-72, 110 Irving St NW, Washington, DC 20010, USA.
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14
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Januzzi JL, Butler J, Sattar N, Tefera E, Rosenthal N, Yavin Y, Bull S, Jardine M, Pollock C, Heerspink HJ, Hansen MK. INSULIN-LIKE GROWTH FACTOR BINDING PROTEIN-7 PREDICTS CARDIOVASCULAR AND RENAL OUTCOMES IN PATIENTS WITH TYPE 2 DIABETES AND CHRONIC KIDNEY DISEASE: THE CREDENCE TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01290-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Abu El Hawa AA, Klein D, Bekeny JC, Severin JH, Zolper EG, Tefera E, Evans KK, Fan KL, Attinger CE. The impact of statins on wound healing: an ally in treating the highly comorbid patient. J Wound Care 2022; 31:S36-S41. [PMID: 35148640 DOI: 10.12968/jowc.2022.31.sup2.s36] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 11/11/2022]
Abstract
OBJECTIVE To identify the impact that HMG-CoA reductase inhibitors (statins) use has on wound healing outcomes in patients with comorbidities. METHOD A retrospective chart review evaluating all new patients presenting to our tertiary wound care centre in 2013 with lower extremity wounds. Patients were divided into two groups depending on whether they took statins or not. Data on wound healing outcomes and wound/patient characteristics were collected. Primary outcomes included healing rate and progression to complete wound healing. Patients were excluded if they had incomplete data or were lost to follow-up before healing status could be confirmed. RESULTS A total of 194 patients met the inclusion criteria and were allocated to either the statin group (n=89) or to the non-statin group (n=105). Median initial wound size was 0.6cm3 (Interquartile range (IQR): 0.15-2.4) (p=0.684). In the statin group, 54 (60.6%) patients progressed to complete wound healing compared with 47 (44.7%) in the non-statin group (p=0.027). Median rate of wound healing was 6.7×10-3cm3/day (IQR: 1.5×10-3-2.6×10-2) compared with 3.8×10-3cm3/day (IQR: 1.7×10-3-1.3×10-2) in the non-statin group (p=0.773). Increased age and a higher number of comorbidities were reported in the statin group (p<0.001), respectively). A total of seven patients required amputation: five patients in the statin group and two patients in the non-statin group (p=0.250). CONCLUSION This study revealed increased progression to wound healing in patients who were taking statins. The influence of statins on wound healing is promising, but future trials are needed to justify use of this medication class independent of cardiovascular benefit and exclusively for wound healing.
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Affiliation(s)
- Areeg A Abu El Hawa
- Georgetown University School of Medicine; Washington, District of Columbia, US
| | - Doron Klein
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
| | - Jenna C Bekeny
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
| | - James H Severin
- Georgetown University School of Medicine; Washington, District of Columbia, US
| | - Elizabeth G Zolper
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
| | - Eshetu Tefera
- MedStar Health Research Institute; Washington, District of Columbia, US
| | - Karen K Evans
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
| | - Kenneth L Fan
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
| | - Christopher E Attinger
- Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital; Washington, District of Columbia, US
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16
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Kopcsay KS, Marczak TD, Jeppson PC, Cameron AP, Khavari R, Tefera E, Gutman RE. Treatment of refractory overactive bladder with OnabotulinumtoxinA vs PTNS: TROOP trial. Int Urogynecol J 2022; 33:851-860. [PMID: 34993598 DOI: 10.1007/s00192-021-05030-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 10/19/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS We hypothesized that patients with refractory overactive bladder (rOAB) have similar improvement with percutaneous tibial nerve stimulation (PTNS) and OnabotulinumtoxinA (BTX). METHODS This multicenter cohort study compared BTX and PTNS in women with rOAB. Baseline information included Overactive Bladder Questionnaire (OABq) short form, Urinary Distress Inventory-6 (UDI-6), and voiding diary. Primary outcome was cure, defined as "very much better" or "much better" on the Patient Global Impression of Improvement (PGII) AND a reduction in OABq symptom severity scale (SSS) ≥10 at 3 months after treatment. Assuming 80% power to detect a ten-point difference in OABq-SSS, 80 participants were required per group. RESULTS A total of 150 patients were enrolled; 97 completed 3 months of therapy and were included. At baseline, BTX patients had more detrusor overactivity (70% vs 40%, p = 0.025), urgency incontinence (UUI; OABq-SSS#6 4 vs 3, p = 0.02, SSS 65 vs 56, p = 0.04), but similar health-related quality of life (HRQL 49 vs 54, p = 0.28), voids (7 vs 8, p = 0.13), and UUI episodes (2 vs 2, p = 1.0). At 3 months, cure rates were similar: BTX 50% vs PTNS 44.2% (p = 0.56). Both groups had improved SSS (-37 vs -29, p = 0.08) and HRQL (31 vs 24, p = 0.14). Patients receiving BTX had a greater improvement in urgency (ΔOABq-SSS#2-3 vs -2; p = 0.02) and UUI (ΔOABq-SSS#6-2 vs -1; p = 0.02). No characteristics were predictive of cure. CONCLUSIONS BTX resulted in significantly greater improvement in urgency and UUI than PTNS, but no difference in success based on PGII and OABq-SSS, which may be due to a lack of power.
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Affiliation(s)
- Katelyn Smithling Kopcsay
- Obstetrics & Gynecology, Division of Urogynecology, Baystate Health, 759 Chestnut St, S1681, Springfield, MA, 01199, USA.
| | - Tara Doyle Marczak
- Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Mount Auburn Hospital/Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Peter C Jeppson
- Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Anne P Cameron
- Urology, Division of Neurourology and Pelvic Reconstruction, University of Michigan, Ann Arbor, MI, USA
| | - Rose Khavari
- Urology, Houston Methodist Hospital, Houston, TX, USA
| | - Eshetu Tefera
- Department of Biostatistics and Epidemiology, MedStar Health Research Institute, Hyattsville, MD, USA
| | - Robert E Gutman
- Obstetrics & Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Georgetown University/MedStar Washington Hospital Center, Washington, DC, USA
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Abstract
BACKGROUND Hospitalized patients with advanced heart failure often experience acute and/or chronic pain. While virtual reality has been extensively studied across a wide range of clinical settings, no studies have yet evaluated potential impact on pain management on this patient population. AIM To investigate the impact of a virtual reality experience on self-reported pain, quality-of-life, general distress, and satisfaction compared to a two-dimensional guided imagery active control. DESIGN Single-center prospective randomized controlled study. The primary outcome was the difference in pre- versus post-intervention self-reported pain scores on a numerical rating scale from 0 to 10. Secondary outcomes included changes in quality-of-life scores, general distress, and satisfaction with the intervention. SETTING/PARTICIPANTS Between October 2018 and March 2020, 88 participants hospitalized with advanced heart failure were recruited from an urban tertiary academic medical center. RESULTS Participants experienced significant improvement in pain score after either 10 minutes of virtual reality (change from pre- to post -2.9 ± 2.6, p < 0.0001) or 10 minutes of guided imagery (change from pre- to post -1.3 ± 1.8, p = 0.0001); the virtual reality arm experienced a 1.5 unit comparatively greater reduction in pain score compared to guided imagery (p = 0.0011). Total quality-of-life and general distress scores did not significantly change for either arm. Seventy-eight participants (89%) responded that they would be willing to use the assigned intervention again. CONCLUSION Virtual reality may be an effective nonpharmacologic adjuvant pain management intervention in hospitalized patients with heart failure. TRIAL REGISTRATION ClinicalTrials.gov database (NCT04572425).
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Affiliation(s)
- Hunter Groninger
- Georgetown University Medical Center, Washington, DC, USA.,MedStar Washington Hospital Center, Washington, DC, USA
| | - Diana Stewart
- MedStar Washington Hospital Center, Washington, DC, USA
| | - Julia M Fisher
- Georgetown University School of Medicine, Washington, DC, USA
| | - Eshetu Tefera
- MedStar Health Research Institute, Washington, DC, USA
| | - James Cowgill
- MedStar Institute for Innovation, Washington, DC, USA
| | - Mihriye Mete
- MedStar Health Research Institute, Washington, DC, USA
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18
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Laurence B, Farmer-Dixon CM, Southwell A, Marshall T, Shara N, Taylor G, Edmonds T, Harris D, Grant-Mills D, Tefera E. Sugar-Sweetened Beverage Consumption and Caries Prevalence in Underserved Black Adolescents. Pediatr Dent 2021; 43:363-370. [PMID: 34654498] [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: 06/13/2023]
Abstract
Purpose: The purpose of this study was to examine the association between sugar-sweetened beverage (SSB) consumption and dental caries prevalence among underserved Black adolescents. Methods: This was a cross-sectional study of 545 Black adolescents, ages 12 to 17 years, who participated in the Howard Meharry Adolescent Caries Study (HMACS). The outcome was dental caries prevalence, measured using the decayed, missing, and filled permanent tooth surfaces (DMFS) index. Participants were recruited from middle and high schools in Washington, D.C., USA, and Nashville, Tenn., USA. Questionnaires were used to assess beverage intake, demographic, and health-related behavioral characteristics. The multivariable analysis used marginalized zero-inflated Poisson regression (MZIP) stratified by toothbrushing frequency to estimate adjusted mean caries ratios (MRs), adjusted odds ratios (ORs), and 95 percent confidence intervals (95 percent CIs). Results: The mean age of the participants was 14.1 years. Participants in the highest quartile for SSB consumption had a higher caries ratio than those in the lowest quartile [MR equals (=) 1.59, 95 percent CI equals 1.15 to 2.20] and a lower odds of not being at risk for caries (OR = 0.24, 95 percent CI = 0.09 to 0.61). These findings were only observed among those brushing once a day or less (n =202). Conclusions: Among Black adolescents in this study who brushed once a day or less, high levels of sugar-sweetened beverage consumption were associated with greater caries prevalence and a reduced likelihood of remaining caries-free than those with lower levels of SSB consumption. Future studies will focus on interventions to reduce SSB consumption.
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Affiliation(s)
- Brian Laurence
- Dr. Laurence is a professor, Middle School of Mathematics and Science, Howard University, Washington, D.C., USA;,
| | - Cherae M Farmer-Dixon
- Dr. Farmer-Dixon is dean, Meharry Medical College School of Dentistry, Nashville, Tenn., USA
| | - Angela Southwell
- Dr. Southwell is an assistant professor, Meharry Medical College School of Dentistry, Nashville, Tenn., USA
| | - Teresa Marshall
- Dr. Marshall is a professor, Department of Preventive and Community Dentistry, College of Dentistry, University of Iowa, Iowa City, Iowa, USA
| | - Nawar Shara
- Dr. Shara is director, Department of Biostatistics and Biomedical Informatics, at the Medstar Health Research Institute, Hyattsville, Md., USA
| | - George Taylor
- Dr. Taylor is a professor and an associate dean for diversity and inclusion, University of California San Francisco School of Dentistry, San Francisco, Calif., USA
| | - Tiffany Edmonds
- Ms. Edmonds is an executive assistant, Middle School of Mathematics and Science, Howard University, Washington, D.C., USA
| | - Dianne Harris
- Ms. Harris is director, Health Services, Friendship Charter Schools, Washington, D.C., USA
| | - Donna Grant-Mills
- Dr. Grant-Mills is an associate professor, College of Dentistry, Middle School of Mathematics and Science, Howard University, Washington, D.C., USA
| | - Eshetu Tefera
- Mr. Tefera is a biostatistician, Department of Biostatistics and Biomedical Informatics, at the Medstar Health Research Institute, Hyattsville, Md., USA
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19
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Cates NK, Elmarsafi T, Akbari CM, Tefera E, Evans KK, Steinberg JS, Attinger CE, Kim PJ. Complications of Charcot Reconstruction in Patients With Peripheral Arterial Disease. J Foot Ankle Surg 2021; 60:941-945. [PMID: 33980466 DOI: 10.1053/j.jfas.2019.08.039] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 03/15/2019] [Revised: 04/07/2019] [Accepted: 08/31/2019] [Indexed: 02/03/2023]
Abstract
The primary aim was to determine the rate of complications in patients with peripheral arterial disease and diabetic Charcot neuroarthropathy who underwent osseous reconstruction. Complications included delayed healing, dehiscence, and major lower extremity amputation. A review of patients with Charcot neuroarthropathy requiring reconstruction secondary to ulceration or acute infection was performed. Descriptive analysis compared outcomes between those with and without peripheral arterial disease. Bivariate analysis and multivariate logistic regression were analyzed for delayed healing, dehiscence, and major amputation. In a cohort of 284 patients with diabetic Charcot neuroarthropathy who underwent osseous reconstruction, the rate of peripheral arterial disease was 20.8% (59/284). Bivariate analysis for delayed healing found hypertension (p = .0352), peripheral arterial disease (p = .0051), and smoking history (p = .0276) to be statistically significant factors. Delayed healing was 2.012 times more likely in the presence of peripheral arterial disease [OR 2.012 (95% CI 1.088-3.720)]. Bivariate analysis for major lower extremity amputation found renal disease (0.0003) (renal disease: ESRD and CKD) and peripheral arterial disease (0.0001) to be statistically significant factors. Major amputation was 4.414 times more likely in the presence of peripheral arterial disease [OR 4.414 (95% CI 2.087-9.334)]. Peripheral arterial disease was identified in 20.8% (59/284) of diabetic patients who underwent Charcot osseous reconstruction. Peripheral arterial disease increased the risk of delayed healing by 2.012 fold, and increased the risk of major lower extremity amputation by 4.414 fold. The rates of complications in patients with peripheral arterial disease were significantly higher than those without peripheral arterial disease who underwent osseous reconstruction.
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Affiliation(s)
- Nicole K Cates
- Fellowship Trained Foot and Ankle Surgeon, Hand & Microsurgery Medical Group, San Francisco, CA
| | - Tammer Elmarsafi
- Fellowship Trained Foot and Ankle Surgeon, Potomac Podiatry Group, Great Falls, VA
| | - Cameron M Akbari
- Department of Vascular Surgery, MedStar Georgetown University Hospital, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - Karen K Evans
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
| | - John S Steinberg
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC.
| | | | - Paul J Kim
- Department of Plastic Surgery, Medstar Georgetown University Hospital, Washington, DC
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Marshall T, Tefera E, Laurence B, Farmer-Dixon CM, Southwell A, Edmonds T, Harris D, Taylor G, Shara N, Grant-Mills D. Food Insecurity, Meal Behaviors, Beverage Intake, and Body Mass Index in Underserved Adolescents. J Health Care Poor Underserved 2021; 32:1372-1383. [PMID: 34421037 DOI: 10.1353/hpu.2021.0138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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 Associations between food insecurity, meal patterns, beverage intake, and body mass index (BMI) were investigated using data from the Howard Meharry Adolescent Caries Study. METHODS Secondary analyses of food security status used the Wilcoxon rank sum, chi-square, and Fisher's exact tests. RESULTS The group of adolescents (n=627) was 42.1% male, 14.2±1.9 years, 86.9% African American, and 19.9% food-insecure. Meal frequency, meal structure, most beverage intake, and BMI did not differ by food-security status. Adolescents from Washington, DC were more likely to be food insecure than adolescents from Nashville, TN (P=0.003). Most had unstructured meal patterns and irregular breakfast intake. Median milk intake was below and sugar-sweetened beverage intake above dietary recommendations. CONCLUSIONS This study extends our knowledge concerning food insecurity in urban African American adolescents and suggests public health initiatives designed to encourage meal structure, increase milk intake, and reduce sugar-sweetened beverage intake can improve diet quality of underserved youth.
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Cates NK, Wagler EC, Bunka TJ, Elmarsafi T, Tefera E, Kim PJ, Liu GT, Evans KK, Steinberg JS, Attinger CE. Charcot Reconstruction: Outcomes in Patients With and Without Diabetes. J Foot Ankle Surg 2021; 59:1229-1233. [PMID: 32921562 DOI: 10.1053/j.jfas.2020.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 08/26/2019] [Revised: 04/12/2020] [Accepted: 05/21/2020] [Indexed: 02/03/2023]
Abstract
The objective of this study is to compare risk adjusted matched cohorts of Charcot neuroarthropathy patients who underwent osseous reconstruction with and without diabetes. The 2 groups were matched based on age, body mass index, hypertension, history of end-stage renal disease, and peripheral arterial disease. Bivariate analysis was performed for preoperative infection, location of Charcot breakdown, and post reconstruction outcomes, in patients with a minimum of 1 year follow-up period. Through bivariate analysis, presence of preoperative ulceration (p = .0499) was found to be statistically more likely in the patients with diabetes; whereas, delayed osseous union (p = .0050) and return to ambulation (p ≤ .0001) was statistically more likely in patients without diabetes. The nondiabetic Charcot patients were 17.6 folds more likely to return to ambulation (odds ratio [OR] 17.6 [95% confidence interval {CI} {3.5-87.6}]), and 16.4 folds more likely to have delayed union (OR 16.4 [95% CI {1.9-139.6)]). Subanalysis compared well-controlled diabetic and nondiabetic Charcot neuroarthropathy patients for same factors. Multivariate analysis, in the subanalysis, found return to ambulation was 15.1 times likely to occur in the nondiabetic CN cohort (OR 15.1 [95% CI 1.3-175.8]) compared to the well-controlled diabetic CN cohort.
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Affiliation(s)
- Nicole K Cates
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Emily C Wagler
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Taylor J Bunka
- Resident Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Tammer Elmarsafi
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Eshetu Tefera
- Department of Biostatistician and Biomedical Informatics, MedStar Health Research Institute, Washington DC
| | - Paul J Kim
- Attending Physician, Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - George T Liu
- Attending Physician, Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Karen K Evans
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - John S Steinberg
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC.
| | - Christopher E Attinger
- Attending Physician, Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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22
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Alfawaz A, Kotha VS, Nigam M, Bekeny JC, Black CK, Tefera E, Wang J, Coerdt KM, Dekker PK, Kim KG, Evans KK, Akbari CM, Attinger CE. Popliteal artery patency is an indicator of ambulation and healing after below-knee amputation in vasculopaths. Vascular 2021; 30:708-714. [PMID: 34134560 DOI: 10.1177/17085381211026498] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND The posterior flap is a conventional technique for closing a below-knee amputation (BKA) that uses the gastrocnemius and soleus muscle and relies on the popliteal and posterior compartment arteries. If the prior mentioned arterial blood supply is compromised, this flap likely relies on collateral flow. The purpose of this study is to identify and differentiate any significant associations between preoperative popliteal and tibial arterial flow and BKA outcomes and patient-reported function. METHODS A retrospective review identified patients from a single tertiary wound care center who received BKAs and angiogram between 2010 and 2017 by a single surgeon. BKA complications, wound healing, and amputee ambulatory status at latest follow-up were all stratified for differences according to baseline tibial vessel run-off (VRO) status, popliteal artery patency, and popliteal angioplasty outcome. Chi-square, Fisher's exact, and Wilcoxon rank sum tests were used with significance defined as p ≤ 0.05. RESULTS BKAs were performed on 313 patients, of which, 167 underwent preoperative angiography. Thirty-two were excluded due to lack of adequate follow-up leaving a total of 135 patients in the studied population. Diabetes was present in 87%, and 36% had end-stage renal disease. By the study's conclusion, 92% of BKAs had fully healed, with median time-to-healing of 79 days (range 19-1314 days). 60% of patients were ambulatory at 9.5 months. Higher VRO was associated with higher healing rates and lower complications and time-to-healing. The conversion rate of BKA to above-knee amputation (AKA) was 4%. Preoperative popliteal patency was associated with higher postoperative ambulation rates when compared to patients without popliteal flow preoperatively (patent: 71/109, 65%; occluded: 10/26, 40%; p = 0.02) and independently increased the likelihood of postoperative ambulation. CONCLUSIONS The posterior flap design for BKA works even in the setting of popliteal occlusion. Complication rates are higher in patients with more compromised blood flow, which may ultimately lead to AKA. Given poor ambulation rates in patients who undergo AKA, the results of this study should encourage surgeons to consider a more functional BKA, even in instances when the popliteal artery is occluded.
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Affiliation(s)
- Abdullah Alfawaz
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Vascular Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Vikas S Kotha
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Manas Nigam
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jenna C Bekeny
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Cara K Black
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Eshetu Tefera
- 121577MedStar Health Research Institute, Washington, DC, USA
| | - Jing Wang
- Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kathleen M Coerdt
- Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Paige K Dekker
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kevin G Kim
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Karen K Evans
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Cameron M Akbari
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Vascular Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
| | - Christopher E Attinger
- Center for Wound Healing and Hyperbaric Medicine, 71541MedStar Georgetown University Hospital, Washington, DC, USA.,Department of Plastic and Reconstructive Surgery, 71541MedStar Georgetown University Hospital, Washington, DC, USA
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Johnson‐Arbor K, Tefera E, Farrell J. Characteristics and treatment of elemental mercury intoxication: A case series. Health Sci Rep 2021; 4:e293. [PMID: 34136656 PMCID: PMC8177896 DOI: 10.1002/hsr2.293] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 04/20/2021] [Accepted: 04/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND AND AIMS Elemental mercury toxicity is a rare condition which can be difficult to diagnose due to its nonspecific signs and symptoms. The purpose of this investigation is to describe the presenting characteristics and treatment of adult and pediatric patients with elemental mercury poisoning. METHODS A retrospective review was performed in six patients with elemental mercury exposure or intoxication who were treated in an outpatient medical toxicology clinic. Clinical signs and symptoms, laboratory assessments, and public health responses were reviewed. RESULTS Headache, anorexia, rash, and personality changes were commonly reported symptoms in pediatric patients; the adult patients were asymptomatic or reported signs and symptoms included myalgias, tremors, and hypertension. Delays in diagnosis were common. Symptomatic patients had 24-hour urine mercury concentrations greater than 20 mcg/L. Treatment, including removal from the exposure source as well as chelation with dimercaptosuccinic acid, resulted in resolution of signs and symptoms within 6 months of diagnosis. CONCLUSION The evaluation and treatment of patients with suspected elemental mercury poisoning frequently require a multidisciplinary approach including medical toxicologists and public health officials. A heightened awareness of the clinical presentations of this condition, as well as early identification and removal of patients from the source of exposure and consideration of chelation therapy, can result in accelerated patient recovery.
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Affiliation(s)
- Kelly Johnson‐Arbor
- Department of Plastic and Reconstructive SurgeryMedStar Georgetown University HospitalWashingtonDistrict of Columbia
- National Capital Poison CenterWashingtonDistrict of Columbia
| | - Eshetu Tefera
- Department of Plastic and Reconstructive SurgeryMedStar Georgetown University HospitalWashingtonDistrict of Columbia
- Department of Biostatistics and Biomedical InformaticsMedStar Health Research InstituteHyattsvilleMaryland
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24
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Wu D, Plyku D, Kulkarni K, Garcia C, Atkins F, Tefera E, Burman KD, Wartofsky L, Van Nostrand D. Optimal Time for 124I PET/CT Imaging in Metastatic Differentiated Thyroid Cancer. Clin Nucl Med 2021; 46:283-288. [PMID: 33492859 DOI: 10.1097/rlu.0000000000003505] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The objective of this study was to determine the optimal time for 124I PET/CT imaging to maximize the detection of locoregional and/or distant metastases of differentiated thyroid cancer. METHODS Differentiated thyroid cancer patients suspected of having metastatic disease were prepared with low-iodine diet and appropriate thyroid-stimulating hormone stimulation. 124I PET and low-dose localization CT were performed over 4 days after oral administration of 31.5 or 62.9 MBq (0.85 or 1.7 mCi) of 124I. Each scan was independently reviewed by 2 nuclear medicine physicians. All foci of activity were categorized, and the visual intensity of uptake was scored by a semiquantitative 3-point grading system (1: mild uptake, 2: moderate uptake, 3: intense uptake). Lesion volumes were determined on the CT image or on the PET images. Background (bkg) was also measured for each lesion and on each individual PET image. For each lesion, the mean activity concentration rate per unit administered activity (ACRmean/AA) and lesion-to-bkg ratios were compared across the 5 different time points. The semiquantitative grade and the quantitative measurements were compared. RESULTS A total of 45 124I PET/CT scans were reviewed for 9 patients. In the visual assessment, a total of 31 foci suggestive for or highly suggestive of metastasis were identified on 124I PET/CT. Of these, 6 were seen on the 2-h, 18 on the 24-h, 27 on the 48-h, 24 on the 72-h, and 20 on the 96-h scan. There was a significant difference between the 24- and 48-h scans in the total number of foci (ie, locoregional and distant metastasis) (P < 0.05) and in the number of distant metastases (P < 0.05). The 24-, 48-, and 72-h scans identified the same number of locoregional foci. The 48-h scan visualized more of the distant metastases than any other time point. 124I PET/CT with dual-time-point imaging was superior to single-time-point imaging (97% vs 87%). In the quantitative analysis, the median ACRmean/AA was highest at 24 and 48 h, and the median lesion-to-bkg ratio was variable for different lesion locations. For lung metastases, the highest median lesion-to-bkg ratio was at 72 and 96 h. CONCLUSIONS 124I PET/CT with dual-time-point imaging was superior to any single-time-point imaging (P < 0.10). Based on the visual assessment, dual time points at 48 + 72 h or 48 + 96 h yielded the highest lesion detection rate, whereas for single-time-point imaging, the 48-h images had the highest lesion detection rate. If the 48-h scan is completely negative or has negative 124I uptake in the region of interest, then a 72- or 96-h scan may be valuable. If lung metastases are suspected, then one should consider additional imaging at 72 or 96 h.
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Affiliation(s)
| | | | - Kanchan Kulkarni
- Division of Nuclear Medicine, MedStar Health Washington Hospital Center, Washington, DC
| | - Carlos Garcia
- Division of Nuclear Medicine, MedStar Health Washington Hospital Center, Washington, DC
| | | | - Eshetu Tefera
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Hyattsville, MD
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25
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Peravali M, Gomes-Lima C, Tefera E, Baker M, Sherchan M, Farid S, Burman K, Constantinescu F, Veytsman I. P09.25 Role of Immune Checkpoint Inhibitors (ICPi) in KRAS-Mutated Non-Small Cell Lung Cancer (NSCLC). J Thorac Oncol 2021. [DOI: 10.1016/j.jtho.2021.01.453] [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: 11/17/2022]
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26
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Polland A, Hamner J, Arunachalam D, Dwarica D, Gupta A, Pennycuff J, Tran A, Tefera E, Meriwether K, Gutman R. 128 STOMP: Sexual function Trial of Overactive bladder: Medication versus PTNS. J Sex Med 2021. [DOI: 10.1016/j.jsxm.2021.01.147] [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: 10/21/2022]
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27
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Peravali M, Gomes-Lima C, Tefera E, Baker M, Sherchan M, Farid S, Burman K, Constantinescu F, Veytsman I. Racial disparities in immune-related adverse events of immune checkpoint inhibitors and association with survival based on clinical and biochemical responses. World J Clin Oncol 2021; 12:103-114. [PMID: 33680877 PMCID: PMC7918525 DOI: 10.5306/wjco.v12.i2.103] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 12/14/2020] [Revised: 01/04/2021] [Accepted: 01/21/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immune checkpoint inhibitors (ICPi) cause various immune-related adverse events (irAE) with thyroid dysfunction as a commonly reported abnormality. There is increasing evidence showing positive association with development of irAE and survival. However, prior trials with ICPi had underrepresentation of minorities with < 5% African Americans.
AIM To evaluate the association between development of irAE and survival outcomes among a racially diverse patient population.
METHODS Data on patients with stage IV solid malignancies treated with programmed cell death-protein 1/programmed death ligand 1 blockers between January 2013 and December 2018 across MedStar Georgetown Cancer Institute facilities were retrospectively reviewed. Patients treated with cytotoxic T-lymphocyte-associated protein 4 inhibitors were excluded. Progression free survival (PFS) and overall survival (OS) were primary endpoints and were calculated using Kaplan-Meier methods and Wilcoxon rank sum test for comparison.
RESULTS Out of 293 patients who met eligibility criteria, 91 pts (31%) had any grade irAE; most common AE were endocrine (40.7%) specifically TSH elevation, dermatological (23.1%) and rheumatologic (18.7%). Proportion of irAE was significantly higher in Caucasians vs African Americans (60.4% vs 30.8%), in patients with low programmed death ligand 1, lower LDH, older age, and those who had more treatment cycles with ICPi. Rate of progression was lower in patients with irAE (30.8% vs 46.0%, P = 0.0140). Median PFS (5.8 vs 3.0 mo, P = 0.0204) and OS (17.1 vs 7.2 mo, P < 0.0001) were higher with irAE. Statistically significant difference in OS (17.1 vs 8.6 mo, P = 0.0002) but not in PFS (5.8 vs 3.3 mo, P = 0.0545) was noted with endocrine irAE. No differences in survival were observed among other commonly reported irAE. Differences in survival among subgroups of patients with irAE are described.
CONCLUSION Development of irAE positively correlated with improved PFS and OS as reported in previous studies. To our knowledge, this is the first study observing differences in OS favoring endocrine AE and Caucasian race. These factors may be potential surrogate markers of prognosis pending replication of these results in large-scale studies.
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Affiliation(s)
- Monica Peravali
- Department of Hematology/Oncology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Cristiane Gomes-Lima
- Department of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Washington, DC 20010, United States
| | - Mairead Baker
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Mamta Sherchan
- Department of Rheumatology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Saira Farid
- Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Kenneth Burman
- Department of Endocrinology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Florina Constantinescu
- Department of Rheumatology, MedStar Washington Hospital Center, Washington, DC 20010, United States
| | - Irina Veytsman
- Department of Hematology/Oncology, MedStar Washington Hospital Center, Washington, DC 20010, United States
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28
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Hack B, Timalsina U, Tefera E, Wilkerson B, Paku E, Fernandez S, Fishbein D. Oral Prescription Opioids as a High-Risk Indicator for Hepatitis C Infection: Another Step Toward HCV Elimination. J Prim Care Community Health 2021; 12:21501327211034379. [PMID: 34467805 PMCID: PMC8414604 DOI: 10.1177/21501327211034379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/01/2021] [Accepted: 07/02/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The opioid epidemic across the U.S. poses an array of public health concerns, especially HCV transmission. HCV is now widely curable, yet incident rates are increasing due to the opioid epidemic. Despite the established trajectory from oral prescription opioids (OPOs) to opioid use disorder (OUD), OUD to injection drug use (IDU), and IDU to hepatitis C virus (HCV), OPOs are not a defined risk factor (RF) for HCV infection. The objective of this study was to observe rates of HCV testing and Ab reactivity (HCVAb+) in patients receiving OPOs to substantiate them as a RF, ultimately contributing to HCV elimination. METHODS Data from MedStar Health patients receiving OPOs from 1/2017 to 12/2018 were collected and analyzed using chi-squared or student t-tests and logistic regression for uni- or multi-variable analyses, respectively. Statistical significance was defined as P < .05; Epi Info and SAS v 9·4 were used for statistical analyses; IRB approval was received. RESULTS There were 115 415 individuals prescribed OPOs over the study period. In this population, 8.6% (932) were HCVAb+ when tested and not previously diagnosed (10 900); 3.4% (3893) had an OUD diagnosis, 20.6% (803) of whom were HCV tested; 25.4% (361) of all HCVAb+ (1421) had an OUD diagnosis. OUD (ORadj 8.53 [7.22-10.07]) was an independent predictor of HCVAb+ in this population. CONCLUSIONS (1) In a large population prescribed oral opioids, HCVAb+ was 8.6%, higher than our previously published data (2.5%) and the US rate (1.7%); (2) only 20% of patients diagnosed with OUD were tested; and (3) only 25% of HCVAb+ patients were classified with OUD; this suggests underreporting of OUD in this population. Primary Care and Community Health Recommendations: (1) Re-testing for HCV in patients taking OPOs; (2) increased HCV testing among OUD patients; and (3) improved surveillance and reporting of OUD.
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Affiliation(s)
- Benjamin Hack
- Georgetown University Medical School,
Washington, DC, USA
| | | | - Eshetu Tefera
- MedStar Health Research Institute,
Hyattsville, MD, USA
| | | | - Emily Paku
- MedStar Health Research Institute,
Hyattsville, MD, USA
| | | | - Dawn Fishbein
- MedStar Health Research Institute,
Hyattsville, MD, USA
- MedStar Washington Hospital Center,
Washington, DC, USA
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29
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Peravali M, Gomes-Lima C, Tefera E, Baker M, Sherchan M, Farid S, Burman KD, Constantinescu F, Veytsman I. Racial disparities in immune-related adverse events (irAE) of immune checkpoint inhibitors (ICPi) and association with survival based on clinical and biochemical responses. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.7025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
7025 Background: ICPi cause various irAE with thyroid dysfunction as a commonly reported abnormality. There is increasing evidence showing positive association with development of irAE and survival. However, prior trials with ICPi had underrepresentation of minorities with <5% African Americans (AA). Methods: We retrospectively reviewed patients (pts) with stage IV solid malignancies treated with PD1/PDL1 blockers between 1/2013-12/2018 across MedStar Georgetown Cancer Institute facilities. Pts treated with CTLA-4 inhibitors were excluded. Progression free survival (PFS) and overall survival (OS) were primary endpoints and were calculated using Kaplan-Meier methods and Wilcoxon rank sum test for comparison. Results: 293 pts met eligibility criteria. 91 pts (31%) had any grade irAE; most common AE were endocrine (40.7%) specifically TSH elevation, dermatological (23.1%) and rheumatologic (18.7%). Proportion of irAE was significantly higher in Caucasians versus AA (60.4% vs 30.8%), in pts with low PDL1, lower LDH, older age, and those who had more treatment cycles with ICPi. Rate of progression was lower in pts with irAE (30.8% vs 46.0%, p-0.0140). Median PFS (5.8 vs 3.0 months (mo), p- 0.0204) and OS (17.1 vs 7.2 mo, p value- <0.0001) were higher with irAE. Statistically significant difference in OS (17.1 vs 8.6 mo, p- 0.0002) but not in PFS (5.8 vs 3.3 mo, p: 0.0545) was noted with endocrine irAE. No differences in survival were observed among other commonly reported irAE. Differences in survival among subgroups of pts with irAE are detailed in table. Conclusions: Development of irAE positively correlated with improved PFS and OS as reported in previous studies. To our knowledge, this is the first study observing differences in OS favoring endocrine AE and Caucasian race. These factors may be potential surrogate markers of prognosis pending replication of these results in large-scale studies. [Table: see text]
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Affiliation(s)
| | | | | | | | | | - Saira Farid
- MedStar Washington Hospital Center, Washington, DC
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30
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Adhikari T, Scott R, Timalsina U, Amgalan A, Sawney SL, Tefera E, Fernandez S, Fishbein D. 315. Prenatal Hepatitis C Viral (HCV) Screening Practices and HCV-Associated Fetal, Neonatal and Pregnancy Outcomes in a Large Regional Healthcare System. Open Forum Infect Dis 2019. [PMCID: PMC6810145 DOI: 10.1093/ofid/ofz360.388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Background Prevalence of HCV in pregnancy is 0.1–3.6%. AASLD and IDSA now recommend HCV screening in pregnancy although CDC, USPSTF, or ACOG still do not—though HCV can be perinatally transmitted and carries associated complications for the mother and fetus. Our study objectives were to analyze prenatal HCV screening practices at a large regional healthcare system and the prevalence of HCV-associated maternal and fetal/neonatal outcomes. Methods We performed a nested propensity score (PS) case–control study of pregnant women who tested HCV Ab+ in a cross-sectional study of women presenting for prenatal care at a large regional healthcare system from January 17 to December 18. We collected retrospective EHR data, including state of residency, HCV Ab, RNA, care engagement, HCV risk factors, comorbidities, maternal and fetal/neonatal morbidity, and neonatal HCV testing (when available). Mixed and generalized linear models were used to examine differences in continuous and categorical variables, respectively, between cases and controls Results 14,363 women were seen for prenatal care; 4,891 (34%) were HCV tested, 75 (1.5%) tested HCV Ab+. Demographic and comorbidity data are shown in Table 1. HCV Ab+ cases had more co-morbidities, including obesity, heart disease, opioid use, and behavioral health issues compared with the controls. HCV risk factors included IVDU (64%) and tattoos (24%) (Figure 1). Neither past/current pregnancy-related complications nor fetal or neonatal adverse events (Figure 2) were statistically significantly different except for cholestasis in HCV Ab+ cases (5.3 vs. 0%, P = 0.04). Conclusion Our study showed only one-third of pregnant women are currently HCV screened in our health system. Universal screening would likely increase the number of HCV-infected women identified. Early HCV detection, repeated testing, and behavioral health intervention of those at high-risk may decrease further horizontal and vertical transmission of HCV in pregnancy. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Rachel Scott
- MedStar Health Research Institute, Washington, DC
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Laurence B, Rogers I, Grant-Mills D, Smith D, Tefera E, Barbarinde A, Champagne D, Thomas M. Reducing Dental Plaque Scores in Long-term Care Facilities Using a Checklist and Random Inspections: A Pilot Study. Bull Tokyo Dent Coll 2019; 60:177-184. [PMID: 31217390 DOI: 10.2209/tdcpublication.2018-0056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 11/06/2022]
Abstract
The development and use of tailored interventions in overcoming barriers to optimum health in long-term care facility residents is of the highest importance. One successful approach to improving health outcomes is the use of a checklist by health care providers. Despite the evidence of the success of such checklists in nursing and medicine, there is little evidence on their use in improving dental outcomes. This study investigated whether an intervention comprising the daily use of a checklist for oral care by nursing staff supplemented by random inspections by a charge nurse resulted in lower dental plaque scores in patient participants at a long-term care facility (n=19) as compared with in those at another long-term care facility that did not receive the intervention (n=13). All participants received a dental cleaning at baseline. At a follow-up examination at 6 to 8 weeks post-baseline, significant differences were observed in the plaque scores between the participants at each location, with the median plaque scores in those undergoing the intervention being less than half of those in the patients that did not (20.8% vs. 52.8%, p<0.001). After adjusting for age in a linear regression model, this difference remained significant. The use of a daily checklist for oral care supplemented by random inspections by a charge nurse was associated with lower plaque scores (p<0.001). These results warrant further research, including prospective studies aimed at establishing how use of both clinical supervision and a checklist for oral health may influence plaque scores in geriatric patients in long-term care facilities over time.
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Ammar H, Ohri C, Hajouli S, Kulkarni S, Tefera E, Fouda R, Govindu R. Prevalence and Predictors of Pulmonary Embolism in Hospitalized Patients with Syncope. South Med J 2019; 112:421-427. [PMID: 31375838 DOI: 10.14423/smj.0000000000001009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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
OBJECTIVES Approximately one in six patients hospitalized with syncope have pulmonary embolism (PE), according to the PE in Syncope Italian Trial study. Subsequent studies using administrative data have reported a PE prevalence of <3%. The aim of the study was to determine the prevalence and predictors of PE in hospitalized patients with syncope. METHODS We retrospectively reviewed the records of patients who were hospitalized in the MedStar Washington Hospital Center between May 1, 2015 and June 30, 2017 with deep venous thrombosis, PE, and syncope. Only patients who presented to the emergency department with syncope were included in the final analysis. PE was diagnosed by either positive computed tomographic angiography or a high-probability ventilation-perfusion scan. Univariate and multivariate logistic regressions were used to assess the associations between clinical variables and the diagnosis of PE in patients with syncope. RESULTS Of the 408 patients hospitalized with syncope (mean age, 67.5 years; 51% men [N = 208]), 25 (6%) had a diagnosis of PE. Elevated troponin levels (odds ratio 6.6, 95% confidence interval 1.9-22.9) and a dilated right ventricle on echocardiogram (odds ratio 6.9, 95% confidence interval 2.0-23.6) were independently associated with the diagnosis of PE. Age, active cancer, and history of deep venous thrombosis were not associated with the diagnosis of PE. CONCLUSIONS The prevalence of PE in this study is approximately one-third of the reported prevalence in the PE in Syncope Italian Trial study and almost three times the value reported in administrative data-based studies. PE should be suspected in patients with syncope and elevated troponin levels or a dilated right ventricle on echocardiogram.
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Affiliation(s)
- Hussam Ammar
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Chaand Ohri
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Said Hajouli
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Shaunak Kulkarni
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Eshetu Tefera
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Ragai Fouda
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
| | - Rukma Govindu
- From the Internal Medicine Department, MedStar Washington Hospital Center, Washington, DC, MedStar Health Research Institute, Hyattsville, Maryland, George Eliot Hospital NHS Trust, Nuneaton, United Kingdom, and the Internal Medicine Department, University of Texas Health Science Center at Houston, Houston
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Nosti PA, Gutman RE, Iglesia CB, Park AJ, Tefera E, Sokol AI. Defining Cervical Elongation: A Prospective Observational Study. J Obstet Gynaecol Can 2019; 39:223-228. [PMID: 28413041 DOI: 10.1016/j.jogc.2016.10.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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: 08/28/2016] [Revised: 10/14/2016] [Accepted: 10/18/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Our primary aim was to define cervical elongation (CE) using the following methods: (1) measurement of pathology specimen, (2) physician perception, (3) intraoperative estimate of anterior cervical length, and (4) office Pelvic Organ Prolapse Quantification (POP-Q) points C and D. Our secondary aim was to determine whether these definitions correlate with perioperative outcomes. METHODS Women undergoing vaginal hysterectomy and prolapse repair were enrolled. Office POP-Q measurements were collected. Estimates of cervical length were made based on points C minus D of the POP-Q and by manual exam using the surgeon's index and middle fingers. Cervical dimensions were measured from the pathology specimen at the end of the case. CE was defined as one standard deviation (SD) above the mean for each definition. Additional intraoperative data was collected to determine the surgeon perception of cervical anatomy. RESULTS A total of 90 patients were enrolled during the study period. Our definitions for CE were as follows: (1) 5 cm (70 without and 20 with CE), (2) physician perception (67 without and 23 with CE), (3) 3.4 cm (79 without and 11 with CE), and (4) 8.3 cm (77 without and 13 with CE). After controlling for uterine weight and the presence of fibroids, the operative time was the only outcome measure that remained elevated for patients with CE using our first definition (42.4 ± 20.1 without vs. 53.8 ± 19.2 with CE, P = 0.03). CONCLUSIONS CE using our first definition was associated with a statistically significant increase in operative time in women undergoing hysterectomy at the time of prolapse repair.
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Affiliation(s)
- Patrick A Nosti
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Women and Infants' Services, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC.
| | - Robert E Gutman
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Women and Infants' Services, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC
| | - Cheryl B Iglesia
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Women and Infants' Services, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC
| | - Amy J Park
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Women and Infants' Services, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistics and Epidemiology, Medstar Health Research Institute, Hyattsville, MD
| | - Andrew I Sokol
- Section of Female Pelvic Medicine and Reconstructive Surgery, Department of Women and Infants' Services, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, DC
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Amgalan A, Scott R, Tefera E, Sawney S, Deeb H, Fishbein D. Current Practices in Hepatitis C Screening in Pregnant Women in a Regional Health System [36J]. Obstet Gynecol 2019. [DOI: 10.1097/01.aog.0000558852.84073.1f] [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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Abstract
BACKGROUND Physician characteristics and perceptions and their effect on choice of therapies for patients with thyroid cancer have been well studied. Some data also exist about physician characteristics and prescribing treatment for subclinical hypothyroidism. The effect of physician characteristics on prescribing thyroid preparations for treating overt hypothyroidism is less studied. METHODS Members of the American Thyroid Association were surveyed in 2017. Physicians were presented with 13 different theoretical patients with hypothyroidism and asked to choose among six therapeutic options, including levothyroxine, synthetic combination therapy, thyroid extract, and liothyronine monotherapy. The 13 patient scenarios incorporated parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, and documentation of deiodinase polymorphisms). Repeated-measures logistic regression analysis was performed to examine the prescribing of the various therapies. Data regarding the responding physicians were also collected. These data included number of years in practice, country of practice, and specialty. Multivariate repeated-measures logistic regression analysis of prescribing patterns was also conducted controlling for all patient and physician characteristics. RESULTS Of the 389 survey respondents, 93% prescribed therapy for hypothyroidism. Fifty-three percent of respondents had been in practice for >20 years, and 23% had been in practice for 11-20 years. Sixty-four percent practiced in North America, and 18% practiced in Europe. Eight-six percent were endocrinologists, and 5% were surgeons. In multivariate analysis, physicians from North America were both more likely to prescribe any triiodothyronine-containing therapies (odds ratio [OR] = 1.8 [confidence interval (CI) 1.3-2.4]) and more likely to add liothyronine to levothyroxine therapy (OR = 1.9 [CI 1.2-2.9]). In addition, they were more likely to prescribe desiccated thyroid extract or liothyronine monotherapy (OR = 1.7 [CI 1.0-2.9]). CONCLUSIONS A previous analysis of this survey showed that patient characteristics profoundly affect physician prescribing patterns. The current multivariate analysis shows that physician characteristics affect prescribing patterns. Whether this is due to impact upon physicians of patient-related experiences, media exposure, influence from pharmaceutical companies, educational activities, or other concerns cannot be determined. However, these results have potential importance for understanding physician-patient interactions at a time when the benefits and risks of triiodothyronine-containing therapies have not been fully documented.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology Georgetown University, Washington, DC
- Address correspondence to: Jacqueline Jonklaas, MD, PhD, Department of Endocrinology, Georgetown University Medical Center, 4000 Reservoir Road, NW, Washington, DC 20007
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - Nawar Shara
- Division of Endocrinology Georgetown University, Washington, DC
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
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Jonklaas J, Tefera E, Shara N. Short-Term Time Trends in Prescribing Therapy for Hypothyroidism: Results of a Survey of American Thyroid Association Members. Front Endocrinol (Lausanne) 2019; 10:31. [PMID: 30761091 PMCID: PMC6363658 DOI: 10.3389/fendo.2019.00031] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 01/16/2019] [Indexed: 12/27/2022] Open
Abstract
Objective: Hypothyroid patients frequently request specific therapies from their physicians. Combination therapy is vigorously discussed at professional meetings. We wished to determine if physician prescribing patterns for hypothyroidism changed during 2017 after specific educational events. Methods: A survey addressing treatment of hypothyroidism was emailed to American Thyroid Association (ATA) members on three occasions in 2017. The Spring emails were sent prior to a satellite symposium addressing hypothyroidism, and prior to the annual Endocrine Society and ATA meetings; the December emails were sent after these events. Physicians were presented with thirteen theoretical patients and chose from 6 therapeutic options, including levothyroxine, synthetic combination therapy, thyroid extract, and liothyronine monotherapy. The patient scenarios successively incorporated factors potentially providing reasons for considering combination therapy. Multivariate repeated measures logistic regression analyses first examined effects of physician characteristics on prescribing the various therapies. Then, analyses also incorporated timing, by comparing prescribing patterns in February, March, and December. Results: In analyses of prescribing levothyroxine monotherapy vs. any T3 therapy, there was a trend of borderline significance (p = 0.053) for T3 therapy to be prescribed more in December compared with February-March combined. When multivariate analyses were performed controlling for time and physician characteristics, choice of therapy was only significantly affected by country of practice (OR 1.7, CI 1.3-2.2). Physician choice of therapies was also examined for the options of continuing (1) levothyroxine, vs. (2) increasing levothyroxine, (3) adding liothyronine either with or without levothyroxine reduction, or (4) replacing levothyroxine with desiccated thyroid extract or liothyronine. When multivariate analyses incorporating time and physician characteristics were performed, respondents in December (OR 1.5, CI 1.0-2.3) and those practicing in North America (OR 1.8, CI 1.2-2.6) were more likely to prescribe liothyronine. Conclusions: This survey shows that although current North American guidelines do not recommend combination therapy, such therapy is being prescribed more over time and is also more commonly prescribed in North America. It is possible our guidelines are failing to incorporate evidence that physicians are considering when prescribing combination therapy. Such evidence could include data about patient preferences, and this needs to be a focus of future studies.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC, United States
- *Correspondence: Jacqueline Jonklaas
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical Informatics, Medstar Health Research Institute, Hyattsville, MD, United States
| | - Nawar Shara
- Division of Endocrinology, Georgetown University, Washington, DC, United States
- Department of Biostatistics and Biomedical Informatics, Medstar Health Research Institute, Hyattsville, MD, United States
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Lumley CJ, Kaffenberger TM, Desale S, Tefera E, Han CJ, Rafei H, Maxwell JH. Post-diagnosis aspirin use and survival in veterans with head and neck cancer. Head Neck 2018; 41:1220-1226. [PMID: 30537085 DOI: 10.1002/hed.25518] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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: 05/31/2018] [Revised: 08/26/2018] [Accepted: 10/06/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Our objective was to determine the effect of post-diagnosis aspirin use on survival in veterans with head and neck squamous cell carcinoma. METHODS Retrospective cohort study of 584 veterans with head and neck squamous cell carcinoma treated at the Washington DC VA Medical Center between 1995 and 2015. Charts were queried for clinical-pathologic data, aspirin prescriptions, and outcome. The Kaplan-Meier method was used to determine overall survival (OS) and disease-specific survival (DSS) among aspirin users and nonusers. RESULTS A total of 329 patients met inclusion criteria. Primary subsites included oropharynx (n = 143), larynx (n = 105), oral cavity (n = 62), and hypopharynx (n = 19). Eighty-four patients were aspirin users (25.5%). Aspirin users demonstrated significantly better 3-year OS and DSS (78.6% and 88.1%) compared to nonaspirin users (OS: 55.9% and DSS: 70.2%; P = .0003 and P = .0019, respectively). On multivariate analysis, aspirin use remained independently associated with improved survival. CONCLUSION Aspirin use following diagnosis and curative treatment of head and neck squamous cell carcinoma is associated with improved OS and DSS.
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Affiliation(s)
- Catherine J Lumley
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Thomas M Kaffenberger
- Department of Otolaryngology-Head and Neck Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Sameer Desale
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Washington, District of Columbia
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical informatics, MedStar Health Research Institute, Washington, District of Columbia
| | - Chihun Jim Han
- Department of Otolaryngology-Head and Neck Surgery, Georgetown University School of Medicine, Washington, District of Columbia
| | - Hind Rafei
- Department of Medicine, George Washington University School of Medicine, Washington, District of Columbia
| | - Jessica H Maxwell
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia.,Department of Surgery, Washington DC Veterans Affairs Medical Center, Washington, District of Columbia
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Abstract
BACKGROUND Most endocrinologists encounter patients who are dissatisfied with their current hypothyroidism therapy and request combination therapy with either liothyronine (LT3) or thyroid extract. METHODS A survey of American Thyroid Association members was conducted in 2017. Respondents were presented with 13 scenarios describing patients with hypothyroidism and were asked to choose among six therapeutic options. The index patient was satisfied taking levothyroxine (LT4) therapy. Twelve variations introduced parameters that potentially provide reasons for considering combination therapy (presence of symptoms, low serum triiodothyronine concentration, documentation of deiodinase polymorphisms). Therapeutic options included (i) continuing LT4, (ii) increasing LT4, (iii) adding LT3 to a reduced LT4 dose, (iv) adding LT3 to the current LT4 dose, (v) replacing LT4 with thyroid extract, and (vi) replacing LT4 with LT3. Repeated-measures logistic regression analysis was performed to examine both the prescribing of LT4 (options i and ii) versus all other therapies and the choice of continuing LT4 (option i) versus either increasing LT4 (option ii), adding LT3 (options iii and iv), or replacing LT4 with thyroid extract or LT3 (options v and vi). RESULTS Of the 389 survey respondents, 363 physicians prescribed therapy for hypothyroidism. For the index patient, 98% of physicians continued current LT4 therapy. However, as the patient scenario incorporated other patient characteristics, physicians opted to increase LT4 dose or prescribe other therapies. The tendency to prescribe alternative therapies was powerfully increased by patient symptoms (odds ratio = 25.6 [confidence interval 9-73], p < 0.0001). Older age and the presence of a comorbidity reduced the likelihood that an alternative therapy was prescribed (p = 0.0002 and <0.0001, respectively). All other characteristics, except athyreotic status, patient sex, and body mass index, significantly increased the likelihood that alternative therapies would be prescribed in multivariate analyses (p < 0.0001). CONCLUSIONS Even with the acknowledged limitations of survey methodology, this analysis appears to show a marked increase in the willingness of physicians to prescribe combination therapy in specific circumstances. If current prescribing patterns do incorporate the use of therapies other than LT4, there is a critical need for more research into the benefits and risks of these therapies.
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Affiliation(s)
- Jacqueline Jonklaas
- Division of Endocrinology, Georgetown University, Washington, DC
- Address correspondence to: Jacqueline Jonklaas, MD, PhD, Department of Endocrinology, Georgetown University Medical Center, 4000 Reservoir Road, NW, Washington, DC 20007
| | - Eshetu Tefera
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
| | - Nawar Shara
- Department of Biostatistics and Biomedical Informatics, MedStar Health Research Institute, Washington, DC
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Trotman GE, Mackey E, Tefera E, Gomez-Lobo V. Comparison of Parental and Adolescent Views on the Confidential Interview and Adolescent Health Risk Behaviors within the Gynecologic Setting. J Pediatr Adolesc Gynecol 2018; 31:516-521. [PMID: 29580917 DOI: 10.1016/j.jpag.2018.03.006] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 02/19/2018] [Accepted: 03/12/2018] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE To explore parental and adolescent views on the confidential interview in the gynecologic setting and compare adolescent reported risk-taking behaviors with parental perception. DESIGN Anonymous surveys were administered separately to parents/guardians and adolescents between the ages of 11 and 17 years. Information pertaining to the patient's Tanner stage and reason for visit was obtained from the provider. This first phase served as the usual care group. In the second phase of the study, surveys were again distributed after a brief educational intervention. Linear regression analysis, Wilcoxon rank sum test, and Fisher exact test were used where appropriate. SETTING AND PARTICIPANTS Pediatric and adolescent gynecology clinics in 2 tertiary hospitals. INTERVENTIONS Brief educational handout on key concepts of the confidential interview. MAIN OUTCOME MEASURES Parental perception of the confidential interview and adolescent risk-taking behaviors. RESULTS A total of 248 surveys were included in the final analysis, which accounts for 62 adolescent and parent/guardian pairs in each group. Most parents and adolescents reported perceived benefit to the confidential interview. However, parents were less likely to rate benefits of private time specifically for their own adolescent and less than half of the parents believed that adolescents should have access to private time in the gynecologic setting. Parents/guardians as well as adolescents feared that the confidential interview would limit the parent's ability to take part in decision-making. The low support for confidential time for their adolescent was not different in the usual care group compared with the intervention group, although there was a trend toward parental acceptance with increased adolescent age. Adolescents were consistently more likely to report more risk-taking behaviors than their parents perceived. CONCLUSION There is a discord between parental perception and adolescent reports of risk-taking behaviors. This is coupled with a lack of understanding or comfort regarding the benefits of the confidential interview among parents and adolescents who present for gynecologic care. A short educational intervention had only a modest effect on parental perceptions regarding the confidential interview.
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Affiliation(s)
- Gylynthia E Trotman
- Children's National Health Services, Pediatric and Adolescent Gynecology, Washington, DC; Medstar Washington Hospital Center, Department of Obstetrics and Gynecology, Washington, DC.
| | - Eleanor Mackey
- Children's National Health Services, Department of Psychology and Behavioral Health, Washington, DC
| | | | - Veronica Gomez-Lobo
- Children's National Health Services, Pediatric and Adolescent Gynecology, Washington, DC; Medstar Washington Hospital Center, Department of Obstetrics and Gynecology, Washington, DC; MedStar Georgetown University School of Medicine, Department of Obstetrics and Gynecology, Washington, DC
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Burke AM, Carrasquilla M, Tefera E, Jean WC, Collins BT, Anaizi AN, Gibney GT, Atkins MB, Collins SP. (OA15) Clinical Outcomes of Patients With Melanoma Brain Metastases Treated With Stereotactic Radiosurgery and Immunotherapy. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.02.054] [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: 10/17/2022]
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Alam P, Jones T, Baxter B, Siddique M, Tefera E, Gutman R, Iglesia C. 14: Perioperative outcomes in patients with autoimmune connective tissue disorders (AICTDs). Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.12.198] [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: 12/01/2022]
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Polfer EM, Zimmerman RM, Tefera E, Katz RD, Higgins JP, Means KR. The Effect of Skin Pigmentation on Determination of Limb Ischemia. J Hand Surg Am 2018; 43:24-32.e1. [PMID: 29103849 DOI: 10.1016/j.jhsa.2017.09.002] [Citation(s) in RCA: 6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 08/02/2017] [Accepted: 09/06/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Timely identification of tissue ischemia is critical, both in the traumatized limb and following free tissue transfer. The purpose of this study was to determine if skin pigmentation affects the ability to detect limb ischemia. METHODS We conducted a study of healthy controls exposed to limb ischemia. The subjects were classified based on skin pigmentation using a defined skin type assessment tool, a visual color scale, and self-description of race. Participants were randomized by limb and tourniquet status; surgeons were blinded to both. Ischemia was induced by tourniquet insufflations, and board-certified orthopedic and plastic surgeons who had completed an accredited hand surgery fellowship conducted physical examinations. The surgeons monitored the forearms at 2, 6, and 10 minutes based on appearance of ischemia, capillary refill, and color in 3 locations on the limbs (posterior interosseous artery flap skin territory, radial forearm flap skin territory, and the digits). RESULTS We found a significant decrease in the ability to detect ischemia in participants with increased skin pigmentation, as documented by all metrics, when evaluating the posterior interosseous artery and radial forearm flap skin territories at all time points. For example, when monitoring the posterior interosseous artery flap with the tourniquet insufflated at time 10 minutes, 92.9% of Caucasians were correctly identified as being ischemic whereas only 23.3% of African Americans were correctly identified. CONCLUSIONS Skin pigmentation significantly affects the identification of an ischemic limb/skin flaps on physical examination. Whereas the standard treatment for monitoring of free tissue transfer is clinical examination, that may not be sufficient for patients with increased skin pigmentation. Surgeons should exercise particular vigilance during physical examination of a potentially ischemic limb/skin flaps with greater skin pigmentation. TYPE OF STUDY/LEVEL OF EVIDENCE Diagnostic II.
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Affiliation(s)
- Elizabeth M Polfer
- Walter Reed National Military Medical Center, Bethesda, MD; Curtis National Hand Center, Baltimore, MD
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Parikh LI, Iqbal SN, Jelin AC, Overcash RT, Tefera E, Fries MH. Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy. J Matern Fetal Neonatal Med 2017; 32:1337-1341. [DOI: 10.1080/14767058.2017.1405385] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Laura I. Parikh
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medstar Washington Hospital Center, Washington, DC, USA
| | - Sara N. Iqbal
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medstar Washington Hospital Center, Washington, DC, USA
| | - Angie C. Jelin
- Department of Gynecology and Obstetrics, Division of Maternal-Fetal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Rachael T. Overcash
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medstar Washington Hospital Center, Washington, DC, USA
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, Medstar Health Research Institute, Hyattsville, MD, USA
| | - Melissa H. Fries
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Medstar Washington Hospital Center, Washington, DC, USA
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Robinson BN, Newman AF, Tefera E, Herbolsheimer P, Nunes R, Gallagher C, Randolph-Jackson P, Omogbehin A, Dilawari A, Pohlmann PR, Mohebtash M, Lee Y, Ottaviano Y, Mohapatra A, Lynce F, Brown R, Mete M, Swain SM. Video intervention increases participation of black breast cancer patients in therapeutic trials. NPJ Breast Cancer 2017; 3:36. [PMID: 28944289 PMCID: PMC5603544 DOI: 10.1038/s41523-017-0039-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 07/24/2017] [Accepted: 08/03/2017] [Indexed: 11/24/2022] Open
Abstract
There is a striking racial and ethnic disparity in incidence and mortality of cancer yet minorities remain markedly underrepresented in clinical trials. This pilot study set out to determine the impact of a 15-min culturally tailored educational video on three outcomes relating to clinical trials: likely participation, attitudes (assessed based on six barriers), and actual enrollment. Breast cancer patients with Stage I-III, if diagnosed within previous 6 months, or metastatic disease who self-identified as black or African American were invited to participate. The primary outcome measure was the decision to participate in a therapeutic clinical trial after the intervention. Patients’ intention to enroll on a therapeutic clinical trial and the change in attitudes toward clinical trials were measured by the previously developed Attitudes and Intention to Enroll in Therapeutic Clinical Trials (AIET) questionnaire. Of the 200 patients that participated, 39 (19.5%) patients signed consent to participate in a therapeutic clinical trial; 27 (13.5%) patients enrolled, resulting in a 7.5% increase from our baseline comparison of 6% clinical trial enrollment rate in black cancer patients (p < .001). Pre-test versus post-test assessment demonstrated the proportion of patients expressing likelihood to enroll in a therapeutic trial following the intervention increased by 14% (p < .001). Among 31 AIET items, 25 (81%) showed statistically significant and positive change post-intervention. The findings suggest the promising utility of a culturally tailored video intervention for improving black patients’ attitudes regarding clinical trial participation and resultant enrollment. Future efforts should continue to target facilitators of population-specific recruitment, enrollment, and retention in therapeutic and non-therapeutic clinical trials. A culturally tailored educational video can boost participation among black patients in clinical trials of new breast cancer treatments. A US team led by Sandra Swain from Georgetown University Medical Center in Washington, DC, created a 15-min video designed to address six of the concerns commonly cited by blacks about human subjects research. The researchers showed the video to 200 black patients, and saw a large bump in the number of women willing to sign up for a therapeutic trial. On average, only 6% of black cancer patients typically enroll in clinical trials. But in the video intervention study, 19.5% agreed to participate and then 13.5% went ahead with a trial. Video watchers also reported a positive change in their attitude toward clinical research. The study points to the need for population-specific recruitment efforts.
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Affiliation(s)
- Brandi N Robinson
- MedStar Health Research Institute, Hyattsville, MD USA.,Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | - Antoinette F Newman
- MedStar Health Research Institute, Hyattsville, MD USA.,Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | - Eshetu Tefera
- MedStar Health Research Institute, Hyattsville, MD USA
| | - Pia Herbolsheimer
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | - Raquel Nunes
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | | | | | - Adedamola Omogbehin
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | - Asma Dilawari
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC USA
| | - Paula R Pohlmann
- Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC USA
| | | | - Young Lee
- MedStar Harbor Hospital, Baltimore, MD USA
| | | | - Avani Mohapatra
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA
| | - Filipa Lynce
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA.,Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC USA
| | - Richard Brown
- Virginia Commonwealth University School of Medicine, Richmond, VA USA
| | - Mihriye Mete
- MedStar Health Research Institute, Hyattsville, MD USA
| | - Sandra M Swain
- Washington Cancer Institute, MedStar Washington Hospital Center, Washington, DC USA.,Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC USA
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Goyal M, Bhat R, Graf SK, Dubin JS, Bhooshan A, Tefera E, Frohna WJ. Body mass index is associated with inappropriate tidal volumes in adults intubated in the emergency department. Am J Emerg Med 2017; 35:1964. [PMID: 28610771 DOI: 10.1016/j.ajem.2017.06.005] [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] [Received: 05/29/2017] [Accepted: 06/04/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Munish Goyal
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, United States
| | - Rahul Bhat
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, United States.
| | - Shannon K Graf
- Department of Emergency Medicine, MedStar Union Memorial Hospital, Baltimore, MD, United States
| | - Jeffrey S Dubin
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, United States
| | - Anu Bhooshan
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD, United States
| | - William J Frohna
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC, United States; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC, United States
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Jarin J, Pine-Twaddell E, Trotman G, Stevens J, Conard LA, Tefera E, Gomez-Lobo V. Cross-Sex Hormones and Metabolic Parameters in Adolescents With Gender Dysphoria. Pediatrics 2017; 139:peds.2016-3173. [PMID: 28557738 DOI: 10.1542/peds.2016-3173] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Endocrine Society states that adolescents with gender dysphoria may start cross-sex hormones. The goal of this study was to identify patterns in metabolic parameters in transgender adolescents receiving cross-sex hormones. METHODS Data from adolescents aged 14 to 25 years seen in 1 of 4 clinical sites between 2008 and 2014 were retrospectively analyzed. Subjects were divided into affirmed male (female-to-male) patients taking testosterone and affirmed female (male-to-female) patients taking estrogen. Previously recorded measurements of blood pressure, BMI, testosterone, estradiol, prolactin, lipids, electrolytes, liver function tests, hemoglobin/hematocrit, and hemoglobin A1c were reviewed. These values were obtained from before the start of therapy, at 1 to 3 months after initiation, at 4 to 6 months, and at 6 months and beyond. Repeated measures analysis of variance models were used to evaluate changes over time. RESULTS One hunderd and sixteen adolescents were included (72 female-to-male subjects and 44 male-to-female subjects). Of the 72 subjects taking testosterone, a significant increase in hemoglobin/hematocrit levels and BMI, as well as a decrease in high-density lipoprotein level, was recorded at each visit. No significant changes in any other parameter tested were found. Of the 44 subjects taking estrogen, no statistically significant changes were noted in the measured metabolic parameters. CONCLUSIONS Testosterone use was associated with increased hemoglobin and hematocrit, increased BMI, and lowered high-density lipoprotein levels; estrogen was associated with lower testosterone and alanine aminotransferase levels. Otherwise, cross-sex hormone administration in adolescents was not associated with significant differences in the selected metabolic parameters over time.
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Affiliation(s)
- Jason Jarin
- Obstetrics and Gynecology, University of Texas Southwestern and Children's Health, Dallas, Texas
| | - Elyse Pine-Twaddell
- University of Maryland, Baltimore, Maryland.,Chase Brexton Health Care, Baltimore, Maryland
| | | | | | - Lee Ann Conard
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Eshetu Tefera
- MedStar Health Research Institute, Hyattsville, Maryland; and
| | - Veronica Gomez-Lobo
- MedStar Washington Hospital Center/Children's National Medical Center, Washington, District of Columbia
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Shah N, Andriani L, Howard J, Mahoney L, Yurteri-Kaplan L, Tefera E, Iglesia C. 8: The power of Healing statements In Post-operative Pain control (HIPP): A randomized controlled trial. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.12.132] [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: 10/20/2022]
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Swain S, Robinson BN, Newman AF, Tefera E, Herbolsheimer P, Nunes R, Gallagher C, Randolph-Jackson P, Omogbehin A, Dilawari A, Pohlmann P, Mohebtash M, Ottaviano Y, Mohapatra A, Lynce F, Mete M. Abstract P3-10-02: Increasing participation in research - breast cancer (Inspire-BrC). Cancer Res 2017. [DOI: 10.1158/1538-7445.sabcs16-p3-10-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Increasing Black patients' participation in cancer clinical trials is important because of the population's lower survival rate. Accrual for Blacks is the lowest of all groups at 0.5-1.5%. Our study aims to increase trial participation rates among Black breast cancer patients by testing the effectiveness of a culturally tailored video intervention on the decision to participate in a clinical trial.
Methods: We hypothesized that the intervention would increase clinical trial enrollment by 6 percentage points compared to our 2012 enrollment baseline of 6% (22/384). Self- identified Black patients with invasive breast cancer at 5 MedStar Hospitals watched a 15' video about clinical trials, targeting six cultural and attitudinal barriers to participation. The Attitudes and Intention to Enroll in therapeutic clinical Trials (AIET) pre-/post-/follow-up tests with 31 items was used to determine the impact of the video on three domains: actual trial enrollment; likely participation in trials; and attitudes toward trials. The pre-test was conducted at baseline; post-test immediately after video; and follow-up 7-21 days after the intervention. Participants were followed for 6 months to assess trial enrollment status. Descriptive statistics were used to describe study subjects with respect to basic characteristics; means and standard deviations for continuous variables; and frequencies and percentages for categorical variables. Repeated measures analysis of variance was used to examine whether the changes in attitudinal barriers were statistically significant over time. The primary outcome measure was the proportion of Black breast cancer patients who signed consent and/or enrolled in a therapeutic clinical trial.
Results: From Mar/2014 to Sept/2015, 279 patients were approached to join INSPIRE-BrC prior to discussion about therapeutic clinical trials; 52 declined participation. 208 signed consent and 200 completed it. Average age was 59 yrs (SD=12), 75% were stage I-III; 29% were married; 85% had 1 or more children; 29% attended some college or technical school; 53% had private insurance, 31% Medicare, 16% Medicaid; and 53% had a household income <$40,000/yr. A total of 41 INSPIRE-BrC participants (20.5%) signed consent and 29 (14.5%) enrolled onto a therapeutic study (one-sided p=0.027 vs H0: P=0.06). Pre-video, 52% of patients expressed that it was likely they would participate in a hypothetical therapeutic clinical trial; immediately post-video, 67% (p=<0.001) and 7-21 days after the intervention, 64% (p=0.003). Among 31 AIET items, 25 (81%) showed statistically significant and positive change after the intervention. Specifically, trust in the doctor increased and, suspicion in trials decreased (p<0.001). Further, patient views on fairness for treatment of poor people and Blacks became significantly more positive (p<0.001).
Conclusion: Study findings show that the video is a promising tool for rapid dissemination of a theory-driven, evidence-based model to enhance clinical trial accrual among Black cancer patients. The video also has the potential to positively change attitudes about clinical trial participation.
The study was supported by the Breast Cancer Research Foundation.
Citation Format: Swain S, Robinson BN, Newman AF, Tefera E, Herbolsheimer P, Nunes R, Gallagher C, Randolph-Jackson P, Omogbehin A, Dilawari A, Pohlmann P, Mohebtash M, Ottaviano Y, Mohapatra A, Lynce F, Mete M. Increasing participation in research - breast cancer (Inspire-BrC) [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P3-10-02.
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Affiliation(s)
- S Swain
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - BN Robinson
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - AF Newman
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - E Tefera
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - P Herbolsheimer
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - R Nunes
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - C Gallagher
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - P Randolph-Jackson
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - A Omogbehin
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - A Dilawari
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - P Pohlmann
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - M Mohebtash
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - Y Ottaviano
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - A Mohapatra
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - F Lynce
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
| | - M Mete
- MedStar Health Research Institute, Washington, DC; MedStar Washington Hospital Institute, Washington Cancer Institute, Washington, DC; Lombardi Comprehensive Cancer Center, MedStar Georgetown University Hospital, Washington, DC; MedStar Union Memorial Hospital, Baltimore, MD; MedStar Franklin Square Medical Center, Baltimore, MD; Georgetown University Medical Center, Washington, DC
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Sullivan SD, Nash MS, Tefera E, Tinsley E, Blackman MR, Groah S. Prevalence and Etiology of Hypogonadism in Young Men With Chronic Spinal Cord Injury: A Cross-Sectional Analysis From Two University-Based Rehabilitation Centers. PM R 2016; 9:751-760. [PMID: 27871967 DOI: 10.1016/j.pmrj.2016.11.005] [Citation(s) in RCA: 18] [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] [Received: 04/21/2016] [Revised: 09/28/2016] [Accepted: 11/13/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Spinal cord injury (SCI) triggers an "accelerated aging" process that may include development of hypogonadism, even among younger men with SCI; however, few studies have investigated the prevalence or etiology of hypogonadism in men with SCI. Young men with SCI also are at increased risk for developing metabolic dysfunction after injury, which may be exacerbated by concomitant testosterone (T) deficiency, thus identifying the prevalence and risk factors for T deficiency in men with SCI is important for their long-term health. OBJECTIVE To investigate the prevalence, risk factors, and etiology of T deficiency (hypogonadism) in otherwise-healthy men with chronic, motor complete SCI. DESIGN Secondary cross-sectional analysis. SETTING Rehabilitation research centers in Washington, DC, and Miami, Florida. PARTICIPANTS Men (n = 58) aged 18-45 years with chronic (≥1 year), motor complete SCI without comorbidities or use of testosterone therapy. METHODS Plasma concentrations of hormones were measured with standardized assays. Body composition was assessed with dual-energy x-ray absorptiometry scan. MAIN OUTCOME MEASUREMENTS Serum total T and calculated free T. RESULTS T deficiency was more common in men after SCI than in a matched cohort of similarly-aged men without SCI (25%, SCI versus 6.7%, non-SCI, P < .001). The risk of hypogonadism appeared to be increased in men with more extensive injury and with higher percent body fat. The majority of men with SCI with low T had low serum LH levels, suggesting that central suppression of the hypothalamic-pituitary-gonadal axis may be the most common etiology of hypogonadism after SCI. CONCLUSIONS Hypogonadism is more common in young men with SCI than in similarly aged men without SCI, suggesting that SCI should be identified as a risk factor for T deficiency and that routine screening for hypogonadism should be performed in the SCI population. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Shannon D Sullivan
- Center for Drug Evaluation and Research, US Food and Drug Administration, 10903 New Hampshire Ave, Building 22, Room 3373, Silver Spring, MD 20993(∗).
| | - Mark S Nash
- Departments of Neurological Surgery and Rehabilitation Medicine, University of Miami Miller School of Medicine, Miami, FL(†)
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, Medstar Health Research Institute, Hyattsville, MD(‡)
| | - Emily Tinsley
- Department of Rehabilitation Medicine, Medstar National Rehabilitation Hospital, Washington, DC(§)
| | - Marc R Blackman
- Research Service, Washington, DC VA Medical Center, Washington, DC; Departments of Medicine and Rehabilitation Medicine, Georgetown University School of Medicine, Washington, DC; Departments of Medicine, Biochemistry and Molecular Medicine, George Washington University School of Medicine, Washington, DC(¶)
| | - Suzanne Groah
- Department of Rehabilitation Medicine, Medstar National Rehabilitation Hospital, Washington, DC; Department of Rehabilitation Medicine, Medstar Georgetown University Hospital, Washington, DC(#)
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50
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Bhat R, Mazer-Amirshahi M, Sun C, Vaughns J, Dynin M, Tefera E, Towle D, Goyal M. Accuracy of rapid sequence intubation medication dosing in obese patients intubated in the ED. Am J Emerg Med 2016; 34:2423-2425. [PMID: 27727068 DOI: 10.1016/j.ajem.2016.09.056] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Revised: 09/22/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE There are limited data regarding appropriateness of sedative and paralytic dosing of obese patients undergoing rapid sequence intubation (RSI) in the emergency department. The goal of this study was to compare rates of appropriate succinylcholine and etomidate doses in obese and nonobese patients. METHODS Retrospective review using a database of endotracheally intubated patients using RSI in an urban, tertiary care academic emergency department, from November 2009 to June 2011. Dosing for succinylcholine and etomidate was calculated as milligrams per kilogram of total body weight (TBW) for each patient, defining appropriate dosing as succinylcholine 1-1.5 mg/kg TBW and etomidate 0.2-0.4 mg/kg TBW. Logistic regression analysis was used to estimate the association between appropriate dosing and World Health Organization body mass index classification. RESULTS A total of 440 patients were included in the study, 311 (70.7%) classified as nonobese and 129 (29.3%) as obese. two hundred thirty-three (56%) received an inappropriate succinylcholine dose and 107 (24%) received an inappropriate etomidate dose. Obese patients were more likely to be underdosed with succinylcholine (odds ratio [OR], 63.7; 95% confidence interval [CI], 17.8-228.1) and etomidate (OR, 178.3; 95% CI, 37.6-844.7). Nonobese patients were more likely to be overdosed with succinylcholine (OR, 62.5; 95% CI, 17.9-250) and etomidate (OR, 166.7; 95% CI, 37.0-1000). CONCLUSION Obese patients were more likely to be underdosed during RSI compared with nonobese patients, whereas nonobese patients were more likely to be overdosed with RSI medications. Most obese and nonobese patients were inappropriately dosed with RSI medications, suggesting that physicians are not dosing these medications based on weight.
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Affiliation(s)
- Rahul Bhat
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
| | - Maryann Mazer-Amirshahi
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
| | - Christie Sun
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
| | - Janelle Vaughns
- Division of Anesthesiology, Pain and Perioperative Medicine, Children's National Medical Center, Washington, DC
| | - Maria Dynin
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
| | - Eshetu Tefera
- Department of Biostatistics and Bioinformatics, MedStar Health Research Institute, Hyattsville, MD
| | - Daryn Towle
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC
| | - Munish Goyal
- Department of Emergency Medicine, MedStar Washington Hospital Center, Washington, DC; Department of Emergency Medicine, Georgetown University School of Medicine, Washington, DC; Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC
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