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Bevins J, Bhulani N, Goksu SY, Sanford NN, Gao A, Ahn C, Paulk ME, Terauchi S, Pruitt SL, Tavakkoli A, Rhodes RL, Ali Kazmi SM, Beg MS. Early Palliative Care Is Associated With Reduced Emergency Department Utilization in Pancreatic Cancer. Am J Clin Oncol 2021; 44:181-186. [PMID: 33710133 PMCID: PMC8062302 DOI: 10.1097/coc.0000000000000802] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVES Most patients with pancreatic cancer have high symptom burden and poor outcomes. Palliative care (PC) can improve the quality of care through expert symptom management, although the optimal timing of PC referral is still poorly understood. We aimed to assess the association of early PC on health care utilization and charges of care for pancreatic cancer patients. MATERIALS AND METHODS We selected patients with pancreatic cancer diagnosed between 2000 and 2009 who received at least 1 PC encounter using the Surveillance, Epidemiology, and End Results (SEER)-Medicare. Patients who had unknown follow-up were excluded. We defined "early PC" if the patients received PC within 30 days of diagnosis. RESULTS A total of 3166 patients had a PC encounter; 28% had an early PC. Patients receiving early PC were more likely to be female and have older age compared with patients receiving late PC (P<0.001). Patients receiving early PC had fewer emergency department (ED) visits (2.6 vs. 3.0 visits, P=0.004) and lower total charges of ED care ($3158 vs. $3981, P<0.001) compared with patients receiving late PC. Patients receiving early PC also had lower intensive care unit admissions (0.82 vs. 0.98 visits, P=0.006) and total charges of intensive care unit care ($14,466 vs. $18,687, P=0.01). On multivariable analysis, patients receiving early PC were significantly associated with fewer ED visits (P=0.007) and lower charges of ED care (P=0.018) for all patients. CONCLUSIONS Early PC referrals were associated with lower ED visits and ED-related charges. Our findings support oncology society guideline recommendations for early PC in patients with advanced malignancies such as pancreatic cancer.
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Affiliation(s)
- Jack Bevins
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Nizar Bhulani
- Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Suleyman Yasin Goksu
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Nina Niu Sanford
- Department of Radiation Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Ang Gao
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Chul Ahn
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Mary Elizabeth Paulk
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Palliative Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Stephanie Terauchi
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Palliative Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Sandi L. Pruitt
- Department of Population and Data Sciences, UT Southwestern Medical Center, Dallas, TX
| | - Anna Tavakkoli
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, TX
| | - Ramona L. Rhodes
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Geriatric Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Syed Mohammad Ali Kazmi
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, TX
| | - Muhammad Shaalan Beg
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
- Division of Hematology and Oncology, UT Southwestern Medical Center, Dallas, TX
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Cox L, He C, Bevins J, Clemens JQ, Stoffel JT, Cameron AP. Gentamicin bladder instillations decrease symptomatic urinary tract infections in neurogenic bladder patients on intermittent catheterization. Can Urol Assoc J 2017; 11:E350-E354. [PMID: 29382457 DOI: 10.5489/cuaj.4434] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION This study aimed to determine if gentamicin bladder instillations reduce the rate of symptomatic urinary tract infection (UTI) in neurogenic bladder (NGB) patients on intermittent self-catheterization (ISC) who have recurrent UTIs. Secondary aims were to examine the effects of intravesical gentamicin on the organism resistance patterns. METHODS We retrospectively reviewed our prospective NGB database. Inclusion criteria were NGB patients performing ISC exclusively for bladder drainage with clinical data available for six months before and six months after initiating prophylactic intravesical gentamicin instillations. Symptomatic UTIs were defined as symptoms consistent with UTI plus the need for antibiotic treatment. RESULTS Twenty-two patients met inclusion criteria; etiology of NGB was 63.6% spinal cord injury, 13.6% multiple sclerosis. Median time since injury/diagnosis was 14 years and 6/22 (27.3%) had undergone urological reconstruction. Patients had fewer symptomatic UTI's (median 4 vs. 1 episodes; p<0.004) and underwent fewer courses of oral antibiotics after initiating gentamicin (median 3.5 vs. 1; p<0.01). Days of oral antibiotic therapy decreased from 15 before to five after gentamicin, but this did not reach significance. There were fewer telephone encounters for UTI concerns per patient (median 3 vs. 0; p=0.03). The proportion of multi-drug-resistant organisms in urine cultures decreased from 58.3% to 47.1% (p=0.04) and the rate of gentamicin resistance did not increase. Adverse events were mild and rare. CONCLUSIONS Gentamicin bladder instillations decrease symptomatic UTI episodes and reduce oral antibiotics in patients with NGB on ISC who were suffering from recurrent UTIs. Antibiotic resistance decreased while on gentamicin instillations.
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Affiliation(s)
- Lindsey Cox
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Chang He
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Jack Bevins
- College of Medicine; University of Michigan, Ann Arbor, MI, United States
| | - J Quentin Clemens
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - John T Stoffel
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
| | - Anne P Cameron
- Department of Urology; University of Michigan, Ann Arbor, MI, United States
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Lussiez A, Bevins J, Plaska A, Rosin V, Reddy RM. General Surgery Resident Satisfaction on Cardiothoracic Rotations. J Surg Educ 2016; 73:95-100. [PMID: 26531743 DOI: 10.1016/j.jsurg.2015.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/21/2015] [Accepted: 09/07/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVE General surgery residents' exposure to cardiothoracic (CT) surgery rotations has decreased, which may affect resident satisfaction. We surveyed general surgery graduates to assess the relationships among rotation satisfaction, CT disease exposure, rotation length, mentorship, and mistreatment. DESIGN A survey assessing CT curriculum, exposure, mentorship, and satisfaction was forwarded to general surgery graduates from 17 residency programs. A Wilcoxon rank-sum test was used to assess statistical significance of ordinal level data. Statistical significance was defined as p < 0.05. SETTING This study was conducted at the University of Michigan Health System in Ann Arbor, MI, a tertiary care center. PARTICIPANTS The survey was sent to approximately 1300 graduates of general surgery residency programs who graduated between the years of 1999 to 2014. A total of 94 responses were completed and received. RESULTS Receiving adequate exposure to CT procedures and disease management was significantly associated with higher satisfaction ratings for all procedures, particularly thoracotomy incisions (p < 0.001), empyemas and pleural effusions (p < 0.001), and lung cancer care (p < 0.001). The absence of mistreatment and good/very good mentorship were both positively associated with higher reported satisfaction (p = 0.018 and p < 0.001, respectively). Increased length of time on CT rotation was neither associated with improved levels of satisfaction nor with an improvement in the quality of mentorship. CONCLUSION Rotation satisfaction is positively associated with procedure exposure, better mentorship, and the absence of mistreatment. Longer rotation length was not associated with satisfaction. Shorter rotations are not detrimental to training if they have focused clinical exposure and invested mentors to maximize resident satisfaction. These specific markers of rotation quality are useful in curricular design.
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Affiliation(s)
- Alisha Lussiez
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Jack Bevins
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Andrew Plaska
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Vadim Rosin
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Rishindra M Reddy
- University of Michigan Medical School, Ann Arbor, Michigan; Department of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan.
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Noh J, Wende AR, Olsen CD, Kim B, Bevins J, Zhu Y, Zhang QJ, Riehle C, Abel ED. Phosphoinositide dependent protein kinase 1 is required for exercise-induced cardiac hypertrophy but not the associated mitochondrial adaptations. J Mol Cell Cardiol 2015; 89:297-305. [PMID: 26476238 DOI: 10.1016/j.yjmcc.2015.10.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [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: 07/09/2015] [Revised: 09/28/2015] [Accepted: 10/12/2015] [Indexed: 01/17/2023]
Abstract
Phosphoinositide-dependent protein kinase-1 (PDPK1) is an important mediator of phosphatidylinositol 3-kinase (PI3K) signaling. We previously reported that PI3K but not Akt signaling mediates the increase in mitochondrial oxidative capacity following physiological cardiac hypertrophy. To determine if PDPK1 regulates these metabolic adaptations we examined mice with cardiomyocyte-specific heterozygous knockout of PDPK1 (cPDPK1(+/-)) after 5 wk. exercise swim training. Akt phosphorylation at Thr308 increased by 43% in wildtype (WT) mice but not in cPDPK1(+/-) mice following exercise training. Ventricular contractile function was not different between WT and cPDPK1(+/-) mice at baseline. In addition, exercise did not influence ventricular function in WT or cPDPK1(+/-) mice. Heart weight normalized to tibia length ratios increased by 13.8% in WT mice (6.2±0.2 vs. 7.1±0.2, P=0.001), but not in cPDPK1(+/-) (6.2±0.3 vs. 6.5±0.2, P=0.20) mice after swim training. Diastolic LV dimension increased in WT mice (3.7±0.1 vs. 4.0±0.1 mm, P=0.01) but not in cPDPK1(+/-) (3.8±0.1 vs. 3.7±0.1 mm, P=0.56) following swim training. Maximal mitochondrial oxygen consumption (VADP, nmol/min/mg) using palmitoyl carnitine as a substrate was significantly increased in mice of all genotypes following swim training (WT: 13.6±0.6 vs.16.1±0.9, P=0.04; cPDPK1(+/-): 12.4±0.6 vs.15.9±1.2, P=0.04). These findings suggest that PDPK1 is required for exercise-induced cardiac hypertrophy but does not contribute to exercise-induced increases in mitochondrial function.
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Affiliation(s)
- Junghyun Noh
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Division of Endocrinology and Metabolism, College of Medicine, Inje University, Goyang, South Korea
| | - Adam R Wende
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Department of Pathology, University of Alabama at Birmingham, Birmingham, AL 35294, USA
| | - Curtis D Olsen
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Bumjun Kim
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Jack Bevins
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA
| | - Yi Zhu
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Touchstone Diabetes Center, University of Texas Southwestern, Dallas, TX 75390, USA
| | - Quan-Jiang Zhang
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Fraternal Order of Eagles Diabetes Research Center and Division of Endocrinology and Metabolism, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
| | - Christian Riehle
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Hannover Medical School, Department of Cardiology and Angiology, Carl-Neuberg-Str., 130625 Hannover, Germany
| | - E Dale Abel
- Program in Molecular Medicine and Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT 84112, USA; Fraternal Order of Eagles Diabetes Research Center and Division of Endocrinology and Metabolism, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA.
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Park SY, Richardson RS, Abel ED, Rossman MJ, Valdez S, Bevins J, Symons JD, Riehle C. Swim Training Improves Indices Of Vascular Mitochondrial Function. Med Sci Sports Exerc 2015. [DOI: 10.1249/01.mss.0000478779.28010.55] [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: 11/21/2022]
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Riehle C, Wende AR, Sena S, Pires KM, Pereira RO, Zhu Y, Bugger H, Frank D, Bevins J, Chen D, Perry CN, Dong XC, Valdez S, Rech M, Sheng X, Weimer BC, Gottlieb RA, White MF, Abel ED. Insulin receptor substrate signaling suppresses neonatal autophagy in the heart. J Clin Invest 2013; 123:5319-33. [PMID: 24177427 DOI: 10.1172/jci71171] [Citation(s) in RCA: 99] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 08/29/2013] [Indexed: 01/12/2023] Open
Abstract
The induction of autophagy in the mammalian heart during the perinatal period is an essential adaptation required to survive early neonatal starvation; however, the mechanisms that mediate autophagy suppression once feeding is established are not known. Insulin signaling in the heart is transduced via insulin and IGF-1 receptors (IGF-1Rs). We disrupted insulin and IGF-1R signaling by generating mice with combined cardiomyocyte-specific deletion of Irs1 and Irs2. Here we show that loss of IRS signaling prevented the physiological suppression of autophagy that normally parallels the postnatal increase in circulating insulin. This resulted in unrestrained autophagy in cardiomyocytes, which contributed to myocyte loss, heart failure, and premature death. This process was ameliorated either by activation of mTOR with aa supplementation or by genetic suppression of autophagic activation. Loss of IRS1 and IRS2 signaling also increased apoptosis and precipitated mitochondrial dysfunction, which were not reduced when autophagic flux was normalized. Together, these data indicate that in addition to prosurvival signaling, insulin action in early life mediates the physiological postnatal suppression of autophagy, thereby linking nutrient sensing to postnatal cardiac development.
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