1
|
Franco Z, Ruffalo L, Curry B, Gollin-Graves M, Ahamed SI, Winstead O, Hooyer K, Pazdera M, Rein L, Lizarraga Mazaba J, Hossain MF, Stoffel V, Flower M, Madiraju P, Melka S, Berte K, Whittle J. Impact of veteran-led peer mentorship on posttraumatic stress disorder. J Trauma Stress 2024. [PMID: 38635149 DOI: 10.1002/jts.23038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 02/05/2024] [Accepted: 03/23/2024] [Indexed: 04/19/2024]
Abstract
Peer mentorship shows promise as a strategy to support veteran mental health. A community-academic partnership involving a veteran-led nonprofit organization and institutions of higher education evaluated a collaboratively developed peer mentor intervention. We assessed posttraumatic stress disorder (PTSD), postdeployment experiences, social functioning, and psychological strengths at baseline, midpoint, and 12-week discharge using the PTSD Checklist for DSM-5 (PCL-5), Deployment Risk and Resilience Inventory-2, Social Adaptation Self-evaluation Scale, and Values in Action Survey. Brief weekly check-in surveys reinforced mentor contact and assessed retention. The sample included 307 veterans who were served by 17 veteran peer mentors. Mixed-effects linear models found a modest effect for PTSD symptom change, with a mean PCL-5 score reduction of 4.04 points, 95% CI [-6.44, -1.64], d = 0.44. More symptomatic veterans showed a larger effect, with average reductions of 9.03 points, 95% CI [-12.11, -5.95], d = 0.77. There were no significant findings for other outcome variables. Compared to younger veterans, those aged 32-57 years were less likely to drop out by 6 weeks, aORs = 0.32-0.26. Week-by-week hazard of drop-out was lower with mentors ≥ 35 years old, aHR = 0.62, 95% CI [0.37, 1.05]. Unadjusted survival differed by mentor military branch, p = .028, but the small mentor sample reduced interpretability. Like many community research efforts, this study lacked a control group, limiting the inferences that can be drawn. Continued study of veteran peer mentorship is important as this modality is often viewed as more tolerable than therapy.
Collapse
Affiliation(s)
- Zeno Franco
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Leslie Ruffalo
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Bob Curry
- Great Lakes Dryhootch, Milwaukee, Wisconsin, USA
| | | | - Sheikh Iqbal Ahamed
- Department of Computer Science, Marquette University, Milwaukee, Wisconsin, USA
| | | | - Katinka Hooyer
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Myah Pazdera
- Office of Community Engagement, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lisa Rein
- Institute for Health & Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Jose Lizarraga Mazaba
- Department of Family and Community Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Md Fitrat Hossain
- Department of Computer Science, Marquette University, Milwaukee, Wisconsin, USA
| | - Virginia Stoffel
- Department of Rehabilitation Sciences & Technology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Mark Flower
- Mental Health America of Wisconsin, Milwaukee, Wisconsin, USA
| | - Praveen Madiraju
- Department of Computer Science, Marquette University, Milwaukee, Wisconsin, USA
| | - Stephen Melka
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Karen Berte
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Jeffrey Whittle
- Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| |
Collapse
|
2
|
Martin TC, Duewell BE, Juul JJ, Rinka JRG, Rein L, Feih JT. Comparison of Outcomes in Patients Requiring Mechanical Circulatory Support Who Received Cangrelor in Addition to Anticoagulation Versus Anticoagulation Alone. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00160-5. [PMID: 38521630 DOI: 10.1053/j.jvca.2024.02.039] [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: 10/11/2023] [Revised: 02/19/2024] [Accepted: 02/26/2024] [Indexed: 03/25/2024]
Abstract
OBJECTIVES To evaluate the safety of cangrelor administered concurrently with heparin or bivalirudin in patients on mechanical circulatory support. DESIGN A single-center, retrospective cohort study of adult patients consecutively admitted between January 2016 and October 2020. SETTING A tertiary medical center. PARTICIPANTS Adult patients admitted to the cardiovascular intensive care unit put on mechanical circulatory support for acute myocardial infarction (AMI) or non-AMI indications. Patients who received cangrelor underwent percutaneous coronary intervention with stenting during the index event or within the last year. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was the incidence of major bleeding, defined by the Extracorporeal Life Support Organization criteria, in patients with mechanical circulatory support receiving cangrelor plus anticoagulation with heparin or bivalirudin with or without aspirin versus patients who did not receive cangrelor. Sixty-eight patients were included in the study. Twenty-nine patients received cangrelor, and 39 did not. Cangrelor was not associated with an increase in major bleeding; however, the CI was wide (adjusted hazard ratio 1.93, 95% CI 0.61-6.11; p = 0.262). CONCLUSIONS Patients receiving cangrelor did not appear to be at higher risk of major bleeding compared to patients not receiving cangrelor. Larger trials should be conducted to better evaluate the safety of cangrelor in patients with mechanical circulatory support.
Collapse
Affiliation(s)
- Trent C Martin
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI.
| | | | - Janelle J Juul
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI
| | - Joseph R G Rinka
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; School of Pharmacy, Concordia University Wisconsin, Mequon, WI
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Joel T Feih
- Department of Pharmacy, Froedtert Hospital, Milwaukee, WI; Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
3
|
Chanas T, Gibson G, Langenstroer E, Herrmann DJ, Carver TW, Alexander K, Chui SHJ, Rein L, Ha M, Maynard KM, Bamberg K, O'Keefe M, O'Brien M, Gonzalez MC, Hobbs B, Pajoumand M, Peppard WJ. Multicenter study evaluating target attainment of anti-Factor Xa levels using various enoxaparin prophylactic dosing practices in adult trauma patients. Pharmacotherapy 2024; 44:258-267. [PMID: 38148134 DOI: 10.1002/phar.2904] [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: 08/08/2023] [Revised: 11/08/2023] [Accepted: 12/05/2023] [Indexed: 12/28/2023]
Abstract
STUDY OBJECTIVE Enoxaparin is standard of care for venous thromboembolism (VTE) prophylaxis in adult trauma patients, but fixed-dose protocols are suboptimal. Dosing based on body mass index (BMI) or total body weight (TBW) improves target prophylactic anti-Xa level attainment and reduces VTE rates. A novel strategy using estimated blood volume (EBV) may be more effective based on results of a single-center study. This study compared BMI-, TBW-, EBV-based, and hybrid enoxaparin dosing strategies at achieving target prophylactic anti-Factor Xa (anti-Xa) levels in trauma patients. DESIGN Multicenter, retrospective review. DATA SOURCE Electronic health records from participating institutions. PATIENTS Adult trauma patients who received enoxaparin twice daily for VTE prophylaxis and had at least one appropriately timed anti-Xa level (collected 3 to 6 hours after the previous dose after three consecutive doses) from January 2017 through December 2020. Patients were excluded if the hospital-specific dosing protocol was not followed or if they had thermal burns with > 20% body surface area involvement. INTERVENTION Dosing strategy used to determine initial prophylactic dose of enoxaparin. MEASUREMENTS The primary end point was percentage of patients with peak anti-Xa levels within the target prophylactic range (0.2-0.4 units/mL). MAIN RESULTS Nine hospitals enrolled 742 unique patients. The most common dosing strategy was based on BMI (43.0%), followed by EBV (29.0%). Patients dosed using EBV had the highest percentage of target anti-Xa levels (72.1%). Multiple logistic regression demonstrated EBV-based dosing was significantly more likely to yield anti-Xa levels at or above target compared to BMI-based dosing (adjusted odds ratio (aOR) 3.59, 95% confidence interval (CI) 2.29-5.62, p < 0.001). EBV-based dosing was also more likely than hybrid dosing to yield an anti-Xa level at or above target (aOR 2.30, 95% CI 1.33-3.98, p = 0.003). Other pairwise comparisons between dosing strategy groups were nonsignificant. CONCLUSIONS An EBV-based dosing strategy was associated with higher odds of achieving anti-Xa level within target range for enoxaparin VTE prophylaxis compared to BMI-based dosing and may be a preferred method for VTE prophylaxis in adult trauma patients.
Collapse
Affiliation(s)
- Tyler Chanas
- ECU Health Medical Center, Greenville, North Carolina, USA
| | | | | | - David J Herrmann
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Thomas W Carver
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Kaitlin Alexander
- University of Florida College of Pharmacy, Gainesville, Florida, USA
| | | | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Michael Ha
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Kaylee M Maynard
- University of Rochester Medical Center, Rochester, New York, USA
| | | | - Mary O'Keefe
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marisa O'Brien
- UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | | | - Brandon Hobbs
- Orlando Regional Medical Center, Orlando, Florida, USA
| | | | - William J Peppard
- Froedtert & The Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
4
|
Carter C, Denny K, Carver TW, Jung B, Rein L, Peppard WJ. Evaluation of an Association Between Enoxaparin Dose per Estimated Blood Volume and Clinically Relevant Bleeding in Low-Weight Trauma Patients. Ann Pharmacother 2024; 58:118-125. [PMID: 37138511 DOI: 10.1177/10600280231169523] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The optimal dosing for enoxaparin venous thromboembolism (VTE) prophylaxis in low-weight trauma patients is unknown. Estimated blood volume (EBV) has shown promise as a dose modifier. OBJECTIVE To characterize the association of enoxaparin dose per EBV with the prevalence of VTE and bleeding in low-weight trauma patients. METHODS This was a retrospective study of trauma patients admitted over a 4-year period. Included patients were adults weighing <60 kg who received a minimum of 3 consecutive doses of enoxaparin. The primary endpoint was a comparison of enoxaparin dose per EBV in patients experiencing bleeding and VTE. Secondary endpoints included comparisons of dose per body mass index (BMI) and total body weight (TBW) and the ability of dose per EBV to predict clinical endpoints. Subgroup analyses for patients weighing <50 kg were performed for all endpoints. RESULTS A total of 189 patients were included. Statistical comparisons for VTE were not performed because of low prevalence. The dose of enoxaparin per EBV was not statistically different between patients who did and did not bleed in all analyses. Doses per BMI and TBW were also not statistically different between the groups. In patients weighing <50 kg, numerically higher doses per EBV, BMI, and TBW were noted in patients that bled versus those that did not. Enoxaparin dose per EBV was not a statistically significant predictor of bleeding in logistic regression models. CONCLUSION AND RELEVANCE No significant associations between enoxaparin dose per EBV, BMI, or TBW and bleeding were noted in the study. Future analyses of EBV and other dose modifiers should consider inclusion of patients weighing <50 kg.
Collapse
Affiliation(s)
- Chris Carter
- Department of Pharmacy, SSM Health St. Clare Hospital-Fenton, Fenton, MO, USA
| | - Kailey Denny
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thomas W Carver
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Benjamin Jung
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Division of Biostatistics, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, WI, USA
| | - William J Peppard
- Department of Pharmacy, Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
- Division of Trauma and Acute Care Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
5
|
Langenstroer EA, Carver TW, Herrmann DJ, O'Keefe MM, Hubbard S, Holschbach L, Rein L, Peppard WJ. Evaluation of a novel blood volume-based enoxaparin dosing guideline for venous thromboembolism prophylaxis in trauma patients. Am J Health Syst Pharm 2023; 80:1137-1146. [PMID: 37256752 DOI: 10.1093/ajhp/zxad119] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Indexed: 06/02/2023] Open
Abstract
PURPOSE Fixed-dose and body mass index (BMI)-based enoxaparin regimens provide inadequate venous thromboembolism (VTE) prophylaxis for many trauma patients. The purpose of this study was to evaluate the effectiveness of a novel blood volume (BV)-based enoxaparin guideline vs a historical BMI-based guideline for VTE prophylaxis in trauma patients. METHODS This was a retrospective pre/post study completed at a large academic level 1 trauma center. All adult trauma patients admitted from October through December 2019 and August through October 2020 who received prophylactic enoxaparin per guideline were included. The BV dosing was as follows: patients with a BV of 3 to 4.9 L received enoxaparin 30 mg every 12 hours, those with a BV of 5 to 6.9 L received 40 mg every 12 hours, and those with a BV of ≥7 L received 60 mg every 12 hours. The primary outcome was the percentage of patients who attained a target anti-factor Xa (anti-Xa) postdosing level at the first steady-state assessment (0.2 to 0.5 IU/mL). RESULTS A total of 241 patients (99 for the BMI group and 142 for the BV group) were included. The study groups had a median age of 38 vs 42 years, a mean BMI of 27.4 vs 27.7 kg/m2, and a mean BV of 5.1 vs 5.1 L, respectively. A total of 63 patients (62.6%) in the BMI group attained target anti-Xa levels compared to 115 patients (81%) in the BV group (P = 0.008). In multivariate regression, the BV-based guideline was the only variable associated with attainment of target anti-Xa levels (adjusted odds ratio, 2.02; P = 0.01). Clinically relevant bleeding and VTE rates were similar between the groups. CONCLUSION Dosing prophylactic enoxaparin using a BV-based dosing guideline significantly increased attainment of target anti-Xa levels.
Collapse
Affiliation(s)
| | - Thomas W Carver
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - David J Herrmann
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mary M O'Keefe
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sara Hubbard
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Leah Holschbach
- Froedtert & The Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | |
Collapse
|
6
|
Chang CK, Higgins RM, Rein L, Peppard WJ, Herrmann DJ, Kindel T. Effectiveness of Body Mass Index-Based Prophylactic Enoxaparin Dosing in Bariatric Surgery Patients. J Surg Res 2023; 287:168-175. [PMID: 36933548 DOI: 10.1016/j.jss.2023.01.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 01/03/2023] [Accepted: 01/27/2023] [Indexed: 03/19/2023]
Abstract
INTRODUCTION Enoxaparin is administered for venous thromboembolic (VTE) prophylaxis in bariatric surgery patients. There is concern whether body mass index (BMI)-based enoxaparin dosing consistently achieves prophylactic targets in patients with severe obesity. METHODS This retrospective study included patients who underwent bariatric surgery at an academic medical center from Jan 2015-May 2021 and had an anti-Xa level drawn 2.5-6 h after ≥3 doses of BMI-based prophylactic enoxaparin. The primary outcome was the percentage of patients who achieved a target anti-Xa level. Secondary outcomes were prevalence of venous thromboembolic and bleeding events within 30 d post-operatively. RESULTS Overall, 137 patients were included. Mean BMI was 59.1 ± 10.4 kg/m2, mean age was 43.9 ± 13.3 y and 110 patients (80.3%) were female. Target anti-Xa levels were achieved in 116 patients (84.7%); 14 (10.2%) were above target and 7 (5.1%) were below target. Patients with above target anti-Xa levels were significantly shorter in height than those within target range (167.1 versus 159.8 cm, P = 0.003). Five patients (3.6%) had a bleeding event; no thromboembolisms occurred. Anti-Xa levels correlated more strongly with enoxaparin dose per unit estimated blood volume (EBV) than dose per unit BMI (Rho = 0.54 versus Rho = 0.33). CONCLUSIONS Target range anti-Xa levels were achieved in 85% of patients using BMI-based enoxaparin dosing. Patients with above target anti-Xa levels were significantly shorter by nearly 3 inches, suggesting an increased risk of overdosing enoxaparin in shorter, obese patients. An EBV-based dosing regimen may better account for patient height and is supported by a greater correlation with anti-Xa levels with dosing based on EBV than BMI.
Collapse
Affiliation(s)
- Catherine K Chang
- Medical College of Wisconsin School of Medicine, Milwaukee, Wisconsin
| | - Rana M Higgins
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Biostatistics, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William J Peppard
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin
| | - David J Herrmann
- Department of Pharmacy, Froedtert Hospital, Milwaukee, Wisconsin
| | - Tammy Kindel
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
7
|
Janardan A, George B, Ahmed G, Daniel S, Thapa B, Mehdi M, Rein L, Szabo A, Erickson B, Hall WA, Christians KK, Tsai S, Evans DB, Kamgar M. Treatment sequencing for patients with localized duodenal and ampullary adenocarcinoma. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.783] [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: 01/26/2023] Open
Abstract
783 Background: Duodenal adenocarcinomas (DA) and ampullary adenocarcinoma (AA) are rare, comprising less than 1% of all gastrointestinal cancers. Optimal treatment sequencing strategies for patients with localized DA and AA have not been prospectively validated. We analyzed the clinical outcomes of patients with localized DA and AA treated with curative intent, multimodality therapy based on treatment sequencing – upfront surgery versus neoadjuvant therapy. Methods: Our institutional database was interrogated to identify adult patients with localized DA and AA diagnosed between January 2000 to December 2019. Adjusted survival analyses were performed to compare outcomes of patients that received neoadjuvant therapy (NAT - concurrent chemo-radiation +/-induction chemotherapy) versus upfront surgery (+/- adjuvant chemotherapy). Survival time was calculated from date of diagnosis to either death (overall survival; OS) or relapse/death (relapse free survival; RFS). Log-rank test and multiple Cox proportional hazards regression were performed to compare survival between treatment groups and adjust for relevant variables. Results: We identified 79 patients – 32 (41%) with DA and 47 (59%) with AA; Median age at diagnosis was 67. Forty two patients (53%) were male. Sixty-two patients underwent surgery – 27 (43.6%) patients with DA and 35 patients (56.4%) with AA. Among patients with DA, 18 (67%) were treated with upfront surgery, while 9 (33%) were treated with NAT. Among patients with AA, 32 (91%) were treated with upfront surgery while 3 (9%) were treated with NAT. Lymph node (LN) positivity rate in DA and AA patients treated with upfront surgery was 15% and 46% respectively, compared to 50% and 0% respectively, in patients treated with NAT (p = 0.26, p > 0.99 respectively). DA patients treated with upfront surgery had a median relapse free survival (mRFS) of 3.8 years compared to 1.4 years for those treated with NAT (p = 0.370). The median overall survival m(OS) was not reached (NR) for DA patients treated with upfront surgery (4 years +) or NAT (2.6 years +) p = 0.875). AA patients treated with upfront surgery had a median RFS of 4.7 years compared to NR for patients treated with NAT (p = 0.117) while the mOS of AA patients treated with upfront surgery and NAT were 5.9 years and NR respectively (p = 0.158). Conclusions: Among DA patients, there was no difference in outcome based on sequence of treatment delivery – NAT versus upfront surgery. DA patients with more aggressive clinical phenotype were likely treated with NAT, hence similar outcomes in both groups should prompt consideration of NAT for all patients with DA. Role of NAT in AA is not clear considering the small sample size.
Collapse
Affiliation(s)
| | - Ben George
- Froedtert and the Medical College of Wisconsin, Milwaukee, WI
| | | | | | | | | | - Lisa Rein
- Medical College of Wisconsin Center for AIDS Intervention Research, Milwaukee, WI
| | - Aniko Szabo
- Medical College of Wisconsin, Division of Biostatistics, Milwaukee, WI
| | | | | | | | - Susan Tsai
- Medical College of Wisconsin, Milwaukee, WI
| | | | | |
Collapse
|
8
|
McLeish T, Seadler BD, Parrado R, Rein L, Joyce DL. The effect of socioeconomic factors on patient outcomes in cardiac surgery. J Card Surg 2022; 37:5135-5143. [PMID: 36403269 DOI: 10.1111/jocs.17229] [Citation(s) in RCA: 4] [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] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Healthcare delivery is heterogenous; the reasons for this are numerous and complex. Patient-specific factors including geography, income, insurance status, age, and gender have been shown to bias surgical outcomes. Utilizing a prospectively collected all-payer database, we aim to evaluate the influence of socioeconomic factors on mortality and length of stay (LOS) after common cardiac surgical procedures. METHODS We utilized the National Inpatient Sample, Healthcare Cost and Utilization Project, Agency for Healthcare Research and Quality for the year 2019. We included patients undergoing coronary artery bypass grafting (CABG), aortic valve replacement (AVR), transcatheter aortic valve replacement (TAVR), and combined AVR/CABG using the 10th revision of the International Classification of Diseases procedure codes. AVR and CABG were combined into a separate cohort as this was felt to represent a different pathology than isolated valvular or coronary arterial disease. Baseline demographics were summarized. Multivariable regression was performed within each procedure group to model the odds of in-hospital mortality and hospital LOS with age, sex, insurance, zip-code median household income, and location as predictors. RESULTS Baseline patient characteristics including gender, income, geography, and payer status were similar between CABG, AVR, and AVR/CABG. TAVR patients had a higher proportion of female sex and Medicare as the primary payer, with an overall greater age. Multivariable Cox proportional hazards regression found that higher income was strongly associated with decreased LOS following AVR and CABG, and moderately associated in TAVR and AVR/CABG. Private insurance was associated with a decreased LOS in patients undergoing CABG, AVR, TAVR, and AVR/CABG. Female sex and increased age were associated with increased odds of mortality in TAVR, CABG, and AVR/CABG. Private insurance was associated with a decreased odds of mortality in patients undergoing AVR. CONCLUSIONS These findings reveal significant disparities in patient outcomes after routine cardiac operations that are associated with socioeconomic status. Patients who did not have private insurance or had lower incomes were found to be at risk for increased LOS. Women were at a higher risk of mortality for several operations, a finding which has been previously described elsewhere. Private insurance conveyed a decreased odds of mortality in patients undergoing AVR. This data set serves to highlight differences in healthcare outcomes based on a variety of socioeconomic, geographic, and other inherent factors. Additional research is needed to identify the mechanisms behind these disparities with the goal of providing equitable care to all patients.
Collapse
Affiliation(s)
- Tyson McLeish
- Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Benjamin D Seadler
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Raphael Parrado
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David L Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
9
|
Dang-Vu G, Rein L, Szabo A, Venkatesan T. Low patient engagement is associated with reduced health-related quality of life in adults with cyclic vomiting syndrome. Scand J Gastroenterol 2022; 57:1030-1035. [PMID: 35486076 DOI: 10.1080/00365521.2022.2064724] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Patient engagement, adaptation and self-management play a critical role in improving Health Related Quality of Life (HRQOL) and reducing health care utilization in chronic disorders. There is no data on the level of patient engagement in patients with cyclic vomiting syndrome (CVS); we thus sought to determine their level of engagement and its association with clinical covariates. METHODS The Patient Activation Measure (PAM-13), a validated tool that measures the degree of patient engagement in their health was administered prospectively to patients with CVS. Data on demographics, health care utilization, and HRQOL (using the NIH PROMIS 10) were obtained. Patients were stratified into low engagement (PAM 1 & 2) and high engagement (PAM 3 & 4). The Fisher's exact test and Wilcoxon rank-sum tests were used to identifying significant differences between the groups. RESULTS Of 96 patients, 45% of patients had low levels of patient engagement. On multivariate analysis, low patient engagement was significantly associated with an increased number of CVS hospitalizations in the past year (aOR 1.26 [1.07, 1.54] p = .010), lower mental HRQOL scores (aOR 0.88 [0.78, 0.97] p = .022), current tobacco use (aOR 4.85 [1.24, 22.74] p = .031), and patients who were newly established in a specialized CVS clinic (aOR 44.40 [5.38, 70.02] p = .002). CONCLUSION Almost half of CVS patients demonstrate poor patient engagement, which is associated with poor outcomes. Identifying these patients and treatment in a specialized CVS center can potentially improve HRQOL, reduce health care utilization and improve overall healthcare outcomes.
Collapse
Affiliation(s)
- Geoffrey Dang-Vu
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
10
|
Meurer J, Rohloff R, Rein L, Kanter I, Kotagiri N, Gundacker C, Tarima S. Improving Child Development Screening: Implications for Professional Practice and Patient Equity. J Prim Care Community Health 2022; 13:21501319211062676. [PMID: 34986680 PMCID: PMC8743928 DOI: 10.1177/21501319211062676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION AND OBJECTIVES A pediatric group with 25 clinics and 150 providers used multifaceted approaches to implement workflow processes and an electronic health record (EHR) flowsheet to improve child developmental screening. The key outcome was developmental screening done for every patient during 3 periods between ages 8 and 36 months. Identification of developmental concerns was the secondary study outcome. Screening rates and referrals were hypothesized to be optimized for children regardless of demographic backgrounds. METHODS During preventive visits, developmental screens targeted patients in age groups 8 to 12, 13 to 24, and 25 to 36 months. EHRs were analyzed for screening documentation, results, and referrals by patient demographics. Fifteen pediatric professionals were interviewed about their qualitative experiences. Quality improvement interventions included appointing clinic champions, training staff about the screening process and responsibilities, using a standardized tool, employing plan-do-study-act cycles, posting EHR prompts, providing financial incentives, and monitoring screening rates using control charts. RESULTS Within 25 months, screening rates improved from 60% to >95% within the 3 preventive visit age groups for a total of more than 30 000 children. Professionals valued the team process improvements. Children enrolled in Medicaid, black children, and those living in lower income zip codes had lower screening rates than privately insured, white children, and those living in higher income areas. Ages and Stages Questionnaire 3rd edition results were significantly different by gender, race/ethnicity, insurance, and income categories across all groups. Referral rates varied by race/ethnicity and zip code of residence. CONCLUSIONS This project resulted in an effective and efficient process to improve child developmental screening that was valued by pediatric professionals. Analyses of patient demographics revealed disparities in services for the most vulnerable families. Ongoing quality improvement, health services research, and advocacy offer hope to improve health equity.
Collapse
Affiliation(s)
- John Meurer
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
| | | | - Lisa Rein
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
| | | | | | | | - Sergey Tarima
- Medical College of Wisconsin (MCW), Milwaukee, WI, USA
| |
Collapse
|
11
|
Weiss A, Dang C, Mabrey D, Stanton M, Feih J, Rein L, Feldman R. Comparison of Clinical Outcomes with Initial Norepinephrine or Epinephrine for Hemodynamic Support After Return of Spontaneous Circulation. Shock 2021; 56:988-993. [PMID: 34172611 DOI: 10.1097/shk.0000000000001830] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The optimal vasoactive agent for management of patients with return of spontaneous circulation (ROSC) after cardiac arrest has not yet been identified. The Advanced Cardiac Life Support guidelines recommend initiation of either norepinephrine (NE), epinephrine (EPI), or dopamine (DA) to maintain adequate hemodynamics after ROSC is achieved. The goal of this study is to retrospectively assess the impact of initial vasopressor agent on incidence rate of rearrest, death, or need for additional vasopressor in post-cardiac arrest emergency department (ED) patients. METHODS A retrospective review of electronic medical records was conducted at a tertiary care, academic medical center over a 32-month period. Inclusion criteria were any patient who received vasopressors in the ED after achieving ROSC from out-of-hospital cardiac arrest, or in ED cardiac arrest. The incidence of the primary outcome was assessed during care within the ED, at 6 h regardless of location (early resuscitation period), and throughout the entire hospitalization. Secondary outcomes included incidence of tachyarrhythmia while on vasopressor, type of additional therapy needed for refractory shock, and functional status at discharge as determined by discharge location (discharged home without assistance, or discharged to long-term care facility, subacute rehabilitation, or assisted living). RESULTS A total of 93 patients were included for analysis; 45 received NE, 42 EPI, and six DA. Due to small sample size, DA was excluded from reporting post hoc. Significantly more EPI patients met the primary outcome of refractory hypotension, rearrest, or death in the emergency department (EPI 21/42, 50% vs. NE 10/45, 22.2%; P = 0.008). The incidence was no longer significantly different during the early resuscitation period of 6 h (EPI 30/42, 71.4% vs. NE 25/45, 55.6%; P = 0.182), or during the entire hospitalization (EPI 40/42, 95.2% vs. NE 36/45, 80.0%; P = 0.051). Notably, the EPI group had higher rates of rearrest prior to vasopressor initiation, potentially signaling more severe illness despite other prognostic variables being similarly distributed. In an adjusted regression model, which included adjustment for rearrest prior to vasopressor initiation, the odds of reaching the primary outcome in the ED were 3.94 [95%CI 1.38-12.2] (P = 0.013) times higher in the EPI group compared to NE treated patients. No difference in tachyarrhythmia or functional status at discharge was detected between groups. CONCLUSION These data suggest prospective study of initial vasopressors used for hemodynamic support after ROSC may be warranted. Rates of intra-emergency department refractory shock, rearrest, or death were higher among epinephrine treated patients compared to norepinephrine treated patients in this population. However, inability to control for potential confounding variables in retrospective studies limits the findings. These results are hypothesis generating and further study is warranted.
Collapse
Affiliation(s)
- Ashley Weiss
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
| | - Cathyyen Dang
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
| | - Danielle Mabrey
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
| | - Matthew Stanton
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
- The Medical College of Wisconsin, School of Pharmacy, Wisconsin
- The Medical College of Wisconsin, Department of Emergency Medicine, Wisconsin
| | - Jessica Feih
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
| | - Lisa Rein
- The Medical College of Wisconsin, Department of Biostatistics, Wisconsin
| | - Ryan Feldman
- Froedtert & The Medical College of Wisconsin, Department of Pharmacy, Wisconsin
- The Medical College of Wisconsin, School of Pharmacy, Wisconsin
- The Medical College of Wisconsin, Department of Emergency Medicine, Wisconsin
| |
Collapse
|
12
|
Dream S, Park S, Yen TW, Rilling W, Rein L, Doffek K, Findling JW, Magill SB, Kidambi S, Evans DB, Wang TS. Utility of Epinephrine Levels in Determining Adrenal Vein Cannulation During Adrenal Venous Sampling for Primary Aldosteronism. Endocr Pract 2021; 28:276-281. [PMID: 34582994 DOI: 10.1016/j.eprac.2021.09.009] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/16/2021] [Accepted: 09/20/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE In patients with primary aldosteronism, adrenal venous sampling (AVS) is performed to determine the presence of unilateral or bilateral adrenal disease. During AVS, verification of catheter positioning within the left adrenal vein (AV) and the right AV by comparison of AV and inferior vena cava (IVC) cortisol levels can be variable. The objective of this study was to determine the utility of AV epinephrine levels in assessing successful AV cannulation. METHODS This was a single institution, retrospective review of patients who underwent AVS with cosyntropin stimulation for primary aldosteronism between 2009 and 2018. Successful cannulation of the AV was defined by an AV/IVC cortisol ratio selectivity index (SI) ≥3:1. Epinephrine thresholds to predict catheter placement in the AV were determined using logistic regression. The calculated epinephrine thresholds were compared with previously published thresholds. RESULTS AVS was performed on 101 consecutive patients and, based on the SI, successful cannulation of the left AV and right AV occurred in 98 (97%) and 91(90%) patients, respectively. The calculated optimal epinephrine threshold to predict AV cannulation was 364 pg/mL (sensitivity, 92.1%; specificity, 94.6%) and the calculated optimal AV/IVC epinephrine ratio threshold was 27.4, (sensitivity, 92.1%; specificity, 91.3%). Among the 14 patients with failed AV cannulation, 3 patients would have been considered to have successful AVS using AV epinephrine levels >364 pg/mL and AV/IVC epinephrine ratio >27.4 thresholds. CONCLUSION Obtaining 2 right AV samples routinely as well as AV and IVC epinephrine levels during AVS could prevent unnecessary repeat AVS in patients with failed AV cannulation based on cortisol-based SI <3:1.
Collapse
Affiliation(s)
- Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Sandra Park
- Department of Surgery, Tufts Medical Center, Boston, Massachusetts
| | - Tina W Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - William Rilling
- Division of Vascular and Interventional Radiology, Department of Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James W Findling
- Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steven B Magill
- Endocrine Center and Clinics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Srividya Kidambi
- Division of Endocrinology, Metabolism and Clinical Nutrition, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
13
|
Kamalia MA, Smith NJ, Rein L, Ramamurthi A, Miles B, Joyce LD, Mohammed A, Joyce DL. Seasonal trends in donor heart availability: an analysis of the UNOS database. Transpl Int 2021; 34:2166-2174. [PMID: 34510564 DOI: 10.1111/tri.14106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/21/2021] [Accepted: 09/03/2021] [Indexed: 11/29/2022]
Abstract
Despite the widespread belief that donor organ availability varies around holidays and seasons, there is little empirical data supporting this long-held belief. Variations in donor heart availability may be of interest to patients and clinicians. The UNOS/OPTN registry was queried for all heart donations from October 1987 through March 2017. Daily heart donation rates were modeled nationally using Poisson regression including splines for year and day of the year. Seasonality was assessed using a likelihood ratio test for the spine terms for day of the year. The holiday effect was assessed using conditional logistic regression. Seasonal plots suggest a significant, although modest, increase in organ availability during the summer months, except for region 1. The regions with the highest amplitude were region 7 (peak: June 21, amplitude: 16.63%) and region 6 (peak: July 5, amplitude: 11.29%). There was no significant difference in the odds of heart donation when comparing holidays vs. non-holidays using national data (odds ratio [95% CI]: 1.01 [0.98, 1.03], P = 0.560) or any regional subsets. There was no observable correlation between donor heart availability and holidays. However, a significant seasonality effect was observed with higher donation rates occurring during warmer months.
Collapse
Affiliation(s)
| | - Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Bryan Miles
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Asim Mohammed
- Department of Internal Medicine, Division of Cardiology, Lutheran Health Physicians, Fort Wayne, IN, USA
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
14
|
Bhagavatula P, Moore A, Rein L, Szabo A, Ibrahim M. Multi-state outcome analysis of treatment interventions after failure of non-surgical root canal treatment: a 13-year retrospective study. J Appl Oral Sci 2021; 29:e20201079. [PMID: 34495106 PMCID: PMC8425896 DOI: 10.1590/1678-7757-2020-1079] [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] [Received: 01/10/2021] [Accepted: 06/02/2021] [Indexed: 11/28/2022] Open
Abstract
Objective To examine the factors affecting the transitions through treatment interventions after failure of non-surgical root canal treatment (NS-RCT). Methodology Insurance enrollment and claim information for enrollees of Delta Dental of Wisconsin (DDWI), USA were analyzed for 438,487 initial NS-RCT procedures to determine the effect of initial provider type and other covariates on additional treatments (no additional treatment, nonsurgical retreatment, surgical retreatment and extraction). A multi-state model was created using the “mstate” R package. Transitions between the four states identified by Code on Dental Procedures and Nomenclature were analyzed. Cox proportional Hazards regression stratified by transition type was used to estimate the effect of provider type on the risk of each transition, adjusting for covariates. Results The overall survival rates for all teeth that were treated by NS-RCT was 82.8% [95% CI 82.57%, 83.11%] at 10 years. Approximately, 7% of cases changed from the first state of initial NS-RCT during the 13-year study period with ultimately 0.9%, 0.4% and 5% of cases receiving non-surgical retreatment, surgical retreatment or extraction, respectively. Teeth are more likely to be retreated non-surgically than surgically, and to be extracted than retreated. In general, the probability of a tooth having non-surgical retreatment was higher if the initial provider was not an endodontist (Hazard Ratio (HR)=3.2). Molars were more likely to be non-surgically retreated (HR=2.0) or extracted (HR=2.8) when compared to anterior teeth. The probability of non-surgical retreatment (HR=0.93) or extraction (HR=0.50) was lower when a crown was placed within 90 days after NS-RCT. Conclusion Most teeth remained in the same state after treatment with no additional treatment transitions. When a transition occurred, it was more likely to be an extraction. Type of provider, age, location of the tooth, gender, and time to placement of final restoration significantly influence treatment transitions.
Collapse
Affiliation(s)
- Pradeep Bhagavatula
- Marquette University School of Dentistry, Program in Public Health, Milwaukee, Wisconsin, USA
| | - Alex Moore
- Endodontist in private practice in Illinois, USA
| | - Lisa Rein
- Institute for Health & Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aniko Szabo
- Institute for Health & Equity, Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mohamed Ibrahim
- Marquette University School of Dentistry Milwaukee, Program in Endodontics, Wisconsin, USA and Mansoura University, Program in Endodontics, Mansoura, Egypt
| |
Collapse
|
15
|
Feih JT, Wallskog KE, Rinka JRG, Juul JJ, Rein L, Gaglianello N, Baumann Kreuziger LM, Joyce DL, Tawil JN. Heparin Monitoring with an Anti-Xa Protocol Compared to Activated Clotting Time in Patients on Temporary Mechanical Circulatory Support. Ann Pharmacother 2021; 56:513-523. [PMID: 34423673 DOI: 10.1177/10600280211039582] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Temporary mechanical circulatory support (tMCS) devices are used for patients with severe cardiac or respiratory failure; however, these patients are at high risk for clotting and bleeding. The best method to monitor heparin in these patients has not been established. OBJECTIVE To determine the risks for bleeding and clotting while monitoring heparin with either anti-Xa or activated clotting time (ACT) in tMCS patients. METHODS A retrospective cohort study was conducted on tMCS patients who received heparin adjusted according to an anti-Xa or ACT protocol. The primary outcome was incidence of major bleeding. Pertinent secondary outcomes were individual components of the primary outcome, clotting events, and time to therapeutic range. RESULTS There were 103 patients included in the study: 53 in the ACT group and 50 in the anti-Xa group. Overall, there were 30 (56.6%) patients with major bleeding in the ACT group, compared with 16 (32%) patients in the anti-Xa group (P = 0.017). An anti-Xa-based protocol was associated with a decreased hazard of major bleeding (hazard ratio = 0.388 [0.215-0.701]; P = 0.002) in the univariate analysis. In the multivariable analysis, an anti-Xa protocol remained associated with a significantly lower hazard of bleeding. Findings were similar when broken down into more discrete subgroups of the entire cohort, extracorporeal membrane oxygenation life support (ECMO), and non-ECMO groups. CONCLUSION AND RELEVANCE Anti-Xa monitoring was associated with a lower hazard of bleeding during tMCS compared to an ACT-based protocol. Further studies should evaluate if anti-Xa monitoring should be preferentially used in tMCS.
Collapse
Affiliation(s)
- Joel T Feih
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA.,Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Joseph R G Rinka
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA.,Concordia University Wisconsin, Mequon, WI, USA
| | - Janelle J Juul
- Froedtert & the Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | | | | | | |
Collapse
|
16
|
Tyagi S, Friedland DR, Rein L, Tarima SS, Mueller C, Benjamin EJ, Vasan RS, Hamburg NM, Widlansky ME. Abnormal hearing patterns are not associated with endothelium-dependent vasodilation and carotid intima-media thickness: The Framingham Heart Study. Vasc Med 2021; 26:595-601. [PMID: 34286655 DOI: 10.1177/1358863x211025087] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Prior data suggest associations between hearing loss, cardiovascular (CV) risk factors, and CV disease. Whether specific hearing loss patterns, including a strial pattern associated with inner ear vascular disease, are associated with systemic endothelial dysfunction and carotid intima-media thickness (IMT) remains unclear. METHODS We evaluated participants without prevalent CVD in the Framingham Offspring Study who underwent formal audiogram testing and brachial and carotid artery ultrasounds. Audiograms were categorized as normal or as belonging to one of four abnormal patterns: cochlear-conductive, low-sloping, sensorineural, or strial. Endothelial function as measured by brachial artery flow-mediated dilation (FMDmm and FMD%). Internal and common intima-media thicknesses (icIMT and ccIMT, respectively) were compared between audiogram patterns. RESULTS We studied 1672 participants (mean age 59 years, 57.6% women). The prevalence of each hearing pattern was as follows: 43.7% normal; 20.3% cochlear-conductive; 20.3% sensorineural; 7.7% low-sloping; and 8.0% strial. Strial pattern hearing loss was nearly twice as prevalent (p = 0.001) in those in the highest quartile of ccIMT and nearly 50% higher in those in the highest icIMT quartile (p = 0.04). There were no statistically significant differences between the prevalence of the strial pattern comparing the lowest quartiles of FMDmm and FMD% with the upper three quartiles. Age- and sex-adjusted linear regression models did not show significant associations between the vascular measures and hearing patterns. CONCLUSION Abnormal hearing patterns were not significantly associated with impaired brachial FMD and increased carotid IMT after adjusting for age and sex effects, which may reflect age and sex-related distributional differences based on hearing loss pattern.
Collapse
Affiliation(s)
- Sudhi Tyagi
- Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David R Friedland
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sergey S Tarima
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Christopher Mueller
- Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Emelia J Benjamin
- Boston University and NHLBI's Framingham Heart Study, Framingham, MA, USA.,Evans Department of Medicine, Boston University, School of Medicine, Boston, MA, USA.,Department of Epidemiology, Boston University, School of Medicine, Boston, MA, USA
| | - Ramachandran S Vasan
- Boston University and NHLBI's Framingham Heart Study, Framingham, MA, USA.,Evans Department of Medicine, Boston University, School of Medicine, Boston, MA, USA.,Boston University School of Public Health, Boston, MA, USA.,Center for Computing and Data Sciences, Boston University School of Medicine, Boston, MA, USA
| | - Naomi M Hamburg
- Evans Department of Medicine, Boston University, School of Medicine, Boston, MA, USA.,Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, MA, USA
| | - Michael E Widlansky
- Department of Medicine, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, WI, USA.,Department of Pharmacology, Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
17
|
LeClaire JM, Smith NJ, Chandratre S, Rein L, Kamalia MA, Kohmoto T, Joyce LD, Joyce DL. Solid organ donor-recipient race-matching: analysis of the United Network for Organ Sharing database. Transpl Int 2021; 34:640-647. [PMID: 33527542 DOI: 10.1111/tri.13832] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/09/2020] [Accepted: 01/25/2021] [Indexed: 11/26/2022]
Abstract
Donor ethnicity is a prognosticator in organ transplant. However, the impact of donor/recipient race-matching is unclear. We hypothesized that there would be increased survival in donor-recipient race-matched organ recipients because of genetic and physiologic similarities. The UNOS database from 1999 to 2018 was queried for all solid organ transplantations including heart, lung, liver, kidney, and pancreas transplants. Data were sorted by donor and recipient race into matched and unmatched categories for Caucasian, African American, and Hispanic transplant recipients. After controlling for potential confounders via inverse propensity of treatment weighting, post-transplant patient and graft survival were compared between race-matched and -unmatched donor groups for each organ. Race-matched Caucasian recipients experienced 1-3% improvement in mortality across most time points in lung, liver, and pancreas transplants, while Hispanics did not benefit. Matched African American recipients experienced 4-6% improvement in patient and graft survival in liver transplant but had 7-9% worse survival rates at 5 years in lung and pancreas transplants. Race-matching does not influence patient outcomes enough to factor into organ transplant offers. African American liver transplant recipients benefited the most. Matching was detrimental to African American lung and pancreas transplant recipients indicating there may be other factors influencing the outcomes of these transplants.
Collapse
Affiliation(s)
| | - Nathan J Smith
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sonal Chandratre
- Department of Pediatric Endocrinology, Medical College of Wisconsin Central Wisconsin, Wausau, WI, USA.,Ascension Medical Group, Department of Pediatric Endocrinology, Saint Michael's Hospital, Stevens Point, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Takushi Kohmoto
- Department of Pediatric Endocrinology, Medical College of Wisconsin Central Wisconsin, Wausau, WI, USA
| | - Lyle D Joyce
- Department of Pediatric Endocrinology, Medical College of Wisconsin Central Wisconsin, Wausau, WI, USA
| | - David L Joyce
- Department of Pediatric Endocrinology, Medical College of Wisconsin Central Wisconsin, Wausau, WI, USA
| |
Collapse
|
18
|
Conger R, Paulson E, Rein L, Banerjee A, Chen X, Ahunbay E, Erickson B, Straza M, Awan M, Schultz C, Li A, Hall W. Characterization of Daily Shifts and Their Correlation With Plan Quality for Treatments With a 1.5T MR-Linac. Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.757] [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: 11/15/2022]
|
19
|
Dhakal B, Rein L, Szabo A, Padmanabhan A. Use of IV Immunoglobulin G in Heparin-Induced Thrombocytopenia Patients Is Not Associated With Increased Rates of Thrombosis: A Population-Based Study. Chest 2020; 158:1172-1175. [PMID: 32224075 PMCID: PMC7478227 DOI: 10.1016/j.chest.2020.03.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, WI
| | - Anand Padmanabhan
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
20
|
Dhakal B, Miller S, Rein L, Pathak LK, Gloria L, Szabo A, Giri S, Chhabra S, Hamadani M, Paner A, Padmanabhan A, Janz S, D'Souza A, Hari P. Trends in the use of therapeutic plasma exchange in multiple myeloma. J Clin Apher 2020; 35:307-315. [PMID: 32516865 DOI: 10.1002/jca.21798] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 04/29/2020] [Accepted: 05/15/2020] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Therapeutic plasma exchange (TPE) is traditionally performed for hyperviscosity, neuropathy and to mitigate renal injury in the setting of high clonal free light chain burden in patients with multiple myeloma (MM) with unknown clinical benefit. MATERIALS AND METHODS Retrospective study of adults ≥18 years with MM who received TPE in the in-patient setting in the United States from 1993 to 2015. We examined the temporal trends of TPE utilization in MM hospitalizations, hospital charges, in-hospital mortality, and length of hospitalization and the predictors of in-hospital mortality and length of hospitalizations. RESULTS The number of MM-hospitalizations for TPE in adults increased significantly from 1993 to 2015 (1% in 1993-1999 to 2.1% in 2008-2015 of all MM discharges, P for trend <.0001). About 70% of TPE recipients had acute kidney injury (AKI). The median hospital charges increased 5-fold during the time period ($ 24 407 to $ 113 496; P for trend <.0001). In-hospital mortality decreased (17.5% (SE 2.66) in 1993-1997 to 8.7% (1.39) in 2007 to 2013) P for trend <.005) while the length of stay remained unchanged (11.2 days vs 11.9 days, P for trend 0.17). On adjusted analysis, significant predictors of in-hospital mortality among MM TPE recipients include, Charlson Comorbidity Index (CCI) (3 vs 2 adjusted odds ratio, aOR 2.16, 95% CI 1.26-3.71; P = .005), year (continuous) (aOR 0.93, 95% CI 0.90-0.96; P < .001) and race (other vs white; aOR 0.44, 95% CI 0.25-0.78; P = 0.004). CONCLUSIONS There has been a substantial increase in the use and associated cost of TPE in hospitalized MM patients.
Collapse
Affiliation(s)
- Binod Dhakal
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Sophie Miller
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Lin Gloria
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Smith Giri
- Division of Hematology/Oncology, University of Alabama, Birmingham, Alabama, USA
| | - Saurabh Chhabra
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Mehdi Hamadani
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Agne Paner
- Division of Hematology/Oncology/Cell Therapy, Rush University, Chicago, Illinois, USA
| | | | - Siegfried Janz
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Anita D'Souza
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Parameswaran Hari
- Division of Hematology/Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
21
|
Romano T, Rein L, Celebre G, Hardman J. Comparing therapy outcomes of patients before and after enrolling in an anticoagulation
self‐testing
program. J Am Coll Clin Pharm 2020. [DOI: 10.1002/jac5.1226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Teresa Romano
- Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Lisa Rein
- Division of Biostatistics, Institute for Health and Equity Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Gregory Celebre
- Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
| | - Jennifer Hardman
- Froedtert & the Medical College of Wisconsin Milwaukee Wisconsin USA
| |
Collapse
|
22
|
|
23
|
Liu C, Rein L, Clarke C, Mogal H, Tsai S, Christians KK, Gamblin TC. Comparison of overall survival in gallbladder carcinoma at academic versus community cancer centers: An analysis of the National Cancer Data Base. J Surg Oncol 2020; 122:176-182. [PMID: 32383268 DOI: 10.1002/jso.25907] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 02/29/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES Gallbladder carcinoma (GBC) has a poor prognosis. Studies demonstrated that teaching facilities may provide a lower risk of mortality in patients undergoing pancreatic and colon resection vs nonteaching facilities. We hypothesized that survival rates are higher in academic cancer centers (ACCs) vs community cancer centers (CCCs). METHODS Patients with all stages of GBC were identified from the National Cancer Database (2007-2012). Propensity score matching adjusted for selection bias. Descriptive statistics were calculated for all variables. Overall survival (OS) was compared by facility type (ACC vs CCC) and case volume (low vs high) via multivariable Cox proportional hazards regression. RESULTS A total of 7967 patients met the inclusion criteria. Following propensity matching, 2801 patients were analyzed from each facility type. Median OS following surgery was higher for ACC (20.99 months, 95% confidence interval [CI], 19.61-22.64, P = .002) than CCC (17.68 months, 95% CI, 16.46-19.25). Following Cox modeling, GBC treatment at ACCs was a protective factor for OS (adjusted hazard ratio 0.876, 95% CI, 0.801-0.958, P = .004). DISCUSSION GBC treatment at ACCs is an independent predictor of OS. High volume ACCs are associated with improved OS compared with low volume ACCs. The site of care and case volume in ACCs may contribute to improved survival outcomes.
Collapse
Affiliation(s)
- Chrissy Liu
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Callisia Clarke
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Harveshp Mogal
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Susan Tsai
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kathleen K Christians
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - T C Gamblin
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
24
|
Venkatesan T, Hillard CJ, Rein L, Banerjee A, Lisdahl K. Patterns of Cannabis Use in Patients With Cyclic Vomiting Syndrome. Clin Gastroenterol Hepatol 2020; 18:1082-1090.e2. [PMID: 31352091 DOI: 10.1016/j.cgh.2019.07.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [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: 12/06/2018] [Revised: 07/12/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Some patients with cyclic vomiting syndrome (CVS) use cannabis to relieve stress and for its antiemetic properties. However, chronic cannabis use has been associated paradoxically with cannabinoid hyperemesis syndrome (CHS) and some patients with CVS are thought to have CHS. We sought to characterize patterns of cannabis use by patients with CVS and identify those who could be reclassified as having CHS. METHODS We performed a cross-sectional study of 140 patients with CVS (72% female; mean age, 37 ± 13 y) seen at a specialized clinic. Patients were screened for cannabis use with the cannabis use disorder identification test. Patients were classified as regular (use ≥4 times/wk) or occasional users (<4 times/wk). RESULTS Forty-one percent of patients were current cannabis users, with 21% reporting regular use. Regular users were more likely to be male and to report an anxiety diagnosis, and smoked cannabis with higher tetrahydrocannabinol content and for a longer duration. Most users reported that cannabis helped control CVS symptoms. Among all cannabis users, 50 of 57 (88%) reported that they had abstained for longer than 1 month, but only 1 user reported resolution of CVS episodes during the abstinence period. This patient subsequently resumed using cannabis but remains free of symptoms. CONCLUSIONS Cannabis is used commonly among patients with CVS-patients report relief of symptoms with use. We found 21% of patients with CVS to be regular users, but only 1 met the Rome IV criteria for CHS. Longitudinal studies are needed to determine the relationships among cannabis use, hyperemesis, and mood symptoms.
Collapse
Affiliation(s)
- Thangam Venkatesan
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Cecilia J Hillard
- Pharmacology and Toxicology, Neuroscience Research Center, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anjishnu Banerjee
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Krista Lisdahl
- Department of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin
| |
Collapse
|
25
|
Hall S, Flower M, Rein L, Franco Z. Alcohol Use and Peer Mentorship in Veterans. Journal of Humanistic Psychology 2020. [DOI: 10.1177/0022167820905952] [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
Veterans are at an increased risk of developing alcohol use disorder (AUD) and other comorbid psychiatric disorders, yet they often underutilize professional mental health services. Peer mentorship programs offer an alternative option for those seeking help for mental health problems. The purpose of this study was to examine alcohol use in veterans enrolled in a peer mentorship program, determine the effects of peer mentorship on alcohol use and posttraumatic stress disorder (PTSD) symptoms, and assess the interaction between AUD risk and PTSD symptoms over time. Veterans were enrolled in a 12-week peer mentorship program at Dryhootch in Milwaukee, Wisconsin. Measures of AUD risk (Alcohol Use Disorders Identification Test) and PTSD symptoms (PTSD Checklist for DSM-5) were collected before and after 12 weeks. Additionally, the participants reported their total drinks consumed each week throughout the program. Results showed that veterans were at an increased risk for AUD compared with civilian populations. The risk of developing AUD was associated with more PTSD symptoms. While PTSD symptoms were significantly lower after 12 weeks in the program, Alcohol Use Disorders Identification Test scores and the average number of weekly drinks were not significantly different. Further community work should address alcohol use in veterans to achieve better mental health outcomes in the program.
Collapse
Affiliation(s)
- Samuel Hall
- Medical College of Wisconsin, Milwaukee, WI, USA
| | | | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, WI, USA
| | - Zeno Franco
- Medical College of Wisconsin, Milwaukee, WI, USA
| |
Collapse
|
26
|
Isaacson E, Lucjak C, Johnson WK, Yin Z, Wang T, Rein L, Woods RK, Tweddell JS, Hraska V, Mitchell ME. Mitral Valve Surgery in Neonates, Infants, and Children: Surgical Approach, Outcomes, and Predictors. Semin Thorac Cardiovasc Surg 2020; 32:541-550. [PMID: 31972302 DOI: 10.1053/j.semtcvs.2020.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/12/2020] [Indexed: 11/11/2022]
Abstract
The surgical treatment of mitral disease in pediatrics is challenging. Managing diversity in patient anatomy, growth, and the need for long-term anticoagulation requires trade-offs between imperfect solutions. We sought to assess our approach to pediatric mitral valve surgery and identify predictors associated with mortality and recurrent mitral disease. The medical records, echocardiograms, and operative reports of all patients who underwent surgical intervention on the mitral valve from January 2000 to April 2016 were reviewed. A total of 143 patients underwent mitral valve surgery, 64 of which were neonates or infants (ages 10-355 days) and 79 of which were children (ages 1-17.8 years). Neonates and infants had a higher preoperative New York Heart Association heart failure classification in comparison to children (P < 0.001) with a less severe degree of mitral valve insufficiency (P = 0.007). Postoperative outcomes for primary repair patients (n = 133) demonstrated significant differences in recurrence of mitral valve disease, with 38% of neonates/infants and 21% of children affected (P = 0.028). Five-year rates of mortality or transplant were 22% (8%, 33%) in neonates and infants compared to 4% (0%, 10%) in children, P = 0.013. Mitral valve surgery in neonates and infants is particularly high risk and is associated with higher rate of recurrence and reintervention early. However, if successful early, mitral valve repair in neonates and infants can result in a durable freedom from reintervention that parallels freedom from reintervention in older children undergoing repair. Further understanding of mechanisms of failure and better matching of anatomic substrate to strategy is needed.
Collapse
Affiliation(s)
| | | | - William K Johnson
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Ziyan Yin
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Tao Wang
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Ronald K Woods
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - James S Tweddell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Cincinnati, Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Viktor Hraska
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Michael E Mitchell
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Herma Heart Institute, Children's Hospital of Wisconsin, Milwaukee, Wisconsin.
| |
Collapse
|
27
|
Abou-Hanna J, Kugler NW, Rein L, Szabo A, Carver TW. Back so soon? Characterizing emergency department use after trauma. Am J Surg 2019; 220:217-221. [PMID: 31739980 DOI: 10.1016/j.amjsurg.2019.10.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/20/2019] [Accepted: 10/31/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Trauma readmissions have been well studied but little data exists regarding Emergency Department (ED) utilization following an injury. This study was performed to determine the factors associated with a return to the ED after trauma. METHODS A retrospective review of all adult trauma patients evaluated between January and December of 2014 was performed. Demographics, follow-up plan, and characteristics of ED visits within 30 days of discharge were recorded. Predictive factors of ED utilization were identified using univariate analysis and multi-logistic regression. RESULTS Fourteen percent of 1836 consecutive patients returned to the ED within 30 days of initial trauma. On multi-logistic regression, penetrating trauma (OR 2.15 p = 0.001), and scheduled follow-up (OR 1.81 p = 0.046) remained significant predictors. CONCLUSIONS Penetrating trauma victims are at increased risk of returning to the ED, most often because of wound or pain issues. Recognizing these factors allows for targeted interventions to decrease ED resource utilization.
Collapse
Affiliation(s)
- Jameil Abou-Hanna
- Medical College of Wisconsin, Division of Trauma, Critical Care, and Acute Care Surgery, 8701 Watertown Plank Rd. Milwaukee, WI, 53226, USA.
| | - Nathan W Kugler
- Medical College of Wisconsin, Division of Trauma, Critical Care, and Acute Care Surgery, 8701 Watertown Plank Rd. Milwaukee, WI, 53226, USA.
| | - Lisa Rein
- Medical College of Wisconsin, Division of Biostatistics, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Aniko Szabo
- Medical College of Wisconsin, Division of Trauma, Critical Care, and Acute Care Surgery, 8701 Watertown Plank Rd. Milwaukee, WI, 53226, USA; Medical College of Wisconsin, Division of Biostatistics, 8701 Watertown Plank Rd, Milwaukee, WI, 53226, USA.
| | - Thomas W Carver
- Medical College of Wisconsin, Division of Trauma, Critical Care, and Acute Care Surgery, 8701 Watertown Plank Rd. Milwaukee, WI, 53226, USA.
| |
Collapse
|
28
|
Fain R, Lorenz J, Wittman D, Zhang Y, Rein L, Banerjee A, Li A, Erickson B, Hall W. Target Volume Differences Between MRI and CT-Based Boost Strategies in Treatment Planning of Rectal Cancer. Int J Radiat Oncol Biol Phys 2019. [DOI: 10.1016/j.ijrobp.2019.06.2140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
29
|
Kamalia MA, Ramamurthi A, Rein L, Mohammed A, Joyce DL. Detection of Seasonal Trends in National Donor Heart Availability Using the UNOS Dataset. J Card Fail 2019. [DOI: 10.1016/j.cardfail.2019.07.495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
30
|
Kwong JZ, Gray JM, Rein L, Liu Y, Melzer-Lange MD. An educational intervention for medical students to improve self-efficacy in firearm injury prevention counseling. Inj Epidemiol 2019; 6:27. [PMID: 31333993 PMCID: PMC6616463 DOI: 10.1186/s40621-019-0201-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background Most physicians support counseling patients about firearm injury prevention (FIP), but infrequently do so due to lack of training and low confidence. Interventions to increase counseling frequency should focus on improving physician self-efficacy. Firearm injuries affect many clinical specialties; therefore, trainees would benefit from early FIP education. This study aims to determine if a 20-min educational intervention improves self-efficacy in FIP counseling in third-year medical students. Knowledge and beliefs were also assessed as secondary indicators of self-efficacy. Methods This was a prospective study performed at a medical school associated with a tertiary care children’s hospital during the 2016–17 academic year. Groups of 12–15 different third-year medical students were selected to receive either a 20-min intervention or control lecture during their monthly pediatric lectures. The intervention consisted of two clinical vignettes, a brief discussion about the importance of FIP, and suggestions for clinical integration. The control session was a case-based lecture about pediatric emergencies. Participants completed baseline electronic assessments. Intervention students also completed post-intervention assessments immediately following each session. All participants completed final assessments at 6 months. Data were analyzed using Wilcoxon signed-rank tests and Wilcoxon rank-sum. Results We surveyed a total of 130 students. Sixty-five students completed the entire series of assessments – 22 from the control and 43 from the intervention group. There were no significant differences between the control and intervention groups at baseline. Immediately after, intervention, participants reported feeling more self-efficacious, had improved knowledge of FIP risk factors, and had beliefs more consistent with providing FIP anticipatory guidance (p < 0.001 for all three measures). After 6 months, participants sustained improvement in one of two self-efficacy questions (“I feel ready to counsel patients about firearm injury prevention”) and retained knowledge of risk factors (p < 0.05 for both). However, their beliefs did not significantly favor FIP counseling, and they were not more likely to engage in a conversation about firearm safety. Conclusions A 20-min educational intervention acutely improved self-efficacy in FIP counseling in third-year medical students, but improvements weakened after six months. Without further training, the beneficial effects of a one-time intervention will likely wane with time.
Collapse
Affiliation(s)
- Jacky Z Kwong
- 1Department of Pediatrics - Section of Emergency Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Jennifer M Gray
- 1Department of Pediatrics - Section of Emergency Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Lisa Rein
- 2Department of Biostatistics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Ying Liu
- 2Department of Biostatistics, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 USA
| | - Marlene D Melzer-Lange
- 1Department of Pediatrics - Section of Emergency Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226 USA
| |
Collapse
|
31
|
Dhakal B, Giri S, Levin A, Rein L, Fenske TS, Chhabra S, Shah NN, Szabo A, D'Souza A, Pasquini M, Hari P, Hamadani M. Factors Associated With Unplanned 30-Day Readmissions After Hematopoietic Cell Transplantation Among US Hospitals. JAMA Netw Open 2019; 2:e196476. [PMID: 31276175 DOI: 10.1001/jamanetworkopen.2019.6476] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Hematopoietic cell transplantation (HCT) is a therapeutic strategy in the management of several hematological cancers. Limited data exist on the incidence and predictors of 30-day readmission after HCT. OBJECTIVE To measure the incidence of and risk factors associated with 30-day readmission following HCT in the United States. DESIGN, SETTING, AND PARTICIPANTS This cohort study examined patient data from the US population-based Nationwide Readmissions Database. All adults (age ≥18 years) who underwent autologous (auto-) or allogenic (allo-) HCT in US hospitals between January 1, 2012, and November 30, 2014, were included. The analysis was performed from June 2018 to February 2019. MAIN OUTCOMES AND MEASURES The main outcome was 30-day readmission rates for auto-HCT and allo-HCT. Factors associated with readmission, including baseline demographic characteristics and disease- and hospital-related characteristics (including annual case volume), were measured. RESULTS A total of 28 356 index admissions for auto-HCT in 244 centers (191 low-volume, 38 medium-volume, and 15 high-volume centers) and 17 217 index admissions for allo-HCT in 211 centers (161 low-volume, 37 medium-volume, and 13 high-volume centers) were identified during the study period. The overall 30-day readmission rates were 11.6% for auto-HCT and 24.4% for allo-HCT. The odds of readmission were significantly higher in low-volume hospitals compared with high-volume hospitals (adjusted odds ratio [aOR], 1.69; 95% CI, 1.08-2.64 for auto-HCT and aOR, 1.41; 95% CI, 1.09-1.82 for allo-HCT) but comparable to medium-volume hospitals (aOR, 1.06; 95% CI, 0.62-1.83 for auto-HCT and aOR, 1.19; 95% CI, 0.90-1.57 for allo-HCT). Other factors associated with readmission for auto-HCT included younger age (aOR for age ≥50 vs <49 years, 0.82; 95% CI, 0.68-0.98), female sex (aOR, 1.21; 95% CI, 1.06-1.36), disease type (aOR for other vs myeloma, 1.37; 95% CI, 1.06-1.77), and Elixhauser comorbidity index score (aOR for ≥20 vs 0, 1.5; 95% CI, 1.17-1.93). For allo-HCT, factors associated with readmission included disease type (aOR for acute lymphoblastic leukemia vs acute myelogenous leukemia, 1.30; 95% CI, 1.04-1.62), insurance (aOR for Medicare vs private, 1.18; 95% CI, 1.02-1.36), and Elixhauser comorbidity index score (aOR for 1-9 vs 0, 1.2; 95% CI, 1.04-1.39). Infections, neutropenic fever, and gastrointestinal symptoms were the most common reasons for readmission for both types of HCT. CONCLUSIONS AND RELEVANCE This study found substantial rates of readmission for both types of HCT and an inverse association between hospital HCT volume and 30-day readmission. These results may provide guidance when developing quality indicators and policies penalizing hospitals for HCT readmission.
Collapse
Affiliation(s)
- Binod Dhakal
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Smith Giri
- Division of Hematology and Oncology, Yale University, New Haven, Connecticut
| | - Adam Levin
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Lisa Rein
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Timothy S Fenske
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Saurabh Chhabra
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Nirav N Shah
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Aniko Szabo
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee
| | - Anita D'Souza
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Marcelo Pasquini
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Parameswaran Hari
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee
| |
Collapse
|
32
|
Esteban JPG, Rein L, Szabo A, Saeian K, Rhodes M, Marks S. Attitudes of Liver and Palliative Care Clinicians toward Specialist Palliative Care Consultation for Patients with End-Stage Liver Disease. J Palliat Med 2019; 22:804-813. [DOI: 10.1089/jpm.2018.0553] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
| | - Lisa Rein
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Kia Saeian
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mary Rhodes
- Section of Palliative Care, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sean Marks
- Section of Palliative Care, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| |
Collapse
|
33
|
Lorenz JW, Schott D, Rein L, Mostafaei F, Noid G, Lawton C, Bedi M, Li XA, Schultz CJ, Paulson E, Hall WA. Serial T2-Weighted Magnetic Resonance Images Acquired on a 1.5 Tesla Magnetic Resonance Linear Accelerator Reveal Radiomic Feature Variation in Organs at Risk: An Exploratory Analysis of Novel Metrics of Tissue Response in Prostate Cancer. Cureus 2019; 11:e4510. [PMID: 31259119 PMCID: PMC6590865 DOI: 10.7759/cureus.4510] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
"Delta-radiomics" investigates variations in quantitative image metrics over time and can yield important clinical information. We hypothesized that in patients undergoing active radiation therapy (RT) for prostate cancer (PCa), there would exist observable variation in the quantitative metrics that describe the T2-weighted (T2W) intensity histogram in the prostate and surrounding organs at risk (OAR) over time. We investigated the feasibility of acquisition and subsequent analysis of the delta-radiomic profiles of these regions of interest (ROI) in serial T2W magnetic resonance (MR) images obtained on a 1.5 Tesla (T) Magnetic Resonance Linear Accelerator (MRL). Principally, we sought to illustrate the significance of longitudinal radiomic data acquisition for tissue response monitoring and provide a framework for future hypothesis driven research. Patients with PCa undergoing treatment with RT were compiled from an ongoing prospective observational imaging trial using a 1.5 T MRL (NCT30500081). Contiguous axial slices of prostate parenchyma were contoured and temporally normalized to sections of Sartorius muscle which served as a control. Similarly, contiguous sections of rectal and bladder wall adjacent to the prostate were contoured and temporally normalized to regions of these organs further removed from the planning target volume (PTV). First order statistical descriptors of the T2W intensity histogram were extracted and evaluated for changes over time using linear mixed effects regression modeling and post-hoc contrasts. Benjamini-Hochberg corrections were employed to reduce the effects of multiple testing and control for the false discovery rate (FDR). Four patients with a median age of 69 comprised this exploratory cohort. One patient had low-risk disease, two had intermediate (one favorable, one unfavorable), and one had high risk disease. Three out of four patients underwent definitive radiation to 75.6 Gray (Gy) in 42 fractions and one received hypofractionated therapy to a total dose of 70 Gy over 28 fractions, and all received treatment on a conventional linear accelerator. The most significant acute toxicity event was grade 2 GU dysfunction observed in two patients. Follow up ranged from 1 month to 10 months post treatment, and no long-term complications were reported in patients who completed treatment at least one month prior. Bladder wall adjacent to the prostate demonstrated significant variation in the mean and median metric values after the first week of treatment. In addition, rectal wall adjacent to the prostate exhibited significant variation in the mean, median, and standard deviation metric values by the second week of treatment. No significant variation in any radiomic feature was observed in the Sartorius control. This exploratory study is one of the earliest examining the delta-radiomic characteristics of the T2W intensity histogram in OAR extracted from images acquired on a 1.5 T MRL in patients actively being treated with RT for PCa. We demonstrated a feasible approach to longitudinal radiomic data acquisition providing limitless opportunity for future research. Analysis of the delta-radiomic profiles in OAR revealed significant variation in metrics after only one week of RT in bladder and rectal wall adjacent to the prostate. These findings must be further investigated and validated with expanded data sets with long-term follow up and correlation to clinical outcomes including toxicity and tumor control.
Collapse
Affiliation(s)
- Joshua W Lorenz
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Diane Schott
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Lisa Rein
- Biostatistics, Medical College of Wisconsin, Milwaukee, USA
| | | | - George Noid
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Colleen Lawton
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - Meena Bedi
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - X A Li
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | | | - Eric Paulson
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| | - William A Hall
- Radiation Oncology, Medical College of Wisconsin, Milwaukee, USA
| |
Collapse
|
34
|
Baig M, Rein L, Sergey T, Conti M, Mohammed A. SIX-MINUTE WALK DISTANCE UNDER 130 METERS PREDICTS FREQUENT HEART FAILURE READ MISSIONS IN PATIENTS WITH STAGE C AND D HEART FAILURE. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)31603-1] [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: 11/25/2022]
|
35
|
Patel G, Hari P, Szabo A, Rein L, Kreuziger LB, Chhabra S, Dhakal B, D'Souza A. Acquired factor X deficiency in light-chain (AL) amyloidosis is rare and associated with advanced disease. Hematol Oncol Stem Cell Ther 2019; 12:10-14. [DOI: 10.1016/j.hemonc.2018.05.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/12/2018] [Accepted: 05/12/2018] [Indexed: 11/25/2022] Open
|
36
|
Slevin AR, Hart MJ, Van Horn C, Rahman S, Samji NS, Szabo A, Rein L, Werner S, Saeian K. Hepatitis C virus direct-acting antiviral nonadherence: Relationship to sustained virologic response and identification of at-risk patients. J Am Pharm Assoc (2003) 2018; 59:51-56. [PMID: 30545782 DOI: 10.1016/j.japh.2018.10.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 09/03/2018] [Accepted: 10/26/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVES There is a dearth of literature on effects of nonadherence to hepatitis C virus (HCV) direct-acting antiviral (DAA) regimens; thus, the objective of our study was to assess the impact of adherence on sustained virologic response (SVR) and evaluate factors associated with nonadherence, such as race, psychiatric comorbidities, and therapy length. METHODS We conducted a retrospective cohort study of patients completing DAA treatment between January 2014 and May 2016 within an interdisciplinary hepatology clinic. Adherence was defined a priori as 95% or greater of DAA doses taken within the prescribed treatment period. Post hoc analyses were done with adherence thresholds ≥ 90%, ≥ 85%, and ≥ 80% and adherence as a continuous percentage. Patients lost to follow-up before completing therapy or that discontinued therapy early were excluded from analyses. The association between adherence and SVR rates was assessed using Fisher exact test (for adherence thresholds) and the Wilcoxon rank-sum test (for continuous adherence). Factors associated with adherence were assessed similarly using Fisher exact and Wilcoxon rank-sum tests and multivariable logistic regression. RESULTS Overall adherence was high, with an average of 97.8% of DAA doses taken within the prescribed treatment period. Achievement of SVR was not significantly different in adherent and nonadherent patients, at an adherence threshold of 95% or greater (93.4% vs. 88.5%; P = 0.246) or any of the post hoc adherence thresholds (≥ 90% [93.3% vs. 84.0%; P = 0.098], ≥ 85% [92.8% vs. 91.7%; P = 0.601], ≥ 80% [92.9% vs. 80.0%; P = 0.315], or as a continuous percentage [P = 0.328]). Black patients were significantly more likely to be nonadherent to DAAs than non-black patients at each adherence threshold (P < 0.05). No other factors evaluated were associated with nonadherence. CONCLUSION A numerically higher but not statistically significant SVR failure rate was noted in nonadherent patients, although the gold standard definition for adherence remains to be established. Black patients may require additional adherence support.
Collapse
|
37
|
Borkenhagen J, Klawikowski S, Rein L, Gore E. Dosimetric Predictors of Cardiotoxicity in Thoracic Radiation Therapy for Lung Cancer. Int J Radiat Oncol Biol Phys 2018. [DOI: 10.1016/j.ijrobp.2018.07.1790] [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: 11/28/2022]
|
38
|
Dhakal B, Kreuziger LB, Rein L, Kleman A, Fraser R, Aster RH, Hari P, Padmanabhan A. Disease burden, complication rates, and health-care costs of heparin-induced thrombocytopenia in the USA: a population-based study. Lancet Haematol 2018; 5:e220-e231. [PMID: 29703336 DOI: 10.1016/s2352-3026(18)30046-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heparin-induced thrombocytopenia can be a life-threatening and limb-threatening complication of heparin therapy. Incidence and complication rates of this condition have been extrapolated from studies with modest sample sizes, and despite the availability of therapeutic interventions the outcomes of heparin-induced thrombocytopenia are not well understood. We aimed to estimate disease burden, complication rates, and costs of heparin-induced thrombocytopenia in the USA. METHODS In this population-based study we analysed data from 2009 to 2013 from the Nationwide (National) Inpatient Sample (NIS), a large, all-payer inpatient health-care database in the USA. To validate the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for heparin-induced thrombocytopenia (289.84), we defined the sensitivity and specificity of this code using patient data from 2013 from a local hospital (Froedtert Memorial Lutheran Hospital, Milwaukee, WI, USA). The primary outcomes assessed were the incidence of hospital discharges with codes for heparin-induced thrombocytopenia and of discharges for heparin-induced thrombocytopenia associated with cardiopulmonary bypass, haemodialysis, hip or knee arthroplasty, trauma or injury (or both), and gingival or periodontal disease (or both). We also assessed the incidence of thrombosis, bleeding, limb or digit amputation, mortality, length of hospital stay, and associated hospital charges. FINDINGS Between 2009 and 2013, 97 566 discharges from the NIS assigned the ICD-9-CM code for heparin-induced thrombocytopenia, and 149 911 247 discharges coded for non-heparin-induced thrombocytopenia, were analysed. Overall, heparin-induced thrombocytopenia was identified in 97 566 (0·065%; SE 0·0012) of 150 008 813 discharges, corresponding to approximately one in 1500 hospital admissions. Patients undergoing cardiopulmonary bypass had the highest rates of heparin-induced thrombocytopenia (7702 [0·63%; SE 0·03] of 1 230 362), followed by those undergoing haemodialysis (23 012 [0·47%; 0·01] of 4 908 100), those with gingival or periodontal disease, or both (106 [0·12%; 0·03] of 88 621), and those with trauma or injury, or both (541 [0·09%; 0·01] of 602 944); patients with hip (845 [0·04%; 0·004] of 1 943 353) and knee (676 [0·02%; 0·002] of 3 022 602) arthroplasty had the lowest rates of heparin-induced thrombocytopenia. Thrombosis (29 079 [29·8%; SE 0·4] of 97 566) and bleeding (6044 [6·2%; 0·2] of 97 566) were common complications in heparin-induced thrombocytopenia, and 1446 (23·9%; 1·2) of 6044 patients with heparin-induced thrombocytopenia who had haemorrhage died. 742 (0·76%; SE 0·06) of 97 566 patients with heparin-induced thrombocytopenia discharges underwent amputations compared with 173 043 (0·12%; 0·001) of 149 911 247 with non-heparin-induced thrombocytopenia discharges (adjusted odds ratio 5·095 [95% CI 4·309-6·023]; p<0·0001). Overall, in-hospital mortality was 9842 (10·1%; SE 0·2) of 97 508 in discharge summaries coded for heparin-induced thrombocytopenia compared with 3 206 700 (2·1%; 0·01) of 149 811 891 in discharges for non-heparin-induced thrombocytopenia (adjusted odds ratio 4·075 [95% CI 3·846-4·317]; p<0·0001). The median length of stay among live discharges was 8·9 days (IQR 4·6-17·1) and total hospital charges were US$83 072 (IQR 37 240-188 419) for heparin-induced thrombocytopenia discharges compared with 2·6 days (1·4-4·8) and $21 360 (11 426-41 917) for non-heparin-induced thrombocytopenia discharges (p<0·0001 for both). 333 discharges from a local hospital were analysed to assess the diagnostic sensitivity and specificity of the heparin-induced thrombocytopenia ICD-9-CM code; sensitivity was 90·9% (95% CI 57·1-99·5) and specificity was 94·4% (91·1-96·6). INTERPRETATION Complication rates for heparin-induced thrombocytopenia remain high and more effective preventive and treatment interventions are needed. FUNDING None.
Collapse
Affiliation(s)
- Binod Dhakal
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lisa Baumann Kreuziger
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Lisa Rein
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Ariel Kleman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Raphael Fraser
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Richard H Aster
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA
| | - Parameswaran Hari
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Anand Padmanabhan
- Department of Pathology, Medical College of Wisconsin, Milwaukee, WI, USA; Medical Sciences Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA; Blood Research Institute, BloodCenter of Wisconsin, Milwaukee, WI, USA.
| |
Collapse
|
39
|
Baig MM, Rein L, Tarima S, Conti M, Mohammed A. Six-Minute Walk Distance Under 135 Meters Predicts Early and Frequent 30-day Heart Failure Readmissions in Patients with Stage C and D Heart Failure. J Card Fail 2018. [DOI: 10.1016/j.cardfail.2018.07.293] [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]
|
40
|
Zeitlin R, Yu G, Wheatley M, Morrow N, Rownd J, Rein L, Banerjee A, Bedi M, Erickson B. Dosimetric Predictors of Local Control and Complications in Transperineal Implant Patients. Brachytherapy 2018. [DOI: 10.1016/j.brachy.2018.04.111] [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]
|
41
|
Liu C, Berger NG, Rein L, Tarima S, Clarke C, Mogal H, Christians KK, Tsai S, Gamblin TC. Gallbladder carcinoma: An analysis of the national cancer data base to examine hispanic influence. J Surg Oncol 2018; 117:1664-1671. [DOI: 10.1002/jso.25050] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 02/26/2018] [Indexed: 12/26/2022]
Affiliation(s)
- Chrissy Liu
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Nicholas G. Berger
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Lisa Rein
- Division of Biostatistics; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Sergey Tarima
- Division of Biostatistics; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Callisia Clarke
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Harveshp Mogal
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Kathleen K. Christians
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - Susan Tsai
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| | - T. Clark Gamblin
- Division of Surgical Oncology; Department of Surgery; Medical College of Wisconsin; Milwaukee Wisconsin
| |
Collapse
|
42
|
Patel JJ, Kurman J, Al-Ghandour E, Thandra K, Mawari S, Graf J, Kovac J, Rein L, Simpson SQ. Predictors of 24-h mortality after inter-hospital transfer to a tertiary medical intensive care unit. J Intensive Care Soc 2018; 19:319-325. [PMID: 30515241 DOI: 10.1177/1751143718765412] [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] [Indexed: 11/15/2022] Open
Abstract
Purpose To identify variables associated with 24-h mortality after inter-hospital transfer. Materials and methods Single center retrospective study of adult patients transferred to a tertiary care medical ICU between 1 January 2010 and 15 April 2014. Demographic, clinical, physiologic, and laboratory data were collected. The Lasso method was used for logistic regression to identify predictors of 24-h mortality after inter-hospital ICU transfer. Results We identified 773 patients. Median age was 58 years (IQR 45-69), 49% were female, 83% Caucasian, and 48% had Medicare. The median length of stay at the transferring facility was 1.0 day (IQR 0-2). Median SOFA score on the day of ICU transfer was 5 (IQR 2-8). Twenty-two (3%) died within 24 h after inter-hospital transfer. SOFA score of 12-16 the day of inter-hospital transfer (odds ratio (OR) 7.77, 95% CI 1.21-66.26, p = 0.037), FiO2 0.8-1.0 on ICU arrival, and cardiac arrest prior to transfer (OR 4.94, 95% CI 1.43-15.96, p = 0.009) were associated with an increased risk for 24-h mortality after inter-hospital transfer. Conclusions Our study identified biologically plausible and potentially modifiable factors associated with 24-h mortality after inter-hospital medical ICU transfer, which may serve to inform patients and families of readiness and risk for mortality after inter-hospital transfer.
Collapse
Affiliation(s)
- Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Jonathan Kurman
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Chicago, Chicago, IL, USA
| | | | - Krishna Thandra
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samih Mawari
- John Dingell Veteran's Affairs Medical Center, Detroit, MI, USA
| | - Jeanette Graf
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, WI, USA
| | - Jennifer Kovac
- Department of Emergency Medicine, Medical College of Wisconsin, WI, USA
| | - Lisa Rein
- Institute for Health and Society, Medical College of Wisconsin, WI, USA
| | - Steven Q Simpson
- Division of Pulmonary and Critical Care Medicine, University of Kansas, Kansas City, KS, USA
| |
Collapse
|
43
|
Thapa B, Powell J, Yi J, McGee J, Landis J, Rein L, Kim S, Shrestha S, Karmacharya B. Adolescent Health Risk and Behavior Survey: A School Based Survey in Central Nepal. Kathmandu Univ Med J (KUMJ) 2017; 15:301-307. [PMID: 30580346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Background A comprehensive study of adolescent health risk specific to the Dhulikhel catchment area has not been performed. Objective This survey assesses trends in demographics, nutrition, hygiene and related infrastructure, causes of injury, violence, mental health, substance abuse, and menstrual hygiene. Method A 40 question survey was adapted from the Center for Disease Control (CDC) Youth Risk Behavior Surveillance System, translated into the Nepali language, and administered to 1200 students in eight different schools in central Nepal. Descriptive statistics were used to summarize the data. Result The data has identified nutrition, infrastructure, mental health, and menstrual hygiene as areas for improvement. The number of adolescents who reported going hungry some, most, or all of the time (30.5%, 25.8%, 13.9%) reveals a need for better food access. Approximately 44.5 % of students had no access to soap and water at school. Students who endorse dissatisfaction with themselves was 6.5% and those with suicidal ideation or attempt was 11.8% of the surveyed population. A significantly greater percentage of students who reported suicidal ideation also reported engaging in behaviors related to physical violence, substance abuse, being dissatisfaction with themselves, insomnia due to anxiety, and loneliness. Of the female students, 40.1% reported missing school at least once in the last three months due to their period. Conclusion This data shows a need for better food access, improved infrastructure in schools in central Nepal, and the need to address the prevalence of mental health issues through program interventions.
Collapse
Affiliation(s)
- B Thapa
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - J Powell
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - J Yi
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - J McGee
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - J Landis
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - L Rein
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - S Kim
- Department of Medicine, Medical College of Wisconsin, 8701 W Watertown Plank Rd, Milwaukee, WI 53226
| | - S Shrestha
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Kavre
| | - B Karmacharya
- Department of Community Programs, Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Kavre
| |
Collapse
|
44
|
Levin A, Kleman A, Rein L, Tarima S, Michaelis LC, Carlson KS, Hamadani M, Fenske TS, Hari P, Atallah E, Dhakal B. Early mortality in patients with acute myelogenous leukemia treated in teaching versus non-teaching hospitals: A large database analysis. Am J Hematol 2017. [PMID: 28631379 DOI: 10.1002/ajh.24825] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Adam Levin
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Ariel Kleman
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Lisa Rein
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Sergey Tarima
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Laura C. Michaelis
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Karen Sue Carlson
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Mehdi Hamadani
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Timothy S. Fenske
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Parameswaran Hari
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Ehab Atallah
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| | - Binod Dhakal
- Medical College of Wisconsin; 8701 Watertown Plank Road Milwaukee Wisconsin
| |
Collapse
|
45
|
Charu V, Rosenberg PB, Schneider LS, Drye LT, Rein L, Shade D, Lyketsos CG, Frangakis CE. Characterizing Highly Benefited Patients in Randomized Clinical Trials. Int J Biostat 2017; 13:/j/ijb.2017.13.issue-1/ijb-2016-0045/ijb-2016-0045.xml. [PMID: 28541924 PMCID: PMC6428065 DOI: 10.1515/ijb-2016-0045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 11/15/2022]
Abstract
Physicians and patients may choose a certain treatment only if it is predicted to have a large effect for the profile of that patient. We consider randomized controlled trials in which the clinical goal is to identify as many patients as possible that can highly benefit from the treatment. This is challenging with large numbers of covariate profiles, first, because the theoretical, exact method is not feasible, and, second, because usual model-based methods typically give incorrect results. Better, more recent methods use a two-stage approach, where a first stage estimates a working model to produce a scalar predictor of the treatment effect for each covariate profile; and a second stage estimates empirically a high-benefit group based on the first-stage predictor. The problem with these methods is that each of the two stages is usually agnostic about the role of the other one in addressing the clinical goal. We propose a method that characterizes highly benefited patients by linking model estimation directly to the particular clinical goal. It is shown that the new method has the following two key properties in comparison with existing approaches: first, the meaning of the solution with regard to the clinical goal is the same, and second, the value of the solution is the best that can be achieved when using the working model as a predictor, even if that model is incorrect. In the Citalopram for Agitation in Alzheimer's Disease (CitAD) randomized controlled trial, the new method identifies substantially larger groups of highly benefited patients, many of whom are missed by the standard method.
Collapse
Affiliation(s)
- Vivek Charu
- Department of Biostatistics, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD 21205, USA
| | - Paul B. Rosenberg
- Department of Psychiatry, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Lon S. Schneider
- Department of Psychiatry, University of Southern California, Los Angeles, CA, USA
| | - Lea T. Drye
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, USA
| | - Lisa Rein
- Biostatistics Consulting Center, Medical College of Wisconsin, Milwaukee, WI, USA
| | - David Shade
- Department of Psychiatry, Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | | | - Constantine E. Frangakis
- Corresponding author: Constantine E. Frangakis, Department of Biostatistics, Johns Hopkins University, 615 N Wolfe St, Baltimore, MD 21205, USA,
| |
Collapse
|
46
|
Bock A, Chintamaneni K, Rein L, Frazer T, Kayastha G, MacKinney T. Improving pneumococcal vaccination rates of medical inpatients in urban Nepal using quality improvement measures. BMJ Qual Improv Rep 2016; 5:bmjquality_uu212047.w4835. [PMID: 27933153 PMCID: PMC5128775 DOI: 10.1136/bmjquality.u212047.w4835] [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] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 09/03/2016] [Indexed: 12/03/2022]
Abstract
Streptococcus pneumoniae infection is associated with high morbidity and mortality in low income countries. In Nepal, there is a high lung disease burden and incidence of pneumonia due to multiple factors including indoor air pollution, dust exposure, recurrent infections, and cigarette smoking. Despite the ready availability of effective pneumococcal vaccines (PNV), vaccine coverage rates remain suboptimal globally. Quality Improvement (QI) principles could be applied to improve compliance, but it is a virtually new technology in Nepal. This QI study for Patan Hospital sought to introduce the concept of QI there, to measure the baseline pneumococcal vaccination rate of qualifying adult patients discharged from the medical wards and to assess reasons for non-vaccination. QI interventions were instituted to improve this rate, measuring the effectiveness of QI methods to produce the desired outcomes using the Model for Improvement, Plan-Do-Study-Change (PDSA) methodology. In the three week baseline assessment, 2 out of 81 (2%) eligible patients recalled ever receiving a prior pneumococcal vaccine; 68 (84%) unvaccinated patients responded that they were not asked or were unaware of the PNV. After the QI interventions, the pneumococcal vaccination rate significantly increased to 42% (23/56, p<0.001). Post-intervention, the leading reason for non-vaccination was cost (20%, 11/56). Only 5 (9%) unvaccinated patients were not asked or were unaware of the PNV, a significant change in that process outcome from baseline (p<0.001). Quality improvement measures were effective in increasing pneumococcal vaccination rates, despite the limited familiarity with QI methods at this major teaching hospital. QI techniques may be useful in this and other efforts to improve quality in resource-limited settings, without great cost.
Collapse
|
47
|
Schneider LS, Frangakis C, Drye LT, Devanand D, Marano CM, Mintzer J, Mulsant BH, Munro CA, Newell JA, Pawluczyk S, Pelton G, Pollock BG, Porsteinsson AP, Rabins PV, Rein L, Rosenberg PB, Shade D, Weintraub D, Yesavage J, Lyketsos CG. Heterogeneity of Treatment Response to Citalopram for Patients With Alzheimer's Disease With Aggression or Agitation: The CitAD Randomized Clinical Trial. Am J Psychiatry 2016; 173:465-72. [PMID: 26771737 PMCID: PMC6419726 DOI: 10.1176/appi.ajp.2015.15050648] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Pharmacological treatments for agitation and aggression in patients with Alzheimer's disease have shown limited efficacy. The authors assessed the heterogeneity of response to citalopram in the Citalopram for Agitation in Alzheimer Disease (CitAD) study to identify individuals who may be helped or harmed. METHOD In this double-blind parallel-group multicenter trial of 186 patients with Alzheimer's disease and clinically significant agitation, participants were randomly assigned to receive citalopram or placebo for 9 weeks, with the dosage titrated to 30 mg/day over the first 3 weeks. Five planned potential predictors of treatment outcome were assessed, along with six additional predictors. The authors then used a two-stage multivariate method to select the most likely predictors; grouped participants into 10 subgroups by their index scores; and estimated the citalopram treatment effect for each. RESULTS Five covariates were likely predictors, and treatment effect was heterogeneous across the subgroups. Patients for whom citalopram was more effective were more likely to be outpatients, have the least cognitive impairment, have moderate agitation, and be within the middle age range (76-82 years). Patients for whom placebo was more effective were more likely to be in long-term care, have more severe cognitive impairment, have more severe agitation, and be treated with lorazepam. CONCLUSIONS Considering several covariates together allowed the identification of responders. Those with moderate agitation and with lower levels of cognitive impairment were more likely to benefit from citalopram, and those with more severe agitation and greater cognitive impairment were at greater risk for adverse responses. Considering the dosages used and the association of citalopram with cardiac QT prolongation, use of this agent to treat agitation may be limited to a subgroup of people with dementia.
Collapse
Affiliation(s)
- Lon S. Schneider
- Department of psychiatry and the behavioral sciences, and department of neurology, Keck School of Medicine of the University of Southern California
| | | | - Lea T Drye
- Department of Epidemiology, Center for Clinical Trials and Evidence Synthesis, Johns Hopkins Bloomberg School of Public Health
| | - D.P. Devanand
- Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Medical Center
| | - Christopher M. Marano
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins Bayview, Johns Hopkins Medicine
| | - Jacob Mintzer
- Clinical Biotechnology Research Institute, Roper St. Francis Healthcare, Charleston, South Carolina
| | - Benoit H. Mulsant
- Campbell Institute, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto
| | - Cynthia A. Munro
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Jeffery A. Newell
- Culture and Mental Health Laboratory, University of Southern California
| | - Sonia Pawluczyk
- Department of psychiatry and the behavioral sciences, and department of neurology, Keck School of Medicine of the University of Southern California
| | - Gregory Pelton
- Division of Geriatric Psychiatry, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Medical Center
| | - Bruce G Pollock
- Campbell Institute, Centre for Addiction and Mental Health; Department of Psychiatry, University of Toronto
| | | | - Peter V. Rabins
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Lisa Rein
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine
| | - Paul B. Rosenberg
- Department of Psychiatry, University of Rochester School of Medicine and Dentistry
| | - David Shade
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health
| | - Daniel Weintraub
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania
| | - Jerome Yesavage
- Department of Veterans Affairs Health Care System, Palo Alto, California, and Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine
| | | | | |
Collapse
|
48
|
Dhakal B, Ramalingam S, Fesnke T, Hamadani M, Rein L, Shuff J, Ericskon B. ID: 44: LOCAL CONTROL OF OCULAR ADNEXAL LYMPHO-PROLIFERATIVE DISORDERS (OALD): SIMILAR OUTCOMES IN MALT AND NON-MALT HISTOLOGIES. J Investig Med 2016. [DOI: 10.1136/jim-2016-000120.76] [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: 11/03/2022]
Abstract
BackgroundThe outcomes of local radiation therapy (RT) in MALT vs. non-MALT OALD are not known. Herein we present outcomes of local therapy in MALT vs. non-MALT OALD treated at a specialized lymphoma program.Abstract ID: 44 Table 1:Baseine characteristics.MALTNON-MALTTOTAL, N=11271 (63.3%)41 (36.6%)Age (median), years64 (22–84)66 (25–87)Sex, M25 (35.2%)16 (39%)Symptoms at presentation–Mass/Swelling–Visual changes–Other35 (49.2%)11 (15.4%)2 (2.8%)27 (66%)11(27%)1 (2.4%)Site of origin–Orbital–Conjunctival–Lacrimal gland–Eyelid–Other31 (43.6%)26 (36.6%)10 (14%)1 (1.4%)4 (5.6%)14 (34.1%)14 (34.1%)10 (24.3%)3 (7.3%)0Unilateral Involvement60 (86%)34 (83%)Stage at presentation–I–II–III–IV–Unknown60 (85%)01 (1.4%)8 (11.2%)2 (2.8%)24 (59%)4 (9.7%)2 (4.8%)7 (17%)4 (9.7%)MethodsThe analysis included 112 consecutive patients (pts) with OALD diagnosed at our institution between 1975–2014. Histology was reviewed by an expert hematopathologist. The primary objective of the study was to assess the failure free survival (FFS) in pts. with marginal zone lymphoma of mucosa associated lymphoid tissue (MALT) of ocular adnexa (OA) and non–MALT OA lymphomas treated with local radiation therapy. Complete remission was defined as absence of any disease by imaging. Local failure was defined as any failure within the OA; extra-orbital failure was either regional (within the radiation field) or distant (for cases with limited stage disease at presentation). FFS was defined as time from treatment to any failure (local, regional and distant). FFS was estimated using the Kaplan-Meier methods.ResultsBaseline characteristics are shown in table 1. Of 112, 71(57.7%) of the pts had ocular MALT, and 41(33.3%) had non-MALT (23 follicular, 8 diffuse large cell B cell lymphomas, 3 mantle cell, 6 small lymphocytic lymphoma and 1 T cell lymphoma). Unilateral eye involvement (83.9%) with mass/swelling (55.3%) was the most common presentation. Staging was performed with CT scan and bone marrow biopsy in select cases (n=63, 51%). PET scan was utilized in 33 (29.4%) pts. but was able to upstage in only 5 cases.For ocular MALT, 62 (87.3%) received involved field radiation therapy (IFRT), 9 (12.6%) chemotherapy. For non-MALT, 34 (82.9%) had IFRT,7 (17%) chemotherapy. Among those who received IFRT, 55 (75%) in MALT and 21 (52%) in non-MALT had limited stage disease (I/II).Among OALD pts treated with only IFRT, 91.7% in ocular MALT and 90.9% in non-MALT achieved complete remission. Resolution of symptoms occurred in 83.3% and 93.3% of ocular MALT and non-MALT respectively. Failure rates of IFRT in ocular MALT vs. non-MALT were as follows: local (7% vs. 12.1%), regional (9.8% vs. 7.3%), and distant (5.6% vs 2.4%). Median follow-up was 3 (1–22) years in each group. Median time to failure was 14 years for ocular MALT and 9 years for non-MALT. 3 year and 5 year failure-free survival was 88% and 81% for ocular MALT and 78% and 71% for non-MALT respectively (log rank p=0.26 for FFS) (figure 1).ConclusionsBoth the MALT and non-MALT OALD pts achieved excellent disease control with IFRT with no significant difference in local, regional and distant failure rates. 3 year and 5 year failure free survival were comparable between the two groups. PET scan resulted in upstaging in 5% of pts but did not alter treatment selection, indicating that PET had minimal utility in initial staging of OALD.
Collapse
|
49
|
Singh M, Dhakal B, Shrestha A, Atallah E, Carlson K, Pasquini MC, Rein L, Banerjee A, Esselmann J, Ramirez S, Zellner K, Essenmacher A, Hari PN, Michaelis LC. Salvage Therapy with Hypomethylating Agents (HMA) and/or Lenalidomide (len) for Patients with Myelodysplastic Syndrome (MDS) or Acute Myeloid Leukemia (AML) Relapse Following Allogeneic Stem Cell Transplantation (allo-SCT). Biol Blood Marrow Transplant 2016. [DOI: 10.1016/j.bbmt.2015.11.855] [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: 10/22/2022]
|
50
|
Abstract
BACKGROUND The clinical course of patients with omphalocele is challenging to predict. There is no standard method to characterize omphalocele size. Previous studies suggest that the ratio of abdominal circumference to omphalocele defect in-utero is indicative of postnatal outcomes. We hypothesize that omphalocele ratio correlates with outcomes of primary closure versus staged closure. METHODS A retrospective chart review of all neonates diagnosed with omphalocele from 2002 to 2013 with prenatal ultrasounds available (n=30) was conducted. Omphalocele ratio was defined as omphalocele diameter/abdominal circumference (OD/AC). Data collected included primary versus staged closure, time to full feeds, duration of mechanical ventilation, and length of stay (LOS). Long-term outcomes and quality of life were also reported. RESULTS ROC curve analysis generated optimal OD/AC ratio of 0.26. Twenty of 30 patients had a ratio less than this cutoff. Sixty percent (12/20) in the low-ratio group achieved primary closure versus zero (0/10) in the high-ratio group (p=0.001). Time on mechanical ventilation was 15.8 days (low-ratio) versus 79 days (high-ratio) (p=0.05). LOS was 33.8 days (low-ratio) versus 85.6 days (high-ratio) (p=0.119). PedsQL™ mean score was 85.5 ± 11.0 (n=20) at long-term follow-up. Readmission rates yielded no difference. CONCLUSIONS The omphalocele ratio is a promising predictor of postnatal outcomes.
Collapse
Affiliation(s)
- Jason A Fawley
- Medical College of Wisconsin, Milwaukee WI, USA; Children's Hospital of Wisconsin, Milwaukee WI, USA
| | | | - Melissa A Christensen
- Medical College of Wisconsin, Milwaukee WI, USA; Children's Hospital of Wisconsin, Milwaukee WI, USA
| | - Lisa Rein
- Medical College of Wisconsin, Milwaukee WI, USA
| | - Amy J Wagner
- Medical College of Wisconsin, Milwaukee WI, USA; Children's Hospital of Wisconsin, Milwaukee WI, USA.
| |
Collapse
|