1
|
Ferrante ND, Kallan MJ, Sukkestad S, Kodani M, Kitahata MM, Cachay ER, Bhattacharya D, Heath S, Napravnik S, Moore RD, Yendewa G, Mayer KH, Reddy KR, Hayden T, Kamili S, Martin JN, Kim HN, Lo Re V. Prevalence and determinants of hepatitis delta virus infection among HIV/hepatitis B-coinfected adults in care in the United States. J Viral Hepat 2023; 30:879-888. [PMID: 37488783 PMCID: PMC10592429 DOI: 10.1111/jvh.13874] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
Hepatitis delta virus (HDV) infection increases the risk of liver complications compared to hepatitis B virus (HBV) alone, particularly among persons with human immunodeficiency virus (HIV). However, no studies have evaluated the prevalence or determinants of HDV infection among people with HIV/HBV in the US. We performed a cross-sectional study among adults with HIV/HBV coinfection receiving care at eight sites within the Center for AIDS Research Network of Integrated Clinical Systems (CNICS) between 1996 and 2019. Among patients with available serum/plasma specimens, we selected the first specimen on or after their initial HBV qualifying test. All samples were tested for HDV IgG antibody and HDV RNA. Multivariable log-binomial generalized linear models were used to estimate prevalence ratios (PRs) with 95% CIs of HDV IgG antibody-positivity associated with determinants of interest (age, injection drug use [IDU], high-risk sexual behaviour). Among 597 adults with HIV/HBV coinfection in CNICS and available serum/plasma samples (median age, 43 years; 89.9% male; 52.8% Black; 42.4% White), 24/597 (4.0%; 95% CI, 2.4%-5.6%) were HDV IgG antibody-positive, and 10/596 (1.7%; 95% CI, 0.6%-2.7%) had detectable HDV RNA. In multivariable analysis, IDU was associated with exposure to HDV infection (adjusted PR = 2.50; 95% CI, 1.09-5.74). In conclusion, among a sample of adults with HIV/HBV coinfection in care in the US, 4.0% were HDV IgG antibody-positive, among whom 41.7% had detectable HDV RNA. History of IDU was associated with exposure to HDV infection. These findings emphasize the importance of HDV testing among persons with HIV/HBV coinfection, especially those with a history of IDU.
Collapse
Affiliation(s)
- Nicole D. Ferrante
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
| | - Michael J. Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sophia Sukkestad
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Maja Kodani
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Mari M. Kitahata
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Edward R. Cachay
- Department of Medicine, Division of Infectious Diseases and Global Public Health University of California, San Diego, CA
| | - Debika Bhattacharya
- Department of Medicine, Division of Infectious Diseases, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Sonya Heath
- Division of Infectious Disease, Department of Medicine, University of Alabama, Birmingham, AL
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Richard D. Moore
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - George Yendewa
- Department of Medicine, Case Western Reserve University, Cleveland, OH
| | - Kenneth H. Mayer
- The Fenway Institute, Fenway Health, Boston, MA; Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA
| | - K. Rajender Reddy
- Division of Gastroenterology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tonya Hayden
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Saleem Kamili
- Division of Viral Hepatitis, Centers for Disease Control and Prevention, Atlanta, GA
| | - Jeffrey N. Martin
- Department of Epidemiology and Biostatistics, University of California, San Francisco, CA
| | - H. Nina Kim
- Division of Allergy and Infectious Disease, Department of Medicine, University of Washington School of Medicine, Seattle, WA
| | - Vincent Lo Re
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA
- Division of Infectious Diseases, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
2
|
Pollack J, Yang W, Schnellinger EM, Arnaoutakis GJ, Kallan MJ, Kimmel SE. Dynamic prediction modeling of postoperative mortality among patients undergoing surgical aortic valve replacement in a statewide cohort over a 12-year period. JTCVS Open 2023; 15:94-112. [PMID: 37808034 PMCID: PMC10556941 DOI: 10.1016/j.xjon.2023.07.011] [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] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 06/07/2023] [Accepted: 06/21/2023] [Indexed: 10/10/2023]
Abstract
Objective Clinical prediction models for surgical aortic valve replacement mortality, are valuable decision tools but are often limited in their ability to account for changes in medical practice, patient selection, and the risk of outcomes over time. Recent research has identified methods to update models as new data accrue, but their effect on model performance has not been rigorously tested. Methods The study population included 44,546 adults who underwent an isolated surgical aortic valve replacement from January 1, 1999, to December 31, 2018, statewide in Pennsylvania. After chronologically splitting the data into training and validation sets, we compared calibration, discrimination, and accuracy measures amongst a nonupdating model to 2 methods of model updating: calibration regression and the novel dynamic logistic state space model. Results The risk of mortality decreased significantly during the validation period (P < .01) and the nonupdating model demonstrated poor calibration and reduced accuracy over time. Both updating models maintained better calibration (Hosmer-Lemeshow χ2 statistic) than the nonupdating model: nonupdating (156.5), calibration regression (4.9), and dynamic logistic state space model (8.0). Overall accuracy (Brier score) was consistently better across both updating models: dynamic logistic state space model (0.0252), calibration regression (0.0253), and nonupdating (0.0256). Discrimination improved with the dynamic logistic state space model (area under the curve, 0.696) compared with the nonupdating model (area under the curve, 0.685) and calibration regression method (area under the curve, 0.687). Conclusions Dynamic model updating can improve model accuracy, discrimination, and calibration. The decision as to which method to use may depend on which measure is most important in each clinical context. Because competing therapies have emerged for valve replacement models, updating may guide clinical decision making.
Collapse
Affiliation(s)
- Jackie Pollack
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Fla
| | - Wei Yang
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | | | - George J. Arnaoutakis
- Division of Cardiovascular and Thoracic Surgery, University of Texas at Austin Dell Medical School, Austin, Tex
| | - Michael J. Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pa
| | - Stephen E. Kimmel
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, Fla
| |
Collapse
|
3
|
Ali ZS, Albayar A, Nguyen J, Gallagher RS, Borja AJ, Kallan MJ, Maloney E, Marcotte PJ, DeMatteo RP, Malhotra NR. A Randomized Controlled Trial to Assess the Impact of Enhanced Recovery After Surgery on Patients Undergoing Elective Spine Surgery. Ann Surg 2023; 278:408-416. [PMID: 37317857 DOI: 10.1097/sla.0000000000005960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To conduct a prospective, randomized controlled trial (RCT) of an enhanced recovery after surgery (ERAS) protocol in an elective spine surgery population. BACKGROUND Surgical outcomes such as length of stay (LOS), discharge disposition, and opioid utilization greatly contribute to patient satisfaction and societal healthcare costs. ERAS protocols are multimodal, patient-centered care pathways shown to reduce postoperative opioid use, reduced LOS, and improved ambulation; however, prospective ERAS data are limited in spine surgery. METHODS This single-center, institutional review board-approved, prospective RCT-enrolled adult patients undergoing elective spine surgery between March 2019 and October 2020. Primary outcomes were perioperative and 1-month postoperative opioid use. Patients were randomized to ERAS (n=142) or standard-of-care (SOC; n=142) based on power analyses to detect a difference in postoperative opioid use. RESULTS Opioid use during hospitalization and the first postoperative month was not significantly different between groups (ERAS 112.2 vs SOC 117.6 morphine milligram equivalent, P =0.76; ERAS 38.7% vs SOC 39.4%, P =1.00, respectively). However, patients randomized to ERAS were less likely to use opioids at 6 months postoperatively (ERAS 11.4% vs SOC 20.6%, P =0.046) and more likely to be discharged to home after surgery (ERAS 91.5% vs SOC 81.0%, P =0.015). CONCLUSION Here, we present a novel ERAS prospective RCT in the elective spine surgery population. Although we do not detect a difference in the primary outcome of short-term opioid use, we observe significantly reduced opioid use at 6-month follow-up as well as an increased likelihood of home disposition after surgery in the ERAS group.
Collapse
Affiliation(s)
- Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ahmed Albayar
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jessica Nguyen
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ryan S Gallagher
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Austin J Borja
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eileen Maloney
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Paul J Marcotte
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ronald P DeMatteo
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
4
|
Eberly LA, Lin A, Park J, Khoshnab M, Garg L, Chee J, Kallan MJ, Walsh K, Supple GE, Schaller RD, Santangeli P, Riley MP, Nazarian S, Arkles J, Hyman M, Lin D, Guandalini G, Kumareswaran R, Deo R, Zado ES, Epstein A, Frankel DS, Callans DJ, Marchlinski FE, Dixit S. Presence of sinus rhythm at time of ablation in patients with persistent atrial fibrillation undergoing pulmonary vein isolation is associated with improved long-term arrhythmia outcomes. J Interv Card Electrophysiol 2023; 66:1455-1464. [PMID: 36525168 DOI: 10.1007/s10840-022-01441-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/27/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adverse structural and electrical remodeling underlie persistent atrial fibrillation (PersAF). Restoration of sinus rhythm (SR) prior to ablation in PersAF may improve the underlying substrate, thus improving arrhythmia outcomes. The aim of this study was to evaluate if the presence of SR at time of ablation is associated with improved long-term arrhythmia outcomes of a limited catheter ablation (CA) strategy in PersAF. METHODS Patients with PersAF undergoing pulmonary vein isolation at our institution from 2014-2018 were included. We compared patients who presented for ablation in SR (by cardioversion and/or antiarrhythmic drugs [AADs]) to those who presented in AF. Primary outcome of interest was freedom from atrial arrhythmias (AAs) on or off AADs at 1 year after single ablation. Secondary outcomes included freedom from AAs on or off AADs overall, freedom from AAs off AADs at 1 year, and time to recurrent AF. RESULTS Five hundred seventeen patients were included (322 presented in AF, 195 SR). The primary outcome was higher in those who presented for CA in SR as compared to AF (85.6% vs. 77.0%, p = 0.017). Freedom from AAs off AAD at 12 months was also higher in those presenting in SR (59.0% vs. 44.4%; p = 0.001) and time to recurrent AF was longer (p = 0.008). Presence of SR at CA was independently associated with the primary outcome at 12 months (OR 1.77; 95% CI 1.08-2.90) and overall (OR 1.89; 95% CI 1.26-2.82). CONCLUSIONS Presence of SR at time of ablation is associated with improved long-term arrhythmia outcomes of limited CA in PersAF.
Collapse
Affiliation(s)
- Lauren A Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, USA
| | - Aung Lin
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Joseph Park
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia, USA
| | - Mirmilad Khoshnab
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Lohit Garg
- Electrophysiology Section, Division of Cardiology, University of Colorado Anschutz, Aurora, USA
| | - Jennifer Chee
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA
| | - Katie Walsh
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Gregory E Supple
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Robert D Schaller
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Pasquale Santangeli
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Michael P Riley
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Saman Nazarian
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Jeffrey Arkles
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Matthew Hyman
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - David Lin
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Gustavo Guandalini
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Ramanan Kumareswaran
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Rajat Deo
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Erica S Zado
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Andrew Epstein
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - David S Frankel
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - David J Callans
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Francis E Marchlinski
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA
| | - Sanjay Dixit
- Electrophysiology Section, Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, 9 Gates, 3400 Spruce St, Philadelphia, PA, 19104, USA.
| |
Collapse
|
5
|
Natarajan J, Yegya-Raman N, Kegelman TP, Kallan MJ, Roshkovan L, Katz S, Ky B, Fradley M, Xiao Y, Lee SH, Zhang Z, Langer C, Aggarwal C, Cohen R, Cengel K, Levin W, Berman AT, Feigenberg SJ. Cardiovascular Substructure Dose and Cardiac Events following Proton- and Photon-Based Chemoradiotherapy for Non-Small Cell Lung Cancer. Adv Radiat Oncol 2023. [DOI: 10.1016/j.adro.2023.101235] [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: 04/08/2023] Open
|
6
|
Yegya-Raman N, Kegelman TP, Ho Lee S, Kallan MJ, Kim KN, Natarajan J, Deek MP, Zou W, O'Reilly SE, Zhang Z, Levin W, Cengel K, Kao G, Cohen RB, Sun LL, Langer CJ, Aggarwal C, Singh AP, O'Quinn R, Ky B, Apte A, Deasy J, Xiao Y, Berman AT, Jabbour SK, Feigenberg SJ. Death without progression as an endpoint to describe cardiac radiation effects in locally advanced non-small cell lung cancer. Clin Transl Radiat Oncol 2023; 39:100581. [PMID: 36691564 PMCID: PMC9860414 DOI: 10.1016/j.ctro.2023.100581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 01/03/2023] [Accepted: 01/11/2023] [Indexed: 01/14/2023] Open
Abstract
Background and purpose Prior studies have examined associations of cardiovascular substructure dose with overall survival (OS) or cardiac events after chemoradiotherapy (CRT) for non-small cell lung cancer (NSCLC). Herein, we investigate an alternative endpoint, death without cancer progression (DWP), which is potentially more specific than OS and more sensitive than cardiac events for understanding CRT toxicity. Materials and methods We retrospectively reviewed records of 187 patients with locally advanced or oligometastatic NSCLC treated with definitive CRT from 2008 to 2016 at a single institution. Dosimetric parameters to the heart, lung, and ten cardiovascular substructures were extracted. Charlson Comorbidity Index (CCI), excluding NSCLC diagnosis, was used to stratify patients into CCI low (0-2; n = 66), CCI intermediate (3-4; n = 78), and CCI high (≥5; n = 43) groups. Primary endpoint was DWP, modeled with competing risk regression. Secondary endpoints included OS. An external cohort consisted of 140 patients from another institution. Results Median follow-up was 7.3 years for survivors. Death occurred in 143 patients (76.5 %), including death after progression in 118 (63.1 %) and DWP in 25 (13.4 %). On multivariable analysis, increasing CCI stratum and mean heart dose were associated with DWP. For mean heart dose ≥ 10 Gy vs < 10 Gy, DWP was higher (5-year rate, 16.9 % vs 6.7 %, p = 0.04) and OS worse (median, 22.9 vs 34.1 months, p < 0.001). Ventricle (left, right, and bilateral) and pericardial but not atrial substructure dose were associated with DWP, whereas all three were inversely associated with OS. Cutpoint analysis identified right ventricle mean dose ≥ 5.5 Gy as a predictor of DWP. In the external cohort, we confirmed an association of ventricle, but not atrial, dose with DWP. Conclusion Cardiovascular substructure dose showed distinct associations with DWP. Future cardiotoxicity studies in NSCLC could consider DWP as an endpoint.
Collapse
Affiliation(s)
- Nikhil Yegya-Raman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Timothy P. Kegelman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Sang Ho Lee
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael J. Kallan
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kristine N. Kim
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Jyotsna Natarajan
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Matthew P. Deek
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Wei Zou
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Shannon E. O'Reilly
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Zheng Zhang
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - William Levin
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Keith Cengel
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Gary Kao
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Roger B. Cohen
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lova L. Sun
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Corey J. Langer
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Charu Aggarwal
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aditi P. Singh
- Division of Hematology and Oncology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Rupal O'Quinn
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Aditya Apte
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Joseph Deasy
- Department of Medical Physics, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Ying Xiao
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Abigail T. Berman
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Salma K. Jabbour
- Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, NJ, United States
| | - Steven J. Feigenberg
- Department of Radiation Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
7
|
Howard SD, Aysola J, Montgomery CT, Kallan MJ, Xu C, Mansour M, Nguyen J, Ali ZS. Post-operative neurosurgery outcomes by race/ethnicity among enhanced recovery after surgery (ERAS) participants. Clin Neurol Neurosurg 2023; 224:107561. [PMID: 36549219 DOI: 10.1016/j.clineuro.2022.107561] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 10/20/2022] [Revised: 12/08/2022] [Accepted: 12/11/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Prior work reveals that Enhanced Recovery After Surgery (ERAS) programs decrease opioid use, improve mobilization, and shorten length of stay (LOS) among patients undergoing spine surgery. The impact of ERAS on outcomes by race/ethnicity is unknown. This study examined outcomes by race/ethnicity among neurosurgical patients enrolled in an ERAS program. METHODS Patients undergoing elective spine or peripheral nerve surgeries at a multi-hospital university health system from April 2017 to November 2020 were enrolled in an ERAS program that involves preoperative, perioperative, and postoperative phases focused on improving outcomes through measures such as specialty consultations for co-morbidities, multimodal analgesia, early mobilization, and wound care education. The following outcomes for ERAS patients were compared by race/ethnicity: length of stay, discharge disposition, complications, readmission, pain level at discharge, and post-operative health rating. We estimated the association between race/ethnicity and the outcomes using linear and logistic regression models adjusting for age, sex, insurance, BMI, comorbid conditions, and surgery type. RESULTS Among participants (n = 3449), 2874 (83.3%) were White and 575 (16.7%) were Black, Indigenous, and people of color (BIPOC). BIPOC patients had significantly longer mean length of stay compared to White patients (3.8 vs. 3.4 days, p = 0.005) and were significantly more likely to be discharged to a rehab or subacute nursing facility compared to White patients (adjusted odds ratio (95% CI): 3.01 (2.26-4.01), p < 0.001). The complication rate did not significantly differ between BIPOC and White patients (13.7% vs. 15.5%, p = 0.29). BIPOC patients were not significantly more likely to be readmitted within 30 days compared to White patients in the adjusted model (adjusted odds ratio (95% CI): 1.30 (0.91-1.86), p = 0.15) CONCLUSION: BIPOC as compared to White ERAS participants in ERAS undergoing neurosurgical procedures had significantly longer hospital stays and were significantly less likely to be discharged home. ERAS protocols present an opportunity to provide consistent high quality post-operative care, however while there is evidence that it improves care in aggregate, our results suggest significant disparities in outcomes by patient race/ethnicity despite enrollment in ERAS. Future inquiry must identify contributors to these disparities in the recovery pathway.
Collapse
Affiliation(s)
- Susanna D Howard
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA.
| | - Jaya Aysola
- Penn Medicine Center for Health Equity Advancement, Office of Chief Medical Officer, University of Pennsylvania Health System and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Canada T Montgomery
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chang Xu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maikel Mansour
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica Nguyen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Zarina S Ali
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
8
|
Schreiber JE, Cole JCM, Houtrow AJ, Kallan MJ, Thom EA, Howell LJ, Adzick NS. Maternal Depressive Risk in Prenatal versus Postnatal Surgical Closure of Myelomeningocele: Associations with Parenting Stress and Child Outcomes. Fetal Diagn Ther 2021; 48:479-484. [PMID: 34182547 DOI: 10.1159/000516602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 04/14/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Depressive risk is higher for mothers of infants with chronic medical conditions. The present study examined maternal depressive risk and associations with parent and child outcomes among mothers of young children who were randomized to either prenatal or postnatal surgical closure for myelomeningocele. METHODS Using the Management of Myelomeningocele Study database, maternal depressive risk was examined at 3 time points as follows: prior to birth, 12 months, and 30 months post birth. Separate multivariate analyses examined associations among change in depressive risk (between baseline and 30 months), parenting stress, and child outcomes at 30 months. RESULTS Mean scores were in the minimal depressive risk range at all the time points. Post birth depressive risk did not differ by prenatal versus postnatal surgery. Mean change scores reflected a decrease in depressive risk during the first 30 months. Only 1.1-4.5% of mothers reported depressive risk in the moderate to severe range across time points. Increased depressive risk during the first 30 months was associated with increased parenting stress scores and slightly lower child cognitive scores at 30 months. CONCLUSION Most mothers reported minimal depressive risk that decreased over time, regardless of whether their infant underwent prenatal or postnatal surgery. Only a small percentage of mothers endorsed moderate to severe depressive risk, but an increase in depressive risk over time was associated with higher parental stress and slightly lower child cognitive development.
Collapse
Affiliation(s)
- Jane E Schreiber
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joanna C M Cole
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Psychiatry, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Amy J Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Michael J Kallan
- Department of Biostatistics Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elizabeth A Thom
- George Washington University Biostatistics Center, Washington, District of Columbia, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| |
Collapse
|
9
|
Flanders TM, Ifrach J, Sinha S, Joshi DS, Ozturk AK, Malhotra NR, Pessoa R, Kallan MJ, Fleisher LA, Ashburn MA, Maloney E, Welch WC, Ali ZS. Reduction of Postoperative Opioid Use After Elective Spine and Peripheral Nerve Surgery Using an Enhanced Recovery After Surgery Program. Pain Med 2021; 21:3283-3291. [PMID: 32761129 DOI: 10.1093/pm/pnaa233] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Enhanced recovery after surgery (ERAS) pathways have previously been shown to be feasible and safe in elective spinal procedures. As publications on ERAS pathways have recently emerged in elective neurosurgery, long-term outcomes are limited. We report on our 18-month experience with an ERAS pathway in elective spinal surgery. METHODS A historical cohort of 149 consecutive patients was identified as the control group, and 1,141 patients were prospectively enrolled in an ERAS protocol. The primary outcome was the need for opioid use one month postoperation. Secondary outcomes were opioid and nonopioid consumption on postoperative day (POD) 1, opioid use at three and six months postoperation, inpatient pain scores, patient satisfaction scores, postoperative Foley catheter use, mobilization/ambulation on POD0-1, length of stay, complications, and intensive care unit admissions. RESULTS There was significant reduction in use of opioids at one, three, and six months postoperation (38.6% vs 70.5%, P < 0.001, 36.5% vs 70.9%, P < 0.001, and 23.6% vs 51.9%, P = 0.008) respectively. Both groups had similar surgical procedures and demographics. PCA use was nearly eliminated in the ERAS group (1.4% vs 61.6%, P < 0.001). ERAS patients mobilized faster on POD0 compared with control (63.5% vs 20.7%, P < 0.001). Fewer patients in the ERAS group required postoperative catheterization (40.7% vs 32.7%, P < 0.001). The ERAS group also had decreased length of stay (3.4 vs 3.9 days, P = 0.020). CONCLUSIONS ERAS protocols for all elective spine and peripheral nerve procedures are both possible and effective. This standardized approach to patient care decreases opioid usage, eliminates the use of PCAs, mobilizes patients faster, and reduces length of stay.
Collapse
Affiliation(s)
- Tracy M Flanders
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph Ifrach
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Saurabh Sinha
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Disha S Joshi
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ali K Ozturk
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil R Malhotra
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Pessoa
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Lee A Fleisher
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael A Ashburn
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Eileen Maloney
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William C Welch
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zarina S Ali
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
10
|
Soni S, Moldenhauer JS, Kallan MJ, Rintoul N, Adzick NS, Hedrick HL, Khalek N. Influence of Gestational Age and Mode of Delivery on Neonatal Outcomes in Prenatally Diagnosed Isolated Congenital Diaphragmatic Hernia. Fetal Diagn Ther 2021; 48:372-380. [PMID: 33951652 DOI: 10.1159/000515252] [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: 05/07/2020] [Accepted: 02/15/2021] [Indexed: 11/19/2022]
Abstract
AIM The optimal gestational age (GA) at delivery and mode of delivery (MoD) for pregnancies with fetal congenital diaphragmatic hernia (CDH) is undetermined. The impact of early term (37-38 weeks 6 days) versus full term (39-40 weeks 6 days) and MoD on immediate neonatal outcomes in prenatally diagnosed isolated CDH cases was evaluated. MATERIAL AND METHODS A retrospective chart review of pregnancies evaluated and delivered with the prenatal diagnosis of CDH between July 1, 2008, and December 31, 2018. The primary outcome was survival to hospital discharge. Secondary outcomes included neonatal intensive care unit (NICU) length of stay (LOS), extracorporeal membrane oxygenation (ECMO) requirement and need for supplemental oxygen at day 30 of life. RESULTS A total of 296 patients were prenatally evaluated for CDH and delivered in a single center during the study period. After applying exclusion criteria, data were available on 113 women who delivered early term and 72 women who delivered full term. Survival to hospital discharge was comparable between the 2 groups - 83.2% in the early term versus 93.1% in the full term (p = 0.07; 95% CI of 0.13-1.04). No difference was observed in any other secondary outcomes. MoD was stratified into spontaneous vaginal, induced vaginal, unplanned cesarean and scheduled cesarean delivery with associated neonatal survival rates of 74.2, 90.6, 89.7 and 88.2%, respectively, p = 0.13. The 5-min Apgar score was higher in the elective cesarean group (7.94) followed by the induced vaginal delivery group (7.8) compared to 7.17 and 7.18 in the spontaneous vaginal and unplanned cesarean groups, respectively (p = 0.03). The GA and MoD did not influence survival to hospital discharge nor NICU LOS in multivariate analysis. CONCLUSIONS Though there were no significant differences in neonatal outcomes for early term compared to full term deliveries of CDH neonates, a trend toward improved survival rates and lower ECMO requirements in the full term group may suggest an underlying importance GA at delivery. Further studies are warranted to validate these findings.
Collapse
Affiliation(s)
- Shelly Soni
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julie S Moldenhauer
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Natalie Rintoul
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Holly L Hedrick
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nahla Khalek
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
11
|
Torgersen J, Kallan MJ, Carbonari DM, Park LS, Mehta RL, D'Addeo K, Tate JP, Lim JK, Goetz MB, Rodriguez-Barradas MC, Gibert CL, Bräu N, Brown ST, Roy JA, Taddei TH, Justice AC, Lo Re V. HIV RNA, CD4+ Percentage, and Risk of Hepatocellular Carcinoma by Cirrhosis Status. J Natl Cancer Inst 2021; 112:747-755. [PMID: 31687755 DOI: 10.1093/jnci/djz214] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 09/19/2019] [Accepted: 10/25/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Despite increasing incidence of hepatocellular carcinoma (HCC) among HIV-infected patients, it remains unclear if HIV-related factors contribute to development of HCC. We examined if higher or prolonged HIV viremia and lower CD4+ cell percentage were associated with HCC. METHODS We conducted a cohort study of HIV-infected individuals who had HIV RNA, CD4+, and CD8+ cell counts and percentages assessed in the Veterans Aging Cohort Study (1999-2015). HCC was ascertained using Veterans Health Administration cancer registries and electronic records. Cox regression was used to determine hazard ratios (HR, 95% confidence interval [CI]) of HCC associated with higher current HIV RNA, longer duration of detectable HIV viremia (≥500 copies/mL), and current CD4+ cell percentage less than 14%, adjusting for traditional HCC risk factors. Analyses were stratified by previously validated diagnoses of cirrhosis prior to start of follow-up. RESULTS Among 35 659 HIV-infected patients, 302 (0.8%) developed HCC over 281 441 person-years (incidence rate = 107.3 per 100 000 person-years). Among patients without baseline cirrhosis, higher HIV RNA (HR = 1.25, 95% CI = 1.12 to 1.40, per 1.0 log10 copies/mL) and 12 or more months of detectable HIV (HR = 1.47, 95% CI = 1.02 to 2.11) were independently associated with higher risk of HCC. CD4+ percentage less than 14% was not associated with HCC in any model. Hepatitis C coinfection was a statistically significant predictor of HCC regardless of baseline cirrhosis status. CONCLUSION Among HIV-infected patients without baseline cirrhosis, higher HIV RNA and longer duration of HIV viremia increased risk of HCC, independent of traditional HCC risk factors. This is the strongest evidence to date that HIV viremia contributes to risk of HCC in this group.
Collapse
Affiliation(s)
- Jessie Torgersen
- Division of Infectious Diseases, Department of Medicine.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Dena M Carbonari
- Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| | - Lesley S Park
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Center for Population Health Sciences, Stanford University School of Medicine, Stanford, CA
| | - Rajni L Mehta
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Kathryn D'Addeo
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Janet P Tate
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Joseph K Lim
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Cynthia L Gibert
- Washington DC VA Medical Center and George Washington University Medical Center, Washington, DC
| | - Norbert Bräu
- James J. Peters VA Medical Center, Bronx, NY, and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sheldon T Brown
- James J. Peters VA Medical Center, Bronx, NY, and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jason A Roy
- Department of Biostatistics, Rutgers University School of Public Health, New Brunswick, NJ
| | - Tamar H Taddei
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Amy C Justice
- VA Connecticut Healthcare System, West Haven, CT.,Yale University School of Medicine, New Haven, CT
| | - Vincent Lo Re
- Division of Infectious Diseases, Department of Medicine.,Department of Biostatistics, Epidemiology, and Informatics, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training
| |
Collapse
|
12
|
Vahdatpour CA, Pichler A, Palevsky HI, Kallan MJ, Patel NB, Kinniry PA. Interstitial Lung Disease Associated Acute Respiratory Failure Requiring Invasive Mechanical Ventilation: A Retrospective Analysis. Open Respir Med J 2020; 14:67-77. [PMID: 33425069 PMCID: PMC7774098 DOI: 10.2174/1874306402014010067] [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] [Received: 07/15/2020] [Revised: 09/22/2020] [Accepted: 09/30/2020] [Indexed: 12/16/2022] Open
Abstract
Background: Interstitial Lung Disease [ILD] patients requiring Invasive Mechanical Ventilation [IMV] for Acute Respiratory Failure [ARF] are known to have a poor prognosis. Few studies have investigated determinants of outcomes and the utility of trialing Non-Invasive Positive Pressure Ventilation [NIPPV] prior to IMV to see if there are any effect[s] on mortality or morbidity. Methods: A retrospective study was designed using patients at four different intensive care units within one health care system. The primary objective was to determine if there are differences in outcomes for in-hospital and one-year mortality between patients who undergo NIPPV prior to IMV and those who receive only IMV. A secondary objective was to identify potential determinants of outcomes. Results: Out of 54 ILD patients with ARF treated with IMV, 20 (37.0%) survived until hospital discharge and 10 (18.5%) were alive at one-year. There was no significant mortality difference between patients trialed on NIPPV prior to IMV and those receiving only IMV. Several key determinants of outcomes were identified with higher mortality, including higher ventilatory support, idiopathic pulmonary fibrosis (IPF) subtype, high dose steroids, use of vasopressors, supraventricular tachycardias (SVTs), and higher body mass index. Conclusion: Considering that patients trialed on NIPPV prior to IMV were associated with no mortality disadvantage to patients treated with only IMV, trialing patients on NIPPV may identify responders and avoid complications associated with IMV. Increased ventilator support, need of vasopressors, SVTs, and high dose steroids reflect higher mortality and palliative care involvement should be considered as early as possible if a lung transplant is not an option.
Collapse
Affiliation(s)
- Cyrus A Vahdatpour
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Florida, Gainesville, Florida
| | - Alexander Pichler
- Department of Internal Medicine, Medical University of Vienna, Vienna, Austria
| | - Harold I Palevsky
- Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Penn Presbyterian Medical Center, Philadelphia, Pennsylvania.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Namrata B Patel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Kinniry
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Pulmonary, Allergy, and Critical Care Division, Department of Medicine, Pennsylvania Hospital, Philadelphia, Pennsylvania
| |
Collapse
|
13
|
Eberly LA, Kallan MJ, Julien HM, Haynes N, Khatana SAM, Nathan AS, Snider C, Chokshi NP, Eneanya ND, Takvorian SU, Anastos-Wallen R, Chaiyachati K, Ambrose M, O’Quinn R, Seigerman M, Goldberg LR, Leri D, Choi K, Gitelman Y, Kolansky DM, Cappola TP, Ferrari VA, Hanson CW, Deleener ME, Adusumalli S. Patient Characteristics Associated With Telemedicine Access for Primary and Specialty Ambulatory Care During the COVID-19 Pandemic. JAMA Netw Open 2020; 3:e2031640. [PMID: 33372974 PMCID: PMC7772717 DOI: 10.1001/jamanetworkopen.2020.31640] [Citation(s) in RCA: 422] [Impact Index Per Article: 105.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE The coronavirus disease 2019 (COVID-19) pandemic has required a shift in health care delivery platforms, necessitating a new reliance on telemedicine. OBJECTIVE To evaluate whether inequities are present in telemedicine use and video visit use for telemedicine visits during the COVID-19 pandemic. DESIGN, SETTING, AND PARTICIPANTS In this cohort study, a retrospective medical record review was conducted from March 16 to May 11, 2020, of all patients scheduled for telemedicine visits in primary care and specialty ambulatory clinics at a large academic health system. Age, race/ethnicity, sex, language, median household income, and insurance type were all identified from the electronic medical record. MAIN OUTCOMES AND MEASURES A successfully completed telemedicine visit and video (vs telephone) visit for a telemedicine encounter. Multivariable models were used to assess the association between sociodemographic factors, including sex, race/ethnicity, socioeconomic status, and language, and the use of telemedicine visits, as well as video use specifically. RESULTS A total of 148 402 unique patients (86 055 women [58.0%]; mean [SD] age, 56.5 [17.7] years) had scheduled telemedicine visits during the study period; 80 780 patients (54.4%) completed visits. Of 78 539 patients with completed visits in which visit modality was specified, 35 824 (45.6%) were conducted via video, whereas 24 025 (56.9%) had a telephone visit. In multivariable models, older age (adjusted odds ratio [aOR], 0.85 [95% CI, 0.83-0.88] for those aged 55-64 years; aOR, 0.75 [95% CI, 0.72-0.78] for those aged 65-74 years; aOR, 0.67 [95% CI, 0.64-0.70] for those aged ≥75 years), Asian race (aOR, 0.69 [95% CI, 0.66-0.73]), non-English language as the patient's preferred language (aOR, 0.84 [95% CI, 0.78-0.90]), and Medicaid insurance (aOR, 0.93 [95% CI, 0.89-0.97]) were independently associated with fewer completed telemedicine visits. Older age (aOR, 0.79 [95% CI, 0.76-0.82] for those aged 55-64 years; aOR, 0.78 [95% CI, 0.74-0.83] for those aged 65-74 years; aOR, 0.49 [95% CI, 0.46-0.53] for those aged ≥75 years), female sex (aOR, 0.92 [95% CI, 0.90-0.95]), Black race (aOR, 0.65 [95% CI, 0.62-0.68]), Latinx ethnicity (aOR, 0.90 [95% CI, 0.83-0.97]), and lower household income (aOR, 0.57 [95% CI, 0.54-0.60] for income <$50 000; aOR, 0.89 [95% CI, 0.85-0.92], for $50 000-$100 000) were associated with less video use for telemedicine visits. These results were similar across medical specialties. CONCLUSIONS AND RELEVANCE In this cohort study of patients scheduled for primary care and medical specialty ambulatory telemedicine visits at a large academic health system during the early phase of the COVID-19 pandemic, older patients, Asian patients, and non-English-speaking patients had lower rates of telemedicine use, while older patients, female patients, Black, Latinx, and poorer patients had less video use. Inequities in accessing telemedicine care are present, which warrant further attention.
Collapse
Affiliation(s)
- Lauren A. Eberly
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Michael J. Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Howard M. Julien
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Norrisa Haynes
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Sameed Ahmed M. Khatana
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ashwin S. Nathan
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Christopher Snider
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Neel P. Chokshi
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Center for Digital Cardiology, University of Pennsylvania, Philadelphia
| | - Nwamaka D. Eneanya
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Renal-Electrolyte and Hypertension, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Samuel U. Takvorian
- Hematology and Oncology Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Rebecca Anastos-Wallen
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Krisda Chaiyachati
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Marietta Ambrose
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Rupal O’Quinn
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Matthew Seigerman
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Lee R. Goldberg
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Damien Leri
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Katherine Choi
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Yevginiy Gitelman
- Department of Internal Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Daniel M. Kolansky
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - Thomas P. Cappola
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
| | - Victor A. Ferrari
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
| | - C. William Hanson
- Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia
| | - Mary Elizabeth Deleener
- Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia
| | - Srinath Adusumalli
- Division of Cardiovascular Medicine, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center, Cardiovascular Institute, University of Pennsylvania, Philadelphia
- Penn Cardiovascular Center for Health Equity and Social Justice, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
- Office of the Chief Medical Information Officer, University of Pennsylvania Health System, Philadelphia
| |
Collapse
|
14
|
Ifrach J, Basu R, Joshi DS, Flanders TM, Ozturk AK, Malhotra NR, Pessoa R, Kallan MJ, Maloney E, Welch WC, Ali ZS. Efficacy of an Enhanced Recovery After Surgery (ERAS) Pathway in Elderly Patients Undergoing Spine and Peripheral Nerve Surgery. Clin Neurol Neurosurg 2020; 197:106115. [DOI: 10.1016/j.clineuro.2020.106115] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 07/25/2020] [Accepted: 07/25/2020] [Indexed: 01/22/2023]
|
15
|
Rintoul NE, Keller RL, Walsh WF, Burrows PK, Thom EA, Kallan MJ, Howell LJ, Adzick NS. The Management of Myelomeningocele Study: Short-Term Neonatal Outcomes. Fetal Diagn Ther 2020; 47:865-872. [PMID: 32866951 PMCID: PMC7845433 DOI: 10.1159/000509245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 06/06/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION The Management of Myelomeningocele Study was a multicenter randomized trial to compare prenatal and standard postnatal repair of myelomeningocele (MMC). Neonatal outcome data for 158 of the 183 randomized women were published in The New England Journal of Medicine in 2011. OBJECTIVE Neonatal outcomes for the complete trial cohort (N = 183) are presented outlining the similarities with the original report and describing the impact of gestational age as a mediator. METHODS Gestational age, neonatal characteristics at delivery, and outcomes including common complications of prematurity were assessed. RESULTS Analysis of the complete cohort confirmed the initial findings that prenatal surgery was associated with an increased risk for earlier gestational age at birth. Delivery occurred before 30 weeks of gestation in 11% of neonates that had fetal MMC repair. Adverse pulmonary sequelae were rare in the prenatal surgery group despite an increased rate of oligohydramnios. There was no significant difference in other complications of prematurity including patent ductus arteriosus, sepsis, necrotizing enterocolitis, periventricular leukomalacia, and intraventricular hemorrhage. CONCLUSION The benefits of prenatal surgery outweigh the complications of prematurity.
Collapse
Affiliation(s)
- Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA,
| | - Roberta L Keller
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California, USA
| | - William F Walsh
- Division of Neonatology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pamela K Burrows
- The Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Elizabeth A Thom
- The Biostatistics Center, George Washington University, Washington, District of Columbia, USA
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology & Informatics, Perlelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lori J Howell
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - N Scott Adzick
- Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
16
|
Bryer EJ, Kallan MJ, Chiu T, Scheuba KM, Henry DH. A retrospective analysis of venous thromboembolism trends in chemotherapy‐induced anemia: Red blood cell transfusion versus erythrocyte stimulating agent administration. eJHaem 2020; 1:35-43. [PMID: 35847693 PMCID: PMC9175772 DOI: 10.1002/jha2.18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 04/30/2020] [Accepted: 04/05/2020] [Indexed: 11/25/2022]
Abstract
Background Patients receiving a variety of chemotherapy regimens often develop chemotherapy‐induced anemia (CIA), which contributes to poor outcomes including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Optimal therapy of CIA is controversial and involves the solitary and combined use of intravenous iron, red blood cell (RBC) transfusions, and erythropoietin stimulating agents (ESAs). Despite the baseline coagulopathies present in patients with malignancy, administration of both RBC transfusions and ESAs is associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive RBC transfusions or ESAs. Methods A retrospective study analyzed 10,269 University of Pennsylvania Health System patients with malignancies of various type, stage, and histopathology who developed CIA between 2008 and 2017. Using multivariate Cox regression, we determined adjusted hazard ratios (and corresponding 95% confidence intervals) of VTE development after adjusting for RBC and ESA intervention (all during the 90 days following CIA diagnosis). Results Among the 10,269 patients with CIA, 2,642 (25.7%) developed a VTE within the 90‐day period. VTE risk following RBC transfusion (HR = 1.37, 95% CI 1.24‐1.50, P < .001) was more than twice as common as VTE risk following ESA administration (HR = 0.53, 95% CI 0.40‐0.69, P < .001). Conclusion While both RBC transfusion and ESA are independently associated with VTE, our data suggest a greater risk of VTE development with RBC transfusion as compared with ESA.
Collapse
Affiliation(s)
- Emily J. Bryer
- Pennsylvania HospitalUniversity of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - Michael J. Kallan
- Department of BiostatisticsEpidemiology, and InformaticsPerelman School of MedicineUniversity of Pennsylvania Philadelphia Pennsylvania USA
| | - Ting‐Shan Chiu
- Data Analytics CenterPerelman School of MedicineUniversity of Pennsylvania Philadelphia Pennsylvania USA
| | - Katharina M. Scheuba
- Pennsylvania HospitalUniversity of Pennsylvania Health System Philadelphia Pennsylvania USA
| | - David H. Henry
- Pennsylvania HospitalUniversity of Pennsylvania Health System Philadelphia Pennsylvania USA
| |
Collapse
|
17
|
Bryer EJ, Kallan MJ, Chiu TS, Scheuba KM, Henry DH. A retrospective analysis of venous thromboembolism trends in chemotherapy-induced anemia. J Clin Oncol 2020. [DOI: 10.1200/jco.2020.38.15_suppl.e15515] [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: 11/20/2022] Open
Abstract
e15515 Background: Anemia is a common and unfortunate consequence of chemotherapy. Patients receiving a variety of chemotherapy regimens often develop chemotherapy–induced anemia (CIA), which contributes to poor outcomes, including increased mortality. Prompt and effective treatment of CIA is essential to prevent fewer chemotherapy dose delays and reductions. Despite the baseline coagulopathies present in patients with malignancy, administration of RBC transfusions is associated with venous thromboembolism (VTE). It remains unknown whether the risk of VTE in patients with CIA is greater among patients who receive single or multiple RBC transfusions. Methods: A retrospective study analyzed 10,269 University of Pennsylvania Health System patients with malignancies of various type, stage, and histopathology who developed CIA between 5/1/08-12/31/17. We analyzed rates of VTE development after adjusting for RBC intervention with a 95% confidence interval during the 90 days following CIA diagnosis. Results: Among the 10,269 patients with CIA, 2,008 patients (19.6%) received only RBC transfusion as anemia treatment; of that group, 545 (27.1%) developed a VTE. Transfusion of 2+ units RBC compared with 1 unit of RBC was associated with an increase in VTE development (RR = 1.37, 95% CI 1.09-1.72). The relationship of higher VTE development with increasing number of transfusions is displayed below. Conclusions: While RBC transfusion in patients with CIA is independently associated with VTE, our data further suggests an exponential risk of VTE development with increasing numbers of RBC transfusions. [Table: see text] [Table: see text]
Collapse
Affiliation(s)
- Emily Jane Bryer
- Pennsylvania Hospital, University of Pennsylvania School of Medicine, Philadelphia, PA
| | | | | | | | - David H. Henry
- Pennsylvania Hospital, University of Pennsylvania School of Medicine, Philadelphia, PA
| |
Collapse
|
18
|
Schmitz KH, Troxel AB, Dean LT, DeMichele A, Brown JC, Sturgeon K, Zhang Z, Evangelisti M, Spinelli B, Kallan MJ, Denlinger C, Cheville A, Winkels RM, Chodosh L, Sarwer DB. Effect of Home-Based Exercise and Weight Loss Programs on Breast Cancer-Related Lymphedema Outcomes Among Overweight Breast Cancer Survivors: The WISER Survivor Randomized Clinical Trial. JAMA Oncol 2019; 5:1605-1613. [PMID: 31415063 DOI: 10.1001/jamaoncol.2019.2109] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance To our knowledge, no randomized clinical trials have assessed the effects of the combination of weight loss and home-based exercise programs on lymphedema outcomes. Objective To assess weight loss, home-based exercise, and the combination of weight loss and home-based exercise with clinical lymphedema outcomes among overweight breast cancer survivors. Design, Setting, and Participants This randomized clinical trial (Women in Steady Exercise Research [WISER] Survivor clinical trial ) of 351 overweight breast cancer survivors with breast cancer-related lymphedema (BCRL) was conducted in conference rooms at academic and community hospitals and in the homes of participants from March 12, 2012, to May 28, 2016; follow-up was conducted for 1 year from the start of the intervention. Statistical analysis by intention to treat was performed from September 26, 2018, to October 28, 2018. Interventions A 52-week, home-based exercise program of strength/resistance training twice per week and 180 minutes of walking per week, a weight loss program of 20 weeks of meal replacements and 52 weeks of lifestyle modification counseling, and a combination of the home-based exercise and weight loss programs. Main Outcomes and Measures The 12-month change in the percentage of interlimb volume difference. Results Of 351 participants, 90 were randomized to the control group (facility-based lymphedema care with no home-based exercise or weight loss intervention), 87 to the exercise intervention group, 87 to the weight loss intervention group, and 87 to the combined exercise and weight loss intervention group; 218 (62.1%) were white, 122 (34.8%) were black, and 11 (3.1%) were of other races or ethnicities. Median time since breast cancer diagnosis was 6 years (range, 1-29 years). Mean (SD) total upper extremity score changes from the objective clinical evaluation were -1.40 (11.10) in the control group, -2.54 (13.20) in the exercise group, -3.54 (12.88) in the weight loss group, and -3.84 (10.09) in the combined group. Mean (SD) overall upper extremity score changes from the self-report survey were -0.39 (2.33) in the control group, -0.12 (2.14) in the exercise group, -0.57 (2.47) in the weight loss group, and -0.62 (2.38) in the combined group. Weight loss from baseline was -0.55% (95% CI, -2.22% to 1.11%) in the control group, -8.06% (95% CI, -9.82% to 6.29%) in the combined group, -7.37% (95% CI, -8.90% to -5.84%) in the weight loss group, and -0.44% (95% CI, -1.81% to 0.93%) in the exercise group. Conclusions and Relevance Study results indicate that weight loss, home-based exercise, and combined interventions did not improve BCRL outcomes; a supervised facility-based program of exercise may be more beneficial than a home-based program for improving lymphedema outcomes. Trial Registration ClinicalTrials.gov identifier: NCT01515124.
Collapse
Affiliation(s)
- Kathryn H Schmitz
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey
| | - Andrea B Troxel
- Department of Biostatistics, New York University School of Medicine, New York
| | - Lorraine T Dean
- Department of Epidemiology, Johns Hopkins University, Baltimore, Maryland
| | - Angela DeMichele
- Department of Hematology/Oncology, Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Justin C Brown
- Department of Population and Public Health Sciences, Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Kathleen Sturgeon
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey
| | - Zi Zhang
- Department of Radiology, Harlem Hospital Center, New York, New York
| | - Margaret Evangelisti
- Department of Hematology/Oncology, Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bryan Spinelli
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Crystal Denlinger
- Division of Hematology/Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania
| | - Andrea Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, Minnesota
| | - Renate M Winkels
- Department of Public Health Sciences, Pennsylvania State College of Medicine, Hershey
| | - Lewis Chodosh
- Department of Hematology/Oncology, Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David B Sarwer
- Department of Social and Behavioral Sciences, Temple University, Philadelphia, Pennsylvania
| |
Collapse
|
19
|
Abstract
IMPORTANCE Total knee arthroplasty (TKA) is one of the most common elective procedures performed in adults with end-stage arthritis. Racial disparities in TKA outcomes have been described in the literature. OBJECTIVES To assess the association of race/ethnicity with discharge disposition and hospital readmission after elective primary TKA and to assess the association of nonhome discharge disposition with hospital readmission risk. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Pennsylvania Health Care Cost Containment Council Database, a large regional database that included demographic data from all discharges of patients who underwent elective primary TKA in 170 nongovernmental acute care hospitals in Pennsylvania from April 1, 2012, to September 30, 2015. Data analyses were conducted from September 29, 2017, to November 29, 2017. EXPOSURES Patient race/ethnicity and discharge disposition. MAIN OUTCOMES AND MEASURES Discharge disposition and 90-day hospital readmission. RESULTS Among 107 768 patients, 7287 (6.8%) were African American, 68 372 (63.4%) were women, 46 420 (43.1%) were younger than 65 years, and 60 636 (56.3%) were insured by Medicare. In multivariable logistic regression, among patients younger than 65 years, African American patients were more likely than white patients to be discharged to inpatient rehabilitation facility (IRF) (adjusted relative risk ratio [aRRR], 2.49 [95% CI, 1.42-4.36]; P = .001) or a skilled nursing facility (SNF) (aRRR, 3.91 [95% CI, 2.17-7.06]; P < .001) and had higher odds of 90-day hospital readmission (adjusted odds ratio [aOR], 1.30 [95% CI, 1.02-1.67]; P = .04). Compared with white patients 65 years or older, African American patients 65 years or older were more likely to be discharged to SNF (aRRR, 3.30 [95% CI, 1.81-6.02]; P < .001). In both age groups, discharge to an IRF (age <65 years: aOR, 3.62 [95% CI, 2.33-5.64]; P < .001; age ≥65 years: aOR, 2.85 [95% CI, 2.25-3.61]; P < .001) or SNF (age <65 years: aOR, 1.91 [95% CI, 1.37-2.65]; P < .001; age ≥65 years: aOR, 1.55 [95% CI, 1.27-1.89]; P < .001) was associated with higher odds of 90-day readmission. CONCLUSIONS AND RELEVANCE This cohort study found that race/ethnicity was associated with higher odds of discharge to an IRF or SNF for postoperative care after primary TKA. Among patients younger than 65 years, African American patients were more likely than white patients to be readmitted to the hospital within 90 days. Discharge to an IRF or SNF for postoperative care and rehabilitation was also associated with a higher risk of readmission to an acute care hospital.
Collapse
Affiliation(s)
- Jasvinder A. Singh
- Medicine Service, Virginia Medical Center, Birmingham, Alabama
- School of Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham
| | - Michael J. Kallan
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | - Yong Chen
- Perelman School of Medicine, Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia
| | | | - Said A. Ibrahim
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| |
Collapse
|
20
|
Torgersen J, Taddei TH, Park LS, Carbonari DM, Kallan MJ, Mitchell Richards K, Zhang X, Jhala D, Bräu N, Homer R, D'Addeo K, Mehta R, Skanderson M, Kidwai-Khan F, Justice AC, Lo Re V. Differences in Pathology, Staging, and Treatment between HIV + and Uninfected Patients with Microscopically Confirmed Hepatocellular Carcinoma. Cancer Epidemiol Biomarkers Prev 2019; 29:71-78. [PMID: 31575557 DOI: 10.1158/1055-9965.epi-19-0503] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/21/2019] [Accepted: 09/25/2019] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The incidence of hepatocellular carcinoma (HCC) is substantially higher among HIV-infected (HIV+) than uninfected persons. It remains unclear if HCC in the setting of HIV infection is morphologically distinct or more aggressive. METHODS We evaluated differences in tumor pathology in a cohort of HIV+ and uninfected patients with microscopically confirmed HCC in the Veterans Aging Cohort Study from 2000 to 2015. We reviewed pathology reports and medical records to determine Barcelona Clinic Liver Cancer stage (BCLC), HCC treatment, and survival by HIV status. Multivariable Cox regression was used to determine the hazard ratio [HR; 95% confidence interval (CI)] of death associated with HIV infection after microscopic confirmation. RESULTS Among 873 patients with HCC (399 HIV+), 140 HIV+ and 178 uninfected persons underwent liver tissue sampling and had microscopically confirmed HCC. There were no differences in histologic features of the tumor between HIV+ and uninfected patients, including tumor differentiation (well differentiated, 19% vs. 28%, P = 0.16) and lymphovascular invasion (6% vs. 7%, P = 0.17) or presence of advanced hepatic fibrosis (40% vs. 39%, P = 0.90). There were no differences in BCLC stage (P = 0.06) or treatment (P = 0.29) by HIV status. After adjustment for risk factors, risk of death was higher among HIV-infected than uninfected patients (HR = 1.37; 95% CI, 1.02-1.85). CONCLUSIONS We found no differences in HCC tumor characteristics or background hepatic parenchyma by HIV status, yet HIV was associated with poorer survival. Of note, pathology reports often omitted these characteristics. IMPACT Systematic evaluation of HCC pathology by HIV status is needed to understand tumor characteristics associated with improved survival.
Collapse
Affiliation(s)
- Jessie Torgersen
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania. .,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Tamar H Taddei
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Lesley S Park
- Stanford Center for Population Health Sciences, Stanford University School of Medicine, Stanford, California
| | - Dena M Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Darshana Jhala
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Norbert Bräu
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,James J. Peters VA Medical Center, Bronx, New York
| | - Robert Homer
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,Department of Pathology, Yale School of Medicine, New Haven, Connecticut
| | - Kathryn D'Addeo
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Rajni Mehta
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Melissa Skanderson
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Farah Kidwai-Khan
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Amy C Justice
- Department of Medicine, Yale School of Medicine, New Haven, Connecticut.,VA Connecticut Healthcare System, West Haven, Connecticut
| | - Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
21
|
Ali ZS, Flanders TM, Ozturk AK, Malhotra NR, Leszinsky L, McShane BJ, Gardiner D, Rupich K, Chen HI, Schuster J, Marcotte PJ, Kallan MJ, Grady MS, Fleisher LA, Welch WC. Enhanced recovery after elective spinal and peripheral nerve surgery: pilot study from a single institution. J Neurosurg Spine 2019; 30:1-9. [PMID: 30684933 DOI: 10.3171/2018.9.spine18681] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [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: 05/30/2018] [Accepted: 09/10/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVEEnhanced recovery after surgery (ERAS) protocols address pre-, peri-, and postoperative factors of a patient's surgical journey. The authors sought to assess the effects of a novel ERAS protocol on clinical outcomes for patients undergoing elective spine or peripheral nerve surgery.METHODSThe authors conducted a prospective cohort analysis comparing clinical outcomes of patients undergoing elective spine or peripheral nerve surgery after implementation of the ERAS protocol compared to a historical control cohort in a tertiary care academic medical center. Patients in the historical cohort (September-December 2016) underwent traditional surgical care. Patients in the intervention group (April-June 2017) were enrolled in a unique ERAS protocol created by the Department of Neurosurgery at the University of Pennsylvania. Primary objectives were as follows: opioid and nonopioid pain medication consumption, need for opioid use at 1 month postoperatively, and patient-reported pain scores. Secondary objectives were as follows: mobilization and ambulation status, Foley catheter use, need for straight catheterization, length of stay, need for ICU admission, discharge status, and readmission within 30 days.RESULTSA total of 201 patients underwent surgical care via an ERAS protocol and were compared to a total of 74 patients undergoing traditional perioperative care (control group). The 2 groups were similar in baseline demographics. Intravenous opioid medications postoperatively via patient-controlled analgesia was nearly eliminated in the ERAS group (0.5% vs 54.1%, p < 0.001). This change was not associated with an increase in the average or daily pain scores in the ERAS group. At 1 month following surgery, a smaller proportion of patients in the ERAS group were using opioids (38.8% vs 52.7%, p = 0.041). The ERAS group demonstrated greater mobilization on postoperative day 0 (53.4% vs 17.1%, p < 0.001) and postoperative day 1 (84.1% vs 45.7%, p < 0.001) compared to the control group. Postoperative Foley use was decreased in the ERAS group (20.4% vs 47.3%, p < 0.001) without an increase in the rate of straight catheterization (8.1% vs 11.9%, p = 0.51).CONCLUSIONSImplementation of this novel ERAS pathway safely reduces patients' postoperative opioid requirements during hospitalization and 1 month postoperatively. ERAS results in improved postoperative mobilization and ambulation.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Lee A Fleisher
- 3Department of Anesthesia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | |
Collapse
|
22
|
Spinelli B, Kallan MJ, Zhang X, Cheville A, Troxel A, Cohn J, Dean L, Sturgeon K, Evangelista M, Zhang Z, Ebaugh D, Schmitz KH. Intra- and Interrater Reliability and Concurrent Validity of a New Tool for Assessment of Breast Cancer-Related Lymphedema of the Upper Extremity. Arch Phys Med Rehabil 2018; 100:315-326. [PMID: 30291828 DOI: 10.1016/j.apmr.2018.08.185] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 07/27/2018] [Accepted: 08/23/2018] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The goal of this study was to develop and assess intra- and interrater reliability and validity of a clinical evaluation tool for breast cancer-related lymphedema, for use in the context of outcome evaluation in clinical trials. DESIGN Blinded repeated measures observational study. SETTING Outpatient research laboratory. PARTICIPANTS Breast cancer survivors with and without lymphedema (N=71). INTERVENTIONS Not applicable. MAIN OUTCOME MEASURE The assessment of intraclass correlation coefficients (ICCs) for the Breast Cancer-Related Lymphedema of the Upper Extremity (CLUE) standardized clinical evaluation tool. RESULTS Intrarater reliability for the CLUE tool was ICC: 0.88 (95% confidence interval [95% CI], 0.71-0.96). Interrater reliability for the CLUE tool was ICC: 0.90 (95% CI, 0.79-0.95). Concurrent validity of the CLUE score (Pearson r) was 0.79 with perometric interlimb difference and 0.53 with the Norman lymphedema overall score. CONCLUSIONS The CLUE tool shows excellent inter- and intrarater reliability. The overall CLUE score for the upper extremity also shows moderately strong concurrent validity with objective and subjective measures. This newly developed clinical, physical assessment of upper extremity lymphedema provides standardization and a single score that accounts for multiple constructs. Next steps include evaluation of sensitivity to change, which would establish usefulness to evaluate intervention efficacy.
Collapse
Affiliation(s)
- Bryan Spinelli
- Department of Physical Therapy, Thomas Jefferson University, Philadelphia, PA
| | - Michael J Kallan
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Xiaochen Zhang
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Andrea Cheville
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN
| | - Andrea Troxel
- Department of Biostatistics, New York University, New York, NY
| | - Joy Cohn
- Good Shepherd Penn Partners, Philadelphia, PA
| | - Lorraine Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Kathleen Sturgeon
- Department of Public Health Sciences, Penn State Cancer Institute, Penn State College of Medicine, Hershey, PA
| | - Margaret Evangelista
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - Zi Zhang
- Department of Radiology, Harlem Hospital Center, Columbia University, New York, NY
| | - David Ebaugh
- Department of Physical Therapy, Drexel University, Philadelphia, PA
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Penn State Cancer Institute, Penn State College of Medicine, Hershey, PA.
| |
Collapse
|
23
|
Chrisinger BW, Kallan MJ, Whiteman ED, Hillier A. Where do U.S. households purchase healthy foods? An analysis of food-at-home purchases across different types of retailers in a nationally representative dataset. Prev Med 2018; 112:15-22. [PMID: 29555187 PMCID: PMC5970989 DOI: 10.1016/j.ypmed.2018.03.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 02/16/2018] [Accepted: 03/14/2018] [Indexed: 11/28/2022]
Abstract
Food shopping decisions are pathways between food environment, diet and health outcomes, including chronic diseases such as diabetes and obesity. The choices of where to shop and what to buy are interrelated, though a better understanding of this dynamic is needed. The U.S. Department of Agriculture's nationally representative Food Acquisitions and Purchase Survey food-at-home dataset was joined with other databases of retailer characteristics and Healthy Eating Index-2010 (HEI) of purchases. We used linear regression models with general estimating equations to assess relationships between trip, store, and shopper characteristics with trip HEI scores. We examined HEI component scores for conventional supermarkets and discount/limited assortment retailers with descriptive statistics. Overall, 4962 shoppers made 11,472 shopping trips over one-week periods, 2012-2013. Trips to conventional supermarkets were the most common (53.6%), followed by supercenters (18.6%). Compared to conventional supermarkets, purchases at natural/gourmet stores had significantly higher HEI scores (β = 6.48, 95% CI = [4.45, 8.51], while those from "other" retailers (including corner and convenience stores) were significantly lower (-3.89, [-5.87, -1.92]). Older participants (versus younger) and women (versus men) made significantly healthier purchases (1.19, [0.29, 2.10]). Shoppers with less than some college education made significantly less-healthy purchases, versus shoppers with more education, as did households participating in SNAP, versus those with incomes above 185% of the Federal Poverty Level. Individual, trip, and store characteristics influenced the healthfulness of foods purchased. Interventions to encourage healthy purchasing should reflect these dynamics in terms of how, where, and for whom they are implemented.
Collapse
Affiliation(s)
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, USA
| | - Eliza D Whiteman
- Department of City & Regional Planning, School of Design, University of Pennsylvania, USA
| | - Amy Hillier
- Department of City & Regional Planning, School of Design, University of Pennsylvania, USA; School of Social Policy and Practice, University of Pennsylvania, USA
| |
Collapse
|
24
|
Danzer E, Hoffman C, D'Agostino JA, Boelig MM, Gerdes M, Bernbaum JC, Rosenthal H, Waqar LN, Rintoul NE, Herkert LM, Kallan MJ, Peranteau WH, Flake AW, Adzick NS, Hedrick HL. Short-Term Neurodevelopmental Outcome in Children Born With High-Risk Congenital Lung Lesions. Ann Thorac Surg 2018; 105:1827-1834. [PMID: 29438655 DOI: 10.1016/j.athoracsur.2018.01.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Revised: 12/30/2017] [Accepted: 01/09/2018] [Indexed: 10/18/2022]
Abstract
BACKGROUND This study sought to evaluate neurodevelopmental outcome in survivors of high-risk congenital lung lesions (CLLs) who underwent prenatal intervention or postnatal surgery within the first month of life. METHODS Forty-five high-risk CLL survivors underwent assessment using the Bayley Scales of Infant Development, 3rd Edition between July 2004 and December 2016. Scores were grouped as average, at-risk, and delayed based on SD intervals. Correlations between outcome and risk factors were analyzed by Fisher's exact test or two-sided t test as appropriate, with significant p values <0.05. RESULTS Open prenatal intervention was required in 13 (28.9%) children (fetal surgical resection, n = 4 , ex utero intrapartum treatment, n = 9), whereas 32 (71.1%) children had respiratory distress postnatally and required resection within the first month of life. Mean age at follow-up was 19.3 ± 10.3 months. Mean composite scores were within the expected average range. A total of 62.2% scored within the average range for all domains. At-risk scores were found in 26.7% of children in at least one domain, and 11.1% had delays in at least one domain. Neurodevelopmental outcome was similar between treatment groups. Prolonged ventilator support and neonatal intensive care unit stay, need for supplemental oxygen at day of life 30, gastroesophageal reflux disease, and delayed enteral feeding were associated with neurologic delays (all p < 0.05). CONCLUSIONS Neurodevelopmental scores for high-risk CLL survivors in infancy and toddlerhood are age appropriate. Neither fetal intervention nor the need for postnatal resection within the first month of life increases the risk of delays. Surrogate markers of a complicated neonatal course are predictive of adverse outcome.
Collapse
Affiliation(s)
- Enrico Danzer
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
| | - Casey Hoffman
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jo Ann D'Agostino
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Matthew M Boelig
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Marsha Gerdes
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Judy C Bernbaum
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Hannah Rosenthal
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lindsay N Waqar
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Lisa M Herkert
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - William H Peranteau
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Alan W Flake
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - N Scott Adzick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Holly L Hedrick
- The Center for Fetal Diagnosis and Treatment, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| |
Collapse
|
25
|
Vina ER, Kallan MJ, Collier A, Nelson CL, Ibrahim SA. Race and Rehabilitation Destination After Elective Total Hip Arthroplasty: Analysis of a Large Regional Data Set. Geriatr Orthop Surg Rehabil 2018; 8:192-201. [PMID: 29318080 PMCID: PMC5755837 DOI: 10.1177/2151458517726409] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 07/22/2017] [Accepted: 07/22/2017] [Indexed: 12/15/2022] Open
Abstract
Background: Three-quarters of patients who undergo total hip replacement (THR) receive postsurgical rehabilitation care in an inpatient rehabilitation facility (IRF), a skilled nursing facility (SNF), or through a home health agency. The objectives of this study are to examine racial differences where THR recipients receive postsurgical rehabilitation care and determine whether discharge destination is associated with hospital readmission. Methods: Using the Pennsylvania Health Care Cost Containment Council database, we selected African American (AA) or white adults who underwent THR surgery (n = 68,016). We used multinomial logistic regression models to assess the relationship between race and postsurgical discharge destination. We calculated 90-day hospital readmission as function of discharge destination. Results: Among patients <65 years, compared to whites, AAs had a higher risk of discharge to an IRF (adjusted relative risk ratio [aRRR]: 2.56, 95% confidence interval [CI]: 1.77-3.71) and a SNF (aRRR 3.37, 95% CI: 2.07-5.49). Among those ≥65 years, AA patients also had a higher risk of discharge to an IRF (aRRR: 1.96, 95% CI: 1.39-2.76) and a SNF (aRRR: 3.66, 95% CI: 2.29-5.84). Discharge to either IRF or SNF, instead of home with self-care, was significantly associated with higher odds of 90-day hospital readmission (<65 years: adjusted odds ratio [aOR]: 4.06, 95% CI: 3.49-4.74; aOR: 2.05, 95% CI: 1.70-2.46, respectively; ≥65 years: aOR: 4.32, 95% CI: 3.67-5.09, respectively; aOR: 1.74, 95% CI: 1.46-2.07, respectively). Conclusions: Compared to whites, AAs who underwent THR were more likely to be discharged to an IRF or SNF. Discharge to either facility was associated with a higher risk of hospital readmission.
Collapse
Affiliation(s)
- Ernest R Vina
- University of Arizona Arthritis Center, University of Arizona School of Medicine, Tucson, AZ, USA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, USA.,University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Aliya Collier
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Charles L Nelson
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Said A Ibrahim
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, PA, USA
| |
Collapse
|
26
|
Goldberg D, Kallan MJ, Fu L, Ciccarone M, Ramirez J, Rosenberg P, Arnold J, Segal G, Moritsugu KP, Nathan H, Hasz R, Abt PL. Changing Metrics of Organ Procurement Organization Performance in Order to Increase Organ Donation Rates in the United States. Am J Transplant 2017; 17:3183-3192. [PMID: 28726327 DOI: 10.1111/ajt.14391] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [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: 03/14/2017] [Revised: 06/05/2017] [Accepted: 06/05/2017] [Indexed: 01/25/2023]
Abstract
The shortage of deceased-donor organs is compounded by donation metrics that fail to account for the total pool of possible donors, leading to ambiguous donor statistics. We sought to assess potential metrics of organ procurement organizations (OPOs) utilizing data from the Nationwide Inpatient Sample (NIS) from 2009-2012 and State Inpatient Databases (SIDs) from 2008-2014. A possible donor was defined as a ventilated inpatient death ≤75 years of age, without multi-organ system failure, sepsis, or cancer, whose cause of death was consistent with organ donation. These estimates were compared to patient-level data from chart review from two large OPOs. Among 2,907,658 inpatient deaths from 2009-2012, 96,028 (3.3%) were a "possible deceased-organ donor." The two proposed metrics of OPO performance were: (1) donation percentage (percentage of possible deceased-donors who become actual donors; range: 20.0-57.0%); and (2) organs transplanted per possible donor (range: 0.52-1.74). These metrics allow for comparisons of OPO performance and geographic-level donation rates, and identify areas in greatest need of interventions to improve donation rates. We demonstrate that administrative data can be used to identify possible deceased donors in the US and could be a data source for CMS to implement new OPO performance metrics in a standardized fashion.
Collapse
Affiliation(s)
- D Goldberg
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, PA.,Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - M J Kallan
- Department of Epidemiology, Biostatistics, and Informatics, University of Pennsylvania, Philadelphia, PA
| | - L Fu
- The Bridgespan Group, New York, NY
| | | | | | | | | | | | - K P Moritsugu
- Former Acting Surgeon General of the United States, Great Falls, MT
| | - H Nathan
- Gift of Life Institute, Philadelphia, PA
| | - R Hasz
- Gift of Life Institute, Philadelphia, PA
| | - P L Abt
- Division of Transplant Surgery, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
27
|
Medford-Davis LN, Holena DN, Karp D, Kallan MJ, Delgado MK. Which transfers can we avoid: Multi-state analysis of factors associated with discharge home without procedure after ED to ED transfer for traumatic injury. Am J Emerg Med 2017; 36:797-803. [PMID: 29055613 DOI: 10.1016/j.ajem.2017.10.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 07/06/2017] [Revised: 10/07/2017] [Accepted: 10/09/2017] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Among injured patients transferred from one emergency department (ED) to another, we determined factors associated with being discharged from the second ED without procedures, or admission or observation. METHODS We analyzed all patients with injury diagnosis codes transferred between two EDs in the 2011 Healthcare Utilization Project State Emergency Department and State Inpatient Databases for 6 states. Multivariable hierarchical logistic regression evaluated the association between patient (demographics and clinical characteristics) and hospital factors, and discharge from the second ED without coded procedures. RESULTS In 2011, there were a total of 48,160 ED-to-ED injury transfers, half of which (49%) were transferred to non-trauma centers, including 23% with major trauma. A total of 22,011 transfers went to a higher level of care, of which 36% were discharged from the ED without procedures. Relative to torso injuries, discharge without procedures was more likely for patients with soft tissue (OR 6.8, 95%CI 5.6-8.2), head (OR 3.7, 95%CI 3.1-4.6), facial (OR 3.8, 95%CI 3.1-4.7), or hand (OR 3.1, 95%CI 2.6-3.8) injuries. Other factors included Medicaid (OR 1.3, 95%CI 1.2-1.5) or uninsured (OR 1.3, 95%CI 1.2-1.5) status. Treatment at the receiving ED added an additional $2859 on average (95% CI $2750-$2968) per discharged patient to the total charges for injury care, not including the costs of ambulance transport between facilities. CONCLUSION Over a third of patients transferred to another ED for traumatic injury are discharged from the second ED without admission, observation, or procedures. Telemedicine consultation with sub-specialists might reduce some of these transfers.
Collapse
Affiliation(s)
- Laura N Medford-Davis
- Department of Emergency Medicine, Baylor College of Medicine, 1504 Taub Loop, Houston, TX 77030, United States.
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine, University of Pennsylvania, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
| | - David Karp
- University of Pennsylvania Wharton Geographic Information Systems Lab, 923 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - Michael J Kallan
- University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States.
| | - M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, 933 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; University of Pennsylvania Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, 523 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Colonial Penn Center, 3641 Locust Walk, Philadelphia, PA 19104, United States.
| |
Collapse
|
28
|
Pierce JT, Kositratna G, Attiah MA, Kallan MJ, Koenigsberg R, Syre P, Wyler D, Marcotte PJ, Kofke WA, Welch WC. Efficiency of spinal anesthesia versus general anesthesia for lumbar spinal surgery: a retrospective analysis of 544 patients. Local Reg Anesth 2017; 10:91-98. [PMID: 29066932 PMCID: PMC5644537 DOI: 10.2147/lra.s141233] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 11/23/2022] Open
Abstract
Background Previous studies have shown varying results in selected outcomes when directly comparing spinal anesthesia to general in lumbar surgery. Some studies have shown reduced surgical time, postoperative pain, time in the postanesthesia care unit (PACU), incidence of urinary retention, postoperative nausea, and more favorable cost-effectiveness with spinal anesthesia. Despite these results, the current literature has also shown contradictory results in between-group comparisons. Materials and methods A retrospective analysis was performed by querying the electronic medical record database for surgeries performed by a single surgeon between 2007 and 2011 using procedural codes 63030 for diskectomy and 63047 for laminectomy: 544 lumbar laminectomy and diskectomy surgeries were identified, with 183 undergoing general anesthesia and 361 undergoing spinal anesthesia (SA). Linear and multivariate regression analyses were performed to identify differences in blood loss, operative time, time from entering the operating room (OR) until incision, time from bandage placement to exiting the OR, total anesthesia time, PACU time, and total hospital stay. Secondary outcomes of interest included incidence of postoperative spinal hematoma and death, incidence of paraparesis, plegia, post-dural puncture headache, and paresthesia, among the SA patients. Results SA was associated with significantly lower operative time, blood loss, total anesthesia time, time from entering the OR until incision, time from bandage placement until exiting the OR, and total duration of hospital stay, but a longer stay in the PACU. The SA group experienced one spinal hematoma, which was evacuated without any long-term neurological deficits, and neither group experienced a death. The SA group had no episodes of paraparesis or plegia, post-dural puncture headaches, or episodes of persistent postoperative paresthesia or weakness. Conclusion SA is effective for use in patients undergoing elective lumbar laminectomy and/or diskectomy spinal surgery, and was shown to be the more expedient anesthetic choice in the perioperative setting.
Collapse
Affiliation(s)
| | | | | | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania
| | | | | | - David Wyler
- Department of Anesthesiology and Critical Care, Neurosurgery, Jefferson Hospital of Neuroscience, Thomas Jefferson University, Philadelphia PA, USA
| | | | - W Andrew Kofke
- Department of Neurosurgery.,Department of Anesthesiology and Critical Care
| | | |
Collapse
|
29
|
Re VL, Zeldow B, Kallan MJ, Tate JP, Carbonari DM, Hennessy S, Kostman JR, Lim JK, Goetz MB, Gross R, Justice AC, Roy JA. Risk of liver decompensation with cumulative use of mitochondrial toxic nucleoside analogues in HIV/hepatitis C virus coinfection. Pharmacoepidemiol Drug Saf 2017; 26:1172-1181. [PMID: 28722244 PMCID: PMC5624832 DOI: 10.1002/pds.4258] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 05/13/2017] [Accepted: 06/13/2017] [Indexed: 01/06/2023]
Abstract
PURPOSE Among patients dually infected with human immunodeficiency virus (HIV) and chronic hepatitis C virus (HCV), use of antiretroviral therapy (ART) containing mitochondrial toxic nucleoside reverse transcriptase inhibitors (mtNRTIs) might induce chronic hepatic injury, which could accelerate HCV-associated liver fibrosis and increase the risk of hepatic decompensation and death. METHODS We conducted a cohort study among 1747 HIV/HCV patients initiating NRTI-containing ART within the Veterans Aging Cohort Study (2002-2009) to determine if cumulative mtNRTI use increased the risk of hepatic decompensation and death among HIV-/HCV-coinfected patients. Separate marginal structural models were used to estimate hazard ratios (HRs) of each outcome associated with cumulative exposure to ART regimens that contain mtNRTIs versus regimens that contain other NRTIs. RESULTS Over 7033 person-years, we observed 97 (5.6%) decompensation events (incidence rate, 13.8/1000 person-years) and 125 (7.2%) deaths (incidence rate, 17.8 events/1000 person-years). The risk of hepatic decompensation increased with cumulative mtNRTI use (1-11 mo: HR, 1.79 [95% confidence interval (CI), 0.74-4.31]; 12-35 mo: HR, 1.39 [95% CI, 0.68-2.87]; 36-71 mo: HR, 2.27 [95% CI, 0.92-5.60]; >71 mo: HR, 4.66 [95% CI, 1.04-20.83]; P = .045) versus nonuse. Cumulative mtNRTI use also increased risk of death (1-11 mo: HR, 2.24 [95% CI, 1.04-4.81]; 12-35 mo: HR, 2.05 [95% CI, 0.68-6.20]; 36-71 mo: HR, 3.04 [95% CI, 1.12-8.26]; >71 mo: HR, 3.93 [95% CI, 0.75-20.50]; P = .030). CONCLUSIONS These findings suggest that cumulative mtNRTI use may increase the risk of hepatic decompensation and death in HIV/HCV coinfection. These drugs should be avoided when alternatives exist for HIV/HCV patients.
Collapse
Affiliation(s)
- Vincent Lo Re
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Medical Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Bret Zeldow
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Michael J. Kallan
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Janet P. Tate
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Dena M. Carbonari
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sean Hennessy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jay R. Kostman
- John Bell Health Center, Philadelphia Field Initiating Group for HIV Trials, Philadelphia, PA
| | - Joseph K. Lim
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Robert Gross
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Medical Service, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Amy C. Justice
- VA Connecticut Healthcare System, West Haven, CT
- Yale University School of Medicine, New Haven, CT
| | - Jason A. Roy
- Department of Biostatistics and Epidemiology, Center for Clinical Epidemiology and Biostatistics, and Center for Pharmacoepidemiology Research and Training, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| |
Collapse
|
30
|
Winkels RM, Sturgeon KM, Kallan MJ, Dean LT, Zhang Z, Evangelisti M, Brown JC, Sarwer DB, Troxel AB, Denlinger C, Laudermilk M, Fornash A, DeMichele A, Chodosh LA, Schmitz KH. The women in steady exercise research (WISER) survivor trial: The innovative transdisciplinary design of a randomized controlled trial of exercise and weight-loss interventions among breast cancer survivors with lymphedema. Contemp Clin Trials 2017; 61:63-72. [PMID: 28739540 PMCID: PMC5817634 DOI: 10.1016/j.cct.2017.07.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2017] [Revised: 07/05/2017] [Accepted: 07/20/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Breast cancer survivors face dual challenges: long term sequelae of treatment, and risk of recurrent disease. Obesity and a sedentary lifestyle complicate both challenges. The WISER Survivor trial assessed the effects of exercise and/or weight-loss on lymphedema, biomarkers of breast cancer recurrence, and quality of life. We report on the innovative transdisciplinary design of this trial and report attrition rates. METHODS This one year trial randomized breast cancer survivors who had a BMI of ≥25kg/m2, were sedentary and had breast-cancer-related-lymphedema to 1) exercise (weight training and aerobic exercise) 2) weight-loss 3) exercise and weight-loss 4) or control group. Innovative aspects included: adaptation of a community-based weight training program to a largely home-based program; use of a commercial meal replacement system as part of the lifestyle modification weight-loss program; inclusion of measures of cost-effectiveness to enable economic evaluations; and alignment with a parallel mouse model for breast cancer recurrence to enable transdisciplinary research. In this model, mice bearing dormant residual tumor cells, which spontaneously relapse, were placed on a high-fat diet. Overweight animals were randomly assigned to exercise, calorie restriction, both, or control group and followed for cancer recurrence. The animal model will guide mechanistic biomarkers to be tested in the human trial. RESULTS & DISCUSSION 351 participants were randomized; 13 experienced breast cancer recurrence during the trial. Of the 338 participants without recurrence, 83% completed the trial. The WISER Survivor trial will show the effects of exercise and weight-loss on lymphedema outcomes, biomarkers of recurrence and quality of life. NCT ClinicalTrials.gov registration #: NCT01515124.
Collapse
Affiliation(s)
- Renate M Winkels
- Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, United States
| | - Kathleen M Sturgeon
- Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, United States
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Lorraine T Dean
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States
| | - Zi Zhang
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Margaret Evangelisti
- Center for Human Phenomic Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Justin C Brown
- Division of Population Sciences, Dana Farber Cancer Institute, Boston, MA, United States
| | - David B Sarwer
- Center for Obesity Research and Education, College of Public Health, Temple University, Philadelphia, PA, United States
| | - Andrea B Troxel
- Department of Population Health, New York University School of Medicine, New York City, NY, United States
| | - Crystal Denlinger
- Department of Hematology/Oncology, Fox Chase Cancer Centre, Philadelphia, PA, United States
| | | | - Anna Fornash
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Angela DeMichele
- Division of Hematology/Oncology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Lewis A Chodosh
- Department of Cancer Biology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Kathryn H Schmitz
- Department of Public Health Sciences, Pennsylvania State University, Hershey, PA, United States.
| |
Collapse
|
31
|
Boehme AK, Carr BG, Kasner SE, Albright KC, Kallan MJ, Elkind MSV, Branas CC, Mullen MT. Sex Differences in rt-PA Utilization at Hospitals Treating Stroke: The National Inpatient Sample. Front Neurol 2017; 8:500. [PMID: 29021776 PMCID: PMC5623663 DOI: 10.3389/fneur.2017.00500] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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] [Received: 04/06/2017] [Accepted: 09/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background and purpose Sex and race disparities in recombinant tissue plasminogen activator (rt-PA) use have been reported. We sought to explore sex and race differences in the utilization of rt-PA at primary stroke centers (PSCs) compared to non-PSCs across the US. Methods Data from the National (Nationwide) Inpatient Sample (NIS) 2004–2010 was utilized to assess sex differences in treatment for ischemic stroke in PSCs compared to non-PSCs. Results There were 304,152 hospitalizations with a primary diagnosis of ischemic stroke between 2004 and 2010 in the analysis: 75,160 (24.7%) patients were evaluated at a PSC. A little over half of the patients evaluated at PSCs were female (53.8%). A lower proportion of women than men received rt-PA at both PSCs (6.8 vs. 7.5%, p < 0.001) and non-PSCs (2.3 vs. 2.8%, p < 0.001). After adjustment for potential confounders the odds of being treated with rt-PA remained lower for women regardless of presentation to a PSC (OR 0.87, 95% CI 0.81–0.94) or non-PSC (OR 0.88, 95% CI 0.82–0.94). After stratifying by sex and race, the lowest absolute treatment rates were observed in black women (4.4% at PSC, 1.9% at non-PSC). The odds of treatment, relative to white men, was however lowest for white women (PSC OR = 0.85, 95% CI 0.78–0.93; non-PSC OR = 0.80, 95% CI 0.75–0.85). In the multivariable model, sex did not modify the effect of PSC certification on rt-PA utilization (p-value for interaction = 0.58). Conclusion Women are less likely to receive rt-PA than men at both PSCs and non-PSCs. Absolute treatment rates are lowest in black women, although the relative difference in men and women was greatest for white women.
Collapse
Affiliation(s)
- Amelia K Boehme
- Department of Neurology, Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY, United States.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States.,Department of Epidemiology, School of Public Health, Birmingham, AL, United States
| | - Brendan G Carr
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Scott Eric Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States
| | - Karen C Albright
- Department of Epidemiology, School of Public Health, Birmingham, AL, United States.,Geriatric Research Education and Clinical Center (GRECC), Birmingham VA Medical Center, Birmingham, AL, United States.,Department of Neurology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Mitchell S V Elkind
- Department of Neurology, Mailman School of Public Health, College of Physicians and Surgeons, Columbia University, New York, NY, United States.,Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, United States
| | - Charles C Branas
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, United States.,Leonard Davis Health Institute, University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
32
|
Johnston JM, Wilson JM, Smith AL, Farrar JT, Kallan MJ, Veeder CL. Using a Cageside Device for Testing Glycosylated Hemoglobin in Cynomolgus Macaques ( Macaca fascicularis). J Am Assoc Lab Anim Sci 2017; 56:90-94. [PMID: 28905721 PMCID: PMC5250501] [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] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/11/2016] [Accepted: 08/12/2016] [Indexed: 06/07/2023]
Abstract
Nonhuman primates naturally develop type 2 diabetes mellitus and exhibit clinical features that are similar to those observed in humans, including obesity, insulin resistance, dyslipidemia, and pancreatic pathology. The glycosylated hemoglobin (HbA1C) test is the primary test used for diabetes management in humans because it reflects the average blood glucose levels over the previous 3 mo. The HbA1C results are a better predictor of potential risk of complications than are single or episodic measures of glucose levels. HbA1C levels have proven useful for the diagnosis and monitoring of blood glucose levels in NHP, but for testing by a commercial laboratory, the test requires a vial of whole blood, results are not available for several days, and the test is expensive. The cageside device requires a single drop of blood, it displays the HbA1C percentage in 5 min, and the cost per sample is less than for sending it to a commercial lab. We therefore assessed the correlation between a cageside test using a handheld unit and the commercial lab test for measuring HbA1C in cynomolgus macaques. From both normal and confirmed diabetic animals, 4 mL blood was collected from a peripheral vessel and sent to a commercial lab for HbA1C testing. At the same time, a drop of capillary blood was collected and tested immediately in the HbA1C cageside test. A comparison of the results revealed significant correlation between the cageside and commercial lab tests. Therefore, we feel that the HbA1C test using handheld device may help to rule out nondiabetics and indicate which animals require additional testing.
Collapse
Affiliation(s)
- Jessica M Johnston
- Department of Pathobiology, University Laboratory Animal Resources, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, USA
| | - Jolaine M Wilson
- Laboratory Animal Services, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Abigail L Smith
- Department of Pathobiology, University Laboratory Animal Resources, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, USA
| | - John T Farrar
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Christin L Veeder
- University Laboratory Animal Resources, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, USA.
| |
Collapse
|
33
|
Durnwald CP, Kallan MJ, Allison KC, Sammel MD, Wisch S, Elovitz M, Parry S. A Randomized Clinical Trial of an Intensive Behavior Education Program in Gestational Diabetes Mellitus Women Designed to Improve Glucose Levels on the 2-Hour Oral Glucose Tolerance Test. Am J Perinatol 2016; 33:1145-51. [PMID: 27398697 DOI: 10.1055/s-0036-1585085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 10/21/2022]
Abstract
Objective To evaluate whether women with gestational diabetes mellitus (GDM) enrolled in an intensive behavior education program (IBEP) demonstrate lower mean fasting glucose levels on the 2-hour 75 g oral glucose tolerance test (2-hour OGTT) at 6 to 12 weeks postpartum compared with women who undergo routine GDM management. Study Design A prospective randomized controlled trial of women diagnosed with GDM was conducted. Exclusion criteria were GDM diagnosis ≥ 33 weeks or < 20 weeks. Women were randomly assigned to one of two treatment arms: (1) routine GDM management or (2) an IBEP. Women underwent a 2-hour OGTT at 6 to 12 weeks postpartum. Fisher exact test, t-test, and Wilcoxon rank sum test were used as appropriate. Results Of the 101 women randomized, 49 were assigned to IBEP and 52 received routine GDM management. There was no difference in mean fasting and 2-hour glucose levels on the postpartum 2-hour OGTT between the IBEP and routine management group (88.5 ± 22.9 mg/dL vs. 85.2 ± 13.3 mg/dL, p = 0.49 and 109.8 ± 38.5 mg/dL vs. 109.4 ± 40.8 mg/dL, p = 0.97, respectively). Conclusion GDM women enrolled in a healthy lifestyle intervention program did not demonstrate lower glucose values on the postpartum 2-hour OGTT.
Collapse
Affiliation(s)
- Celeste P Durnwald
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael J Kallan
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kelly C Allison
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mary D Sammel
- Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Susan Wisch
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michal Elovitz
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Samuel Parry
- Maternal and Child Health Research Program, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
34
|
Aparicio HJ, Carr BG, Kasner SE, Kallan MJ, Albright KC, Kleindorfer DO, Mullen MT. Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers. J Am Heart Assoc 2015; 4:e001877. [PMID: 26467999 PMCID: PMC4845141 DOI: 10.1161/jaha.115.001877] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Primary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial disparities in rt-PA use is unknown. METHODS AND RESULTS We used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt-PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis-related group-based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt-PA than whites at non-PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt-PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt-PA did not reach significance (P=0.98). CONCLUSIONS Racial disparities in intravenous rt-PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non-PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt-PA in the fully adjusted model.
Collapse
Affiliation(s)
- Hugo J Aparicio
- Department of Neurology, Boston University, Boston, MA (H.J.A.) Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Brendan G Carr
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA (B.G.C.)
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.)
| | - Michael J Kallan
- Center for Clinical Epidemiology & Biostatistics, University of Pennsylvania, Philadelphia, PA (M.J.K.)
| | - Karen C Albright
- Health Services and Outcomes Research Center for Outcome and Effectiveness Research and Education, University of Alabama at Birmingham, AL (K.C.A.) Center of Excellence in Comparative Effectiveness Research for Eliminating Disparities/Minority Health & Health Disparities Research Center, University of Alabama at Birmingham, AL (K.C.A.) Department of Epidemiology, University of Alabama at Birmingham, AL (K.C.A.)
| | | | - Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA (H.J.A., S.E.K., M.T.M.) Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA (M.T.M.)
| |
Collapse
|
35
|
Lo Re V, Kallan MJ, Tate JP, Lim JK, Goetz MB, Klein MB, Rimland D, Rodriguez-Barradas MC, Butt AA, Gibert CL, Brown ST, Park LS, Dubrow R, Reddy KR, Kostman JR, Justice AC, Localio AR. Predicting Risk of End-Stage Liver Disease in Antiretroviral-Treated Human Immunodeficiency Virus/Hepatitis C Virus-Coinfected Patients. Open Forum Infect Dis 2015; 2:ofv109. [PMID: 26284259 PMCID: PMC4536329 DOI: 10.1093/ofid/ofv109] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [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] [Received: 06/03/2015] [Accepted: 07/05/2015] [Indexed: 12/15/2022] Open
Abstract
Background. End-stage liver disease (ESLD) is an important cause of morbidity among human immunodeficiency virus (HIV)/hepatitis C virus (HCV)-coinfected patients. Quantifying the risk of this outcome over time could help determine which coinfected patients should be targeted for risk factor modification and HCV treatment. We evaluated demographic, clinical, and laboratory variables to predict risk of ESLD in HIV/HCV-coinfected patients receiving antiretroviral therapy (ART). Methods. We conducted a retrospective cohort study among 6016 HIV/HCV-coinfected patients who received ART within the Veterans Health Administration between 1997 and 2010. The main outcome was incident ESLD, defined by hepatic decompensation, hepatocellular carcinoma, or liver-related death. Cox regression was used to develop prognostic models based on baseline demographic, clinical, and laboratory variables, including FIB-4 and aspartate aminotransferase-to-platelet ratio index, previously validated markers of hepatic fibrosis. Model performance was assessed by discrimination and decision curve analysis. Results. Among 6016 HIV/HCV patients, 532 (8.8%) developed ESLD over a median of 6.6 years. A model comprising FIB-4 and race had modest discrimination for ESLD (c-statistic, 0.73) and higher net benefit than alternative strategies of treating no or all coinfected patients at relevant risk thresholds. For FIB-4 >3.25, ESLD risk ranged from 7.9% at 1 year to 26.0% at 5 years among non-blacks and from 2.4% at 1 year to 14.0% at 5 years among blacks. Conclusions. Race and FIB-4 provided important predictive information on ESLD risk among HIV/HCV patients. Estimating risk of ESLD using these variables could help direct HCV treatment decisions among HIV/HCV-coinfected patients.
Collapse
Affiliation(s)
- Vincent Lo Re
- Departments of Medicine ; Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia ; Medical Service , Philadelphia VA Medical Center , Pennsylvania
| | - Michael J Kallan
- Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia
| | - Janet P Tate
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - Joseph K Lim
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - Matthew Bidwell Goetz
- VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , California
| | - Marina B Klein
- Chronic Viral Illness Service , McGill University Health Centre , Montreal , Canada
| | - David Rimland
- Atlanta VA Medical Center and Emory University School of Medicine , Georgia
| | - Maria C Rodriguez-Barradas
- Infectious Diseases Section, Michael E. DeBakey VA Medical Center and Department of Medicine , Baylor College of Medicine , Houston, Texas
| | - Adeel A Butt
- VA Pittsburgh Healthcare System , Pennsylvania ; Hamad Healthcare Quality Institute , Doha, Qatar ; Hamad Medical Corporation , Doha, Qatar
| | - Cynthia L Gibert
- Washington DC VA Medical Center , George Washington University Medical Center , Washington, District of Columbia
| | - Sheldon T Brown
- James J. Peters VA Medical Center and Mt. Sinai School of Medicine , New York, New York
| | - Lesley S Park
- Yale University School of Medicine , New Haven, Connecticut ; Yale School of Public Health , New Haven, Connecticut
| | - Robert Dubrow
- Yale University School of Medicine , New Haven, Connecticut ; Yale School of Public Health , New Haven, Connecticut
| | | | | | - Amy C Justice
- VA Connecticut Healthcare System , West Haven ; Yale University School of Medicine , New Haven, Connecticut
| | - A Russell Localio
- Biostatistics and Epidemiology and Center for Clinical Epidemiology and Biostatistics , Perelman School of Medicine, University of Pennsylvania , Philadelphia
| |
Collapse
|
36
|
Durbin DR, Jermakian JS, Kallan MJ, McCartt AT, Arbogast KB, Zonfrillo MR, Myers RK. Rear seat safety: Variation in protection by occupant, crash and vehicle characteristics. Accid Anal Prev 2015; 80:185-192. [PMID: 25912100 DOI: 10.1016/j.aap.2015.04.006] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 04/06/2015] [Accepted: 04/09/2015] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Current information on the safety of rear row occupants of all ages is needed to inform further advances in rear seat restraint system design and testing. The objectives of this study were to describe characteristics of occupants in the front and rear rows of model year 2000 and newer vehicles involved in crashes and determine the risk of serious injury for restrained crash-involved rear row occupants and the relative risk of fatal injury for restrained rear row vs. front passenger seat occupants by age group, impact direction, and vehicle model year. METHOD Data from the National Automotive Sampling System Crashworthiness Data System (NASS-CDS) and Fatality Analysis Reporting System (FARS) were queried for all crashes during 2007-2012 involving model year 2000 and newer passenger vehicles. Data from NASS-CDS were used to describe characteristics of occupants in the front and rear rows and to determine the risk of serious injury (AIS 3+) for restrained rear row occupants by occupant age, vehicle model year, and impact direction. Using a combined data set containing data on fatalities from FARS and estimates of the total population of occupants in crashes from NASS-CDS, logistic regression modeling was used to compute the relative risk (RR) of death for restrained occupants in the rear vs. front passenger seat by occupant age, impact direction, and vehicle model year. RESULTS Among all vehicle occupants in tow-away crashes during 2007-2012, 12.3% were in the rear row where the overall risk of serious injury was 1.3%. Among restrained rear row occupants, the risk of serious injury varied by occupant age, with older adults at the highest risk of serious injury (2.9%); by impact direction, with rollover crashes associated with the highest risk (1.5%); and by vehicle model year, with model year 2007 and newer vehicles having the lowest risk of serious injury (0.3%). Relative risk of death was lower for restrained children up to age 8 in the rear compared with passengers in the right front seat (RR=0.27, 95% CI 0.12-0.58 for 0-3 years, RR=0.55, 95% CI 0.30-0.98 for 4-8 years) but was higher for restrained 9-12-year-old children (RR=1.83, 95% CI 1.18-2.84). There was no evidence for a difference in risk of death in the rear vs. front seat for occupants ages 13-54, but there was some evidence for an increased relative risk of death for adults age 55 and older in the rear vs. passengers in the right front seat (RR=1.41, 95% CI 0.94-2.13), though we could not exclude the possibility of no difference. After controlling for occupant age and gender, the relative risk of death for restrained rear row occupants was significantly higher than that of front seat occupants in model year 2007 and newer vehicles and significantly higher in rear and right side impact crashes. CONCLUSIONS Results of this study extend prior research on the relative safety of the rear seat compared with the front by examining a more contemporary fleet of vehicles. The rear row is primarily occupied by children and adolescents, but the variable relative risk of death in the rear compared with the front seat for occupants of different age groups highlights the challenges in providing optimal protection to a wide range of rear seat occupants. Findings of an elevated risk of death for rear row occupants, as compared with front row passengers, in the newest model year vehicles provides further evidence that rear seat safety is not keeping pace with advances in the front seat.
Collapse
Affiliation(s)
- Dennis R Durbin
- The Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, United States; The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia Research Institute, United States; The Insurance Institute for Highway Safety, United States.
| | | | - Michael J Kallan
- The Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Anne T McCartt
- The Insurance Institute for Highway Safety, United States
| | - Kristy B Arbogast
- The Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, United States; The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia Research Institute, United States
| | - Mark R Zonfrillo
- The Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, United States; The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia Research Institute, United States
| | - Rachel K Myers
- The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia Research Institute, United States
| |
Collapse
|
37
|
Quinley KE, Falck A, Kallan MJ, Datner EM, Carr BG, Schreiber CA. Validation of ICD-9 Codes for Stable Miscarriage in the Emergency Department. West J Emerg Med 2015; 16:551-6. [PMID: 26265967 PMCID: PMC4530913 DOI: 10.5811/westjem.2015.4.24946] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Revised: 03/28/2015] [Accepted: 04/26/2015] [Indexed: 11/16/2022] Open
Abstract
Introduction International Classification of Disease, Ninth Revision (ICD-9) diagnosis codes have not been validated for identifying cases of missed abortion where a pregnancy is no longer viable but the cervical os remains closed. Our goal was to assess whether ICD-9 code “632” for missed abortion has high sensitivity and positive predictive value (PPV) in identifying patients in the emergency department (ED) with cases of stable early pregnancy failure (EPF). Methods We studied females ages 13–50 years presenting to the ED of an urban academic medical center. We approached our analysis from two perspectives, evaluating both the sensitivity and PPV of ICD-9 code “632” in identifying patients with stable EPF. All patients with chief complaints “pregnant and bleeding” or “pregnant and cramping” over a 12-month period were identified. We randomly reviewed two months of patient visits and calculated the sensitivity of ICD-9 code “632” for true cases of stable miscarriage. To establish the PPV of ICD-9 code “632” for capturing missed abortions, we identified patients whose visits from the same time period were assigned ICD-9 code “632,” and identified those with actual cases of stable EPF. Results We reviewed 310 patient records (17.6% of 1,762 sampled). Thirteen of 31 patient records assigned ICD-9 code for missed abortion correctly identified cases of stable EPF (sensitivity=41.9%), and 140 of the 142 patients without EPF were not assigned the ICD-9 code “632”(specificity=98.6%). Of the 52 eligible patients identified by ICD-9 code “632,” 39 cases met the criteria for stable EPF (PPV=75.0%). Conclusion ICD-9 code “632” has low sensitivity for identifying stable EPF, but its high specificity and moderately high PPV are valuable for studying cases of stable EPF in epidemiologic studies using administrative data.
Collapse
Affiliation(s)
- Kelly E Quinley
- Highland Hospital of Alameda Health System, Department of Emergency Medicine, Oakland, California
| | - Ailsa Falck
- James Madison University, Harrisonburg, Virginia
| | - Michael J Kallan
- Perelman School of Medicine, University of Pennsylvania, Center for Clinical Epidemiology and Biostatistics, Philadelphia, Pennsylvania
| | - Elizabeth M Datner
- Perelman School of Medicine, University of Pennsylvania, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Brendan G Carr
- Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Courtney A Schreiber
- Perelman School of Medicine, University of Pennsylvania, Department of Obstetrics and Gynecology, Philadelphia, Pennsylvania
| |
Collapse
|
38
|
Gaieski DF, Edwards JM, Kallan MJ, Mikkelsen ME, Goyal M, Carr BG. The relationship between hospital volume and mortality in severe sepsis. Am J Respir Crit Care Med 2014; 190:665-74. [PMID: 25117723 DOI: 10.1164/rccm.201402-0289oc] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
RATIONALE Severe sepsis is increasing in incidence and has a high rate of inpatient mortality. Hospitals that treat a larger number of patients with severe sepsis may offer a survival advantage. OBJECTIVES We sought to assess the effect of severe sepsis case volume on mortality, hypothesizing that higher volume centers would have lower rates of inpatient death. METHODS We performed a retrospective cohort study over a 7-year period (2004-2010), using a nationally representative sample of hospital admissions, examining the relation between volume, urban location, organ dysfunction, and survival. MEASUREMENTS AND MAIN RESULTS To identify potential differences in outcomes, hospitals were divided into five categories (<50, 50-99, 100-249, 250-499, and 500+ annual cases) and adjusted mortality was compared by volume. A total of 914,200 patients with severe sepsis were identified over a 7-year period (2004-2010). Overall in-hospital mortality was 28.1%. In a fully adjusted model, there was an inverse relationship between severe sepsis case volume and inpatient mortality. Hospitals in the highest volume category had substantially improved survival compared with hospitals with the lowest case volume (adjusted odds ratio, 0.64; 95% confidence interval, 0.60-0.69). In cases of severe sepsis with one reported organ dysfunction, a mortality of 18.9% was found in hospitals with fewer than 50 annual cases compared with 10.4% in hospitals treating 500+ cases (adjusted odds ratio, 0.54; 95% confidence interval, 0.49-0.59). Similar differences were found in patients with up to three total organ dysfunctions. CONCLUSIONS Patients with severe sepsis treated in hospitals with higher case volumes had improved adjusted outcomes.
Collapse
Affiliation(s)
- David F Gaieski
- 1 Department of Emergency Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | | | | | | | | |
Collapse
|
39
|
Lo Re V, Kallan MJ, Tate JP, Localio AR, Lim JK, Goetz MB, Klein MB, Rimland D, Rodriguez-Barradas MC, Butt AA, Gibert CL, Brown ST, Park L, Dubrow R, Reddy KR, Kostman JR, Strom BL, Justice AC. Hepatic decompensation in antiretroviral-treated patients co-infected with HIV and hepatitis C virus compared with hepatitis C virus-monoinfected patients: a cohort study. Ann Intern Med 2014; 160:369-79. [PMID: 24723077 PMCID: PMC4254786 DOI: 10.7326/m13-1829] [Citation(s) in RCA: 119] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The incidence and determinants of hepatic decompensation have been incompletely examined among patients co-infected with HIV and hepatitis C virus (HCV) in the antiretroviral therapy (ART) era, and few studies have compared outcome rates with those of patients with chronic HCV alone. OBJECTIVE To compare the incidence of hepatic decompensation between antiretroviral-treated patients co-infected with HIV and HCV and HCV-monoinfected patients and to evaluate factors associated with decompensation among co-infected patients receiving ART. DESIGN Retrospective cohort study. SETTING Veterans Health Administration. PATIENTS 4280 co-infected patients who initiated ART and 6079 HCV-monoinfected patients receiving care between 1997 and 2010. All patients had detectable HCV RNA and were HCV treatment-naive. MEASUREMENTS Incident hepatic decompensation, determined by diagnoses of ascites, spontaneous bacterial peritonitis, or esophageal variceal hemorrhage. RESULTS The incidence of hepatic decompensation was greater among co-infected than monoinfected patients (7.4% vs. 4.8% at 10 years; P < 0.001). Compared with HCV-monoinfected patients, co-infected patients had a higher rate of hepatic decompensation (hazard ratio [HR] accounting for competing risks, 1.56 [95% CI, 1.31 to 1.86]). Co-infected patients who maintained HIV RNA levels less than 1000 copies/mL still had higher rates of decompensation than HCV-monoinfected patients (HR, 1.44 [CI, 1.05 to 1.99]). Baseline advanced hepatic fibrosis (FIB-4 score >3.25) (HR, 5.45 [CI, 3.79 to 7.84]), baseline hemoglobin level less than 100 g/L (HR, 2.24 [CI, 1.20 to 4.20]), diabetes mellitus (HR, 1.88 [CI, 1.38 to 2.56]), and nonblack race (HR, 2.12 [CI, 1.65 to 2.72]) were each associated with higher rates of decompensation among co-infected patients. LIMITATION Observational study of predominantly male patients. CONCLUSION Despite receiving ART, patients co-infected with HIV and HCV had higher rates of hepatic decompensation than HCV-monoinfected patients. Rates of decompensation were higher for co-infected patients with advanced liver fibrosis, severe anemia, diabetes, and nonblack race. PRIMARY FUNDING SOURCE National Institutes of Health.
Collapse
|
40
|
Aparicio HJ, Carr BG, Kasner SE, Albright KC, Kallan MJ, Kleindorfer DO, Mullen MT. Abstract W P308: Racial Disparities in IV rt-PA Use Persist at Primary Stroke Centers. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp308] [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
Background:
Primary Stroke Centers (PSCs) utilize more recombinant tissue plasminogen activator (rt-PA) than non-PSCs. The impact of PSCs on racial and ethnic disparities in rt-PA usage is unknown. We sought to evaluate for differential access to PSCs and disparities in rt-PA use using an administrative database.
Methods:
The Nationwide Inpatient Sample was used from 2004-2010, limited to states that publicly reported both hospital identity and race/ethnicity. Patients ≥18 years with a primary ICD9 diagnosis of ischemic stroke (433.x1, 434.x1, 436) were included. Data from The Joint Commission was used to identify PSCs and determine if evaluating hospitals were certified at admission. Rt-PA was defined by ICD9 code 99.10. Multivariable models were constructed, additionally adjusting for year, age, sex, insurance, medical comorbidities, a DRG-based mortality risk indicator, ZIP code median income, and hospital characteristics.
Results:
Data from 26 states met eligibility criteria, including 304,152 discharges of which there were 71.5% White, 15.0% Black, 7.9% Hispanic, and 5.6% Other (Asian/Pacific Islander, Native American, or other). Overall, 24.7% of White, 27.4% of Black, 16.2% of Hispanic, and 29.8% of Other patients presented to PSCs. A higher proportion received rt-PA at PSCs than non-PSCs in all racial/ethnic groups (White 7.6% vs 2.6%, Black 4.8% vs 2.0%, Hispanic 7.1% vs 2.4%, Other 7.2% vs 2.5%). In the fully adjusted model Blacks were less likely to receive rt-PA than Whites at non-PSCs (OR=0.58, 95% CI 0.50-0.67) and PSCs (OR=0.63, 95% CI 0.54-0.74). This disparity was consistent across all subgroups (Figure 1).
Conclusions:
Black patients were less likely to receive rt-PA than White patients at both non-PSCs and PSCs. Relatively fewer Hispanic patients were evaluated at PSCs, though they received rt-PA at a rate similar to White patients. More research is necessary to understand the patient and provider factors underlying these disparities.
Collapse
Affiliation(s)
| | - Brendan G Carr
- Emergency Medicine, Univ of Pennsylvania, Philadelphia, PA
| | | | | | | | | | | |
Collapse
|
41
|
Kallan MJ, Winston FK, Zonfrillo MR. Child passenger safety practices and injury risk in crashes with father versus mother drivers. Inj Prev 2013; 20:272-5. [DOI: 10.1136/injuryprev-2013-040990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
42
|
Myers SR, Branas CC, French BC, Nance ML, Kallan MJ, Wiebe DJ, Carr BG. Safety in numbers: are major cities the safest places in the United States? Ann Emerg Med 2013; 62:408-418.e3. [PMID: 23886781 DOI: 10.1016/j.annemergmed.2013.05.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 03/04/2013] [Accepted: 05/29/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVES Many US cities have experienced population reductions, often blamed on crime and interpersonal injury. Yet the overall injury risk in urban areas compared with suburban and rural areas has not been fully described. We begin to investigate this evidence gap by looking specifically at injury-related mortality risk, determining the risk of all injury death across the rural-urban continuum. METHODS A cross-sectional time-series analysis of US injury deaths from 1999 to 2006 in counties classified according to the rural-urban continuum was conducted. Negative binomial generalized estimating equations and tests for trend were completed. Total injury deaths were the primary comparator, whereas differences by mechanism and age were also explored. RESULTS A total of 1,295,919 injury deaths in 3,141 US counties were analyzed. Injury mortality increased with increasing rurality. Urban counties demonstrated the lowest death rates, significantly less than rural counties (mean difference=24.0 per 100,000; 95% confidence interval 16.4 to 31.6 per 100,000). After adjustment, the risk of injury death was 1.22 times higher in the most rural counties compared with the most urban (95% confidence interval 1.07 to 1.39). CONCLUSION Using total injury death rate as an overall safety metric, US urban counties were safer than their rural counterparts, and injury death risk increased steadily as counties became more rural. Greater emphasis on elevated injury-related mortality risk outside of large cities, attention to locality-specific injury prevention priorities, and an increased focus on matching emergency care needs to emergency care resources are in order.
Collapse
Affiliation(s)
- Sage R Myers
- Division of Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, University of Pennsylvania's Perelman School of Medicine, Philadelphia, PA.
| | | | | | | | | | | | | |
Collapse
|
43
|
Mills AM, Holena DN, Kallan MJ, Carr BG, Reinke CE, Kelz RR. Effect of insurance status on patients admitted for acute diverticulitis. Colorectal Dis 2013; 15:613-20. [PMID: 23078007 DOI: 10.1111/codi.12066] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 08/21/2012] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. METHOD A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death. RESULTS In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87). CONCLUSION In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.
Collapse
Affiliation(s)
- A M Mills
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | | | | | | | | | | |
Collapse
|
44
|
Abstract
Background The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt‐PA) for ischemic stroke than would non‐PSCs. Methods and Results Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt‐PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt‐PA was administered to 3.1% overall: 2.2% at non‐PSCs and 6.7% at PSCs. Between 2004 and 2009, rt‐PA administration increased from 1.4% to 3.3% at non‐PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG‐based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt‐PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16). Conclusions Subjects evaluated at PSCs were more likely to receive rt‐PA than those evaluated at non‐PSCs. This association was significant after adjustment for patient and hospital‐level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.
Collapse
Affiliation(s)
- Michael T Mullen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | | | |
Collapse
|
45
|
Abstract
Object
A positive correlation between outcomes and the volume of patients seen by a provider has been supported by numerous studies. Volume-outcome relationships (VORs) have been well documented in the setting of both neurosurgery and trauma care and have shaped regionalization policies to optimize patient outcomes. Several authors have also investigated the correlation between patient volume and cost of care, known as the volume-cost relationship (VCR), with mixed results. The purpose of the present study was to investigate VORs and VCRs in the treatment of common intracranial injuries by testing the hypotheses that outcomes suffer at small-volume centers and costs rise at large-volume centers.
Methods
The authors performed a cross-sectional cohort study of patients with neurological trauma using the 2006 Nationwide Inpatient Sample, the largest nationally representative all-payer data set. Patients were identified using ICD-9 codes for subdural, subarachnoid, and extradural hemorrhage following injury. Transfers were excluded from the study. In the primary analysis the association between a facility's neurotrauma patient volume and patient survival was tested. Secondary analyses focused on the relationships between patient volume and discharge status as well as between patient volume and cost. Analyses were performed using logistic regression.
Results
In-hospital mortality in the overall cohort was 9.9%. In-hospital mortality was 14.9% in the group with the smallest volume of patients, that is, fewer than 6 cases annually. At facilities treating 6–11, 12–23, 24–59, and 60+ patients annually, mortality was 8.0%, 8.3%, 9.5%, and 10.0%, respectively. For these groups there was a significantly reduced risk of in-hospital mortality as compared with the group with fewer than 6 annual patients; the adjusted ORs (and corresponding 95% CIs) were 0.45 (0.29–0.68), 0.56 (0.38–0.81), 0.63 (0.44–0.90), and 0.59 (0.41–0.87), respectively. For these same groups (once again using < 6 cases/year as the reference), there were no statistically significant differences in either estimated actual cost or duration of hospital stay.
Conclusions
A VOR exists in the treatment of neurotrauma, and a meaningful threshold for significantly improved mortality is 6 cases per year. Emergency and interfacility transport policies based on this threshold might improve national outcomes. Cost of care does not differ significantly with patient volume.
Collapse
Affiliation(s)
- R. Carter Clement
- 1Perelman School of Medicine at the University of Pennsylvania
- 2Wharton School of Business at the University of Pennsylvania
| | - Brendan G. Carr
- 3Departments of Emergency Medicine
- 4Leonard Davis Institute of Healthcare Economics
- 5Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; and
| | - Michael J. Kallan
- 5Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; and
| | - Catherine Wolff
- 5Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania; and
| | | | - Neil R. Malhotra
- 7Neurological Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|
46
|
Abstract
OBJECTIVES To compare restraint-use practices and injuries among children in crashes with grandparent versus parent drivers. METHODS This was a cross-sectional study of motor vehicle crashes that occurred from January 15, 2003, to November 30, 2007, involving children aged 15 years or younger, with cases identified via insurance claims and data collected via follow-up telephone surveys. We calculated the relative risk of significant child-passenger injury for grandparent-driven versus parent-driven vehicles. Logistic regression modeling estimated odds ratios (ORs) and 95% confidence intervals (CIs), adjusting for several child occupant, driver, vehicle, and crash characteristics. RESULTS Children driven by grandparents comprised 9.5% of the sample but resulted in only 6.6% of the total injuries. Injuries were reported for 1302 children, for an overall injury rate of 1.02 (95% CI: 0.90-1.17) per 100 child occupants. These represented 161 weighted injuries (0.70% injury rate) with grandparent drivers and 2293 injuries (1.05% injury rate) with parent drivers. Although nearly all children were reported to have been restrained, children in crashes with grandparent drivers used optimal restraint slightly less often. Despite this, children in grandparent-driven crashes were at one-half the risk of injuries as those in parent-driven crashes (OR: 0.50 [95% CI: 0.33- 0.75]) after adjustment. CONCLUSIONS Grandchildren seem to be safer in crashes when driven by grandparents than by their parents, but safety could be enhanced if grandparents followed current child-restraint guidelines. Additional elucidation of safe grandparent driving practices when carrying their grandchildren may inform future child-occupant driving education guidelines for all drivers.
Collapse
Affiliation(s)
- Fred M Henretig
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
47
|
Curry AE, Hafetz J, Kallan MJ, Winston FK, Durbin DR. Prevalence of teen driver errors leading to serious motor vehicle crashes. Accid Anal Prev 2011; 43:1285-1290. [PMID: 21545856 DOI: 10.1016/j.aap.2010.10.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Revised: 10/12/2010] [Accepted: 10/18/2010] [Indexed: 05/30/2023]
Abstract
OBJECTIVES Motor vehicle crashes are the leading cause of adolescent deaths. Programs and policies should target the most common and modifiable reasons for crashes. We estimated the frequency of critical reasons for crashes involving teen drivers, and examined in more depth specific teen driver errors. METHODS The National Highway Traffic Safety Administration's (NHTSA) National Motor Vehicle Crash Causation Survey collected data at the scene of a nationally representative sample of 5470 serious crashes between 7/05 and 12/07. NHTSA researchers assigned a single driver, vehicle, or environmental factor as the critical reason for the event immediately leading to each crash. We analyzed crashes involving 15-18 year old drivers. RESULTS 822 teen drivers were involved in 795 serious crashes, representing 335,667 teens in 325,291 crashes. Driver error was by far the most common reason for crashes (95.6%), as opposed to vehicle or environmental factors. Among crashes with a driver error, a teen made the error 79.3% of the time (75.8% of all teen-involved crashes). Recognition errors (e.g., inadequate surveillance, distraction) accounted for 46.3% of all teen errors, followed by decision errors (e.g., following too closely, too fast for conditions) (40.1%) and performance errors (e.g., loss of control) (8.0%). Inadequate surveillance, driving too fast for conditions, and distracted driving together accounted for almost half of all crashes. Aggressive driving behavior, drowsy driving, and physical impairments were less commonly cited as critical reasons. Males and females had similar proportions of broadly classified errors, although females were specifically more likely to make inadequate surveillance errors. CONCLUSIONS Our findings support prioritization of interventions targeting driver distraction and surveillance and hazard awareness training.
Collapse
Affiliation(s)
- Allison E Curry
- The Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, 3535 Market Street, Suite 1150, Philadelphia, PA 19104, USA.
| | | | | | | | | |
Collapse
|
48
|
Nance ML, Kallan MJ, Arbogast KB, Park MS, Durbin DR, Winston FK. Factors associated with clinically significant head injury in children involved in motor vehicle crashes. Traffic Inj Prev 2010; 11:600-605. [PMID: 21128190 DOI: 10.1080/15389588.2010.513072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE Head injury is the most common cause of death for child occupants in motor vehicle crashes (MVCs). The morbidity associated with nonlethal MVC-related head injuries is of great clinical consequence as well. The purpose of this study was to identify the frequency of, and risk factors for, clinically significant head injury (CSHI) in child occupants in MVCs. METHODS A large, child-specific crash surveillance system linking insurance claims data to telephone survey data was utilized. Qualifying crashes involved model year 1990 or newer vehicles in crashes with one or more child occupants (age 4 to 15 years) occurring in 15 U.S. states. Data were accrued between March 2000 and December 2007. A probability sample of crashes was selected for telephone survey with the driver of the insured vehicle. A clinically significant head injury, as reported by the child's parent using a validated survey, included concussions, skull fractures, and intracranial hemorrhages. Multivariate logistic regression was used to identify factors associated with a CSHI. RESULTS During the period of study, completed interviews were obtained on 19,075 children aged 4-15, representing 318,527 children involved in 219,511 crashes. The overall rate of CSHI in child occupants was 1.08 percent. Factors associated with an increased risk of head injury included rollover (odds ratio [OR] = 8.60, 95% confidence interval [CI] 6.40-11.57) and near-side impact crashes (OR = 2.39, 95% CI 1.73-3.30) vs. frontal impact; lack of restraint (OR = 3.13, 95% CI 2.26-4.33) vs. restrained; and driver age < 25 years (OR = 1.43, 95% CI 1.12-1.81) vs. driver age ≥ 25 years. Some factors varied based on occupant age, and younger child age had a protective effect on the risk for head injury. CONCLUSION The risk of CSHI for 4- to 15-year-old child occupants was 1.08 percent. Several demographic and crash factors were associated with CSHI in child occupants. This information may help inform design safety initiatives.
Collapse
Affiliation(s)
- Michael L Nance
- Department of Surgery and the Center for Injury Research and Prevention, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | | | |
Collapse
|
49
|
Norman SA, Localio AR, Kallan MJ, Weber AL, Torpey HAS, Potashnik SL, Miller LT, Fox KR, DeMichele A, Solin LJ. Risk factors for lymphedema after breast cancer treatment. Cancer Epidemiol Biomarkers Prev 2010; 19:2734-46. [PMID: 20978176 PMCID: PMC2976830 DOI: 10.1158/1055-9965.epi-09-1245] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.9] [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: 11/16/2022] Open
Abstract
BACKGROUND As cancer treatments evolve, it is important to reevaluate their effect on lymphedema risk in breast cancer survivors. METHODS A population-based random sample of 631 women from metropolitan Philadelphia, Pennsylvania, diagnosed with incident breast cancer in 1999 to 2001, was followed for 5 years. Risk factor information was obtained by questionnaire and medical record review. Lymphedema was assessed with a validated questionnaire. Using Cox proportional hazards models, we estimated the relative incidence rates [hazard ratios (HR)] of lymphedema with standard adjusted multivariable analyses ignoring interactions, followed by models including clinically plausible treatment interactions. RESULTS Compared with no lymph node surgery, adjusted HRs for lymphedema were increased following axillary lymph node dissection [ALND; HR, 2.61; 95% confidence interval (95% CI), 1.77-3.84] but not sentinel lymph node biopsy (SLNB; HR, 1.04; 95% CI, 0.58-1.88). Risk was not increased following irradiation [breast/chest wall only: HR, 1.18 (95% CI, 0.80-1.73); breast/chest wall plus supraclavicular field (+/- full axilla): HR, 0.86 (95% CI, 0.48-1.54)]. Eighty-one percent of chemotherapy was anthracycline based. The HR for anthracycline chemotherapy versus no chemotherapy was 1.46 (95% CI, 1.04-2.04), persisting after stratifying on stage at diagnosis or number of positive nodes. Treatment combinations involving ALND or chemotherapy resulted in approximately 4- to 5-fold increases in HRs for lymphedema [e.g., HR of 4.16 (95% CI, 1.32-12.45) for SLNB/chemotherapy/no radiation] compared with no treatment. CONCLUSION With standard multivariable analyses, ALND and chemotherapy increased lymphedema risk whereas radiation therapy and SLNB did not. However, risk varied by combinations of exposures. IMPACT Treatment patterns should be considered when counseling and monitoring patients for lymphedema.
Collapse
Affiliation(s)
- Sandra A Norman
- Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, Philadelphia, PA 19104-6021, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
50
|
Abstract
OBJECTIVE We examined whether firearm mortality rates among children varied across US counties along a rural-urban continuum. METHODS US vital statistics data were accessed for all pediatric (age: 0-19 years) firearm deaths from 1999 through 2006. Deaths were analyzed according to a modified rural-urban continuum code (based on population size and proximity to metropolitan areas) assigned to each county (3141 counties). RESULTS In the 8-year study period, there were 23649 pediatric firearm deaths (15190 homicides, 7082 suicides, and 1377 unintentional deaths). Pediatric nonfirearm mortality rates were significantly higher in the most-rural counties (adjusted rate ratio: 1.36 [95% confidence interval [CI]: 1.13-1.64]), compared with the most-urban counties. The most-rural counties demonstrated virtually identical pediatric firearm mortality rates (adjusted rate ratio: 0.91 [95% CI: 0.63-1.32]), compared with the most-urban counties. The most-rural counties had higher rates of pediatric firearm suicide (adjusted rate ratio: 2.01 [95% CI: 1.43-2.83]) and unintentional firearm death (adjusted rate ratio: 2.19 [95% CI: 1.27-3.77]), compared with the most-urban counties. Pediatric firearm homicides rates were significantly higher in the most-urban counties (adjusted rate ratio: 3.69 [95% CI: 2.00-6.80]), compared with the most-rural counties. CONCLUSIONS Children in the most-rural US counties had firearm mortality rates that were statistically indistinguishable from those for children in the most-urban counties. This finding reflects a greater homicide rate in urban counties counterbalanced by greater suicide and unintentional firearm death rates in rural counties. Nonfirearm mortality rates were significantly greater outside the most-urban US counties.
Collapse
Affiliation(s)
- Michael L Nance
- Children's Hospital of Philadelphia, Department of Surgery, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104-4227, USA.
| | | | | | | | | |
Collapse
|