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Kwong M, Rajasekar G, Utter GH, Nuno M, Mell MW. Poor utilization of palliative care among Medicare patients with chronic limb-threatening ischemia. J Vasc Surg 2023; 78:464-472. [PMID: 37088446 DOI: 10.1016/j.jvs.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/20/2023] [Accepted: 02/06/2023] [Indexed: 04/25/2023]
Abstract
OBJECTIVE Patients with chronic limb-threatening ischemia (CLTI) experience high annual mortality and would benefit from timely palliative care intervention. We sought to better characterize use of palliative care among patients with CLTI in the Medicare population. METHODS Using Medicare data from 2017 to 2018, we identified patients with CLTI, defined as two or more encounters with a CLTI diagnosis code. Palliative care evaluations were identified using ICD-10-CM Z51.5 "Encounter for palliative care." Time intervals between CLTI diagnosis, palliative consultation, and death or end of follow-up were calculated. Associations between patient demographics, comorbidities, and palliative care consultation were assessed. RESULTS A total of 12,133 Medicare enrollees with complete data were categorized as having CLTI. Of these, 7.4% (894) underwent a palliative care evaluation at a median of 170 days (interquartile range, 45-352 days) from their CLTI diagnosis. Compared with those who did not undergo evaluation, palliative patients were more likely to be dual eligible for Medicaid (45.2% vs 38.1%; P < .001) and had more comorbid conditions (P < .001). After controlling for gender and race, age (odds ratio [OR], 1.03; 95% confidence interval [CI], 1.02-1.04), dual eligibility (OR, 1.40; 95% CI, 1.22-1.62), solid organ malignancy (OR, 2.82; 95% CI, 1.92-4.14), hematologic malignancy (OR, 2.24; 95% CI, 1.27-3.98), congestive heart failure (OR, 1.44; 95% CI, 1.15-1.88), complicated diabetes (OR, 1.35; 95% CI, 1.11-1.65), dementia (OR, 1.32; 95% CI, 1.04-1.66), and severe renal failure (OR, 1.56; 85% CI. 1.24-1.98) were independently associated with palliative care evaluation. During mean follow up of 410 ± 220 days, 16.9% (2044) of patients died at a mean of 268 (±189) days after their CLTI diagnosis. Among living patients, only 3.2% (325) underwent palliative evaluation. Comparatively, 27.8% (569) of patients who died received palliative care at a median of 196 days (interquartile range, 55-362 days) after their diagnosis and 15 days (interquartile range, 5-63 days) prior to death. CONCLUSIONS Despite high mortality, palliative care services were rarely provided to Medicare patients with CLTI. Age, medical complexity, and income status may play a role in the decision to consult palliative care. When obtained, evaluations occurred closer to time of death than to time of CLTI diagnosis, suggesting misuse of palliative care as end-of-life care.
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Affiliation(s)
- Mimmie Kwong
- Department of Surgery, Division of Vascular Surgery, University of California Davis School of Medicine, Sacremento, CA.
| | - Ganesh Rajasekar
- Department of Public Health Sciences, University of California Davis School of Medicine, Sacremento, CA
| | - Garth H Utter
- Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, University of California Davis School of Medicine, Sacremento, CA
| | - Miriam Nuno
- Department of Public Health Sciences, University of California Davis School of Medicine, Sacremento, CA
| | - Matthew W Mell
- Department of Surgery, Division of Vascular Surgery, University of California Davis School of Medicine, Sacremento, CA
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Rocha P, Pinheiro D, de Paula Monteiro R, Tubert E, Romero E, Bastos-Filho C, Nuno M, Cadeiras M. Adaptive Content Tuning of Social Network Digital Health Interventions Using Control Systems Engineering for Precision Public Health: Cluster Randomized Controlled Trial. J Med Internet Res 2023; 25:e43132. [PMID: 37256680 DOI: 10.2196/43132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 03/13/2023] [Accepted: 04/14/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Social media has emerged as an effective tool to mitigate preventable and costly health issues with social network interventions (SNIs), but a precision public health approach is still lacking to improve health equity and account for population disparities. OBJECTIVE This study aimed to (1) develop an SNI framework for precision public health using control systems engineering to improve the delivery of digital educational interventions for health behavior change and (2) validate the SNI framework to increase organ donation awareness in California, taking into account underlying population disparities. METHODS This study developed and tested an SNI framework that uses publicly available data at the ZIP Code Tabulation Area (ZCTA) level to uncover demographic environments using clustering analysis, which is then used to guide digital health interventions using the Meta business platform. The SNI delivered 5 tailored organ donation-related educational contents through Facebook to 4 distinct demographic environments uncovered in California with and without an Adaptive Content Tuning (ACT) mechanism, a novel application of the Proportional Integral Derivative (PID) method, in a cluster randomized trial (CRT) over a 3-month period. The daily number of impressions (ie, exposure to educational content) and clicks (ie, engagement) were measured as a surrogate marker of awareness. A stratified analysis per demographic environment was conducted. RESULTS Four main clusters with distinctive sociodemographic characteristics were identified for the state of California. The ACT mechanism significantly increased the overall click rate per 1000 impressions (β=.2187; P<.001), with the highest effect on cluster 1 (β=.3683; P<.001) and the lowest effect on cluster 4 (β=.0936; P=.053). Cluster 1 is mainly composed of a population that is more likely to be rural, White, and have a higher rate of Medicare beneficiaries, while cluster 4 is more likely to be urban, Hispanic, and African American, with a high employment rate without high income and a higher proportion of Medicaid beneficiaries. CONCLUSIONS The proposed SNI framework, with its ACT mechanism, learns and delivers, in real time, for each distinct subpopulation, the most tailored educational content and establishes a new standard for precision public health to design novel health interventions with the use of social media, automation, and machine learning in a form that is efficient and equitable. TRIAL REGISTRATION ClinicalTrials.gov NTC04850287; https://clinicaltrials.gov/ct2/show/NCT04850287.
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Affiliation(s)
- Paulo Rocha
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - Diego Pinheiro
- International School, Catholic University of Pernambuco, Recife, Brazil
| | | | - Ela Tubert
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | - Erick Romero
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
| | | | - Miriam Nuno
- Division of Biostatistics, Department of Public Health Sciences, University of California Davis, Davis, CA, United States
| | - Martin Cadeiras
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of California, Davis, Sacramento, CA, United States
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3
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DiLosa K, Brown C, Rajasekar G, Nuno M, Humphries MD. Provider ankle brachial index and wound classification teaching as part of a comprehensive limb preservation outreach program. J Vasc Surg 2023; 77:1462-1467. [PMID: 36565782 PMCID: PMC10122695 DOI: 10.1016/j.jvs.2022.12.025] [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] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/14/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Utilization of evidence-based specialty guidelines is low in primary care settings. Early use of ankle-brachial index (ABI) testing and a validated wound classification system allows prompt referral of patients for specialty care. We implemented a program to teach providers ABI testing and the use of the Wound, Ischemia, and foot Infection (WIfI) classification tool. Here, we report program outcomes and provider perceptions. METHODS Physicians and non-physicians from wound care centers, nursing and physician education programs, primary care offices, and federally qualified health centers were invited to participate in the educational program teaching ABI testing and the use of the WIfI tool. Pretest and posttest responses and intention to use content in the future were assessed with descriptive statistics. RESULTS A total of 101 subjects completed the ABI module, and 84 indicated their occupation (59 physicians, 25 non-physicians). Seventy-nine subjects completed the WIfI module, and 89% indicated their occupation (50 physicians, 20 non-physicians). Physicians had lower pre-test knowledge scores for the ABI module than non-physicians (mean scores of 7.9 and 8.2, respectively). Both groups had improved knowledge scores on the post-test (physicians, 13.4; non-physicians, 13.8; P < .001). Non-physicians in practice longer than 10 years at wound care centers had the lowest baseline knowledge scores, whereas physicians in practice for over 10 years had the highest. In the ABI module, the largest knowledge gap included accurately calculating the ABI, followed by the correct use of the Doppler, and management of incompressible vessels. For the WIfI module, providers struggled to accurately score patients based on wound classification. The greatest barriers to the implementation of ABI testing were the availability of trained personnel, followed by limited time for testing. Barriers to the use of the WIfI tool for physicians included lack of time and national guideline support. For non-physicians, the most notable barrier was a lack of training. CONCLUSIONS Provider understanding of ABI and WIfI tools are limited in wound care centers, primary care offices, and federally qualified health centers. Further barriers include a lack of training in the use of tools, limited potential for point-of-care testing reimbursement, and insufficient dissemination of WIfI guidelines. Such barriers discourage widespread adoption and result in delayed diagnosis of arterial insufficiency.
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Affiliation(s)
- Kathryn DiLosa
- Department of Surgery, University of California, Davis Health, Sacramento, CA.
| | - Christina Brown
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Ganesh Rajasekar
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Miriam Nuno
- Department of Surgery, University of California, Davis Health, Sacramento, CA
| | - Misty D Humphries
- Department of Surgery, University of California, Davis Health, Sacramento, CA
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4
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Wilkinson RL, Castillo C, Herrity A, Wang D, Sharma M, Dietz N, Adams S, Khattar N, Nuno M, Drazin D, Boakye M, Ugiliweneza B. Opioid Dependence and Associated Health Care Utilization and Cost in Traumatic Spinal Cord Injury Population: Analysis Using Marketscan Database. Top Spinal Cord Inj Rehabil 2023; 29:118-130. [PMID: 36819927 PMCID: PMC9936895 DOI: 10.46292/sci22-00026] [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] [Indexed: 02/17/2023]
Abstract
Background Postinjury pain is a well-known debilitating complication of spinal cord injury (SCI), often resulting in long-term, high-dose opioid use with the potential for dependence. There is a gap in knowledge about the risk of opioid dependence and the associated health care utilization and cost in SCI. Objectives To evaluate the association of SCI with postinjury opioid use and dependence and evaluate the effect of this opioid dependence on postinjury health care utilization. Methods Using the MarketScan Database, health care utilization claims data were queried to extract 7187 adults with traumatic SCI from 2000 to 2019. Factors associated with post-SCI opioid use and dependence, postinjury health care utilization, and payments were analyzed with generalized linear regression models. Results After SCI, individuals were more likely to become opioid users or transition from nondependent to dependent users (negative change: 31%) than become nonusers or transition from dependent to nondependent users (positive change: 14%, p < .0001). Individuals who were opioid-dependent users pre-SCI had more than 30 times greater odds of becoming dependent after versus not (OR 34; 95% CI, 26-43). Dependent users after injury (regardless of prior use status) had 2 times higher utilization payments and 1.2 to 6 times more health care utilization than nonusers. Conclusion Opioid use and dependence were associated with high health care utilization and cost after SCI. Pre-SCI opioid users were more likely to remain users post-SCI and were heavier consumers of health care. Pre- and postopioid use history should be considered for treatment decision-making in all individuals with SCI.
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Affiliation(s)
| | - Camilo Castillo
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - April Herrity
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Lousville, Kentucky
| | - Dengzhi Wang
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Lousville, Kentucky
| | - Mayur Sharma
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Nick Dietz
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Shawn Adams
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Nicholas Khattar
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
| | - Miriam Nuno
- Department of Public Health Science, University of California, Davis
| | - Doniel Drazin
- College of Medicine Pacific Northwest, Yamika, Washington
| | - Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Lousville, Kentucky
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky
- Kentucky Spinal Cord Injury Research Center, University of Louisville, Lousville, Kentucky
- Department of Health Management and Systems Science, University of Louisville, Louisville, Kentucky
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5
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Ashby J, Nuno M, Ugiliweneza B, Deshmukh M, Boakye M. THE RISK OF DEMENTIA AMONG INDIVIDUALS WITH DEPRESSION AFTER A TRAUMATIC BRAIN INJURY. Innov Aging 2022. [PMCID: PMC9766806 DOI: 10.1093/geroni/igac059.1811] [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: 12/24/2022] Open
Abstract
Although traumatic brain injury (TBI) has been found to be associated with dementia and depression, large‐scale studies of US non‐Veteran populations are limited. This study assesses the role of depression on dementia risk after TBI. Data was analyzed from 80,423 individuals with TBI age 55+ in the IBM MarketScan Commercial Claims and Encounter Database and the Medicare Supplemental Database between January 1, 2000 and December 31, 2019. Dementia diagnosis was captured from inpatient or outpatient visits with a “wash out” period of one year. Depression was defined based on documented diagnosis and/or the prescription of antidepressants. The median age was 69 years, 51% female, with a majority covered by Medicaid (51%). 62% of TBIs were moderate/severe and 16% mild. 44,234 (55.1%) individuals were diagnosed with depression with a median of 2.1 months after TBI and 24.4 months prior to dementia. Depression rates differed by sex (female: 54%, male: 44%, p< 0.0001) and insurance (Commercial: 36%, Medicaid: 49%, p< 0.0001). The median time to dementia was 158 months. The median time to dementia was 128 months among those with depression, while patients without depression did not reach this estimate within 250 months of follow-up (p< 0.0001). The risk of dementia increased significantly over time after depression among patients with TBI. This study provides evidence to support that depression after TBI represents a symptom of TBI rather than a prodrome of dementia. Future research will investigate the role of depression in the risk of dementia by race/ethnicity, insurance status, and TBI severity.
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Affiliation(s)
- Joan Ashby
- University of California, Davis/Davis, Davis, California, United States
| | - Miriam Nuno
- University of California, Davis/Davis, Davis, California, United States
| | | | - Maya Deshmukh
- University of California, Davis/Davis, Davis, California, United States
| | - Maxwell Boakye
- Univerisity of Louisville/Louisville, Louisville, Kentucky, United States
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6
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Tuncer N, Timsina A, Nuno M, Chowell G, Martcheva M. Parameter identifiability and optimal control of an SARS-CoV-2 model early in the pandemic. J Biol Dyn 2022; 16:412-438. [PMID: 35635313 DOI: 10.1080/17513758.2022.2078899] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/28/2022] [Indexed: 06/15/2023]
Abstract
We fit an SARS-CoV-2 model to US data of COVID-19 cases and deaths. We conclude that the model is not structurally identifiable. We make the model identifiable by prefixing some of the parameters from external information. Practical identifiability of the model through Monte Carlo simulations reveals that two of the parameters may not be practically identifiable. With thus identified parameters, we set up an optimal control problem with social distancing and isolation as control variables. We investigate two scenarios: the controls are applied for the entire duration and the controls are applied only for the period of time. Our results show that if the controls are applied early in the epidemic, the reduction in the infected classes is at least an order of magnitude higher compared to when controls are applied with 2-week delay. Further, removing the controls before the pandemic ends leads to rebound of the infected classes.
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Affiliation(s)
- Necibe Tuncer
- Department of Mathematical Sciences, Florida Atlantic University, Boca Raton, FL, USA
| | - Archana Timsina
- Department of Mathematical Sciences, Florida Atlantic University, Boca Raton, FL, USA
| | - Miriam Nuno
- Department of Biostatistics, University of California, Davis, CA, USA
| | - Gerardo Chowell
- Department of Population Health Sciences, Georgia State University, Atlanta, GA, USA
| | - Maia Martcheva
- Department of Mathematics, University of Florida, Gainesville, FL, USA
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7
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DiLosa K, Brown C, Rajasekar G, Nuno M, Humphries M. Ankle Brachial Index and Wound Classification Teaching to Providers as Part of a Comprehensive Limb Preservation Outreach Program. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.07.094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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8
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Hanna GK, Madany M, Tay ASMS, Edwards LA, Kim S, Michael JS, Nuno M, Thomas T, Li A, Berel D, Black KL, Fan X, Zhang W, Rudnick JD, Wang R, Yu JS. ZEB1 loss increases glioma stem cell tumorigenicity and resistance to chemoradiation. J Neurosurg 2022; 138:1313-1324. [PMID: 36115050 DOI: 10.3171/2022.7.jns22259] [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: 01/30/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Glioblastoma has been known to be resistant to chemotherapy and radiation, whereas the underlying mechanisms of resistance have not been fully elucidated. The authors studied the role of the transcription factor ZEB1 (zinc finger E-box-binding homeobox 1 protein), which is associated with epithelial-mesenchymal transition (EMT) and is central to the stemness of glioblastoma, to determine its role in therapeutic resistance to radiation and chemotherapy. The authors previously demonstrated that ZEB1 is deleted in a majority of glioblastomas. METHODS The authors explored resistance to therapy in the context of ZEB1 loss and overexpression in glioma stem cells (GSCs) and in patient data. RESULTS Patients with ZEB1 loss had a shorter survival time than patients with wild-type ZEB1 in both the high- and low-MGMT groups. Consistent with the clinical data, mice implanted with ZEB1 knockdown GSCs showed shortened survival compared with mice inoculated with nonsilencing control (NS) short-hairpin RNA (shRNA) GSC glioblastoma. ZEB1-deleted GSCs demonstrated increased tumorigenicity with regard to proliferation and invasion. Importantly, GSCs that lose ZEB1 expression develop enhanced resistance to chemotherapy, radiotherapy, and combined chemoradiation. ZEB1 loss may lead to increased HER3 expression through the HER3/Akt pathway associated with this chemoresistance. Conversely, overexpression of ZEB1 in GSCs that are ZEB1 null leads to increased sensitivity to chemoradiation. CONCLUSIONS The study results indicate that ZEB1 loss in cancer stem cells confers resistance to chemoradiation and uncovers a potentially targetable cell surface receptor in these resistant cells.
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Affiliation(s)
| | | | | | | | | | | | - Miriam Nuno
- Departments of1Neurosurgery and.,3Department of Biostatics, University of California, Davis, Sacramento, California
| | | | - Aiguo Li
- 4Neuro-Oncology Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland; and
| | | | | | - Xuemo Fan
- 5Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles
| | - Wei Zhang
- 4Neuro-Oncology Branch, National Institutes of Health/National Cancer Institute, Bethesda, Maryland; and
| | - Jeremy D Rudnick
- Departments of1Neurosurgery and.,6Department of Medicine, Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles
| | - Rongfu Wang
- 7USC Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, California
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9
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Shweikeh F, Nuno M, Adamo M. Retraction Note: Trends in endovascular interventions for pediatric ischemic stroke at the national level: data from 2000 to 2009. Childs Nerv Syst 2022; 38:1837. [PMID: 35857121 DOI: 10.1007/s00381-022-05611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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10
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Kennedy L, Nuno M, Gurkoff GG, Nosova K, Zwienenberg M. Moderate and severe TBI in children and adolescents: The effects of age, sex, and injury severity on patient outcome 6 months after injury. Front Neurol 2022; 13:741717. [PMID: 35989939 PMCID: PMC9382186 DOI: 10.3389/fneur.2022.741717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 06/14/2022] [Indexed: 11/13/2022] Open
Abstract
The interaction of age, sex, and outcomes of children with head injury remains incompletely understood and these factors need rigorous evaluation in prognostic models for pediatric head injury. We leveraged our large institutional pediatric TBI population to evaluate age and sex along with a series of predictive factors used in the acute care of injury to describe the response and outcome of children and adolescents with moderate to severe injury. We hypothesized that younger age at injury and male sex would be associated with adverse outcomes and that a novel GCS-based scale incorporating pupillary response (GCS-P) would have superior performance in predicting 6-month outcome. GCS and GCS-P along with established CT scan variables associated with neurologic outcomes were retrospectively reviewed in children (age birth to 18 years) with moderate or severe head injury. GOS-E was prospectively collected 6 months after injury; 570 patients were enrolled in the study, 520 with TBI and 50 with abusive head trauma, each analyzed separately. In the TBI cohort, the median age of patients was 8 years and 42.7% had a severe head injury. Multiple predictors of outcome were identified in univariate analysis; however, based on a multivariate analysis, the GCS was identified as most reliable, outperforming GCS-P, pupil score, and other clinical and CT scan predictors. After stratifying patients for severity of injury by GCS, no age- or sex-related effects were observed in our patient population, except for a trend toward worse outcomes in the neonatal group. Patients with abusive head trauma were more likely to have severe injury on presentation, increased mortality rate, and unfavorable outcome. Additionally, there was clear evidence that secondary injuries, including hypoxia, hypotension, and hypothermia were significantly associated with lower GCS and higher mortality in both AHT and TBI populations. Our findings support the use of GCS to guide clinical decision-making and prognostication in addition to emphasizing the need to stratify head injuries for severity when undertaking outcome studies. Finally, secondary injuries are a clear predictor of poor outcome and how we record and manage these events need to be considered moving forward.
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Affiliation(s)
- Lori Kennedy
- Center for Nursing Science, University of California Davis Health, Sacramento, CA, United States
| | - Miriam Nuno
- Public Health Sciences, Medical Sciences 1-C, University of California, Davis, Davis, CA, United States
| | - Gene G. Gurkoff
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
- Center for Neuroscience, University of California, Davis, Davis, CA, United States
| | - Kristin Nosova
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
| | - Marike Zwienenberg
- Department of Neurological Surgery, University of California, Davis, Davis, CA, United States
- *Correspondence: Marike Zwienenberg
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Quino JE, Perez F, Perez A, Vang AP, Avendano L, Dang J, Chen MS, Arana AM, Rocha S, Nuno M, Lara PN, Fejerman L, Carvajal-Carmona LG. A Cancer Health Needs Assessment Reveals Important Differences Between US-Born and Foreign-Born Latinos in California. Front Oncol 2022; 12:883200. [PMID: 35875145 PMCID: PMC9300947 DOI: 10.3389/fonc.2022.883200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background Cancer is the leading cause of death among Latinos, the largest minority population in the United States (US). To address cancer challenges experienced by Latinos, we conducted a catchment area population assessment (CAPA) using validated questions from the National Cancer Institute (NCI) population health assessment supplement at our NCI-designated cancer center in California. Methods A mixed-methods CAPA was administered by bilingual-bicultural staff, with a focus on understanding the differences between foreign-born and US-born Latinos. Results 255 Latinos responded to the survey conducted between August 2019 and May 2020. Most respondents were foreign-born (63.9%), female (78.2%), and monolingual Spanish speakers (63.2%). Results showed that compared to US-born Latinos, foreign-born individuals were older, had lower educational attainment, were most likely to be monolingual Spanish speakers, were low-income, and were more likely to be uninsured. Foreign-born Latinos had lower levels of alcohol consumption and higher consumption of fruits and vegetables. The rate of preventive cancer screenings for breast, cervical and colorectal cancer did not differ by birthplace, although a low fraction (35.3%) of foreign-born Latinas who were up-to-date compared to US-born Latinas (83.3%) with colorectal cancer screening was observed. Time since the last routine check-up for all preventable cancers (cervical p=0.0002, breast p=0.0039, and colorectal p=0.0196) is significantly associated with being up to date with cancer screening. Individuals who had a check-up of two or more years ago are 84% less likely to be up to date with pap smears than those who had a check-up within the year (p=0.0060). Individuals without health insurance are 94% less likely to be up to date with mammograms and colonoscopy/FIT tests (p=0.0016 and p=0.0133, respectively) than those who are insured. There is no significant association between screening and nativity. Conclusions Considerable differences in socio-economic and environmental determinants of health and colorectal cancer screening rates were observed between US-born and foreign-born Latinos. The present study represents the foundation for future targeted intervention among immigrant populations at our cancer center’s catchment area.
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Affiliation(s)
- Juanita Elizabeth Quino
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
| | - Fabian Perez
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
- Department of Public Health Sciences, University of California Davis, Davis, CA, United States
| | - Angelica Perez
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
| | - April Pangia Vang
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
| | - Leonie Avendano
- California Department of Public Health, Environmental Health Investigations Branch, Richmond, CA, United States
| | - Julie Dang
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
| | - Moon S. Chen
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
| | - Alexa Morales Arana
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
| | - Sienna Rocha
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
| | - Miriam Nuno
- Department of Public Health Sciences, University of California Davis, Davis, CA, United States
- Department of Surgery, University of California Davis Health, Sacramento, CA, United States
| | - Primo N. Lara
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
| | - Laura Fejerman
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Department of Public Health Sciences, University of California Davis, Davis, CA, United States
| | - Luis G. Carvajal-Carmona
- Comprehensive Cancer Center, University of California Davis, Sacramento, CA, United States
- Genome Center, University of California Davis, Davis, CA, United States
- Department of Biochemistry and Molecular Medicine, School of Medicine, University of California Davis, Davis, CA, United States
- Center for Advancing Cancer Health Equity, School of Medicine, University of California Davis, Davis, CA, United States
- *Correspondence: Luis G. Carvajal-Carmona,
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DiLosa KL, Brown C, Rajasekar G, Nuno M, Humphries M. Ankle-Brachial Index and Wound Classification Teaching to Providers as Part of a Comprehensive Limb Preservation Outreach Program. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2022.03.656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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13
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Pinheiro D, Hartman R, Mai J, Romero E, Soroya M, Bastos-Filho C, de Carvalho Lima R, Gibson M, Ebong I, Bidwell J, Nuno M, Cadeiras M. The Association of Shared Care Networks With 30-Day Heart Failure Excessive Hospital Readmissions: Longitudinal Observational Study. JMIRx Med 2022; 3:e30777. [PMID: 37725539 PMCID: PMC10414461 DOI: 10.2196/30777] [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] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/30/2021] [Accepted: 01/27/2022] [Indexed: 09/21/2023]
Abstract
BACKGROUND Higher-than-expected heart failure (HF) readmissions affect half of US hospitals every year. The Hospital Reduction Readmission Program has reduced risk-adjusted readmissions, but it has also produced unintended consequences. Shared care models have been advocated for HF care, but the association of shared care networks with HF readmissions has never been investigated. OBJECTIVE This study aims to evaluate the association of shared care networks with 30-day HF excessive readmission rates using a longitudinal observational study. METHODS We curated publicly available data on hospital discharges and HF excessive readmission ratios from hospitals in California between 2012 and 2017. Shared care areas were delineated as data-driven units of care coordination emerging from discharge networks. The localization index, the proportion of patients who reside in the same shared care area in which they are admitted, was calculated by year. Generalized estimating equations were used to evaluate the association between the localization index and the excessive readmission ratio of hospitals controlling for race/ethnicity and socioeconomic factors. RESULTS A total of 300 hospitals in California in a 6-year period were included. The HF excessive readmission ratio was negatively associated with the adjusted localization index (β=-.0474, 95% CI -0.082 to -0.013). The percentage of Black residents within the shared care areas was the only statistically significant covariate (β=.4128, 95% CI 0.302 to 0.524). CONCLUSIONS Higher-than-expected HF readmissions were associated with shared care networks. Control mechanisms such as the Hospital Reduction Readmission Program may need to characterize and reward shared care to guide hospitals toward a more organized HF care system.
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Affiliation(s)
- Diego Pinheiro
- Unicap-Icam International School, Universidade Católica de Pernambuco, Recife, Brazil
| | | | - Jing Mai
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
| | - Erick Romero
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
| | - Mohammad Soroya
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
| | | | | | - Michael Gibson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
| | - Imo Ebong
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
| | - Julie Bidwell
- Family Caregiving Institute, Betty Irene Moore School of Nursing, University of California, Davis, Sacramento, CA, United States
| | - Miriam Nuno
- Department of Public Health Sciences, Division of Biostatistics, University of California, Davis, Sacramento, CA, United States
| | - Martin Cadeiras
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, United States
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14
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Dietz N, Sharma M, Alhourani A, Ugiliweneza B, Nuno M, Drazin D, Wang D, Boakye M. Preoperative and Postoperative Opioid Dependence in Patients Undergoing Anterior Cervical Diskectomy and Fusion for Degenerative Spinal Disorders. J Neurol Surg A Cent Eur Neurosurg 2021; 82:232-240. [PMID: 33540452 DOI: 10.1055/s-0040-1718759] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Anterior cervical diskectomy and fusion (ACDF) is a procedure for effectively relieving radiculopathy. Opioids are commonly overprescribed in postsurgical settings and prescriptions vary widely among providers. We identify trends in opioid dependence before and after ACDF. METHODS We used the Truven Health MarketScan data to identify adult patients undergoing ACDF for degenerative cervical spine conditions between 2009 and 2015. Patients were segregated in four cohorts of preoperative and postoperative opioid nondependence (ND) or dependence (D) with 15 months of postoperative follow-up. RESULTS A total of 25,403 patients with median age of 52 years (18-92) who underwent ACDF met the inclusion criteria. Breakdown of the four cohorts was as follows: prior nondependent who remain nondependent (NDND): 62.76% (n = 15,944); prior nondependent who become dependent (NDD): 4.6% (n = 1,168); prior dependent who become nondependent (DND): 14.03% (n = 3,564); and prior dependent who remain dependent (DD): 18.61% (n = 4,727). Opioid dependence decreased 9.43% postoperatively. Overall payments and 30-day readmissions increased 1.96 and 1.79 times for opioid dependent versus nondependent cohorts, respectively. Adjusted payments at 3 to 15 months were significantly increased for dependent cohorts with 3.56-fold increase for the DD cohort when compared with the NDND cohort. Length of stay, complications, medication refills, outpatient measures, and hospital admissions were also higher in those groups with postoperative opioid dependence when compared with those who were not opioid dependent. CONCLUSIONS Opioid dependence after ACDF is associated with increased hospital readmissions, complication rates at 30 days, and payments within 3 months and 3 to 15 months postdischarge. Overall opioid dependence was decreased after ACDF procedure, however, a smaller number of opioid-dependent and opioid-naive patients became dependent postoperatively and should be followed carefully.
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Affiliation(s)
- Nicholas Dietz
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Mayur Sharma
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Ahmad Alhourani
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Beatrice Ugiliweneza
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States
| | - Miriam Nuno
- Department of Neurosurgery, University of California Davis, Davis, California, United States
| | - Doniel Drazin
- Department of Neurosurgery, Pacific Northwest University of Health Sciences, Yakima, Washington, United States
| | - Dengzhi Wang
- Department of Neurosurgery, University of California Davis, Davis, California, United States
| | - Maxwell Boakye
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, United States.,Department of Neurosurgery, Robley Rex VA Medical Center, Louisville, Kentucky, United States
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15
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Schievink WI, Maya M, Prasad RS, Wadhwa VS, Cruz RB, Moser FG, Nuno M. Spontaneous spinal cerebrospinal fluid-venous fistulas in patients with orthostatic headaches and normal conventional brain and spine imaging. Headache 2021; 61:387-391. [PMID: 33484155 DOI: 10.1111/head.14048] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 09/08/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the occurrence of cerebrospinal fluid (CSF)-venous fistulas, a type of spinal CSF leak that cannot be detected with routine computerized tomography myelography, among patients with orthostatic headaches but normal brain and spine magnetic resonance imaging. BACKGROUND Spontaneous spinal CSF leaks cause orthostatic headaches but their detection may require sophisticated spinal imaging techniques. METHODS A prospective cohort study of patients with orthostatic headaches and normal brain and conventional spine imaging who underwent digital subtraction myelography (DSM) to look for CSF-venous fistulas, between May 2018 and May 2020, at a quaternary referral center for spontaneous intracranial hypotension. RESULTS The mean age of the 60 consecutive patients (46 women and 14 men) was 46 years (range, 13-83 years), who had been suffering from orthostatic headaches between 1 and 180 months (mean, 43 months). DSM demonstrated a spinal CSF-venous fistula in 6 (10.0%; 95% confidence interval [CI]: 3.8-20.5%) of the 60 patients. The mean age of these five women and one man was 50 years (range, 41-59 years). Spinal CSF-venous fistulas were identified in 6 (19.4%; 95% CI: 7.5-37.5%) of 31 patients with spinal meningeal diverticula but in none (0%; 95% CI: 0-11.9%) of the 29 patients without spinal meningeal diverticula (p = 0.024). All CSF-venous fistulas were located in the thoracic spine. All patients underwent uneventful surgical ligation of the fistula. Complete and sustained resolution of symptoms was obtained in five patients, while in one patient, partial recurrence of symptoms was noted 3 months postoperatively. CONCLUSION Concerns about a spinal CSF leak should not be dismissed in patients suffering from orthostatic headaches when conventional imaging turns out to be normal, even though the yield of identifying a CSF-venous fistula is low.
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Affiliation(s)
- Wouter I Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Marcel Maya
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Ravi S Prasad
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Vikram S Wadhwa
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rachelle B Cruz
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Franklin G Moser
- Department of Imaging, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Miriam Nuno
- Department of Public Health Sciences, University of California, Davis, Davis, CA, USA
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16
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Shweikeh F, Nuno M, Adamo M. Trends in endovascular interventions for pediatric ischemic stroke at the national level: data from 2000 to 2009. Childs Nerv Syst 2021; 37:161-166. [PMID: 32529548 DOI: 10.1007/s00381-020-04714-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 05/28/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Present knowledge is limited with regard to endovascular and interventional management of pediatric acute ischemic stroke (AIS). The current practice of neurointerventions in this population was analyzed via a national database. METHODS The Kids' Inpatient Database for years 2000, 2003, 2006, and 2009 was examined for patients aged < 18 years discharged with a primary diagnosis of AIS and identified according to ICD-9 codes. Descriptive statistics were tabulated on each of the subcohorts. RESULTS There were 3467 patients identified; 920 (26.5%) underwent angiograms, 51 (1.5%) angiogram + thrombolysis, and 18 (0.5%) received angiogram + endovascular recanalization. The angiogram only subcohort was significantly younger compared with thrombolysis and endovascular procedure subcohorts (9.8 vs. 12.2 vs. 14.9 years, P < 0.001). Mortality was 4.3%, significantly lower for angiogram only than for thrombolysis (1.1% vs. 18.2%, P < 0.0001). Thrombolysis also had significantly higher hospital charges ($149,045 vs. $64,826, P < 0.0001). While not many differences in outcomes between angiogram only versus endovascular procedures, the latter had higher financial burden ($122,482 vs. $64,826, P < 0.0001). CONCLUSIONS This national study suggests that children receiving neurointerventions tend to be older (> 12 years) and heart and valvular defects are their most likely comorbidities. There was a lower mortality and fewer complications with endovascular procedures when compared with intravenous/intraarterial thrombolysis alone. Thrombolysis was also associated with more non-routine discharges and lengthier stay.
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Affiliation(s)
- Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Matthew Adamo
- Department of Neurosurgery, Albany Medical Center, Albany, NY, USA
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17
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Nuno M, Ugiliweneza B, Gilsanz P, Peterson R, Eng CW, George KM, Whitmer RA. Traumatic brain injury and dementia risk: The role of sex, insurance and race. Alzheimers Dement 2020. [DOI: 10.1002/alz.046587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | - Chloe W. Eng
- University of California, San Francisco San Francisco CA USA
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18
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Nuno M, Gilsanz P, Glymour MM, Mayeda ER, Eng CW, Peterson R, George KM, Mungas DM, DeCarli C, Whitmer RA. Head injury at different ages and cognitive performance in a diverse cohort: Findings from the KHANDLE Study. Alzheimers Dement 2020. [DOI: 10.1002/alz.046619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Paola Gilsanz
- Kaiser Permanente Division of Research Oakland CA USA
| | | | - Elizabeth Rose Mayeda
- University of California Los Angeles Fielding School of Public Health Los Angeles CA USA
| | - Chloe W. Eng
- University of California, San Francisco San Francisco CA USA
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19
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Bhargava S, Sharma M, Dietz N, Dettori J, Ugiliweneza B, Nuno M, Boakye M, Drazin D. Demographics and Outcomes of Spine Surgery in Octogenarians and Nonagenarians: A Comparison of the National Inpatient Sample, MarketScan and National Surgical Quality Improvement Program Databases. Cureus 2019; 11:e6195. [PMID: 31886087 PMCID: PMC6922298 DOI: 10.7759/cureus.6195] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Introduction Despite the increasing use of national databases to conduct spine research, questions remain regarding their study validity and consistency. This study tested for similarity and inter-database reliability in reported measures between three commonly used national databases. Methods International Classification of Diseases, 9th edition (ICD-9) codes were used to identify elderly (80-100 years) who underwent spine surgery patients in Truven Health Analytics MarketScan® claims database, National (Nationwide) Inpatient Sample (NIS) discharge database and National Surgical Quality Improvement Program (NSQIP) database (2006-2016). Patient baseline characteristics, comorbid status, insurance enrollment, and outcomes were queried and compared. Results We analyzed 15,105 MarketScan, 40,854 NIS, and 7682 NSQIP patients between ages 80 to 100 years (median, 82 years) who underwent spine surgeries during the study period. A majority of patients in both MarketScan and NIS were insured by Medicare (97% vs. 94%). Patients in MarketScan had lower comorbidity scores (comorbidity, 0-2) compared to those in NIS and NSQIP databases. The most common diagnosis was spinal stenosis in MarketScan (54.4%), NIS (54.6%), and NSQIP databases (65.2%). Fusion was the most common procedure performed in MarketScan (48.9%) and NIS databases (46.2%), whereas decompression (laminectomy/laminotomy) was the most common procedure in the NSQIP database (51.84%). In-hospital complications (any) were 6.5% in the MarketScan cohort, 5.3% in the NIS, and 2.02% in the NSQIP cohort. In terms of 30-day complications (any), the MarketScan database reported higher complications rate (12.7%) compared to the NSQIP database (5.08%). In-hospital mortality was slightly higher in the NIS database (0.32%) compared to MarketScan (0.21%) and NSQIP database (0.2%). MarketScan and NIS databases showed an increased risk of complications with increasing age, whereas NIS and NSQIP showed increasing complications with a higher number of comorbidities. Male gender had higher complication at 30-day post-discharge using MarketScan and NSQIP database. Conclusions Patients in the NSQIP and NIS database have more comorbidities; patients in the MarketScan database had the highest number of perioperative and 30-day post-discharge complications with the highest number of fusion procedures performed. Patients in the NSQIP database had the lowest number of fusion procedures and complication rates. As databases gain popularity in spine surgery, clinicians and reviewers should be cautious in generalizing results to whole populations and pay close attention to the population being represented by the data from which the statistical significance was derived.
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Affiliation(s)
| | - Mayur Sharma
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Nicholas Dietz
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Joseph Dettori
- Evidence Practice Center, Spectrum Research, Tacoma, USA
| | | | - Miriam Nuno
- Statistics, University of California, Davis, USA
| | - Maxwell Boakye
- Neurosurgery, University of Louisville School of Medicine, Louisville, USA
| | - Doniel Drazin
- Medicine, Pacific Northwest University of Health Sciences, Yakima, USA
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20
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Ugiliweneza B, Guest J, Herrity A, Nuno M, Sharma M, Beswick J, Dietz N, Alhourani A, Wang D, Drazin D, Boakye M. A Two-decade Assessment of Changing Practice for Surgical Decompression and Fixation after Traumatic Spinal Cord Injury – Impact on Healthcare Utilization and Cost. Cureus 2019; 11:e6156. [PMID: 31890365 PMCID: PMC6913978 DOI: 10.7759/cureus.6156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Early surgery after traumatic spinal cord injury (TSCI) has been associated with a greater neurological recovery and reduced secondary complications. In this study, we aimed to evaluate the trend of early TSCI surgery (within 24 hours) over two decades and the effect on length of hospitalization, complications, and hospital charges. We extracted emergency admissions of adults diagnosed with TSCI from the National Inpatient Sample database (1998-2016). We analyzed the trend of early surgery and concurrent trends of complication rate, length of stay (LOS) and hospital charges. These outcomes were then compared between early and late surgery cohorts. There were 3942 (53%) TSCI patients who underwent early surgery, and 3446 (47%) were operated after 24 hours. The combined patient group characteristics consisted of median age 43 years (IQR: 29-59), 73% males, 72% white, 44% private payer, 18% Medicare, 17% Medicaid, 51% cervical, 30% thoracic, 75% from large hospitals, and 79% from teaching hospitals. The trend of early surgery, adjusted for annual case-mix, increased from 45% in 1998 to 64% in 2016. Each year was associated with 1.60% more patients undergoing early surgery than the previous year (p-value <0.05). During these years, the total LOS decreased, while hospital charges increased. Patients who underwent early surgery spent four fewer days in the hospital, accrued $28,705 lower in hospital charges and had 2.8% fewer complications than those with delay surgery. We found that the rate of early surgery has significantly increased from 1998 to 2016. However, as of 2016, one-third of patients still did not undergo spinal surgery within 24 hours. Late surgery is associated with higher complications, longer stays, and higher charges. The causes of delayed surgery are undoubtedly justified in some situations but require further delineation. Surgeons should consider performing surgery within 24 hours on patients with TSCI whenever feasible.
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Edwards LA, Kim S, Madany M, Nuno M, Thomas T, Li A, Berel D, Lee BS, Liu M, Black KL, Fan X, Zhang W, Yu JS. ZEB1 Is a Transcription Factor That Is Prognostic and Predictive in Diffuse Gliomas. Front Neurol 2019; 9:1199. [PMID: 30705664 PMCID: PMC6345215 DOI: 10.3389/fneur.2018.01199] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Accepted: 12/31/2018] [Indexed: 01/06/2023] Open
Abstract
Objective: To address the unmet medical need to better prognosticate patients with diffuse gliomas and to predict responses to chemotherapy regimens. Methods: ZEB1 alterations were retrospectively identified from a cohort of 1,160 diffuse glioma patients. Epigenome-wide association scans (EWAS) were performed on available data. We determined the utility of ZEB1 as a prognostic indicator of patient survival in diffuse gliomas and assessed the value of ZEB1 to predict the efficacy of treating diffuse glioma patients with procarbazine, CCNU, and vincristine along with radiation at diagnosis. Decision curve analysis (DCA) was used to determine if ZEB1 added benefit to clinical decision-making over and above conventional methods. Results: Fifteen percent of diffuse glioma patients had a ZEB1 deletion. ZEB1 deletion was associated with poor overall survival (OS) with and without adjustment for age and tumor grade (adjusted HR: 4.25; 95% CI: 2.35 to 7.66; P < 0.001). Decision curve analysis confirmed that ZEB1 status with or without IDH1 was more beneficial to clinical decision making than conventional information such as age and tumor grade. We showed that ZEB1 regulates TERT expression, and patients with ZEB1 deletions likely subsume patients with mutant TERT expression in diffuse gliomas. ZEB1 influenced clinical decision making to initiate procarbazine, CCNU, and vincristine treatment. Conclusion: We demonstrate the prognostic value of ZEB1 in diffuse glioma patients. We further determine ZEB1 to be a vital and influential molecular marker in clinical decisions that exceed conventional methods regarding whether to treat or not treat patients with diffuse glioma.
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Affiliation(s)
- Lincoln A Edwards
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Sungjin Kim
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Mecca Madany
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Miriam Nuno
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Tom Thomas
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Aiguo Li
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - Dror Berel
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Bong-Sup Lee
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Minzhi Liu
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Keith L Black
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Xuemo Fan
- Pathology and Laboratory Medicine Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Wei Zhang
- Neuro-Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD, United States
| | - John S Yu
- Neurosurgery Department, Cedars-Sinai Medical Center, Los Angeles, CA, United States
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22
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Alhourani A, Sharma M, Ugiliweneza B, Nuno M, Drazin D, Boakye M. 323 Health-Care Utilization and Bundled Payment Reimbursement for Patients Undergoing Anterior and Posterior Procedures for Degenerative Cervical Radiculopathy. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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23
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Babu H, Ortega A, Nuno M, Dehghan A, Schweitzer A, Bonert HV, Carmichael JD, Cooper O, Melmed S, Mamelak AN. Long-Term Endocrine Outcomes Following Endoscopic Endonasal Transsphenoidal Surgery for Acromegaly and Associated Prognostic Factors. Neurosurgery 2018; 81:357-366. [PMID: 28368500 DOI: 10.1093/neuros/nyx020] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 01/13/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Long-term remission rates from endoscopic transsphenoidal surgery for acromegaly and their relationship to prognostic indicators of disease aggressiveness are not well documented. OBJECTIVE To investigate long-term remission rates in patients with acromegaly after endoscopic transsphenoidal surgery, and correlate this with molecular and radiographic markers of disease aggressiveness. METHODS We identified all patients undergoing endoscopic transsphenoidal surgery for acromegaly from 2005 to 2013 at Cedars-Sinai Pituitary Center. Hormonal remission was established by normal insulin-like growth factor (IGF)-1, basal serum growth hormone <2.5 ng/mL, and growth hormone suppression to <1 ng/mL following oral glucose tolerance test. Oral glucose tolerance test was performed at 3 months after surgery, and then as indicated. IGF-1 was measured at 3 months and then at least annually. We evaluated tumor granularity, nuclear expression of p21, Ki67 index, and extent of cavernous sinus invasion, and correlated these with remission status. RESULTS Fifty-eight patients that underwent surgery had follow-up from 38 to 98 months (mean 64 ± 32.2 months). There were 21 microadenomas and 37 macroadenomas. Three months after surgery 40 of 58 patients (69%) were in biochemical remission. Four additional patients were in remission at 6 months after surgery, and 1 patient had recurrence within the first year after surgery. At last follow-up, 43 of 44 (74.1%) of patients remained in remission. Cavernous sinus invasion by tumor predicted failure to achieve remission. CONCLUSIONS Prognostic markers of disease aggressiveness other than cavernous sinus invasion did not correlate with surgical outcome. Long-term remission after surgery alone was achieved in 74% of patients, indicating long-term efficacy of endoscopic surgery.
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Affiliation(s)
- Harish Babu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
| | - Alicia Ortega
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia.,Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia.,Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Aaron Dehghan
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Aaron Schweitzer
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
| | - H Vivien Bonert
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - John D Carmichael
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Odelia Cooper
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Shlomo Melmed
- Division of Endocrinology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Adam N Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Cali-fornia
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Sherman DS, Mauser J, Nuno M, Sherzai D. The Efficacy of Cognitive Intervention in Mild Cognitive Impairment (MCI): a Meta-Analysis of Outcomes on Neuropsychological Measures. Neuropsychol Rev 2017; 27:440-484. [PMID: 29282641 PMCID: PMC5754430 DOI: 10.1007/s11065-017-9363-3] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [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: 03/20/2017] [Accepted: 11/05/2017] [Indexed: 12/12/2022]
Abstract
Cognitive training in MCI may stimulate pre-existing neural reserves or recruit neural circuitry as “compensatory scaffolding” prompting neuroplastic reorganization to meet task demands (Reuter-Lorenz & Park, 2014). However, existing systematic reviews and meta-analytic studies exploring the benefits of cognitive interventions in MCI have been mixed. An updated examination regarding the efficacy of cognitive intervention in MCI is needed given improvements in adherence to MCI diagnostic criteria in subject selection, better defined interventions and strategies applied, increased use of neuropsychological measures pre- and post-intervention, as well as identification of moderator variables which may influence treatment. As such, this meta-analytic review was conducted to examine the efficacy of cognitive intervention in individuals diagnosed with mild cognitive impairment (MCI) versus MCI controls based on performance of neuropsychological outcome measures in randomized controlled trials (RCT). RCT studies published from January 1995 to June 2017 were obtained through source databases of MEDLINE-R, PubMed, Healthstar, Global Health, PSYCH-INFO, and Health and Psychological Instruments using search parameters for MCI diagnostic category (mild cognitive impairment, MCI, pre-Alzheimer’s disease, early cognitive decline, early onset Alzheimer’s disease, and preclinical Alzheimer’s disease) and the intervention or training conducted (intervention, training, stimulation, rehabilitation, or treatment). Other inclusion and exclusion criteria included subject selection based on established MCI criteria, RCT design in an outpatient setting, MCI controls (active or passive), and outcomes based on objective neuropsychological measures. From the 1199 abstracts identified, 26 articles met inclusion criteria for the meta-analyses completed across eleven (11) countries; 92.31% of which have been published within the past 7 years. A series of meta-analyses were performed to examine the effects of cognitive intervention by cognitive domain, type of training, and intervention content (cognitive domain targeted). We found significant, moderate effects for multicomponent training (Hedges’ g observed = 0.398; CI [0.164, 0.631]; Z = 3.337; p = 0.001; Q = 55.511; df = 15; p = 0.000; I2 = 72.978%; τ2 = 0.146) as well as multidomain-focused strategies (Hedges’ g = 0.230; 95% CI [0.108, 0.352]; Z = 3.692; p < 0.001; Q = 12.713; df = 12; p = 0.390; I2 = 5.612; τ2 = 0.003). The effects for other interventions explored by cognitive domain, training type, or intervention content were indeterminate due to concerns for heterogeneity, bias, and small cell sizes. In addition, subgroup and meta-regression analyses were conducted with the moderators of MCI category, mode of intervention, training type, intervention content, program duration (total hours), type of control group (active or passive), post-intervention follow-up assessment period, and control for repeat administration. We found significant overall effects for intervention content with memory focused interventions appearing to be more effective than multidomain approaches. There was no evidence of an influence on outcomes for the other covariates examined. Overall, these findings suggest individuals with MCI who received multicomponent training or interventions targeting multiple domains (including lifestyle changes) were apt to display an improvement on outcome measures of cognition post-intervention. As such, multicomponent and multidomain forms of intervention may prompt recruitment of alternate neural processes as well as support primary networks to meet task demands simultaneously. In addition, interventions with memory and multidomain forms of content appear to be particularly helpful, with memory-based approaches possibly being more effective than multidomain methods. Other factors, such as program duration, appear to have less of an influence on intervention outcomes. Given this, although the creation of new primary network paths appears strained in MCI, interventions with memory-based or multidomain forms of content may facilitate partial activation of compensatory scaffolding and neuroplastic reorganization. The positive benefit of memory-based strategies may also reflect transfer effects indicative of compensatory network activation and the multiple-pathways involved in memory processes. Limitations of this review are similar to other meta-analysis in MCI, including a modest number studies, small sample sizes, multiple forms of interventions and types of training applied (some overlapping), and, while greatly improved in our view, a large diversity of instruments used to measure outcome. This is apt to have contributed to the presence of heterogeneity and publication bias precluding a more definitive determination of the outcomes observed.
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Affiliation(s)
- Dale S Sherman
- Cedars-Sinai Medical Center, 444 S. San Vicente Blvd, Suite 103, Los Angeles, CA, 90048, USA. .,University of Southern California, Los Angeles, CA, USA.
| | - Justin Mauser
- Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Miriam Nuno
- University of California, Davis, Davis, CA, USA
| | - Dean Sherzai
- Loma Linda University Health, 11370 Anderson Street B100, Loma Linda, CA, 92354, USA
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Bannykh SI, Nuno M. Ultrastructural comparison of extraventricular and central neurocytomas. Ultrastruct Pathol 2017. [DOI: 10.1080/01913123.2016.1270713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Sergei I. Bannykh
- Department of Pathology and Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
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Annamalai A, Harada MY, Chen M, Tran T, Ko A, Ley EJ, Nuno M, Klein A, Nissen N, Noureddin M. Predictors of Mortality in the Critically Ill Cirrhotic Patient: Is the Model for End-Stage Liver Disease Enough? J Am Coll Surg 2016; 224:276-282. [PMID: 27887981 DOI: 10.1016/j.jamcollsurg.2016.11.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/26/2016] [Accepted: 11/15/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Critically ill cirrhotics require liver transplantation urgently, but are at high risk for perioperative mortality. The Model for End-stage Liver Disease (MELD) score, recently updated to incorporate serum sodium, estimates survival probability in patients with cirrhosis, but needs additional evaluation in the critically ill. The purpose of this study was to evaluate the predictive power of ICU admission MELD scores and identify clinical risk factors associated with increased mortality. STUDY DESIGN This was a retrospective review of cirrhotic patients admitted to the ICU between January 2011 and December 2014. Patients who were discharged or underwent transplantation (survivors) were compared with those who died (nonsurvivors). Demographic characteristics, admission MELD scores, and clinical risk factors were recorded. Multivariate regression was used to identify independent predictors of mortality, and measures of model performance were assessed to determine predictive accuracy. RESULTS Of 276 patients who met inclusion criteria, 153 were considered survivors and 123 were nonsurvivors. Survivor and nonsurvivor cohorts had similar demographic characteristics. Nonsurvivors had increased MELD, gastrointestinal bleeding, infection, mechanical ventilation, encephalopathy, vasopressors, dialysis, renal replacement therapy, requirement of blood products, and ICU length of stay. The MELD demonstrated low predictive power (c-statistic 0.73). Multivariate analysis identified MELD score (adjusted odds ratio [AOR] = 1.05), mechanical ventilation (AOR = 4.55), vasopressors (AOR = 3.87), and continuous renal replacement therapy (AOR = 2.43) as independent predictors of mortality, with stronger predictive accuracy (c-statistic 0.87). CONCLUSIONS The MELD demonstrated relatively poor predictive accuracy in critically ill patients with cirrhosis and might not be the best indicator for prognosis in the ICU population. Prognostic accuracy is significantly improved when variables indicating organ support (mechanical ventilation, vasopressors, and continuous renal replacement therapy) are included in the model.
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Affiliation(s)
| | - Megan Y Harada
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Melissa Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tram Tran
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ara Ko
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Miriam Nuno
- Center for Neurosurgical Outcomes Research, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Andrew Klein
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Nicholas Nissen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mazen Noureddin
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA
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Sarmiento J, Mukherjee D, Black K, Fan X, Hu J, Nuno M, Patil C. Do Long-Term Survivor Primary Glioblastoma Patients Harbor IDH1 Mutations? J Neurol Surg A Cent Eur Neurosurg 2016; 77:195-200. [DOI: 10.1055/s-0035-1566121] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- J. Sarmiento
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Debraj Mukherjee
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Keith Black
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Xuemo Fan
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Jethro Hu
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
| | - Chirag Patil
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, United States
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Murry JS, Zaw AA, Hoang DM, Mehrzadi D, Tran D, Nuno M, Bloom M, Melo N, Margulies DR, Ley EJ. Activation of Massive Transfusion for Elderly Trauma Patients. Am Surg 2015; 81:945-949. [PMID: 26463286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Massive transfusion protocol (MTP) is used to resuscitate patients in hemorrhagic shock. Our goal was to review MTP use in the elderly. All trauma patients who required activation of MTP at an urban Level I trauma center from January 1, 2011 to December 31, 2013 were reviewed retrospectively. Elderly was defined as age ≥ 60 years. Sixty-six patients had MTP activated: 52 nonelderly (NE) and 14 elderly (E). There were no statistically significant differences between the two cohorts for gender, injury severity score, head abbreviated injury scale, emergency department Glasgow Coma Scale, initial hematocrit, intensive care unit length of stay, or hospital length of stay. Mean age for NE was 35 years and 73 years for E (P < 0.01). Less than half (43%) of E patients with activation of MTP received 10 or more units of blood products compared with 69 per cent of the NE (P = 0.07). Mortality rates were similar in the NE and the E (53%vs 50%, P = 0.80). After multivariate analysis with Glasgow Coma Scale, injury severity score, and blunt versus penetrating trauma, elderly age was not a predictor of mortality after MTP (P = 0.35). When MTP is activated, survival to discharge in elderly trauma patients is comparable to younger patients.
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Affiliation(s)
- Jason S Murry
- Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
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Murry JS, Zaw AA, Hoang DM, Mehrzadi D, Tran D, Nuno M, Bloom M, Melo N, Margulies DR, Ley EJ. Activation of Massive Transfusion for Elderly Trauma Patients. Am Surg 2015. [DOI: 10.1177/000313481508101007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Massive transfusion protocol (MTP) is used to resuscitate patients in hemorrhagic shock. Our goal was to review MTP use in the elderly. All trauma patients who required activation of MTP at an urban Level I trauma center from January 1, 2011 to December 31, 2013 were reviewed retrospectively. Elderly was defined as age ≥ 60 years. Sixty-six patients had MTP activated: 52 non-elderly (NE) and 14 elderly (E). There were no statistically significant differences between the two cohorts for gender, injury severity score, head abbreviated injury scale, emergency department Glasgow Coma Scale, initial hematocrit, intensive care unit length of stay, or hospital length of stay. Mean age for NE was 35 years and 73 years for E ( P < 0.01). Less than half (43%) of E patients with activation of MTP received 10 or more units of blood products compared with 69 per cent of the NE ( P = 0.07). Mortality rates were similar in the NE and the E (53% vs 50%, P = 0.80). After multivariate analysis with Glasgow Coma Scale, injury severity score, and blunt versus penetrating trauma, elderly age was not a predictor of mortality after MTP ( P = 0.35). When MTP is activated, survival to discharge in elderly trauma patients is comparable to younger patients.
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Affiliation(s)
- Jason S. Murry
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Andrea A. Zaw
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - David M. Hoang
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Devorah Mehrzadi
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Danielle Tran
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Miriam Nuno
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Matthew Bloom
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Nicolas Melo
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Daniel R. Margulies
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Eric J. Ley
- From the Division of Trauma and Critical Care, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
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Gresham G, Nuno M, Piantadosi S. Predicting protocol completion in randomized clinical trials (RCTs): The occurrence of adverse events in the first treatment cycle. J Clin Oncol 2015. [DOI: 10.1200/jco.2015.33.15_suppl.e17700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Gillian Gresham
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Miriam Nuno
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Steven Piantadosi
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA
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Yu W, Alexander JE, Nuno M, Alexander MJ. Abstract T MP34: Perforator Proximity Is A Strong Independent Risk Factor For Peri-procedural Stroke In Intracranial Stenting For Atherosclerotic Disease With Aggressive Management Of Anti-platelet Therapy. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tmp34] [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
Introduction:
The majority of peri-procedural ischemic strokes in the SAMMPRIS trial were perforator strokes. Contemporary studies of intracranial stenting have not evaluated the proximity of atherosclerotic target lesions to major perforators.
Methods:
The current study evaluates a prospective aggressive anti-platelet therapy management approach at two institutions in a consecutive series of 158 patients with symptomatic intracranial atherosclerotic disease (ICAD) treated with angioplasty and stenting with self-expanding nitinol stents. Peri-procedural strokes were analyzed with respect to proximity of the target lesion to angiographically seen perforators and grouped as target lesion either within 2 mm, or greater than 2 mm from visible perforators.
Results:
A total of 158 patients with symptomatic ICAD were treated from 2005 to 2014. The periprocedural complication rate was 3.8% (6/158) with 1 subarachnoid hemorrhage, 0 intraparenchymal hemorrhages, 5 perforator strokes, and no stent thrombosis. With a mean follow up of 2.3 years, the total ipsilateral stroke and death rate was 6.3% (10/154). Of the 158 patients, 61 (38.6%) arteries were stented in the Middle Cerebral Artery or Basilar Artery. Twenty one of the target lesions were within 2 mm of visible perforators, and there were 4 perforator strokes (19%) in this subgroup. Forty of the target lesions were greater than 2 mm of visible perforators with one perforator stroke (2.5%) in this group. There was an approximately sevenfold higher risk of stroke with lesions within 2 mm of perforators compared to lesions greater than 2 mm in the same arteries. This was statistically significant (Fisher’s exact test, p = 0.0437).
Conclusions:
With aggressive monitoring and management of anti-platelet medications, intracranial stenting complications of stent thrombosis and distal emboli can be reduced, although there is still a significant risk of perforator strokes, particularly in the middle cerebral artery and basilar distributions. Target lesions within 2 mm of angiographically visualized perforators had a sevenfold higher risk for periprocedural stroke (p = 0.0437) than other lesions in the same arteries.
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Affiliation(s)
- Wengui Yu
- Neurology, Cedars-Sinai Med Cntr, Los Angeles, CA
| | | | - Miriam Nuno
- Neurosurgery, Cedars-Sinai Med Cntr, Los Angeles, CA
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Shweikeh F, Sunjaya D, Nuno M, Drazin D, Adamo MA. National trends, complications, and hospital charges in pediatric patients with Chiari malformation type I treated with posterior fossa decompression with and without duraplasty. Pediatr Neurosurg 2015; 50:31-7. [PMID: 25721939 DOI: 10.1159/000371659] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [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: 05/14/2014] [Accepted: 12/16/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND The treatment of type 1 Chiari malformation (CM-1) with posterior fossa decompression without (PFD) or with duraplasty (PFDD) is controversial. The authors analyze both options in a national sample of pediatric patients. METHODS Utilizing the Kids' Inpatient Database, CM-1 patients undergoing PFD or PFDD from 2000 through 2009 were analyzed. RESULTS 1,593 patients with PFD and 1,056 with PFDD were evaluated. The average age was 10.3 years, slightly younger in PFD (9.8 vs. 10.9 years, p = 0.001). PFDD patients were more likely White (81.2 vs 75.6%, p = 0.04) and less likely admitted emergently (8.4 vs. 13.8%, p = 0.007). They also underwent more reoperations (2.1 vs. 0.7%, p = 0.01), had more procedure-related complications (2.3 vs. 0.8%, p = 0.003), a longer length of stay (4.4 vs. 3.8 days, p = 0.001) and higher charges (USD 35,321 vs. 31,483, p = 0.01). CONCLUSIONS This large national study indicates that PFDD is performed more often in Caucasians, less so emergently, and associated with significantly more complications and immediate reoperations, while PFD is more frequent in those with syringomyelia and more economical, requiring fewer hospital resources. Overall, PFD is more favorable for CM-1, though it would be prudent to conduct a prospective trial, as this analysis is limited by data on preoperative presentations and long-term outcomes.
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Affiliation(s)
- Faris Shweikeh
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, Calif., USA
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Maher D, Tran H, Nuno M, Eliashiv D, Yusufali T, D'Attellis N, Chung J. Continuous electroencephalogram patterns are suggestive of eventual neurologic outcomes in post-cardiac arrest patients treated with therapeutic hypothermia. J Crit Care 2014; 30:121-5. [PMID: 25457119 DOI: 10.1016/j.jcrc.2014.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2014] [Revised: 09/05/2014] [Accepted: 10/04/2014] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Therapeutic hypothermia (TH) after cardiac arrest (CA) resuscitation is the first therapy proven to increase survival to discharge and neurologic recovery. Methods for neurologic and mortality prognostication after CA resuscitation have been called into question because they were developed based on evidence that was developed prior to the advent of TH. This study examines the relationship between electroencephalogram (EEG) patterns and mortality and neurologic outcomes in post-CA patients undergoing TH. METHODS Eighty-three of 732 patients who had continuous EEG (cEEG) monitoring during TH were included. Continuous EEG tracings were classified as isoelectric, low voltage, burst suppression, epileptic form, and diffuse slowing. Primary outcomes are survival to discharge and Cerebral Performance Categories (CPCs) at hospital discharge. RESULTS Among patients with favorable neurologic outcomes (CPC1 and CPC2), the duration cardiopulmonary resuscitation and time until return of spontaneous circulation were shorter than observed in patients with poorer neurologic outcomes (CPC3, CPC4, and CPC5). The time to target temperature was equivalent among neurologic outcome groups (499.5 minutes vs 431.0 minutes, P = .09). Favorable neurologic outcome was associated with initial presentation with ventricular tachycardia or ventricular fibrillation and had cEEG patterns suggestive of diffuse slowing and epileptiform waves. DISCUSSION The use of cEEG can provide prognostication information otherwise not obtainable by clinical examination. Specific cEEG patterns predicted probability of mortality for patients according to their initial rhythm of CA as a function of cardiopulmonary resuscitation time.
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Affiliation(s)
- Dermot Maher
- Department of Anesthesiology and Critical Care, Cedars Sinai Medical Center, Los Angeles, CA.
| | - Huy Tran
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA
| | - Miriam Nuno
- Department of Neurosurgery, Cedars Sinai Medical Center, Los Angeles, CA
| | - Dawn Eliashiv
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA
| | - Taizoon Yusufali
- Department of Anesthesiology and Critical Care, Cedars Sinai Medical Center, Los Angeles, CA
| | - Nicholas D'Attellis
- Department of Anesthesiology and Critical Care, Cedars Sinai Medical Center, Los Angeles, CA
| | - Jeffrey Chung
- Department of Neurology, Cedars Sinai Medical Center, Los Angeles, CA
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Wertheimer J, Gottuso AY, Nuno M, Walton C, Duboille A, Tuchman M, Ramig L. The impact of STN deep brain stimulation on speech in individuals with Parkinson's disease: The patient's perspective. Parkinsonism Relat Disord 2014; 20:1065-70. [DOI: 10.1016/j.parkreldis.2014.06.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 05/22/2014] [Accepted: 06/17/2014] [Indexed: 11/30/2022]
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35
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Alexander M, Nuno M, Alexander J, Agutos C, Yu W. E-062 Intracranial Stenting for Atherosclerotic Disease with Aggressive Anti-platelet Therapy Management: A Consecutive Series of 154 Patients. J Neurointerv Surg 2014. [DOI: 10.1136/neurintsurg-2014-011343.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Campian J, Gladstone D, Ambady P, Ye X, King K, Borrello I, Petrik S, Golightly M, Holdhoff M, Grossman S, Bhardwaj R, Chakravadhanula M, Ozols V, Georges J, Carlson E, Hampton C, Decker W, Chiba Y, Hashimoto N, Kagawa N, Hirayama R, Tsuboi A, Oji Y, Oka Y, Sugiyama H, Yoshimine T, Choi B, Gedeon P, Herndon J, Sanchez-Perez L, Mitchell D, Bigner D, Sampson J, Choi YA, Pandya H, Gibo DM, Debinski W, Cloughesy TF, Liau LM, Chiocca EA, Jolly DJ, Robbins JM, Ostertag D, Ibanez CE, Gruber HE, Kasahara N, Vogelbaum MA, Kesari S, Mikkelsen T, Kalkanis S, Landolfi J, Bloomfield S, Foltz G, Pertschuk D, Everson R, Jin R, Safaee M, Lisiero D, Odesa S, Liau L, Prins R, Gholamin S, Mitra SS, Richard CE, Achrol A, Kahn SA, Volkmer AK, Volkmer JP, Willingham S, Kong D, Shin JJ, Monje-Deisseroth M, Cho YJ, Weissman I, Cheshier SH, Kanemura Y, Sumida M, Yoshioka E, Yamamoto A, Kanematsu D, Takada A, Nonaka M, Nakajima S, Goto S, Kamigaki T, Takahara M, Maekawa R, Shofuda T, Moriuchi S, Yamasaki M, Kebudi R, Cakir FB, Gorgun O, Agaoglu FY, Darendeliler E, Lin Y, Wang Y, Qiu X, Jiang T, Lin Y, Wang Y, Jiang T, Zhang G, Wang J, Okada H, Butterfield L, Hamilton R, Drappatz J, Engh J, Amankulor N, Lively M, Chan M, Salazar A, Potter D, Shaw E, Lieberman F, Pandya H, Choi Y, Park J, Phuphanich S, Wheeler C, Rudnick J, Hu J, Mazer M, Wang H, Nuno M, Guevarra A, Sanchez C, Fan X, Ji J, Chu R, Bender J, Hawkins E, Black K, Yu J, Reap E, Archer G, Sanchez-Perez L, Norberg P, Schmittling R, Nair S, Cui X, Snyder D, Chandramohan V, Choi B, Kuan CT, Mitchell D, Bigner D, Yan H, Sampson J, Reardon D, Li G, Recht L, Fink K, Nabors L, Tran D, Desjardins A, Chandramouli N, Duic JP, Groves M, Clarke A, Hawthorne T, Green J, Yellin M, Sampson J, Rigakos G, Spyri O, Nomikos P, Stavridi F, Grossi I, Theodorakopoulou I, Assi A, Kouvatseas G, Papadopoulou E, Nasioulas G, Labropoulos S, Razis E, Rudnick J, Ravi A, Sanchez C, Tang DN, Hu J, Yu J, Sharma P, Black K, Sengupta S, Sampath P, Soto H, Erickson K, Malone C, Hickey M, Ha E, Young E, Ellingson B, Prins R, Liau L, Kruse C, Sul J, Hilf N, Kutscher S, Schoor O, Lindner J, Reinhardt C, Kreisl T, Iwamoto F, Fine H, Singh-Jasuja H, Teijeira L, Gil-Arnaiz I, Hernandez-Marin B, Martinez-Aguillo M, Sanchez SDLC, Viudez A, Hernandez-Garcia I, Lecumberri MJ, Grandez R, de Lascoiti AF, Garcia RV, Thomas A, Fisher J, Baron U, Olek S, Rhodes H, Gui J, Hampton T, Tafe L, Tsongalis G, Lefferts J, Wishart H, Kleen J, Miller M, Ernstoff M, Fadul C, Vlahovic G, Desjardins A, Peters K, Ranjan T, Herndon J, Friedman A, Friedman H, Bigner D, Archer G, Lally-Goss D, Sampson J, Wainwright D, Dey M, Chang A, Cheng Y, Han Y, Lesniak M, Weller M, Kaulich K, Hentschel B, Felsberg J, Gramatzki D, Pietsch T, Simon M, Westphal M, Schackert G, Tonn JC, Loeffler M, Reifenberger G, Yu J, Rudnick J, Hu J, Phuphanich S, Mazer M, Wang H, Xu M, Nuno M, Patil C, Chu R, Black K, Wheeler C. IMMUNOTHERAPY/BIOLOGICAL THERAPIES. Neuro Oncol 2013; 15:iii68-iii74. [PMCID: PMC3823893 DOI: 10.1093/neuonc/not178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
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Alexandru D, Satyadev R, So W, Lee SH, Lee YS, Hong YK, Kang CS, Rodgers SD, Marascalchi BJ, Strom RG, Riina H, Samadani U, Frempong-Boadu A, Babu R, Sen C, Zagzag D, Anderson MD, Abel TW, Moots PL, Odia Y, Orr BA, Eberhart CG, Rodriguez F, Sweis RT, Lavingia J, Connelly J, Cochran E, van den Bent M, Hartmann C, Preusser M, Strobel T, Dubbink HJ, Kros JM, von Deimling A, Boisselier B, Sanson M, Halling KC, Diefes KL, Aldape K, Giannini C, Rodriguez FJ, Ligon AH, Horkayne-Szakaly I, Rushing EJ, Ligon KL, Vena N, Garcia DI, Douglas Cameron J, Eberhart CG, Raghunathan A, Wani K, Armstrong TS, Vera-Bolanos E, Fouladi M, Gajjar A, Goldman S, Lehman NL, Metellus P, Mikkelsen T, Necesito-Reyes MJT, Omuro A, Packer RJ, Partap S, Pollack IF, Prados MD, Ian Robbins H, Soffietti R, Wu J, Gilbert MR, Aldape KD, Prosniak M, Harshyne LA, Andrews DW, Craig Hooper D, Kagawa N, Hosen N, Kijima N, Hirayama R, Chiba Y, Yamamoto F, Kinoshita M, Hashimoto N, Fujimoto Y, Yoshimine T, Hu J, Nuno M, Patil C, Rudnick J, Phuphanich S, Bannykh S, Chu R, Yu J, Black K, Choi J, Kim D, Shim KW, Kim SH, Kanno H, Nishihara H, Tanaka S, Nishihara H, Yanagi T, Kanno H, Tanaka S, Buczkowicz P, Khuong-Quang DA, Rakopoulos P, Bouffet E, Morrison A, Bartels U, Pfister SM, Jabado N, Hawkins C, Weinberg BD, Newell KL, Kumar P, Wang F, Venneti S, Madden M, Coyne T, Phillips J, Gorovets D, Huse J, Kofler J, Lu C, Tihan T, Sullivan L, Santi M, Judkins A, Thompson C, Perry A, Iorgulescu JB, Laufer I, Hameed M, Lis E, Boland P, Komotar R, Bilsky M, Amato-Watkins AC, Neal J, Rees AD, Davies JS, Hayhurst C, Lu-Emerson C, Snuderl M, Davidson C, Kirkpatrick ND, Huang Y, Duda DG, Ancukiewicz M, Stemmer-Rachamimov A, Batchelor TT, Jain RK, Ellezam B, Theeler BJ, Sadighi ZS, Mehta V, Tran MDT, Adesina AM, Puduvalli VK, Bruner JM. CLIN-PATHOLOGY. Neuro Oncol 2012. [DOI: 10.1093/neuonc/nos233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Reback CJ, Peck JA, Fletcher JB, Nuno M, Dierst-Davies R. Lifetime substance use and HIV sexual risk behaviors predict treatment response to contingency management among homeless, substance-dependent MSM. J Psychoactive Drugs 2012; 44:166-72. [PMID: 22880545 DOI: 10.1080/02791072.2012.684633] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Homeless, substance-dependent men who have sex with men (MSM) continue to suffer health disparities, including high rates of HIV. One-hundred and thirty one homeless, substance-dependent MSM were randomized into a contingency management (CM) intervention to increase substance abstinence and health-promoting behaviors. Participants were recruited from a community-based, health education/risk reduction HIV prevention program and the research activities were also conducted at the community site. Secondary analyses were conducted to identify and characterize treatment responders (defined as participants in a contingency management intervention who scored at or above the median on three primary outcomes). Treatment responders were more likely to be Caucasian/White (p < .05), report fewer years of lifetime methamphetamine, cocaine, and polysubstance use (p < or = .05), and report more recent sexual partners and high-risk sexual behaviors than nonresponders (p < .05). The application of evidence-based interventions continues to be a public health priority, especially in the effort to implement effective interventions for use in community settings. The identification of both treatment responders and nonresponders is important for intervention development tailored to specific populations, both in service programs and research studies, to optimize outcomes among highly impacted populations.
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Affiliation(s)
- Cathy J Reback
- Friends Research Institute, University of California, Los Angeles, USA.
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Hu JL, Nosova K, Nuno M, Yi A, Elramsisy A, Mukherjee D, Rudnick J, Phuphanich S, Bannykh SI, Yu J, Black KL, Patil C. Retrospective analysis of glioblastoma patients treated with bevacizumab who presented with multifocal disease at diagnosis. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.2080] [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
2080 Background: Glioblastoma patients who present with multifocal disease have an extremely poor prognosis – a recent analysis at our institution demonstrated a median survival of 6 months, versus 11 months for a cohort of unifocal glioblastoma patients matched for age, extent of resection, and KPS. Bevacizumab is frequently used to treat patients with recurrent or progressive glioblastoma. However, its benefit in the setting of multifocal disease is unproven, particularly in light of the concern that antiangiogenic treatment may promote a more invasive, multifocal, and potentially treatment-resistant phenotype. Methods: Between 2004 to 2010, 368 patients were diagnosed with glioblastoma at our institution. We identified 46 patients with multifocal disease on initial presentation, and retrospectively reviewed their clinical course and treatment history. Kaplan-Meier estimates and Wilcoxon tests were used to assess survival distribution. Results: Of the 46 patients with multifocal disease, 12 were treated with bevacizumab (7 upfront and 5 at first recurrence). All 12 bevacizumab-treated patients received external beam radiation therapy, and 11 received temozolomide. In the bevacizumab-treated cohort, median age at the time of surgery was 59 years, and median KPS was 80. For the 34 patients with multifocal disease who did not receive bevacizumab, median age was 69 years, and median KPS was 75. Median survival for the bevacizumab-treated patients was 12.9 months, with 12-month survival of 58.3%. By comparison, median survival for patients with multifocal disease who did not receive bevacizumab was 5.8 months, with 12-month survival of 20.6%. The difference in survival between the two groups was statistically significant, with p-value of 0.045 by the Wilcoxon test. Conclusions: This single-institution retrospective analysis suggests that bevacizumab treatment is associated with a survival benefit for glioblastoma patients who present with multifocal disease. One can infer that the clinical benefit of bevacizumab in this setting outweighs any potential concerns regarding the ability of bevacizumab to promote an invasive, treatment-resistant tumor phenotype.
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Affiliation(s)
| | | | - Miriam Nuno
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Anthony Yi
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Jeremy Rudnick
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - John Yu
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Keith L. Black
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
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Rudnick J, Hu JL, Luptrawan A, Mazer M, Wheeler C, Nuno M, Chu RM, Phuphanich S, Black KL, Yu J. The final report of a phase I trial of surgical resection with biodegradable carmustine (BCNU) wafer placement followed by vaccination with dendritic cells pulsed with tumor lysate for patients with glioblastoma. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.2084] [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
2084 Background: Our prior immunotherapy trials demonstrated efficacy in generating a tumor specific immune response in malignant glioma and the potential for high tumor-specific toxicity and sustained tumoricidal activity. Immunotherapy may synergize with chemotherapy and biodegradable carmustine (BCNU) wafers and have a modest impact to extend overall survival. We exploited this synergistic effect to maintain a cytotoxic environment around the tumor milieu, and this is a presentation of the final results of our clinical trial. Methods: Patients with glioblastoma were eligible after maximal resection with biodegradable carmustine (BCNU) wafer placement. Screening leukapheresis was used to isolate mononuclear cells which were differentiated into dendritic cells, pulsed with tumor lysate, and then 3 intradermal vaccines administered at 2-week intervals. Patients continued systemic chemotherapy after vaccine or at progression. Results: Twenty three patient with glioblastoma received therapy including 8 with newly diagnosed disease (35%) and 15 with recurrent disease (65%) were evaluable. Immune response data is available for 20/23 patients although survival data is present for all. One grade 3 SAE of fever and chills was noted otherwise therapy was well tolerated. Within the newly diagnosed GBM cohort the median overall survival (OS) was 25.5 months (15,31+), and within the recurrent GBM cohort, the median OS was 16 months (8,23+). Among the recurrent GBM an increase of >1.5 X baseline interferon gamma production post vaccination was associated with a prolonged median OS 22 months (8,40) in 4/12 patients versus 17 months (9,27) in 8/12 patients. Conclusions: We were able to generate an immune response in 25% of patients which is lower than what we have seen in previous trials and suggests a limited synergy with local control. However, within the recurrent GBM cohort we did find prolonged survival in both groups with an increased survival noted in immune responders demonstrating the potential for this therapy.
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Affiliation(s)
- Jeremy Rudnick
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Mia Mazer
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Chris Wheeler
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Miriam Nuno
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ray M Chu
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Keith L. Black
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John Yu
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
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Phuphanich S, Wheeler CJ, Rudnick J, Mazer M, Wang HQ, Nuno M, Richardson J, Fan X, Ji J, Chu RM, Bender J, Hawkins ES, Patil C, Black KL, Yu J. Correlation of survival with tumor antigen expression in patients with newly diagnosed glioblastoma receiving a multi-epitope pulsed dendritic cell vaccine. J Clin Oncol 2012. [DOI: 10.1200/jco.2012.30.15_suppl.2087] [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
2087 Background: This study evaluated the safety and immune responses to an autologous dendritic cell vaccine pulsed with class I peptides from tumor associated antigens (TAA) expressed on gliomas and overexpressed in their cancer stem cell population (ICT-107). These TAA epitodes AIM-2. TRP-2, HER2 and AIM-2, are also overexpressed on glioblastoma multiforme (GBM) cancer stem cells. Methods: TAA epitopes included HER2, TRP-2, gp100, MAGE-1, IL13Rα2, and AIM-2. HLA-A1 and/or HLA-A2 positive glioblastoma (GBM) patients with gross total resection were eligible. Mononuclear cells from leukapheresis were differentiated into dendritic cells, pulsed with TAA peptides, and administered intradermally three times at two-week intervals in the axilla region after a standard treatment with concurrent temozolomide (TMZ) and radiation therapy for newly diagnosed (ND-GBM). Results: Twenty-one patients were enrolled with 17 ND-GBM and three recurrent GBM patients and one brainstem glioma. Immune response data on 15 newly diagnosed patients showed 33% responders. TAA expression by qRT-PCR showed all patient tumors expressed at least three TAA with 75% expressing all six. Correlations of increased PFS and quantitative expression of MAGE1, AIM-2, gp100 and HER2 were observed. A decrease or absence of CD133 expression was seen in five patients who underwent a second resection. As of February 1, 2012, six of 16 ND-GBM patients showed no evidence of tumor recurrence (44-63 months). Median progressive free survival (PFS) in newly diagnosed patients was 16.9 months with a two-year PFS rate was 43.8% (95%CI,19.8-66.0 ). The median overall survival rate (OS) was 38.4 months and a two-year OS was 80.3% (95%CI,58.6-96.7). Conclusions: Expression of four ICT-107 targeted antigens in the pre-vaccine tumors correlated with prolonged overall survival and PFS in ND-GBM patients. The goal of targeting tumor antigens highly expressed on glioblastoma cancer stem cells is supported by the observation of decreased or absent CD133 expression in the recurrent areas of gadolinium-enhanced tumor.
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Affiliation(s)
| | | | - Jeremy Rudnick
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Mia Mazer
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Hong Qiang Wang
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Miriam Nuno
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jaime Richardson
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Xuemo Fan
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Jianfei Ji
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ray M Chu
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - James Bender
- Immunocellular Therapeutics, Ltd., Woodland Hills, CA
| | | | - Chirag Patil
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Keith L. Black
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
| | - John Yu
- Neuro-Oncology Program, Cedars-Sinai Medical Center, Los Angeles, CA
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Hickey MJ, Malone CK, Erickson KL, Gerschenson LE, Lin AH, Inagaki A, Hiraoka K, Kasahara N, Mueller B, Kruse CA, Kong S, Tyler B, Zhou J, Carter BS, Brem H, Junghans RP, Sampath P, Lai RK, Recht LD, Reardon DA, Paleologos N, Groves M, Rosenfeld MR, Davis T, Green J, Heimberger A, Sampson J, Hashimoto N, Tsuboi A, Chiba Y, Kijima N, Oka Y, Kinoshita M, Kagawa N, Fujimoto Y, Sugiyama H, Yoshimine T, Birks SM, Burnet M, Pilkington GJ, Yu JS, Wheeler CJ, Rudnick J, Mazer M, Wang HQ, Nuno MA, Richardson JE, Fan X, Ji J, Chu RM, Bender JG, Hawkins EW, Black KL, Phuphanich S, Pollack IF, Jakacki RI, Butterfield LH, Okada H, Hunt MA, Pluhar GE, Andersen BM, Gallardo JL, Seiler CO, SantaCruz KS, Ohlfest JR, Bauer DF, Lamb LS, Harmon DK, Zheng X, Romeo AK, Gillespie GY, Parker JN, Markert JM, Jacobs VL, Landry RP, De Leo JA, Bromberg JE, Doorduijn J, Baars JW, van Imhoff GW, Enting R, van den Bent MJ, Murphy KA, Bedi J, Epstein A, Ohlfest JR, Olin M, Andersen B, Swier L, Ohlfest J, Litterman AJ, Zellmer DM, Ohlfest JR, Chiocca EA, Aguilar LK, Aguilar-Cordova E, Manzanera AG, Harney KR, Portnow J, Badie B, Lesniak M, Bell S, Ray-Chaudhuri A, Kaur B, Hardcastle J, Cavaliere R, McGregor J, Lo S, Chakarvarti A, Grecula J, Newton H, Trask TW, Baskin DS, New PZ, Zeng J, See AP, Phallen J, Belcaid Z, Durham N, Meyer C, Albesiano E, Pradilla G, Ford E, Hammers H, Tyler B, Brem H, Tran PT, Pardoll D, Drake CG, Lim M, Ghazi A, Ashoori A, Hanley P, Salsman V, Schaffer DR, Grada Z, Kew Y, Powell SZ, Grossman R, Scheurer ME, Leen AM, Rooney CM, Bollard CM, Heslop HE, Gottschalk S, Ahmed N, Hu J, Patil C, Nuno M, Wheeler C, Rudnick J, Phuphanich S, Mazer M, Wang HQ, Chu R, Black K, Yu J, Marabelle A, Kohrt H, Brody J, Luong R, Tse V, Levy R, Li YM, Jun H, Shahryar M, Daniel VA, Walter HA, Thaipisuttikul I, Avila E, Mitchell DA, Archer GE, Friedman HS, Herndon JE, Bigner DD, Sampson JH, Johnson LA, Archer GE, Nair SK, Schmittling R, Reap E, Sampson JH, Mitchell DA, Li YM, Shahryar M, Jun H, Daniel VA, Walter HA, Knisely JP, Kluger H, Flanigan J, Sznol M, Yu JB, Chiang VL, Prins RM, Kim W, Soto H, Lisiero DN, Lisiero DN, Liau LM. IMMUNOTHERAPY. Neuro Oncol 2011; 13:iii34-iii40. [PMCID: PMC3199174 DOI: 10.1093/neuonc/nor151] [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: 09/21/2023] Open
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Alexander M, Nuno M, Chowdhary A, Choulakian A, Schievink W. O-024 UHC Data Indicates Higher Mortality Rate in Aneurysms Embolized with Bare Platinum Coils Compared with Polymer Enhanced Coils. J Neurointerv Surg 2011. [DOI: 10.1136/neurintsurg-2011-010097.24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Phuphanich S, Wheeler CJ, Rudnick J, Mazer M, Nuno M, Fan X, Bender J, Hawkins ES, Black KL, Yu J. Glioma-associated antigens associated with prolonged survival in a phase I study of ICT-107 for patients with newly diagnosed glioblastoma. J Clin Oncol 2011. [DOI: 10.1200/jco.2011.29.15_suppl.2042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Butte PV, Mamelak AN, Nuno M, Bannykh SI, Black KL, Marcu L. Fluorescence lifetime spectroscopy for guided therapy of brain tumors. Neuroimage 2011; 54 Suppl 1:S125-35. [PMID: 21055475 PMCID: PMC3335732 DOI: 10.1016/j.neuroimage.2010.11.001] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [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: 09/14/2010] [Revised: 10/27/2010] [Accepted: 11/01/2010] [Indexed: 11/30/2022] Open
Abstract
This study evaluates the potential of time-resolved laser induced fluorescence spectroscopy (TR-LIFS) as intra-operative tool for the delineation of brain tumor from normal brain. Forty two patients undergoing glioma (WHO grade I-IV) surgery were enrolled in this study. A TR-LIFS prototype apparatus (gated detection, fast digitizer) was used to induce in-vivo fluorescence using a pulsed N2 laser (337 nm excitation, 0.7 ns pulse width) and to record the time-resolved spectrum (360-550 nm range, 10 nm interval). The sites of TR-LIFS measurement were validated by conventional histopathology (H&E staining). Parameters derived from the TR-LIFS data including intensity values and time-resolved intensity decay features (average fluorescence lifetime and Laguerre coefficients values) were used for tissue characterization and classification. 71 areas of tumor and normal brain were analyzed. Several parameters allowed for the differentiation of distinct tissue types. For example, normal cortex (N=35) and normal white matter (N=12) exhibit a longer-lasting fluorescence emission at 390 nm (τ390=2.12±0.10 ns) when compared with 460 nm (τ460=1.16±0.08 ns). High grade glioma (grades III and IV) samples (N=17) demonstrate emission peaks at 460 nm, with large variation at 390 nm while low grade glioma (I and II) samples (N=7) demonstrated a peak fluorescence emission at 460 nm. A linear discriminant algorithm allowed for the classification of low-grade gliomas with 100% sensitivity and 98% specificity. High-grade glioma demonstrated a high degree of heterogeneity thus reducing the discrimination accuracy of these tumors to 47% sensitivity and 94% specificity. Current findings demonstrate that TR-LIFS holds the potential to diagnose brain tumors intra-operatively and to provide a valuable tool for aiding the neurosurgeon-neuropathologist team in to rapidly distinguish between tumor and normal brain during surgery.
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Affiliation(s)
- Pramod V. Butte
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA – 90048
| | - Adam N. Mamelak
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA – 90048
| | - Miriam Nuno
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA – 90048
| | - Serguei I. Bannykh
- Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, CA – 90048
| | - Keith L. Black
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA – 90048
| | - Laura Marcu
- Biomedical Engineering, University of California, Davis, CA – 95616
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Fujita M, Kohanbash G, McDonald HA, Delamarre L, Decker SA, Ohlfest JR, Okada H, Okada H, Kalinski P, Ueda R, Hoji A, Kohanbash G, Donegan TE, Mintz AH, Engh JA, Bartlett DL, Brown CK, Zeh H, Holtzman MP, Reinhart TA, Whiteside TL, Butterfield LH, Hamilton RL, Potter DM, Pollack IF, Salazar AM, Lieberman FS, Olin MR, Andersen BM, Grogan PT, Hunt M, Popescu FE, Xiong ZL, Seiler C, Forster CL, SantaCruz KS, Chen W, Blazar BR, Ohlfest JR, Hu J, Wheeler CJ, Phuphanich S, Rudnick J, Nuno M, Serrano N, Dantis J, Richardson J, Mazer M, Wang HQ, Chu R, Black KL, Yu J, Li YM, Vallera DA, Hall WA, Rudnick JD, Wheeler CJ, Phuphanich S, Chu RM, Mazer M, Wang H, Serrano N, Nuno M, Richardson J, Hu J, Black KL, Yu JS, Yang I, Han S, Tihan T, Wrensch M, Parsa AT, Li YM, Vallera DA, Hall WA, Andersen BM, Hunt MA, Gallardo JL, Seiler C, Pluhar GE, Ohlfest JR, Brown CE, Starr R, Martinez C, Bading J, Ressler JA, Badie B, Jensen MC, Glick RP, Ksendzovsky A, Zengou R, Polak P, Simonini V, Lichtor T, Feinstein D, Chow KK, Ahmed N, Salsman VS, Kew Y, Powell S, Grossman R, Heslop HE, Gottschalk S, Barnett FH, Marchetti V, Wang M, Johnson A, Scheppke L, Jacobson R, Nemerow G, Friedlander M, Ahmed N, Salsman V, Kew Y, Leen AM, Bollard CM, Powell S, Grossman R, Rooney C, Heslop HE, Gottschalk S, New PZ, Bollard CM, Salvoldo B, Heslop H. Immunotherapy. Neuro Oncol 2010. [DOI: 10.1093/neuonc/noq116.s5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Reback CJ, Peck JA, Dierst-Davies R, Nuno M, Kamien JB, Amass L. Contingency management among homeless, out-of-treatment men who have sex with men. J Subst Abuse Treat 2010; 39:255-63. [PMID: 20667681 DOI: 10.1016/j.jsat.2010.06.007] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2010] [Revised: 05/28/2010] [Accepted: 06/14/2010] [Indexed: 11/24/2022]
Abstract
Homeless men who have sex with men are a particularly vulnerable population with high rates of substance dependence, psychiatric disorders, and HIV prevalence. Most need strong incentives to engage with community-based prevention and treatment programs. Contingency management (CM) was implemented in a community HIV prevention setting and targeted reduced substance use and increased health-promoting behaviors over a 24-week intervention period. Participants in the CM condition achieved greater reductions in stimulant and alcohol use (χ(2) = 27.36, p < .01) and, in particular, methamphetamine use (χ(2) = 21.78, p < .01) and greater increases in health-promoting behaviors (χ(2) = 37.83, p < .01) during the intervention period than those in the control group. Reductions in substance use were maintained to 9- and 12-month follow-up evaluations. Findings indicate the utility of CM for this high-risk population and the feasibility of implementing the intervention in a community-based HIV prevention program.
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Yamaguchi H, Matsuura H, Kasai R, Tanaka O, Satake M, Kohda H, Izumi H, Nuno M, Katsuki S, Isoda S. Analysis of saponins of wild Panax ginseng. Chem Pharm Bull (Tokyo) 1988; 36:4177-81. [PMID: 3245991 DOI: 10.1248/cpb.36.4177] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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