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Stewart KL, Szczesniak R, Liou TG. Predicting weight gain in patients with cystic fibrosis on triple combination modulator. Pediatr Pulmonol 2024. [PMID: 38607242 DOI: 10.1002/ppul.26982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/12/2024] [Accepted: 03/13/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Cystic fibrosis (CF) is caused by CF transmembrane conductance regulator (CFTR) gene mutations producing dysfunctional CFTR proteins leading to progressive clinical disease. Elexacaftor-tezacaftor-ivacaftor (ETI) remarkably improves lung disease but is associated with substantial weight gain. STUDY DESIGN AND METHODS We performed a single-center longitudinal study predicting 6-month weight gain after ETI initiation. We used linear mixed effects modeling (LME) to determine association of ETI treatment with changing body mass index (BMI). Using linear regression, we examined BMI prediction models with distinct combinations of main effects to identify a model useful for patient counseling. We used up to eight commonly observed clinical characteristics as input variables (age, sex, percent predicted FEV1 [FEV1%], F508del homozygous state, pancreatic sufficiency, HgbA1c, prior modulator use and prior year number of pulmonary exacerbations). RESULTS We evaluated 154 patients (19-73 years old, 54% female, FEV1% = 19-121, 0-6 prior year pulmonary exacerbations). LME demonstrated an association between ETI use and weight increases. Exhaustive testing suggested a parsimonious linear regression model well-fitted to data that is potentially useful for counseling. The two variable model shows that on average, BMI decreases by 0.045 (95% Confidence Interval [CI] = -0.069 to -0.021, p < 0.001) for every year of age and increases by 0.322 (CI = 0.142 to 0.502, p = 0.001) for each additional prior year exacerbation at the time of ETI initiation. INTERPRETATION Young patients with many prior year pulmonary exacerbations likely have the largest 6 month weight gain after starting ETI.
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Affiliation(s)
- Kelly L Stewart
- The Adult Cystic Fibrosis Center, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Theodore G Liou
- The Adult Cystic Fibrosis Center, Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, School of Medicine, University of Utah, Salt Lake City, Utah, USA
- The Center for Quantitative Biology, University of Utah, Salt Lake City, Utah, USA
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2
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Palipana A, Song S, Gupta N, Szczesniak R. Bayesian two-stage modeling of longitudinal and time-to-event data with an integrated fractional Brownian motion covariance structure. Biometrics 2024; 80:ujae011. [PMID: 38483283 PMCID: PMC10938548 DOI: 10.1093/biomtc/ujae011] [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: 01/04/2023] [Revised: 01/10/2024] [Accepted: 02/19/2024] [Indexed: 03/17/2024]
Abstract
It is difficult to characterize complex variations of biological processes, often longitudinally measured using biomarkers that yield noisy data. While joint modeling with a longitudinal submodel for the biomarker measurements and a survival submodel for assessing the hazard of events can alleviate measurement error issues, the continuous longitudinal submodel often uses random intercepts and slopes to estimate both between- and within-patient heterogeneity in biomarker trajectories. To overcome longitudinal submodel challenges, we replace random slopes with scaled integrated fractional Brownian motion (IFBM). As a more generalized version of integrated Brownian motion, IFBM reasonably depicts noisily measured biological processes. From this longitudinal IFBM model, we derive novel target functions to monitor the risk of rapid disease progression as real-time predictive probabilities. Predicted biomarker values from the IFBM submodel are used as inputs in a Cox submodel to estimate event hazard. This two-stage approach to fit the submodels is performed via Bayesian posterior computation and inference. We use the proposed approach to predict dynamic lung disease progression and mortality in women with a rare disease called lymphangioleiomyomatosis who were followed in a national patient registry. We compare our approach to those using integrated Ornstein-Uhlenbeck or conventional random intercepts-and-slopes terms for the longitudinal submodel. In the comparative analysis, the IFBM model consistently demonstrated superior predictive performance.
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Affiliation(s)
- Anushka Palipana
- Duke University School of Nursing, Durham, NC 27710, United States
| | - Seongho Song
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH 45221, United States
| | - Nishant Gupta
- Division of Pulmonary Critical Care and Sleep Medicine, University of Cincinnati, Cincinnati, OH 45221, United States
- Medical Service, Veterans Affairs Medical Center, Cincinnati, OH 45220, United States
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, United States
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229, United States
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH 45221, United States
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3
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Zang H, Kim HJ, Huang B, Szczesniak R. Bayesian causal inference for observational studies with missingness in covariates and outcomes. Biometrics 2023; 79:3624-3636. [PMID: 37553770 PMCID: PMC10840608 DOI: 10.1111/biom.13918] [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: 08/05/2022] [Accepted: 07/13/2023] [Indexed: 08/10/2023]
Abstract
Missing data are a pervasive issue in observational studies using electronic health records or patient registries. It presents unique challenges for statistical inference, especially causal inference. Inappropriately handling missing data in causal inference could potentially bias causal estimation. Besides missing data problems, observational health data structures typically have mixed-type variables - continuous and categorical covariates - whose joint distribution is often too complex to be modeled by simple parametric models. The existence of missing values in covariates and outcomes makes the causal inference even more challenging, while most standard causal inference approaches assume fully observed data or start their works after imputing missing values in a separate preprocessing stage. To address these problems, we introduce a Bayesian nonparametric causal model to estimate causal effects with missing data. The proposed approach can simultaneously impute missing values, account for multiple outcomes, and estimate causal effects under the potential outcomes framework. We provide three simulation studies to show the performance of our proposed method under complicated data settings whose features are similar to our case studies. For example, Simulation Study 3 assumes the case where missing values exist in both outcomes and covariates. Two case studies were conducted applying our method to evaluate the comparative effectiveness of treatments for chronic disease management in juvenile idiopathic arthritis and cystic fibrosis.
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Affiliation(s)
- Huaiyu Zang
- Heart Institute, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
| | - Hang J. Kim
- Division of Statistics and Data Science, University of Cincinnati, OH, U.S.A
| | - Bin Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
- Department of Pediatrics, University of Cincinnati, OH, U.S.A
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, OH, U.S.A
- Department of Pediatrics, University of Cincinnati, OH, U.S.A
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4
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Rosenfeld M, Faino AV, Qu P, Onchiri FM, Blue EE, Collaco JM, Gordon WW, Szczesniak R, Zhou YH, Bamshad MJ, Gibson RL. Association of Pseudomonas aeruginosa infection stage with lung function trajectory in children with cystic fibrosis. J Cyst Fibros 2023; 22:857-863. [PMID: 37217389 DOI: 10.1016/j.jcf.2023.05.004] [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: 12/02/2022] [Revised: 02/25/2023] [Accepted: 05/06/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa (Pa) infection in cystic fibrosis (CF) is characterized in stages: never (prior to first positive culture) to incident (first positive culture) to chronic. The association of Pa infection stage with lung function trajectory is poorly understood and the impact of age on this association has not been examined. We hypothesized that FEV1 decline would be slowest prior to Pa infection, intermediate after incident infection and greatest after chronic Pa infection. METHODS Participants in a large US prospective cohort study diagnosed with CF prior to age 3 contributed data through the U.S. CF Patient Registry. Cubic spline linear mixed effects models were used to evaluate the longitudinal association of Pa stage (never, incident, chronic using 4 different definitions) with FEV1 adjusted for relevant covariates. Models contained interaction terms between age and Pa stage. RESULTS 1,264 subjects born 1992-2006 provided a median 9.5 (IQR 0.25 to 15.75) years of follow up through 2017. 89% developed incident Pa; 39-58% developed chronic Pa depending on the definition. Compared to never Pa, incident Pa infection was associated with greater annual FEV1 decline and chronic Pa infection with the greatest FEV1 decline. The most rapid FEV1 decline and strongest association with Pa infection stage was seen in early adolescence (ages 12-15). CONCLUSIONS Annual FEV1 decline worsens significantly with each Pa infection stage in children with CF. Our findings suggest that measures to prevent chronic infection, particularly during the high-risk period of early adolescence, could mitigate FEV1 decline and improve survival.
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Affiliation(s)
- Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA.
| | - Anna V Faino
- Seattle Children's Research Institute, Seattle, WA, USA
| | - Pingping Qu
- Seattle Children's Research Institute, Seattle, WA, USA
| | | | - Elizabeth E Blue
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William W Gordon
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Rhonda Szczesniak
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH USA
| | - Yi-Hui Zhou
- Bioinformatics Research Center and Department of Statistics, North Carolina State University, Raleigh, NC, USA; Department of Biological Sciences, North Carolina State University, Raleigh, NC, USA
| | - Michael J Bamshad
- Division of Genetic Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Hospital, Seattle, WA, USA; Brotman Baty Institute, Seattle, WA USA
| | - Ronald L Gibson
- Division of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Washington, Seattle, WA, USA; Seattle Children's Research Institute, Seattle, WA, USA
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Stanojevic S, Hamblett N, Szczesniak R, Cromwell E, Keogh R. Median age of survival in the 80s! Is there sufficient evidence to believe it? J Cyst Fibros 2023; 22:592-594. [PMID: 37357035 DOI: 10.1016/j.jcf.2023.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/27/2023]
Affiliation(s)
- Sanja Stanojevic
- Dalhousie University Department of Community Health and Epidemiology, Canada.
| | - Nicole Hamblett
- Department of Pediatrics and Department of Biostatistics at the University of Washington, United States
| | - Rhonda Szczesniak
- Department of Pediatrics and Mathematical Sciences Cincinnati Children's Hospital, USA
| | | | - Ruth Keogh
- Faculty of Epidemiology and Population Health and Department of Medical Statistics at London School of Hygiene and Tropical Medicine, UK
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Szczesniak R, Andrinopoulou ER, Su W, Afonso PM, Burgel PR, Cromwell E, Gecili E, Ghulam E, Goss CH, Mayer-Hamblett N, Keogh RH, Liou TG, Marshall B, Morgan WJ, Ostrenga JS, Pasta DJ, Stanojevic S, Wainwright C, Zhou GC, Fernandez G, Fink AK, Schechter MS. Lung Function Decline in Cystic Fibrosis: Impact of Data Availability and Modeling Strategies on Clinical Interpretations. Ann Am Thorac Soc 2023; 20:958-968. [PMID: 36884219 DOI: 10.1513/annalsats.202209-829oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 03/08/2023] [Indexed: 03/09/2023] Open
Abstract
Rationale: Studies estimating the rate of lung function decline in cystic fibrosis have been inconsistent regarding the methods used. How the methodology used impacts the validity of the results and comparability between studies is unknown. Objectives: The Cystic Fibrosis Foundation established a work group whose tasks were to examine the impact of differing approaches to estimating the rate of decline in lung function and to provide analysis guidelines. Methods: We used a natural history cohort of 35,252 individuals with cystic fibrosis aged ⩾6 years in the Cystic Fibrosis Foundation Patient Registry (CFFPR), 2003-2016. Modeling strategies using linear and nonlinear forms of marginal and mixed-effects models, which have previously quantified the rate of forced expiratory volume in 1 second (FEV1) decline (percent predicted per year), were evaluated under clinically relevant scenarios of available lung function data. Scenarios varied by sample size (overall CFFPR, medium-sized cohort of 3,000 subjects, and small-sized cohort of 150), data collection/reporting frequency (encounter, quarterly, and annual), inclusion of FEV1 during pulmonary exacerbation, and follow-up length (<2 yr, 2-5 yr, entire duration). Results: Rate of FEV1 decline estimates (percent predicted per year) differed between linear marginal and mixed-effects models; overall cohort estimates (95% confidence interval) were 1.26 (1.24-1.29) and 1.40 (1.38-1.42), respectively. Marginal models consistently estimated less rapid lung function decline than mixed-effects models across scenarios, except for short-term follow-up (both were ∼1.4). Rate of decline estimates from nonlinear models diverged by age 30. Among mixed-effects models, nonlinear and stochastic terms fit best, except for short-term follow-up (<2 yr). Overall CFFPR analysis from a joint longitudinal-survival model implied that an increase in rate of decline of 1% predicted per year in FEV1 was associated with a 1.52-fold (52%) increase in the hazard of death/lung transplant, but the results exhibited immortal cohort bias. Conclusions: Differences were as high as 0.5% predicted per year between rate of decline estimates, but we found estimates were robust to lung function data availability scenarios, except short-term follow-up and older age ranges. Inconsistencies among previous study results may be attributable to inherent differences in study design, inclusion criteria, or covariate adjustment. Results-based decision points reported herein will support researchers in selecting a strategy to model lung function decline most reflective of nuanced, study-specific goals.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology and
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics and
| | | | - Weiji Su
- Division of Biostatistics & Epidemiology and
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
- Eli Lilly and Company, Indianapolis, Indiana
| | - Pedro M Afonso
- Department of Biostatistics and
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Pierre-Régis Burgel
- Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- Respiratory Medicine and Cystic Fibrosis National Reference Center, Cochin Hospital, Assistance Publique Hôpitaux de Paris, Paris, France
- European Reference Network for Rare Lung Diseases (ERN-LUNG), Frankfurt, Germany
| | | | - Emrah Gecili
- Division of Biostatistics & Epidemiology and
- Department of Pediatrics and
| | - Enas Ghulam
- Division of Biostatistics & Epidemiology and
- Basic Science Department, College of Science and Health Professions, King Saud bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | | | - Nicole Mayer-Hamblett
- Department of Pediatrics, and
- Department of Biostatistics, University of Washington School of Medicine, Seattle, Washington
- Cystic Fibrosis Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, Washington
| | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Theodore G Liou
- Division of Respiratory, Critical Care and Occupational Pulmonary Medicine, Department of Internal Medicine, School of Medicine, and
- Center for Quantitative Biology, University of Utah, Salt Lake City, Utah
| | | | - Wayne J Morgan
- Department of Pediatrics, University of Arizona, Tucson, Arizona
| | | | - David J Pasta
- formerly ICON Clinical Research, San Francisco, California
| | - Sanja Stanojevic
- Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Claire Wainwright
- Children's Health Queensland Hospital and Health Service, Brisbane, Queensland, Australia
- Child Health Research Centre, The University of Queensland, South Brisbane, Queensland, Australia; and
| | - Grace C Zhou
- Division of Biostatistics & Epidemiology and
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio
| | | | | | - Michael S Schechter
- Childrens Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia
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Boat T, Hente E, Hardie W, Szczesniak R, Gecili E, Zhou G, Taylor J, Amin R. Body composition and functional correlates of CF youth experiencing pulmonary exacerbation and recovery. Pediatr Pulmonol 2023; 58:457-464. [PMID: 36271603 DOI: 10.1002/ppul.26207] [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: 04/28/2022] [Revised: 09/22/2022] [Accepted: 10/11/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Youth with cystic fibrosis (CF) and pulmonary exacerbation (PEx) often experience weight loss, then rapid weight gain. Little is known about body composition and its relationship to functional outcomes during this critical period. METHODS Twenty CF youth experiencing PEx were assessed on the day following admission and 7-17 days later at discharge for body mass index (BMI), fat mass index (FMI), lean mass index (LMI), skeletal muscle mass index (SMMI), and functional measures: percent predicted forced expiratory volume in 1 second (FEV1) (ppFEV1), maximal inspiratory and expiratory pressures (MIPs and MEPs), and handgrip strength (HGS). Changes from admission to discharge and correlations among body composition indices and functional measures at both times are reported. RESULTS Upon admission, participant BMI percentile and ppFEV1 varied from 2 to 97 and 29 to 113, respectively. Thirteen had an LMI below the 25th percentile and nine had a percent body fat above the 75th percentile. BMI and FMI increased significantly (p = 0.03, 0.003) during hospitalization. LMI and SMMI did not change. FEV1 and MIPS increased (p = 0.0003, 0.007), independent of weight gain, during treatment. HGS did not improve. CONCLUSIONS Many youth with CF, independent of BMI, frequently carried a small muscle mass and disproportionate fat at the time of PEx. During hospital treatment, weight gain largely represented fat deposition; muscle mass and strength did not improve. A need for trials of interventions designed to augment muscle mass and function, and limit fat mass accretion, at the time of PEx is suggested by these observations.
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Affiliation(s)
- Thomas Boat
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Elizabeth Hente
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - William Hardie
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Emrah Gecili
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Grace Zhou
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jacqueline Taylor
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Raouf Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Rosenfeld M, Ostrenga J, Cromwell EA, Magaret A, Szczesniak R, Fink A, Schechter MS, Faro A, Ren CL, Morgan W, Sanders DB. Real-world Associations of US Cystic Fibrosis Newborn Screening Programs With Nutritional and Pulmonary Outcomes. JAMA Pediatr 2022; 176:990-999. [PMID: 35913705 PMCID: PMC9344390 DOI: 10.1001/jamapediatrics.2022.2674] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
IMPORTANCE Newborn screening (NBS) for cystic fibrosis (CF) has been universal in the US since 2010, but its association with clinical outcomes is unclear. OBJECTIVE To describe the real-world effectiveness of NBS programs for CF in the US on outcomes up to age 10 years. DESIGN, SETTING, AND PARTICIPANTS This was a retrospective cohort study using CF Foundation Patient Registry data from January 1, 2000, to December 31, 2018. The staggered implementation of NBS programs by state was used to compare longitudinal outcomes among children in the same birth cohort born before vs after the implementation of NBS for CF in their state of birth. Participants included children with an established diagnosis of CF born between January 1, 2000, to December 31, 2018, in any of the 44 states that implemented NBS for CF between 2003 and 2010. Data were analyzed from October 5, 2020, to April 22, 2022. EXPOSURES Birth before vs after the implementation of NBS for CF in the state of birth. MAIN OUTCOMES AND MEASURES Longitudinal trajectory of height and weight percentiles from diagnosis, lung function (forced expiratory volume in 1 second, [FEV1] percent predicted) from age 6 years, and age at initial and chronic infection with Pseudomonas aeruginosa using linear mixed-effects and time-to-event models adjusting for birth cohort and potential confounders. RESULTS A total of 9571 participants (4713 female participants [49.2%]) were eligible for inclusion, with 4510 (47.1%) in the pre-NBS cohort. NBS was associated with higher weight and height percentiles in the first year of life (weight, 6.0; 95% CI, 3.1-8.4; height, 6.6; 95% CI, 3.8-9.3), but these differences decreased with age. There was no association between NBS and FEV1 at age 6 years, but the percent-predicted FEV1 did increase more rapidly with age in the post-NBS cohort. NBS was associated with older age at chronic P aeruginosa infection (hazard ratio, 0.69; 95% CI, 0.54-0.89) but not initial P aeruginosa infection (hazard ratio, 0.88; 95% CI, 0.77-1.01). CONCLUSIONS AND RELEVANCE NBS for CF in the US was associated with improved nutritional status up to age 10 years, a more rapid increase in lung function, and delayed chronic P aeruginosa infection. In the future, as highly effective modulator therapies become available for infants with CF, NBS will allow for presymptomatic initiation of these disease-modifying therapies before irreversible organ damage.
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Affiliation(s)
- Margaret Rosenfeld
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | | | | | - Amalia Magaret
- Division of Pulmonary and Sleep Medicine, Seattle Children’s Hospital, Seattle, Washington,Department of Pediatrics, University of Washington, Seattle
| | - Rhonda Szczesniak
- Cincinnati Children’s Hospital, University of Cincinnati, Cincinnati, Ohio
| | - Aliza Fink
- Cystic Fibrosis Foundation, Bethesda, Maryland,National Organization for Rare Disorders, Washington, District of Columbia
| | | | - Albert Faro
- Cystic Fibrosis Foundation, Bethesda, Maryland
| | - Clement L. Ren
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Wayne Morgan
- Department of Pediatrics, University of Arizona, Tucson
| | - Don B. Sanders
- Department of Pediatrics, Indiana University, Indianapolis
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Jin K, Schnell D, Li G, Salomonis N, Prasath VBS, Szczesniak R, Aronow BJ. CellDrift: inferring perturbation responses in temporally sampled single-cell data. Brief Bioinform 2022; 23:6673850. [PMID: 35998893 PMCID: PMC9487655 DOI: 10.1093/bib/bbac324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/27/2022] [Accepted: 07/18/2022] [Indexed: 11/13/2022] Open
Abstract
Cells and tissues respond to perturbations in multiple ways that can be sensitively reflected in the alterations of gene expression. Current approaches to finding and quantifying the effects of perturbations on cell-level responses over time disregard the temporal consistency of identifiable gene programs. To leverage the occurrence of these patterns for perturbation analyses, we developed CellDrift (https://github.com/KANG-BIOINFO/CellDrift), a generalized linear model-based functional data analysis method that is capable of identifying covarying temporal patterns of various cell types in response to perturbations. As compared to several other approaches, CellDrift demonstrated superior performance in the identification of temporally varied perturbation patterns and the ability to impute missing time points. We applied CellDrift to multiple longitudinal datasets, including COVID-19 disease progression and gastrointestinal tract development, and demonstrated its ability to identify specific gene programs associated with sequential biological processes, trajectories and outcomes.
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Affiliation(s)
- Kang Jin
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Daniel Schnell
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
| | - Guangyuan Li
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH 45229, USA
| | - Nathan Salomonis
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45256, USA
| | - V B Surya Prasath
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Electrical Engineering and Computer Science, University of Cincinnati, OH 45256, USA
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, OH 45229, USA
| | - Bruce J Aronow
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA.,Department of Biomedical Informatics, University of Cincinnati, Cincinnati, OH 45229, USA.,Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH 45256, USA.,Department of Electrical Engineering and Computer Science, University of Cincinnati, OH 45256, USA
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10
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Andrinopoulou ER, Afonso PM, Szczesniak R, Zhou G, Clancy J, Palipana A, Rasnick E, Brokamp C, Ryan P, Keogh R. WS07.05 Investigating the relationship between lung function decline and time to death or lung transplantation, accounting for geographical variability. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00193-x] [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: 11/30/2022]
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Afonso PM, Szczesniak R, Zhou G, Clancy J, Palipana A, Rasnick E, Brokamp C, Ryan P, Keogh R, Andrinopoulou ER. WS15.02 A joint model for lung function and nutritional status decline with recurrent pulmonary exacerbations, death, and lung transplantation using cystic fibrosis patient Registry data. J Cyst Fibros 2022. [DOI: 10.1016/s1569-1993(22)00238-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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12
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Kovaleski C, Courter JD, Ghulam E, Hagedorn PA, Haslam DB, Kurowski EM, Rudloff J, Szczesniak R, Dexheimer JW. Aligning Provider Prescribing With Guidelines for Soft Tissue Infections. Pediatr Emerg Care 2022; 38:e1063-e1068. [PMID: 35226632 DOI: 10.1097/pec.0000000000002667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite evidence-based guidelines, antibiotics prescribed for uncomplicated skin and soft tissue infections can involve inappropriate microbial coverage. Our aim was to evaluate the appropriateness of antibiotic prescribing practices for mild nonpurulent cellulitis in a pediatric tertiary academic medical center over a 1-year period. METHODS Eligible patients treated in the emergency department or urgent care settings for mild nonpurulent cellulitis from January 2017 to December 2017 were identified by an International Classification of Diseases, Tenth Revision, code for cellulitis. The primary outcome was appropriateness of prescribed antibiotics as delineated by adherence with the Infectious Diseases Society of America guidelines. Secondary outcomes include reutilization rate as defined by revisit to the emergency department/urgent cares within 14 days of the initial encounter. RESULTS A total of 967 encounters were evaluated with 60.0% overall having guideline-adherent care. Common reasons for nonadherence included inappropriate coverage of MRSA with clindamycin (n = 217, 56.1%) and single-agent coverage with sulfamethoxazole-trimethoprim (n = 129, 33.3%). There were 29 revisits within 14 days of initial patient encounters or a reutilization rate of 3.0%, which was not significantly associated with the Infectious Diseases Society of America adherence. CONCLUSIONS Our data show antibiotic prescription for nonpurulent cellulitis as a potential area of standardization and optimization of care at our center.
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Affiliation(s)
| | | | | | | | - David B Haslam
- Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | | | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center
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13
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Zhou G, Wang Z, Palipana A, Andrinopoulou E, Afonso P, McPhail G, Clancy J, Gecili E, Szczesniak R. 34: Predicting declines in lung function with the U.S. CF registry: Impact of initiating highly effective modulator therapy. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01459-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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14
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Gecili E, Cheng Y, Siefert M, Skala E, Ziady A, Szczesniak R. 567: Optimization of methods of interrogating large proteomic data sets for disease progression prediction in CF. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01990-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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15
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Bowers K, Ehrlich S, Dolan LM, Gupta R, Altaye M, Ollberding NJ, Szczesniak R, Catalano P, Smith E, Khoury JC. Elevated Anthropometric and Metabolic Indicators among Young Adult Offspring of Mothers with Pregestational Diabetes: Early Results from the Transgenerational Effect on Adult Morbidity Study (the TEAM Study). J Diabetes Res 2021; 2021:6590431. [PMID: 34761006 PMCID: PMC8575612 DOI: 10.1155/2021/6590431] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/30/2021] [Accepted: 10/15/2021] [Indexed: 12/03/2022] Open
Abstract
Exposure to maternal diabetes in utero increases the risk in the offspring for a range of metabolic disturbances. However, the timing and variability of in utero hyperglycemic exposure necessary to cause impairment have not been elucidated. The TEAM Study was initiated to evaluate young adult offspring of mothers with pregestational diabetes mellitus. This paper outlines the unique enrollment challenges of the TEAM Study and preliminary analysis of the association between exposure to diabetes in pregnancy and adverse metabolic outcomes. The TEAM Study enrolls offspring of women who participated in a Diabetes in Pregnancy (DiP) Program Project Grant between 1978 and 1995. The DiP Study collected medical and obstetric data across pregnancy. The first 96 eligible offspring of women with pregestational diabetes were age-, sex-, and race-matched to adults from the National Health and Nutrition Examination Survey (NHANES) 2015-2016 with an OGTT. Descriptive and regression analyses were employed to compare TEAM participants to NHANES participants. Among a subset of TEAM participants, we compared the metabolic outcomes across maternal glucose profiles using a longitudinal data clustering technique that characterizes level and variability, in maternal glucose across pregnancy. By comparing categories of BMI, TEAM Study participants had over 2.0 times the odds of being obese compared to matched NHANES participants (for class III obesity, OR = 2.81; 95% confidence interval (CI): 1.15, 6.87). Increasing levels of two-hour glucose were also associated with in utero exposure to pregestational diabetes in matched analyses. Exposure to pregestational diabetes in utero may be associated with an increased risk of metabolic impairment in the offspring with clinical implications.
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Affiliation(s)
- Katherine Bowers
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Shelley Ehrlich
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Lawrence M. Dolan
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Resmi Gupta
- Biostatistics and Epidemiology/Research Design Component, Division of Clinical and Translational Sciences, Department of Internal Medicine, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Mekibib Altaye
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Nicholas J. Ollberding
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
| | - Patrick Catalano
- Tufts University School of Medicine, Friedman School of Nutrition, Science and Policy, Boston, Massachusetts, USA
| | - Emily Smith
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jane C. Khoury
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- University of Cincinnati College of Medicine, Department of Pediatrics, Cincinnati, Ohio, USA
- Division of Endocrinology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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16
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Woodley F, Gecili E, Szczesniak R, Shrestha C, Nemastil C, Kopp B, Hayes D. 167: Sweat metabolomics profiling of cystic fibrosis pulmonary exacerbations. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)01592-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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17
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Szczesniak R, Heltshe S, Siefert M, Gecili E, Clancy J, Sagel S, Ziady A. 578: Serum biomarkers identified by proteomics and measured by commercially available assays associated with lung function during clinically stable states. J Cyst Fibros 2021. [DOI: 10.1016/s1569-1993(21)02001-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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18
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Mylavarapu G, Gutmark E, Shott S, Fleck R, Mahmoud M, McConnell K, Szczesniak R, Hossain MM, Huang G, Tadesse DG, Schuler CL, Khosla S, Amin R. Predicting critical closing pressure in children with obstructive sleep apnea using fluid-structure interaction. J Appl Physiol (1985) 2021; 131:1629-1639. [PMID: 34528458 PMCID: PMC8616603 DOI: 10.1152/japplphysiol.00694.2020] [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] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 08/04/2021] [Accepted: 08/30/2021] [Indexed: 11/22/2022] Open
Abstract
Surgical treatment of obstructive sleep apnea (OSA) in children requires knowledge of upper airway dynamics, including the closing pressure (Pcrit), a measure of airway collapsibility. We applied a flow-structure interaction (FSI) computational model to estimate Pcrit in patient-specific upper airway models obtained from magnetic resonance imaging (MRI) scans. We sought to examine the agreement between measured and estimated Pcrit from FSI models in children with Down syndrome. We hypothesized that the estimated Pcrit would accurately reflect measured Pcrit during sleep and therefore reflect the severity of OSA as measured by the obstructive apnea-hypopnea index (AHI). All participants (n = 41) underwent polysomnography and sedated sleep MRI scans. We used Bland-Altman plots to examine the agreement between measured and estimated Pcrit. We determined associations between estimated Pcrit and OSA severity, as measured by AHI, using regression models. The agreement between passive and estimated Pcrit showed a fixed bias of -1.31 [confidence interval (CI) = -2.78, 0.15] and a nonsignificant proportional bias. A weaker agreement with active Pcrit was observed. A model including AHI, gender, an interaction term for AHI, and gender and neck circumference explained the largest variation (R2 = 0.61) in the relationship between AHI and estimated Pcrit (P < 0.0001). Overlap between the areas of the airway with the lowest stiffness, and areas of collapse on dynamic MRI, was 77.4 ± 30% for the nasopharyngeal region and 78.6 ± 33% for the retroglossal region. The agreement between measured and estimated Pcrit and the significant association with AHI supports the validity of Pcrit estimates from the FSI model.NEW & NOTEWORTHY We present a noninvasive method for estimating critical closing pressure (Pcrit) using fluid-structure interaction (FSI) simulations and magnetic resonance imaging (MRI) scans in patients with obstructive sleep apnea (OSA). We used patient-specific stiffness measures in our FSI model to account for any individual variability in the elasticity of soft tissues surrounding the upper airway. We validated this model by measuring the degree of agreement between measured and estimated Pcrit.
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Affiliation(s)
- Goutham Mylavarapu
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ephraim Gutmark
- Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, Ohio
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Sally Shott
- Division of Otolaryngology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mohamed Mahmoud
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Keith McConnell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Md Monir Hossain
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Guixia Huang
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dawit G Tadesse
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christine L Schuler
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sid Khosla
- Department of Otolaryngology, University of Cincinnati, Cincinnati, Ohio
| | - Raouf Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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Pearson TA, Califf RM, Roper R, Engelgau MM, Khoury MJ, Alcantara C, Blakely C, Boyce CA, Brown M, Croxton TL, Fenton K, Green Parker MC, Hamilton A, Helmchen L, Hsu LL, Kent DM, Kind A, Kravitz J, Papanicolaou GJ, Prosperi M, Quinn M, Price LN, Shireman PK, Smith SM, Szczesniak R, Goff DC, Mensah GA. Precision Health Analytics With Predictive Analytics and Implementation Research: JACC State-of-the-Art Review. J Am Coll Cardiol 2021; 76:306-320. [PMID: 32674794 DOI: 10.1016/j.jacc.2020.05.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/04/2020] [Indexed: 12/14/2022]
Abstract
Emerging data science techniques of predictive analytics expand the quality and quantity of complex data relevant to human health and provide opportunities for understanding and control of conditions such as heart, lung, blood, and sleep disorders. To realize these opportunities, the information sources, the data science tools that use the information, and the application of resulting analytics to health and health care issues will require implementation research methods to define benefits, harms, reach, and sustainability; and to understand related resource utilization implications to inform policymakers. This JACC State-of-the-Art Review is based on a workshop convened by the National Heart, Lung, and Blood Institute to explore predictive analytics in the context of implementation science. It highlights precision medicine and precision public health as complementary and compelling applications of predictive analytics, and addresses future research and training endeavors that might further foster the application of predictive analytics in clinical medicine and public health.
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Affiliation(s)
- Thomas A Pearson
- College of Medicine and College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida.
| | - Robert M Califf
- School of Medicine and Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Rebecca Roper
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Michael M Engelgau
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Muin J Khoury
- Office of Genomics and Precision Public Health, Centers for Disease Control and Prevention, Atlanta, Georgia
| | | | - Craig Blakely
- School of Public Health and Information Science, University of Louisville, Louisville, Kentucky
| | - Cheryl Anne Boyce
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Marishka Brown
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Thomas L Croxton
- Division of Lung Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Kathleen Fenton
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Melissa C Green Parker
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Lorens Helmchen
- Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Lucy L Hsu
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - David M Kent
- Predictive Analytics and Comparative Effectiveness (PACE) Center, Sackler School of Graduate Biomedical Sciences, Tufts University, Tufts Medical Center, Boston, Massachusetts
| | - Amy Kind
- Department of Medicine Health Services and Care Research Program, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | | | - George John Papanicolaou
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Mattia Prosperi
- College of Medicine and College of Public Health and Health Professions, University of Florida Health Science Center, Gainesville, Florida
| | - Matt Quinn
- Health Technology, Telemedicine and Advanced Technology Research Center, Frederick, Maryland
| | - LeShawndra N Price
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Paula K Shireman
- School of Medicine, University of Texas Health Science Center at San Antonio and South Texas Veterans Health Care System, San Antonio, Texas
| | - Sharon M Smith
- Division of Blood Diseases and Resources, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Division of Pulmonary Medicine, Cincinnati Children's Hospital, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - David Calvin Goff
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - George A Mensah
- Center for Translation Research and Implementation Science, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland.
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20
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Sawnani H, Mayer OH, Modi AC, Pascoe JE, McConnell K, McDonough JM, Rutkowski AM, Hossain MM, Szczesniak R, Tadesse DG, Schuler CL, Amin R. Randomized trial of lung hyperinflation therapy in children with congenital muscular dystrophy. Pediatr Pulmonol 2020; 55:2471-2478. [PMID: 32658385 PMCID: PMC9047443 DOI: 10.1002/ppul.24954] [Citation(s) in RCA: 3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/07/2020] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Respiratory compromise in congenital muscular dystrophy (CMD) occurs, in part, from chest wall contractures. Passive stretch with hyperinsufflation therapy could reduce related costo-vertebral joint contractures. We sought to examine the impact of hyperinsufflation use on lung function and quality of life in children with CMD. STUDY DESIGN We conducted a randomized controlled trial on hyperinsufflation therapy in children with CMD at two centers. An individualized hyperinsufflation regimen of 15 minutes twice daily using a cough assist device over a 12 months period was prescribed. We measured lung function, quality of life, and adherence. To demonstrate reproducibility, pulmonary function was measured twice on the same day. A mixed-effects regression model adjusting for confounders was used to assess the effects of hyperinsufflation. RESULTS We enrolled 34 participants in the study; 31 completed the trial (n = 17 treatment group and n = 14 controls). Participants in the treatment group demonstrated a relative gain in lung volume measured at 4 and 8 months, but not at 12 months. The control group required increases in the maximum insufflation pressures to achieve maximum lung volumes while the treatment group did not. Adherence was best early in the study, peaking at the first visit and decreasing at subsequent visits. Caregiver-reported quality of life was higher in the treatment group. CONCLUSION Hyperinsufflation therapy is effective in increasing and sustaining lung volume over time. Adherence, however, was inconsistent and difficult to maintain. Further research should determine if improved adherence leads to sustained benefits of hyperinsufflation.
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Affiliation(s)
- Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Oscar H Mayer
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Avani C Modi
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Behavioral Medicine and Clinical Psychology, Center for Treatment Adherence and Self-Management, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - John E Pascoe
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Keith McConnell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph M McDonough
- Division of Pulmonary Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Md Monir Hossain
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Szczesniak
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Dawit G Tadesse
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Christine L Schuler
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Raouf Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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21
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Andrinopoulou ER, Nasserinejad K, Szczesniak R, Rizopoulos D. Integrating latent classes in the Bayesian shared parameter joint model of longitudinal and survival outcomes. Stat Methods Med Res 2020; 29:3294-3307. [PMID: 32438854 PMCID: PMC7545534 DOI: 10.1177/0962280220924680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Cystic fibrosis is a chronic lung disease requiring frequent lung-function monitoring to track acute respiratory events (pulmonary exacerbations). The association between lung-function trajectory and time-to-first exacerbation can be characterized using joint longitudinal-survival modeling. Joint models specified through the shared parameter framework quantify the strength of association between such outcomes but do not incorporate latent sub-populations reflective of heterogeneous disease progression. Conversely, latent class joint models explicitly postulate the existence of sub-populations but do not directly quantify the strength of association. Furthermore, choosing the optimal number of classes using established metrics like deviance information criterion is computationally intensive in complex models. To overcome these limitations, we integrate latent classes in the shared parameter joint model through a fully Bayesian approach. To choose the optimal number of classes, we construct a mixture model assuming more latent classes than present in the data, thereby asymptotically "emptying" superfluous latent classes, provided the Dirichlet prior on class proportions is sufficiently uninformative. Model properties are evaluated in simulation studies. Application to data from the US Cystic Fibrosis Registry supports the existence of three sub-populations corresponding to lung-function trajectories with high initial forced expiratory volume in 1 s (FEV1), rapid FEV1 decline, and low but steady FEV1 progression. The association between FEV1 and hazard of exacerbation was negative in each class, but magnitude varied.
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Affiliation(s)
| | | | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology and Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, USA
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22
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Szczesniak R, Rice JL, Brokamp C, Ryan P, Pestian T, Ni Y, Andrinopoulou ER, Keogh RH, Gecili E, Huang R, Clancy JP, Collaco JM. Influences of environmental exposures on individuals living with cystic fibrosis. Expert Rev Respir Med 2020; 14:737-748. [PMID: 32264725 DOI: 10.1080/17476348.2020.1753507] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
INTRODUCTION Natural, social, and constructed environments play a critical role in the development and exacerbation of respiratory diseases. However, less is known regarding the influence of these environmental/community risk factors on the health of individuals living with cystic fibrosis (CF), compared to other pulmonary disorders. AREAS COVERED Here, we review current knowledge of environmental exposures related to CF, which suggests that environmental/community risk factors do interact with the respiratory tract to affect outcomes. Studies discussed in this review were identified in PubMed between March 2019 and March 2020. Although the limited data available do not suggest that avoiding potentially detrimental exposures other than secondhand smoke could improve outcomes, additional research incorporating novel markers of environmental exposures and community characteristics obtained at localized levels is needed. EXPERT OPINION As we outline, some environmental exposures and community characteristics are modifiable; if not by the individual, then by policy. We recommend a variety of strategies to advance understanding of environmental influences on CF disease progression.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Jessica L Rice
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
| | - Cole Brokamp
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Patrick Ryan
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA
| | - Teresa Pestian
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Yizhao Ni
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | | | - Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine , London, UK
| | - Emrah Gecili
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA
| | - Rui Huang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center , Cincinnati, OH, USA.,Department of Mathematical Sciences, University of Cincinnati , Cincinnati, OH, USA
| | - John P Clancy
- Department of Pediatrics, University of Cincinnati , Cincinnati, OH, USA.,Department of Clinical Research, Cystic Fibrosis Foundation , Bethesda, MD, USA
| | - Joseph M Collaco
- Eudowood Division of Pediatric Respiratory Sciences, Department of Pediatrics, Johns Hopkins University School of Medicine , Baltimore, MD, USA
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23
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Stanojevic S, Szczesniak R. Transparency and open access in CF research. J Cyst Fibros 2020; 19:e13. [PMID: 32268992 DOI: 10.1016/j.jcf.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/15/2022]
Affiliation(s)
- Sanja Stanojevic
- Translational Medicine, Hospital for Sick Children, Toronto, Canada.
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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24
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Betz J, Szczesniak R, Lewis K, Pestian T, Bennethum AS, McBride J, Grossoehme DH. Feasibility and Acceptability of a Telephone-Based Chaplaincy Intervention to Decrease Parental Spiritual Struggle. J Relig Health 2019; 58:2065-2085. [PMID: 31584149 DOI: 10.1007/s10943-019-00921-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Spiritual struggles (SSs) are distressing spiritual thoughts associated with poorer health outcomes. This study's purpose was to test feasibility, acceptability, and fidelity of an intervention to decrease SS of parents of children with CF. Parents screening positive for SS were enrolled and were randomized to intervention or attention-control condition. Intervention focused on intra-, inter-, and divine SS. Mixed linear modeling examined between-group differences. We present analyses of N = 23, and participants all showed decreased levels of SS. Acceptability was high; feasibility was higher in the intervention arm. GuideSS_CF is acceptable and feasible and warrants development as a potentially efficacious intervention.
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Affiliation(s)
- John Betz
- Department of Pastoral Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rhonda Szczesniak
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Katrina Lewis
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC2021, Cincinnati, OH, 45229, USA
| | - Teresa Pestian
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC2021, Cincinnati, OH, 45229, USA
| | - Amy Simpson Bennethum
- Department of Pastoral Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Judith McBride
- Department of Pastoral Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Daniel H Grossoehme
- Department of Pediatrics, University of Cincinnati, College of Medicine, Cincinnati, OH, USA.
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC2021, Cincinnati, OH, 45229, USA.
- Department of Pastoral Care, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
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Huang B, Szczesniak R. Can't see the wood for the trees: confounders, colliders and causal inference - a statistician's approach. Thorax 2019; 74:323-325. [PMID: 30733328 DOI: 10.1136/thoraxjnl-2018-212780] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2019] [Indexed: 11/04/2022]
Affiliation(s)
- Bin Huang
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
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Gupta R, Altaye M, Khoury J, Jandarov R, Szczesniak R. Joint modeling of gestational glycemic control and the risk of preterm birth in women with type 1 diabetes mellitus (T1DM). Ann Epidemiol 2018. [DOI: 10.1016/j.annepidem.2018.06.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zou Y, Szczesniak R, Teeters A, Conard LAE, Grossoehme DH. Documenting an epidemic of suffering: low health-related quality of life among transgender youth. Qual Life Res 2018; 27:2107-2115. [PMID: 29564711 DOI: 10.1007/s11136-018-1839-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2018] [Indexed: 12/22/2022]
Abstract
PURPOSE To quantify HRQOL of TGN patients using the PedsQL 4.0 generic core scales, and to compare reported HRQOL of TGN adolescents with published data from comparison populations. METHODS Transgender children and adolescents (N = 142; 68% natal females) ages 6-23 years (M = 15.9, SD = 3.7) attending an outpatient clinic for TGN care at an academic pediatric hospital and caregivers of children and adolescents (N = 95) completed the PedsQL 4.0 generic core scales. Scores were compared with published scores for healthy adolescents and adolescents with 10 chronic diseases. RESULTS TGN youth reported significantly lower overall HRQOL (more than twice the clinically meaningful difference) compared to youth without chronic disease. Total self-reported TGN HRQOL (M(SD), 65.72(17.40)) was lower than all chronic disease comparison groups except for rheumatology and cerebral palsy. TGN youth reported physical functioning (M(SD), 75.33(22.87)) lower than or similar to chronically ill comparisons, but higher than rheumatology and cerebral palsy groups. Psychosocial functioning (M(SD), 59.87(17.83)) was lower than all comparison samples and similar to youth with cerebral palsy. Results were similar for parent proxy-reports of TGN youth HRQOL (LS means: 68.75; 95% CI 65.87-71.61 vs 66.16; 95% CI 62.87-69.45; p = 0.12). CONCLUSIONS TGN youth reported low HRQOL across all domains; most were significantly lower than healthy peers or peers with chronic diseases. Clinicians should understand the magnitude of TGN youth's low HRQOL and offer them and their caregivers resources to maximize their ability to achieve their full potential for healthy and productive lives.
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Affiliation(s)
- Yuanshu Zou
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Alexis Teeters
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC2021, Cincinnati, OH, 45229, USA
| | - Lee Ann E Conard
- Division of Adolescent & Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Daniel H Grossoehme
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue MLC2021, Cincinnati, OH, 45229, USA.
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28
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Keogh RH, Szczesniak R, Taylor-Robinson D, Bilton D. Up-to-date and projected estimates of survival for people with cystic fibrosis using baseline characteristics: A longitudinal study using UK patient registry data. J Cyst Fibros 2018; 17:218-227. [PMID: 29311001 PMCID: PMC5885983 DOI: 10.1016/j.jcf.2017.11.019] [Citation(s) in RCA: 133] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 11/20/2017] [Accepted: 11/29/2017] [Indexed: 12/16/2022]
Abstract
BACKGROUND Cystic fibrosis (CF) is the most common inherited disease in Caucasians, affecting around 10,000 individuals in the UK today. Prognosis has improved considerably over recent decades with ongoing improvements in treatment and care. Providing up-to-date survival predictions is important for patients, clinicians and health services planning. METHODS Flexible parametric survival modelling of UK CF Registry data from 2011 to 2015, capturing 602 deaths in 10,428 individuals. Survival curves were estimated from birth; conditional on reaching older ages; and projected under different assumptions concerning future mortality trends, using baseline characteristics of sex, CFTR genotype (zero, one, two copies of F508del) and age at diagnosis. FINDINGS Male sex was associated with better survival, as was older age at diagnosis, but only in F508del non-homozygotes. Survival did not differ by genotype among individuals diagnosed at birth. Median survival ages at birth in F508del homozygotes were 46years (males) and 41years (females), and similar in non-homozygotes diagnosed at birth. F508del heterozygotes diagnosed aged 5 had median survival ages of 57 (males) and 51 (females). Conditional on survival to 30, median survival age rises to 52 (males) and 49 (females) in homozygotes. Mortality rates decreased annually by 2% during 2006-2015. Future improvements at this rate suggest median survival ages for F508del homozygous babies of 65 (males) and 56 (females). INTERPRETATION Over half of babies born today, and of individuals aged 30 and above today, can expect to survive into at least their fifth decade. RESEARCH IN CONTEXT Evidence before this study We searched PubMed with terms "(cystic fibrosis survival) and (projection OR model OR registry OR United Kingdom OR UK)" to identify relevant studies on survival estimates for individuals with cystic fibrosis (CF). We also considered the most recent annual report from the UK Cystic Fibrosis Registry (Cystic Fibrosis Trust, 2016), a review by Buzzetti and colleagues (2009), the chapter on Epidemiology of Cystic Fibrosis by MacNeill (2016), the study of MacKenzie and colleagues (2014), and references therein. There have been many studies of factors associated with survival in CF; most have focused on identifying risk factors, and only a few have presented estimated survival curves, which are the focus of this work. The most recent study of survival in the UK is by Dodge and colleagues (2007), who used data obtained from CF clinics and the national death register, and gave an estimate of survival for babies born in 2003. We found no previous studies that have obtained detailed information on survival using UK Cystic Fibrosis Registry data. Jackson and colleagues obtained survival estimates for the US and Ireland using registry data (Jackson et al., 2011). MacKenzie and colleagues used US Cystic Fibrosis Foundation Patient Registry data from 2000 to 2010 to project survival for children born and diagnosed with CF in 2010, accounting for sex, genotype and age at diagnosis (MacKenzie et al., 2014). Previous studies on estimated survival in CF have become out of date or have not accounted for the full range of patient characteristics available at birth. Few have presented conditional survival estimates (Dodge et al., 2007). Added value of this study This is the first study to yield detailed survival statistics using the UK Cystic Fibrosis Registry, which is one of the largest national CF registries outside of the US and has almost complete coverage of the UK CF population. The primary goal was to leverage the long-term follow-up of the nearly complete UK CF population available in the Registry for the purposes of producing accurate, precise predictions in the modern era of CF care. Estimates are presented from birth and conditional on survival to older ages. These are the first conditional estimates in CF to also account for genotype, sex and age at diagnosis, which were each included in the modelling using a flexible approach. Projections are also provided under different scenarios based on downward trends in mortality rates. Our use of flexible parametric survival models is novel in this field, and our approach could be used to provide modern survival statistics for other chronic diseases and disorders. Implications of all the available evidence Our estimates of future survival in CF under a range of different scenarios are based on data on nearly all individuals living with the disease in the UK in recent times, reflective of a modern era of care, and are most appropriate for the families of babies being born in the present day with CF. Conditional estimates inform patients who have already reached an older age, and their clinicians. Over half of babies born today, and of individuals aged 30years and above alive today, can expect to survive into their fifth decade. Insights based on our survival projections can be used to inform future needs in CF health care provision.
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Affiliation(s)
- Ruth H Keogh
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, United Kingdom.
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, MLC 5041, 3333 Burnet Ave, Cincinnati 45229, OH, United States
| | - David Taylor-Robinson
- Department of Public Health and Policy, Farr Institute@HERC, University of Liverpool, Liverpool L69 3GB, United Kingdom
| | - Diana Bilton
- Faculty of Medicine, National Heart and Lung Institute, Imperial College London, Guy Scadding Building, Cale Street, London SW3 6LY, United Kingdom
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Szczesniak R, Brokamp C, Su W, McPhail GL, Pestian J, Clancy JP. Early Detection of Rapid Cystic Fibrosis Disease Progression Tailored to Point of Care: A Proof-of-Principle Study. Health Innov Point Care Conf 2017; 2017:204-207. [PMID: 29594261 DOI: 10.1109/hic.2017.8227620] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Slowing cystic fibrosis (CF) lung disease progression is crucial to survival, but point-of-care technologies aimed at early detection-and possibly prevention-of rapid lung function decline are limited. This proof-of-principle study leverages a rich national patient registry and follow-up data on a local CF cohort to build an algorithm and prototype prognostic tool aimed at early detection of rapid lung function decline. The algorithm was developed using a novel longitudinal analysis of lung function (measured as forced expiratory volume in 1 s of % predicted, FEV1). Covariates included clinical and demographic characteristics selected from the registry based on information criterion. Preliminary assessment of algorithm performance suggested excellent predictive accuracy and earlier detection of rapid decline than standard of care being applied at a local center. Graphical displays were presented and evaluated for clinical utility. Predictions from the algorithms and chosen graphical displays were translated into a prototype web application using RShiny and underwent iterative development based on clinician feedback. This paper suggests that the algorithm and its translation could offer a means for earlier detection and treatment of rapid decline, providing clinicians with a viable point-of-care technology to intervene prior to irreversible lung damage.
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Affiliation(s)
- Rhonda Szczesniak
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - Cole Brokamp
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - Weiji Su
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - Gary L McPhail
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - John Pestian
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
| | - John P Clancy
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH 45229 USA
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30
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Kirkendall ES, Kouril M, Dexheimer JW, Courter JD, Hagedorn P, Szczesniak R, Li D, Damania R, Minich T, Spooner SA. Automated identification of antibiotic overdoses and adverse drug events via analysis of prescribing alerts and medication administration records. J Am Med Inform Assoc 2017; 24:295-302. [PMID: 27507653 DOI: 10.1093/jamia/ocw086] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 04/30/2016] [Indexed: 01/22/2023] Open
Abstract
Objectives Electronic trigger detection tools hold promise to reduce Adverse drug event (ADEs) through efficiencies of scale and real-time reporting. We hypothesized that such a tool could automatically detect medication dosing errors as well as manage and evaluate dosing rule modifications. Materials and Methods We created an order and alert analysis system that identified antibiotic medication orders and evaluated user response to dosing alerts. Orders associated with overridden alerts were examined for evidence of administration and the delivered dose was compared to pharmacy-derived dosing rules to confirm true overdoses. True overdose cases were reviewed for association with known ADEs. Results Of 55 546 orders reviewed, 539 were true overdose orders, which lead to 1965 known overdose administrations. Documentation of loose stools and diarrhea was significantly increased following drug administration in the overdose group. Dosing rule thresholds were altered to reflect clinically accurate dosing. These rule changes decreased overall alert burden and improved the salience of alerts. Discussion Electronic algorithm-based detection systems can identify antibiotic overdoses that are clinically relevant and are associated with known ADEs. The system also serves as a platform for evaluating the effects of modifying electronic dosing rules. These modifications lead to decreased alert burden and improvements in response to decision support alerts. Conclusion The success of this test case suggests that gains are possible in reducing medication errors and improving patient safety with automated algorithm-based detection systems. Follow-up studies will determine if the positive effects of the system persist and if these changes lead to improved safety outcomes.
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Affiliation(s)
- Eric S Kirkendall
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Michal Kouril
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Judith W Dexheimer
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Philip Hagedorn
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dan Li
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, Ohio, USA
| | - Rahul Damania
- Northeast Ohio Medical University College of Medicine, Rootstown, Ohio, USA
| | - Thomas Minich
- Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - S Andrew Spooner
- Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Information Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Keogh R, Szczesniak R, Taylor-Robinson D. WS11.2 How can we provide better information on survival for people with CF accounting for current age, sex and genotype? J Cyst Fibros 2017. [DOI: 10.1016/s1569-1993(17)30220-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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32
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Mahmoud M, Ishman SL, McConnell K, Fleck R, Shott S, Mylavarapu G, Gutmark E, Zou Y, Szczesniak R, Amin RS. Upper Airway Reflexes are Preserved During Dexmedetomidine Sedation in Children With Down Syndrome and Obstructive Sleep Apnea. J Clin Sleep Med 2017; 13:721-727. [PMID: 28356179 DOI: 10.5664/jcsm.6592] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 01/20/2017] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES The assessment of pharyngeal collapsibility is difficult to perform in children under normal sleep. An alternative is to perform the assessment under an anesthetic, such as dexmedetomidine (DEX), that induces non-rapid eye movement (NREM) sleep. The objectives of this study were to compare critical closing airway pressure (Pcrit) obtained during natural sleep to that obtained under DEX in patients with Down syndrome (DS) and persistent obstructive sleep apnea (OSA) and determine whether Pcrit measured under sedation predicts the severity of OSA. METHODS The passive and active Pcrit, which represent airway passive mechanical properties and active dynamic responses to airway obstruction, respectively, were measured. Upper airway reflex activity was estimated by calculating the difference between active and passive Pcrit. Subjects underwent overnight polysomnography during which Pcrit was measured during normal sleep. Pcrit was also measured during DEX sedation at a dose of 2 μg/kg/h. RESULTS The study included 50 patients with median age of 11.4 years (interquartile range: 7.0-13.9) and median body mass index of 23.0 kg/m2 (interquartile range: 18.4-29.1), 66% male and 80% Caucasian. Passive Pcrit was significantly higher than active Pcrit when measured during normal sleep and DEX-induced sleep. There was a positive association between apnea-hypopnea index and passive Pcrit (Spearman r = 0.53, P = .0001) and active Pcrit (r = 0.55, P = .0002) under DEX-induced sleep. There were no significant differences between the Pcrit measurements during natural sleep and during DEX sedation. CONCLUSION Patients with OSA can compensate for airway obstruction under DEX-induced sleep. The close association between Pcrit and apnea-hypopnea index suggests that airway responses with DEX sedation parallel those seen during natural sleep. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT01902407.
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Affiliation(s)
- Mohamed Mahmoud
- Department of Anesthesiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stacey L Ishman
- Division of Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Keith McConnell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert Fleck
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sally Shott
- Division of Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Goutham Mylavarapu
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ephraim Gutmark
- Division of Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Aerospace Engineering and Engineering Mechanics, University of Cincinnati, Cincinnati, Ohio
| | - Yuanshu Zou
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Raouf S Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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33
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Dexheimer JW, Kirkendall ES, Kouril M, Hagedorn PA, Minich T, Duan LL, Mahdi M, Szczesniak R, Spooner SA. The Effects of Medication Alerts on Prescriber Response in a Pediatric Hospital. Appl Clin Inform 2017; 8:491-501. [PMID: 28487930 PMCID: PMC6241745 DOI: 10.4338/aci-2016-10-ra-0168] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 10/05/2016] [Accepted: 02/28/2017] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE More than 70% of hospitals in the United States have electronic health records (EHRs). Clinical decision support (CDS) presents clinicians with electronic alerts during the course of patient care; however, alert fatigue can influence a provider's response to any EHR alert. The primary goal was to evaluate the effects of alert burden on user response to the alerts. METHODS We performed a retrospective study of medication alerts over a 24-month period (1/2013-12/2014) in a large pediatric academic medical center. The institutional review board approved this study. The primary outcome measure was alert salience, a measure of whether or not the prescriber took any corrective action on the order that generated an alert. We estimated the ideal number of alerts to maximize salience. Salience rates were examined for providers at each training level, by day of week, and time of day through logistic regressions. RESULTS While salience never exceeded 38%, 49 alerts/day were associated with maximal salience in our dataset. The time of day an order was placed was associated with alert salience (maximal salience 2am). The day of the week was also associated with alert salience (maximal salience on Wednesday). Provider role did not have an impact on salience. CONCLUSION Alert burden plays a role in influencing provider response to medication alerts. An increased number of alerts a provider saw during a one-day period did not directly lead to decreased response to alerts. Given the multiple factors influencing the response to alerts, efforts focused solely on burden are not likely to be effective.
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Affiliation(s)
- Judith W Dexheimer
- Judith Dexheimer, PhD, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, MLC 2008, 3333 Burnet Avenue, Cincinnati, OH 45229-3039, , Phone: 513-803-2962, Fax: 513-803-2581
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Meilleur KG, Linton MM, Fontana J, Rutkowski A, Elliott J, Barton M, McGraw P, Kokkinis A, Donkervoort S, Leach M, Jain M, Dastgir J, Collins J, Szczesniak R, Yang K, Sawnani H, Bönnemann CG. Comparison of sitting and supine forced vital capacity in collagen VI-related dystrophy and laminin α2-related dystrophy. Pediatr Pulmonol 2017; 52:524-532. [PMID: 28085238 PMCID: PMC6309368 DOI: 10.1002/ppul.23622] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 09/06/2016] [Accepted: 09/19/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Progressive, restrictive, respiratory insufficiency is the major cause of morbidity and mortality in Congenital Muscular Dystrophy (CMD). Nocturnal hypoventilation precedes daytime alveolar hypoventilation, and if untreated, may lead to respiratory failure and cor pulmonale. CMD consensus care guidelines recommend screening for respiratory insufficiency by conventional and dynamic (sitting to supine) pulmonary function testing (PFT) and evaluating for sleep disordered breathing if there is more than 20% relative reduction from sitting to supine FVC(L) (ΔFVC). OBJECTIVE The objective of this retrospective study was to explore and characterize dynamic FVC measures in 51 individuals with two common subtypes of CMD, COL6-RD, and LAMA2-RD. METHODS We compared sitting and supine FVC in patients with confirmed mutation(s) in either COL6 or LAMA2. We investigated influences of age, CMD subtype, gender, race, ambulatory status, and non-invasive positive pressure ventilation (NIPPV) status on FVC percent predicted (FVCpp) and ΔFVC. RESULTS COL6-RD participants exhibited a significant difference between sitting and supine mean FVCpp (sitting 66.1, supine 55.1; P < 0.0001) and were 5.4 times more likely to have -ΔFVC >20% than those with LAMA2-RD when controlling for ambulant status. FVCpp sitting correlated inversely with age in individuals ≤18 years. CONCLUSION FVCpp sitting decreases progressively in childhood in both CMD subtypes. However, our results point to a difference in diaphragmatic involvement, with COL6-RD individuals having more disproportionate diaphragmatic weakness than LAMA2-RD. A ΔFVC of greater than -20% should continue to be used to prompt evaluation of sleep-disordered breathing. Timely initiation of NIPPV may be indicated to treat nocturnal hypoventilation. Pediatr Pulmonol. 2017;52:524-532. © 2017 Wiley Periodicals, Inc.
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Affiliation(s)
- Katherine G Meilleur
- National Institute of Nursing Research, NIH, 1 Cloister Court, Building 60, Room 252, Bethesda, Maryland, 20814
| | - Melody M Linton
- National Institute of Nursing Research, NIH, 1 Cloister Court, Building 60, Room 252, Bethesda, Maryland, 20814
| | - Joseph Fontana
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | | | - Jeffrey Elliott
- National Institute of Nursing Research, NIH, 1 Cloister Court, Building 60, Room 252, Bethesda, Maryland, 20814
| | - Mark Barton
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | - Peter McGraw
- National Heart, Lung, and Blood Institute, NIH, Bethesda, Maryland
| | - Angela Kokkinis
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland
| | - Sandra Donkervoort
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland
| | - Meganne Leach
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland.,Children's National Medical Center, Washington, District of Columbia
| | - Minal Jain
- Mark O. Hatfield Clinical Research Center, NIH, Bethesda, Maryland
| | | | - James Collins
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Szczesniak
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kelly Yang
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland
| | - Hemant Sawnani
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Carsten G Bönnemann
- National Institute of Neurological Disorders and Stroke, NIH, Bethesda, Maryland
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Szczesniak R, Turkovic L, Andrinopoulou ER, Tiddens HAWM. Chest imaging in cystic fibrosis studies: What counts, and can be counted? J Cyst Fibros 2017; 16:175-185. [PMID: 28040479 PMCID: PMC5340596 DOI: 10.1016/j.jcf.2016.12.008] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [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: 10/03/2016] [Revised: 12/05/2016] [Accepted: 12/07/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND The dawn of precision medicine and CFTR modulators require more detailed assessment of lung structure in cystic fibrosis (CF) clinical studies. Various imaging markers have emerged and are measurable, but clarity is needed to identify what markers should count for clinical studies. High-resolution chest computed tomography (CT) scoring has yielded sensitive markers for the study of CF disease progression. Once completed, CT scores from ongoing randomized controlled trials can be used to examine relationships between imaging endpoints and therapeutic effectiveness. Similarly, Magnetic Resonance Imaging (MRI) is in development to generate structural as well as functional markers. RESULTS The aim of this review is to characterize the role of currently available CT and MRI markers in clinical studies, and to discuss study design, data processing and statistical challenges unique to these endpoints in CF studies. Suggestions to overcome these challenges in CF studies are included. CONCLUSIONS To maximize the potential of CT and MRI markers in clinical studies and advance treatment of CF disease progression, efforts should be made to conduct longitudinal randomized controlled trials including these modalities, develop data repositories, promote standardization and conduct reproducible research.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology and Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | | | | | - Harm A W M Tiddens
- Department of Pediatric Pulmonology and Allergology, The Netherlands; Department of Radiology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands.
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Szczesniak R, Su W, Clancy JP. Dynamics of Disease Progression and Gastrostomy Tube Placement in Children and Adolescents with Cystic Fibrosis: Application of Joint Models for Longitudinal and Time-to-Event Data. Intern Med Rev (Wash D C) 2017; 2. [PMID: 28232958 DOI: 10.18103/imr.v2i9.163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Previous small-sample studies have examined the effect of gastrostomy (g-) tube placement on weight, height, and lung function in adolescent patients with cystic fibrosis (CF), but there are no RCTs to date reporting efficacy. The goal of this study was to implement a dynamic prediction model to 1) understand the role of rapid lung function decline in g-tube placement in real-world clinical settings; 2) provide a prognostic tool with the potential to aid clinicians in optimizing the timing of g-tube placement, in relation to rate of lung function decline and current nutrition status. METHODS A dynamic prediction model was developed, utilizing data on patients 6-21 years of age from the Cystic Fibrosis Foundation Patient Registry (1997-2013). A joint model was implemented, which coupled a semiparametric mixed model to characterize rapid lung function decline with a time-to-event model to identify risk factors for g-tube initiation. RESULTS The 4,034 individuals (21.3%) who underwent g-tube placement during adolescence or young adulthood had poorer nutrition and lung function at baseline and initially had increased rates of pancreatic enzyme use, infection and gastroesophageal reflux disease, compared to those who did not receive g-tubes; these associations changed over follow up. Rapid lung function decline was associated with increased risk of g-tube supplementation. CONCLUSIONS By jointly modeling longitudinal patterns of lung function decline with g-tube delivery, it is possible to construct prognostic aids to evaluate treatment delivery in relation to the onset of rapid lung function decline and other important clinical markers. These algorithms have the potential to enable more effective monitoring of disease progression and promote more timely treatment delivery.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital, Cincinnati, OH, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Weiji Su
- Department of Mathematical Sciences, University of Cincinnati, Cincinnati, OH, USA
| | - J P Clancy
- Division of Pulmonary Medicine, Cincinnati Children's Hospital, Cincinnati, OH, USA
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Fleck RJ, Ishman SL, Shott SR, Gutmark EJ, McConnell KB, Mahmoud M, Mylavarapu G, Subramaniam DR, Szczesniak R, Amin RS. Dynamic Volume Computed Tomography Imaging of the Upper Airway in Obstructive Sleep Apnea. J Clin Sleep Med 2017; 13:189-196. [PMID: 27784422 PMCID: PMC5263074 DOI: 10.5664/jcsm.6444] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 09/14/2016] [Indexed: 12/22/2022]
Abstract
STUDY OBJECTIVES To describe a dynamic three-dimensional (3D) computed tomography (CT) technique for the upper airway and compare the required radiation dose to that used for common clinical studies of a similar anatomical area, such as for subjects undergoing routine clinical facial CT. METHODS Dynamic upper-airway CT was performed on eight subjects with persistent obstructive sleep apnea, four of whom were undergoing magnetic resonance imaging and an additional four subjects who had a contraindication to magnetic resonance imaging. This Health Insurance Portability and Accountability Act-compliant study was approved by our institutional review board, and informed consent was obtained. The control subjects (n = 41) for comparison of radiation dose were obtained from a retrospective review of the clinical picture-archiving computer system to identify 10 age-matched patients per age-based control group undergoing facial CT. RESULTS Dynamic 3D CT can be performed with an effective radiation dose of less than 0.38 mSv, a dose that is less than or comparable to that used for clinical facial CT. The resulting data- set is a uniquely complete, dynamic 3D volume of the upper airway through a full respiratory cycle that can be processed for clinical and modeling analyses. CONCLUSIONS A dynamic 3D CT technique of the upper airway is described that can be performed with a clinically reasonable radiation dose and sets a benchmark for future use.
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Affiliation(s)
- Robert J. Fleck
- Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Stacey L. Ishman
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Sally R. Shott
- Division of Pediatric Otolaryngology - Head and Neck Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
| | - Ephraim J. Gutmark
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati School of Medicine, Cincinnati, OH
- Department of Aerospace Engineering and Engineering Mechanics, CEAS, University of Cincinnati, Cincinnati, OH
| | - Keith B. McConnell
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Mohamed Mahmoud
- Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Goutham Mylavarapu
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dhananjay R. Subramaniam
- Department of Aerospace Engineering and Engineering Mechanics, CEAS, University of Cincinnati, Cincinnati, OH
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Raouf S. Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
- Department of Pediatrics, University of Cincinnati School of Medicine, Cincinnati, OH
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Szczesniak R, Heltshe SL, Stanojevic S, Mayer-Hamblett N. Use of FEV 1 in cystic fibrosis epidemiologic studies and clinical trials: A statistical perspective for the clinical researcher. J Cyst Fibros 2017; 16:318-326. [PMID: 28117136 DOI: 10.1016/j.jcf.2017.01.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 01/04/2017] [Accepted: 01/05/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Forced expiratory volume in 1s (FEV1) is an established marker of cystic fibrosis (CF) disease progression that is used to capture clinical course and evaluate therapeutic efficacy. The research community has established FEV1 surveillance data through a variety of observational data sources such as patient registries, and there is a growing pipeline of new CF therapies demonstrated to be efficacious in clinical trials by establishing improvements in FEV1. RESULTS In this review, we summarize from a statistical perspective the clinical relevance of FEV1 based on its association with morbidity and mortality in CF, its role in epidemiologic studies of disease progression and comparative effectiveness, and its utility in clinical trials. In addition, we identify opportunities to advance epidemiologic research and the clinical development pipeline through further statistical considerations. CONCLUSIONS Our understanding of CF disease course, therapeutics, and clinical care has evolved immensely in the past decades, in large part due to the thoughtful application of rigorous research methods and meaningful clinical endpoints such as FEV1. A continued commitment to conduct research that minimizes the potential for bias, maximizes the limited patient population, and harmonizes approaches to FEV1 analysis while maintaining clinical relevance, will facilitate further opportunities to advance CF care.
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Affiliation(s)
- Rhonda Szczesniak
- Division of Biostatistics & Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Sonya L Heltshe
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA
| | - Sanja Stanojevic
- Division of Respiratory Medicine, Hospital for Sick Children, Toronto, ON, Canada
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington, Seattle, WA, USA; Cystic Fibrosis Foundation Therapeutics Development Network Coordinating Center, Seattle Children's Research Institute, Seattle, WA, USA; Department of Biostatistics, University of Washington, Seattle, WA, USA
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Amin R, Simakajornboon N, Szczesniak R, Inge T. Early improvement in obstructive sleep apnea and increase in orexin levels after bariatric surgery in adolescents and young adults. Surg Obes Relat Dis 2016; 13:95-100. [PMID: 27720196 DOI: 10.1016/j.soard.2016.05.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 02/29/2016] [Revised: 05/02/2016] [Accepted: 05/25/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) associated with obesity is known to improve after bariatric surgery, but little is known about early changes in this condition after surgery. OBJECTIVES To study the clinical course of OSA after bariatric surgery SETTING: Children's hospital in the United States METHODS: Adolescents and young adults with obstructive sleep apnea undergoing vertical sleeve gastrectomy (n = 6) or gastric bypass (n = 1) were enrolled in this prospective study. Participants underwent formal polysomnography before and at 3 and 5 weeks after bariatric surgery. Anthropometric measurements and assay for orexin and leptin were also performed at study visits. Thirty-one adolescents who underwent 2 polysomnography studies that were 4 weeks apart served as control patients. RESULTS Baseline mean (range) age of participants was 17.8 (15.4-20.7) years, 71% were male, with body mass index of 55.2 (41.3-61.6) kg/m2 and had a median apnea hypopnea index (AHI) of 15.8 (7.1-23.8) events/hour. Differences in least-square means from longitudinal analysis did not show significant differences in AHI in the control group but showed significant postoperative decline in AHI relative to baseline. AHI declined postoperatively from baseline by 9.2 events/hour (95% confidence interval: 3.8 to 14.5) at 3 weeks (P = .002) and 9.1 events/hour (95% confidence interval: 3.8 to 14.5) at 5 weeks (P = .002); there was no significant change from 3 to 5 weeks in AHI. Leptin decreased and orexin levels increased significantly by 3 weeks postoperatively. CONCLUSIONS These observations suggest that OSA responds early and out of proportion to weight loss after metabolic and or bariatric surgery, thus weight independent factors may at least in part be responsible for early improvement in OSA postoperatively.
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Affiliation(s)
- Raouf Amin
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Sleep Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | - Narong Simakajornboon
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Sleep Disorders Center, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Thomas Inge
- Surgical Weight Loss Center for Teens, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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McPhail GL, Ehsan Z, Howells SA, Boesch RP, Fenchel MC, Szczesniak R, Jain V, Agabegi S, Sturm P, Wall E, Redding GJ. Obstructive lung disease in children with idiopathic scoliosis. J Pediatr 2015; 166:1018-21. [PMID: 25684085 DOI: 10.1016/j.jpeds.2014.12.070] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 10/20/2014] [Accepted: 12/23/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To measure the prevalence of obstructive lung disease (OLD) among patients undergoing preoperative pulmonary assessment for idiopathic scoliosis. STUDY DESIGN This was a retrospective, descriptive review from clinical data in a tertiary care pediatric hospital in the US. Patients (n = 176) with idiopathic scoliosis with Cobb angles of ≥ 40 degrees who performed acceptable and repeatable preoperative pulmonary function testing were included. The primary outcome measure was the forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) ratio. RESULTS The prevalence of OLD (low FEV1/FVC ratio) was 39% (68/176 patients). In multivariate modeling, radiographic measures were poor predictors of pulmonary function outcomes of FVC (r(2) 0.06), FEV1 (r(2) 0.05), FEV1/FVC ratio (r(2) 0.08), and total lung capacity (r(2) 0.06). CONCLUSIONS OLD is common in patients with idiopathic scoliosis. We recommend preoperative pulmonary function testing for patients with idiopathic scoliosis under consideration for spinal fusion surgery.
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Affiliation(s)
- Gary L McPhail
- Division of Pulmonary Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Zarmina Ehsan
- Division of Pulmonary Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | | | - R Paul Boesch
- Division of Pulmonary Medicine, Mayo Children's Hospital, Mayo Medical School, Rochester, MN
| | - Matthew C Fenchel
- Division of Pulmonary Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Viral Jain
- Division of Orthopedic Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Steven Agabegi
- Division of Orthopedic Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Peter Sturm
- Division of Orthopedic Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Eric Wall
- Division of Orthopedic Surgery, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Greg J Redding
- Division of Pulmonary Medicine, University of Washington, Seattle Children's Hospital, Seattle, WA
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Grossoehme DH, Szczesniak R, Dodd C, Opipari-Arrigan L. Dyadic Adjustment and Spiritual Activities in Parents of Children with Cystic Fibrosis. Religions (Basel) 2014; 5:385-401. [PMID: 26900486 PMCID: PMC4756918 DOI: 10.3390/rel5020385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Children's diseases can negatively impact marital adjustment and contribute to poorer child health outcomes. To cope with increased marital stress and childhood diseases severity, many people turn to spirituality. While most studies show a positive relationship between spirituality and marital adjustment, spirituality has typically been measured only in terms of individual behaviors. Using the Dyadic Adjustment Scale (DAS) and Daily Phone Diary data from a sample of 126 parents of children with cystic fibrosis as a context for increased marital stress, spiritual behavior of mother-father dyads and of whole families were used as predictors of marital adjustment. Frequency and duration of individual, dyadic and familial spiritual activities correlated positively with dyadic adjustment. Significant differences in spiritual activities existed between couples with marital adjustment scores above and below the cutoff for distress. The only significant factors in regressions of spiritual activities on marital adjustment scores were number of pulmonary exacerbations and parent age. Higher odds of maintaining a marital adjustment score greater than 100 were significantly associated with spending approximately twelve minutes per day in individual, but not conjugal or familial, spiritual activities. The Daily Phone Diary is a feasible tool to study conjugal and familial activities and their relationships with beliefs and attitudes, including spirituality.
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Affiliation(s)
- Daniel H. Grossoehme
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, MLC2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
- Author to whom correspondence should be addressed; ; Tel.: +1-513-636-0848; Fax: +1-513-803-2813
| | - Rhonda Szczesniak
- Division of Pulmonary Medicine, Cincinnati Children’s Hospital Medical Center, MLC2021, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Caitlin Dodd
- Medical Informatics Department, Erasmus University, Rotterdam 3015 GE, The Netherlands
| | - Lisa Opipari-Arrigan
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
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Tan CC, McDowell KM, Fenchel M, Szczesniak R, Kercsmar CM. Spirometry use in children hospitalized with asthma. Pediatr Pulmonol 2014; 49:451-7. [PMID: 24000189 DOI: 10.1002/ppul.22854] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2012] [Accepted: 05/10/2013] [Indexed: 11/07/2022]
Abstract
Asthma is the most common chronic disorder of childhood and continues to be a leading cause of pediatric hospital admission. The National Asthma Education and Prevention Program (NAEPP) recommends that spirometry be obtained for asthma patients upon hospital admission, after bronchodilation during the acute phase of asthma symptoms, and at least one additional time before discharge from the hospital. The objectives of this study were to describe the use of spirometry in children hospitalized with asthma and to determine association of pulmonary function with future exacerbations. A retrospective cohort study design was utilized involving review of medical records of children ≥5 years old admitted with asthma to Cincinnati Children's Hospital Medical Center from September 1, 2009 to March 31, 2011. Hospitalization or emergency department (ED) visits were identified by the ICD-9-CM codes of having either a primary diagnosis of asthma (493) or a respiratory illness (460-496) plus a secondary diagnosis of asthma. Asthma re-exacerbation was defined as either having an ED visit or hospitalization for asthma that occurred within 3 months after the index hospitalization. All spirometries were performed in a pediatric pulmonary function laboratory. Among 1,037 admissions included in this study, 89 (8.6%) had spirometry that was recommended by a consulting asthma specialist and usually performed on the day of discharge. Spirometries for forty-five of these patients (54.9%) met all acceptability and repeatability criteria of the American Thoracic Society. Patients who performed acceptable spirometry were significantly older (12.4 ± 3.8 vs. 10.7 ± 3.0 years; P = 0.041). The average forced expiratory volume in the first second (FEV1 ) was 84.4 ± 19.7% predicted; forced vital capacity (FVC) was 98.1 ± 16.0% predicted; FEV1 /FVC was 74.6 ± 9.6%; forced expiratory flow at 25-75% (FEF25-75 ) was 61.2 ± 30.1% predicted. Ten patients (22%) who performed spirometry developed a re-exacerbation. Patients with versus without re-exacerbation had significantly lower FEV1 /FVC (P = 0.027) and FEF25-75 (P = 0.031). Nevertheless, separate logistic regression models found that FEV1 /FVC and FEF25-75 were not associated with re-exacerbation when adjusted for age and length-of-stay. We found that few children admitted with asthma had spirometry as recommended in the NAEPP guidelines unless recommended by specialists and both lower lung function (FEV1 /FVC and FEF25-75 ) and history of more frequent and more recent prior health-care utilization for asthma were associated with repeat asthma exacerbation. However, the value of performing spirometry on asthmatic children prior to hospital discharge remains unclear and will require prospective study.
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Affiliation(s)
- Chee Chun Tan
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Grossoehme DH, Szczesniak R, McPhail GL, Seid M. Is adolescents' religious coping with cystic fibrosis associated with the rate of decline in pulmonary function?-A preliminary study. J Health Care Chaplain 2013; 19:33-42. [PMID: 23551049 DOI: 10.1080/08854726.2013.767083] [Citation(s) in RCA: 12] [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: 10/27/2022]
Abstract
Religious coping is associated with health outcomes in adolescents with chronic disease. Identifying potentially modifiable spiritual factors is important for improving health outcomes. The purpose of this study was to determine if associations exist between rate of change in pulmonary function and subsequent religious coping by adolescents with cystic fibrosis (CF). Retrospective cohort design employing the Brief R-COPE and calculated decline in lung function over a three-year period were utilized. Data were obtained for 28 adolescents; median age 13.5 years. Use of pleading or negative religious coping was associated with a worse clinical trajectory. Pleading may be ineffective as disease progression is modifiable through adherence to evidence-based treatments. Given established relationships of religious coping with general coping, the effects of declining pulmonary function may be broader. Changes in pulmonary function suggest opportunities for chaplains to explore options to cognitively reframe negative religious coping.
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Affiliation(s)
- Daniel H Grossoehme
- Division of Pulmonary Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229, USA.
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